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For M.P.L.

Opening and Background Conceptual Approach

Cognitive and Perceptual Rehabilitation: Optimizing Cognitive and Perceptual Rehabilitation: Optimiz­
Function aims to provide an up-to-date and com- ing Function was written with three overarching
prehensive overview of the process that has tra- and interrelated approaches in mind: evidence-
ditionally been called cognitive and perceptual based, function-based, and client-centered. Given
rehabilitation but may be better described as the this, the textbook focuses on being a comprehen-
process of improving function in those who are liv­ sive resource of valid and reliable tools that use
ing with cognitive and perceptual impairments. Until functional activities as the basis of assessment.
the recent past, this area of practice has been domi- A particular emphasis has been placed on tools that
nated by assessments, interventions, and outcomes have ecological validity (i.e., reflective of behaviors
that were far removed from everyday function. This observed in everyday function). This focus limits
limitation is steadily being overcome as current cli- the inclusion of assessments that are not perfor-
nicians, researchers, and scientists are once again mance based and that use contrived tasks as the
placing a renewed focus on function-based assess- basis for assessment. This textbook also embraces
ments, evidence-based interventions that promote the inclusion of standardized client and significant
improved performance of necessary and meaning- others reports of daily function. Similarly, this text-
ful activities, decreasing participation restrictions, book highlights and focuses on interventions that
and ultimately improving quality of life. have been empirically tested and that document a
Cognitive and Perceptual Rehabilitation: Optimi­ positive change related to decreasing activity limi-
zing Function aims to be a clinical and educational tations and participation restrictions. An emphasis
resource that summarizes, highlights, and con- has been placed on interventions that use meaning-
structively critiques the state of the art of this area ful activities as the primary change agent to improve
of practice. The overall goal of writing this textbook function.
was to provide clinicians and students with the tools
necessary to make a positive impact on the lives of
those to whom they are providing care.
Chapters 1 and 2 (Overview of Cognitive and
Perceptual Rehabilitation and General Considerations:
Who will benefit from this book?
Evaluations and Interventions for Those Living with
A variety of neurologists, neuropsychologists, Functional Limitations Secondary to Cognitive and
occupational therapists, psychologists, psychiatrist, Perceptual Impairments) provide the necessary foun-
and speech and language pathologists from across dations to using an evidence-based and function-
the world are working in and contributing to the based approach to work with this population and
knowledge base of this area of practice. The pri- are therefore considered prerequisites to all of the
mary audiences for this textbook are students and other chapters. Chapter 3 (Managing Visuospatial
clinicians who are learning about or directly work- Impairments to Optimize Function) provides neces-
ing with clients who are living with functional lim- sary foundation information related to visual impair-
itations secondary to cognitive and/or perceptual ments that must be considered before assessing and
impairments. Other professionals who may find developing intervention plans for other problem
this textbook helpful in the evaluation and inter- areas. Similarly, Chapter 4 (Self-Awareness and Insight:
vention processes include vocational counselors, Foundations for Intervention) focuses on the problem
nurses, physical therapists, and therapeutic recre- of poor awareness and developing awareness as the
ation specialists. Case managers and those making starting point for all interventions. These chapters are
referrals to rehabilitation services may also find the also then considered foundations for the ­subsequent
information contained in this textbook helpful. chapters.

viii pREFACE

Chapters 5 through 10 emphasize functional • Samples of function-based assessments.

limitations caused by various impairments and • Summary tables of assessments highlighting
patterns of impairments including apraxia, neglect, their clinical utility and focus as well as their
agnosia, impaired attention, impaired memory, ­psychometric properties.
and impairments of the executive functions. Theses
chapters are all written as a user-friendly clini-
Learning Aids
cal guide that primarily focus on assessment and
interventions. Learn ing aids include the following:
Finally, Chapter 11 (Application of Concepts: • Key terms
Case Studies) provides further clinical applica- • Learning objectives
tions and integration based on case studies that • Review questions
take place in various treatment environments from • Case studies
acute care to community reintegration. This chap-
ter further examines the process of evaluation and
intervention planning for clients who have func-
tional limitations secondary to typical patterns of Note to reader: This book compiles informa-
impairments. tion from a variety of disciplines and countries.
Multiple terms have been used to describe the
person who is receiving services and who is par-
Distinctive Features
ticipating in research. These terms include patient,
Key features of this book include the following: client, person, subject, participant, etc. The terms
• Inclusion of evidence-based intervention protocols. originally used in the reviewed literature have
• Evidence-based intervention tables focused on been maintained. This in no way undermines the
improving daily function follow each chap- importance of a client-centered approach, which
ter. These include a summary of research and I consider a best practice standard. Adopting a cli-
summary of outcomes. These tables were built ent- and significant other-centered approach is
based on published methodologies of critically a thread and consistent message throughout this
­analyzing the existing research literature. textbook.

T he author would first and foremost like to

acknowledge the clinicians and scientists who
have directly or indirectly shaped the way he con-
creating a stimulating albeit fun environment.
Particularly I need to thank Janet Falk-Kessler for
encouragement and guidance. I look forward to
ceptualizes function based rehabilitation. These working with her for many more years.
include (but are not limited to) Guðrún Árnadóttir, For more than a decade, the editorial team at
M. Carolyn Baum, Anne G. Fisher, Gordon Muir Elsevier has been supportive of my work. The guid-
Giles, and Joan P. Toglia. ance I always receive from both Kathy Falk and
I must also acknowledge my colleagues on the Melissa Kuster has been invaluable. Thank you
faculty of the Programs in Occupational Therapy, (again!).
Columbia University College of Physicians & Finally, I would like to acknowledge the editorial
Surgeons for consistent support, ideas, and for assistance of Jasmine A. Gore and Eva Hatenboer.

Chapter 1
Overview of Cognitive and Perceptual Rehabilitation

Key Terms
Activity Demands Context Performance Skills
Activity Limitation Environmental Factors Quality of Life
Areas of Occupation Impairment
Client-centered Practice Participation Restriction
Client Factors Performance Patterns

Learning Objectives
At the end of this chapter readers will be able to: 3. Understand which outcome measures are appropri­
1. Understand various classification systems that can be ate for this population.
used to guide the evaluation and intervention pro­ 4. Understand patterns of cognitive and perceptual
cess for those living with functional limitations sec­ impairments that interfere with everyday function.
ondary to cognitive and perceptual impairments.
2. Apply the principles of client-centered practice to
this population.

“Best practice is a way of thinking about problems in imaginative ways, applying knowledge
creatively to solve performance problems while also taking responsibility for evaluating the
effectiveness of the innovations to inform future practices.”38

functional activities. In general, this assumption

Perspectives of Cognitive and
has not been supported by empirical research.
Perceptual Rehabilitation
An early example is the elegant work of Neistadt.47
The practice area of cognitive and perceptual The researcher had previously identified a relation­
­rehabilitation has and continues to shift in focus. ship between construction tasks as measured by the
In the recent past, interventions were focused on Wechsler Adult Intelligence Scale-Revised (WAIS-R)
cognitive and perceptual stimulation activities Block Design Test and a standardized assessment of
aimed at the remediation of a particular impair­ meal preparation, the Rabideau Kitchen Evaluation-
ment. It was assumed that the remediation of an Revised, concluding that constructional abilities may
identified impairment or impairments would contribute to meal preparation performance. Based
generalize into the ability to perform meaningful, on these findings a randomized controlled trial was

 cognitive and perceptual rehabilitation: Optimizing function

conducted to examine the effects of interventions to influence function in the real world. In addition, it
focused on retraining meal preparation skills ver­ is becoming clear that how we measure the success
sus the remediation of constructional deficits in of an intervention must be reconsidered. Significant
adult men with head injuries. Outcomes were meal improvement in a letter cancellation test for a person
preparation competence and objective measures of living with unilateral spatial neglect can no longer be
const­ructional abilities. Forty-five subjects, ages 18 interpreted as a positive outcome if more meaning­
to 52, in long-term rehabilitation programs, were ful functional changes (e.g., improved ability to read,
randomly assigned to one of two treatment groups: manage medications, play board games, ­ manage
remediation of construction abilities (n = 22) via money, etc.) cannot be documented.
training with parquetry block assembly, and a meal As rehabilitation professions began to under­
preparation training group (n = 23). Both groups stand the importance of evidence-based practice
received training for three 30-minute sessions per and have refocused on “real-world” functional out­
week for 6 weeks, in addition to their regular reha­ comes, the rehabilitation process has begun to shift
bilitation programs. Results showed task-specific accordingly. Interventions that focus on strategies
learning in both groups and suggested that train­ for living independently, with a purpose, and
ing in functional activities may be the better way to with improved quality of life despite the presence
improve performance in such activities in this popu­ perhaps of cognitive and perceptual impairments are
lation. In other words, those trained in construction slowly becoming the clinical standard. Likewise, out­
tasks performed better on novel tabletop construc­ come measures that focus on documenting improved
tion tasks but did not improve on meal preparation functioning outside of a clinic environment and
measures, whereas those trained in the meal prepa­ those that include test items focused on performing
ration group demonstrated significantly improved functional activities are being embraced.
abilities related to the ability to make a meal at the These positive changes should be welcomed by
end of the intervention despite not improving on clinicians and the individuals to whom they provide
measures of construction ability. Although the results services because making a positive change in the life
of this study are not unexpected based on a current of an individual living with cognitive and percep­
understanding of recovery, the study challenged the tual impairments has been notoriously difficult. It
typical interventions that were being taught in aca­ is expected that as the research literature focused on
demic settings and those that were commonly used testing interventions continues to emerge, further
in the clinic at the time it was published. shifts in practice patterns will occur. Philosophically,
In general, interventions at that time were pro­ the clinical focus of what is called cognitive and per-
vided in controlled environments consisting of ceptual rehabilitation may be better described as the
tabletop activities that were novel and not focused process of improving function and quality of life in
on function. Examples include engaging individuals those individuals living with ­cognitive and perceptual
in block design activities, sequencing picture cards, impairments.
puzzle making, design copying, canceling a tar­
get stimulus on paper, pegboard designs, memory
World Health Organization’s
drills, and so on. As technology became more read­
International Classification of
ily available, specialized cognitive-retraining com­
Function as a Framework for
puterized programs were developed, marketed, and
Choosing Assessments, Interventions,
quickly adopted into the clinical setting. In terms
and Documenting Outcomes
of outcomes, interventions were deemed successful
when improvements were documented on specific The World Health Organization’s (WHO) Inter­
cognitive and perceptual impairment tests. national Classification of Functioning, Disability,
Similar to the interventions that were being used and Health (ICF)68 is a classification system that
at this time, measurement instruments attempted to describes body functions and structures, activities,
isolate a particular impairment via novel and non­ and participation. The various domains are inclu­
functional test items such as copying words and sive and consider the body itself as well as the indi­
designs, picture matching, block building, sequenc­ vidual and societal perspectives. The ICF embraces
ing pictures, free recall of words, memorizing and the relationship between the person and the context
attending to a number string, and so on. It has and in which daily living occurs and therefore includes
continues to become clear that interventions such as environmental factors as part of the classification
these need to be reconsidered if we as clinicians expect system. The ICF is a useful guide to rehabilitation,
Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 

particularly when considering assessments, interven­ • Participation: Involvement in life situations

tions, and outcomes for people living with cognitive • Participation restrictions: A negative aspect man­
and perceptual impairments.6,49 Elements of the clas­ ifested as an individual experiencing problems
sification system (Table 1-1) include the following68: in life situations
• Body structures: Anatomic parts of the body • Environmental factors: Physical, social, and atti­
(organs, limbs, and their components) tudinal environment in which people live and
• Body functions: Physiologic functions of the body conduct their lives; includes environmental as
systems inclusive of psychological functions well as personal factors
• Impairments: A negative aspect related to prob­ From an evaluation, intervention, and reha­
lems in body function or structure such as sig­ bilitation outcomes perspective, it is important to
nificant deviation or loss consider the relationships between the classifica­
• Activities: Execution of a task or action by an tion categories of the ICF rather than focusing on
individual one category at a time (Figure 1-1). For example,
• Activity limitation: A negative aspect mani­ “Mark” may survive a right frontoparietal stroke
fested as an individual’s difficulty in executing resulting in visuospatial impairments and unilat­
activities eral spatial neglect of the left side (impairment of

Table 1-1 Summary of the International Classification of Functioning, Disability, and Health
(ICF) Related to Cognitive and Perceptual Rehabilitation
Element Description/Examples

Body Structures
Structures of the nervous system Cortical lobes (frontal, temporal, parietal, occipital), midbrain, basal ganglia and
related structures, diencephalon, cerebellum, brainstem, cranial nerves

Body Functions
Mental functions Global mental functions: consciousness, energy and drive, orientation, intellectual
functions, psychosocial functions, temperament and personality, etc. Specific
mental functions: attention, memory, psychomotor functions, emotional
functions, language, perceptual functions (e.g., visuospatial, tactile perception),
thought, abstraction, organization/planning, sequencing of complex
movements, judgment, problem solving, body image, insight, calculations, etc.
Seeing functions Visual acuity, visual field, quality of vision, function of the muscles of the eye

Learning and applying knowledge Reading, writing
General tasks and demands Carrying out a daily routine, undertaking a single task, undertaking multiple
Self-care Washing, dressing, toileting
Mobility Changing body positions, handling objects, walking, driving, using
Communication Communication with spoken or nonverbal messages, speaking
Domestic life Household tasks, shopping, assisting others
Interpersonal relationships Social and family relationships
Major life areas Education, work and employment, volunteer work, economic life
Community, social, civic life Recreation, leisure, religion

Environmental Factors
Products and technology Aids for use in daily living, mobility, communication, employment, recreation,
education, design, and construction of buildings for private or public use
Support and relationships Family, friends, animals, health care professionals
Attitudes Personal, societal
Service, systems, and policies Housing, legal, civil protection

Data from World Health Organization: International Classification of Functioning, Disability and Health, Geneva, 2001, World Health Organization.
 cognitive and perceptual rehabilitation: Optimizing function

Health condition
(disorder or disease)

Body Functions Activity Participation

& Structure

Environmental Personal
Factors Factors
Contextual factors
Figure 1-1  Interaction between components of the International Classification of Functioning, Disability, and Health. (From World Health
Organization: International Classification of Functioning, Disability and Health, p. 18, Geneva, 2001, World Health Organization.)

Client-Centered Practice
body functions). These impairments may in turn
result in Mark’s inability to perform tasks such as Client-centered practice is an approach to providing
word processing, driving a car, balancing a check­ rehabilitation services,“which embraces a philosophy
book, or preparing a meal (activity limitations). The of respect for, and partnership with, people receiv­
resultant activity limitations may adversely affect ing services. Client-centered practice recognizes the
Mark’s ability to continue gainful employment or autonomy of individuals, the need for client choice
live on his own (participation restrictions). in making decisions about occupational needs,
the strengths clients bring to a therapy encounter,
the benefits of client-therapist ­partnership, and the
American Occupational Therapy
need to ensure that services are accessible and fit the
Association’s Practice Framework
context in which a client lives.”36
as a Framework for Choosing
Law and colleagues37 as well as Pollock,50 suggest
Assessments and Interventions,
that the therapist implementing this approach to
and Documenting Outcomes
evaluation include the following concepts:
The American Occupational Therapy Association 1. Recognizing that the recipients of therapy are
(AOTA) has published a framework for guiding uniquely qualified to make decisions about their
practice (Table 1-2).2 Components of the frame­ functioning
work include the following: 2. Offering the individual receiving services a
• Performance in areas of occupation: Occupations more active role in defining goals and desired
and daily life activities outcomes
• Client factors: Factors such as body structures 3. Making the client-therapist relationship an
and body functions that affect performance in ­interdependent one to enable the solution of
areas of occupation ­performance dysfunction
• Performance skills: Observable elements of action 4. Shifting to a model in which therapists work
that have implicit functional purposes with individuals to enable them to meet their
• Performance patterns: Patterns of behavior own goals
related to daily life activities 5. Evaluation (and intervention) focusing on the
• Context: Conditions within or surrounding the contexts in which individuals live, their roles and
client that affect and influence performance interests, and their culture
• Activity demands: Aspects of an activity required 6. Allowing the individual who is receiving services
to carry out the activity to be the “problem definer,” so that in turn the
The AOTA Practice Framework and the WHO’s individual will become the “problem solver”
ICF are interrelated despite the use of different ter­ 7. Allowing the client to evaluate his or her own
minology (Figure 1-2). performance and set personal goals
Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 

Table 1-2 Summary of the American Occupational Therapy Association (AOTA) Practice
Framework Related to Cognitive and Perceptual Rehabilitation
Domain Examples

Performance in areas of occupation Basic/personal activities of daily living, instrumental activities of daily living,
education, work, play, leisure, social participation
Client factors Mental Functions: consciousness, energy and drive, orientation, intellectual
functions, psychosocial functions, personality, attention, memory,
psychomotor, language, perceptual functions (e.g., visuospatial), thought,
abstraction, organization, planning, judgment, problem solving, insight,
calculations, motor planning, etc.
Performance skills Process skills: energy, knowledge, temporal organization, organizing space and
objects, adaptation
Motor skills: posture, mobility, coordination, strength and effort, energy
Communication/interaction skills: physicality, information exchange, relations
Performance patterns Habits, routines, roles
Context Cultural, physical, social, personal, spiritual, temporal, virtual
Activity demands Objects and their properties, space demands, social demands, sequence and
timing, required actions, required body functions and structures

Data from American Occupational Therapy Association: Occupational therapy practice framework: domain and process, Am J Occup Ther 56:609-639, 2002.

Practice Framework ICF

Client Factors Body Structures & Body Functions

Performance in Areas of Occupation Activities


Context Environmental Factors

Figure 1-2  Relationships between the American Occupational Therapy Association (AOTA) Practice Framework and the World Health
Organization’s International Classification of Functioning, Disability, and Health (ICF).

Through the use of these strategies the evaluation ­cannot be judged to be effective or ineffective. Moreover,
process becomes more focused and defined, ­clients the quality and type of goal setting sets the tone of the
become immediately empowered, the goals of ther­ interaction between the clinician or treating team and
apy are understood and agreed on, and an individ­ the patient. Goals that are proposed, suggested, or iden­
tified by the clinician tend to be those based on what
ually tailored intervention plan may be ­established.
the clinician believes the patient needs. Of equal, if not
The Canadian Occupational Performance Measure36
more importance, however, is what the patient wants to
is a standardized tool that embraces a client-centered achieve. Patients tend to be motivated toward achieving
approach and is discussed later. or satisfying their wants, and may not be so motivated
van den Broek56 specifically recommends using or quite unmotivated toward achieving other goals. The
a client-centered approach as a way to enhance process of goal setting therefore involves arriving at an
neurorehabilitation outcomes and states that overlap between needs and wants, or where this is not
treatment failure may be secondary to clinicians possible agreeing to work toward wants that represent
focusing interventions on what they believe the a reasonable compromise. Goal setting that ends with
client needs rather than what the client actually treatment goals that consist of needs that the patient does
wants. van den Broek56 affirms that client-centered not want or is indifferent toward is not client centered
but prescriptive, and runs the risk of concluding in an
goal setting is a key to successful ­ rehabilitation
­ineffective outcome.”
­outcomes, stating:
“Goal setting is of central concern as without goals, Another argument for using a client-centered
rehabilitation has no direction and the ­ intervention approach to guide the intervention focus with this
 cognitive and perceptual rehabilitation: Optimizing function

population is that interventions typically used for related to getting her son to school (choosing his
those living with cognitive-perceptual dysfunction clothing, making lunch, etc.). As the sole financial
are notoriously difficult to generalize to other real- provider, Mary spent the greater part of the rest of
world settings and situations. For example, visual the day in her home office working on the com­
scanning training via tabletop activities for those liv­ puter, fielding phone calls, and organizing pres­
ing with unilateral spatial neglect most often will not ent or upcoming jobs. Lunch was usually a quick
automatically generalize to the client’s being able to cold sandwich. Mary stopped working at 3:30 when
use the scanning strategy to find items in the refrig­ her son arrived home from school. Depending on
erator unless the strategy is specifically taught in the the day she would drive her son to Little League or
context of the activity. In addition, strategies that are drum lessons. Mary always cooked a full dinner and
taught to accomplish a specific task (e.g., using an spent the rest of the evening helping with home­
alarm watch to maintain a medication schedule for work and watching television. Mary’s memory
those living with memory loss) will not necessar­ impairments are preventing her from continuing
ily generalize or “carry over” to another task such as to work. For safety reasons, her mother has moved
remembering therapy appointments. Finally, there in to help with childcare, household organization,
are a large number of clients whose level of brain and financial matters. Mary has recently expressed
damage preclude them from generalizing learned feelings of low self-esteem, saying that “she can’t
tasks.48 This issue of task-specificity related to treat­ do anything by herself anymore.” Mary has stated
ment interventions must always be considered by that she is most concerned about starting to work
clinicians working with this population. A client- (finances are limited) and she would like to take a
centered approach will help ensure that outcomes, more active parenting role again. Prior to initiating
goals, and tasks used as the focus of therapy are at interventions, Mary participated in three assess­
least relevant, meaningful, and specific to each client ments including standardized measures of memory
as well as the caretaker or significant others despite the impairment, instrumental activities of daily living
potential lack of being generalizable for a segment (IADL) (e.g., homemaking and child care), and
of the population living with various cognitive and quality of life (QOL).
­perceptual impairments. Possible (noninclusive) outcomes for Mary
based on the ICF68 may include the following:
• Outcome 1: Following cognitive reha­
What Are Appropriate Outcomes
bilitation, Mary has improved her scores
When Designing Interventions
on a standardized memory scale (decreased
for People Living with Cognitive
impairment) but changes are not detected on
and Perceptual Impairments?
measures of IADL and QOL (stable activity
Although not as a problematic as the recent past, the limitations/participation restrictions).
practice area of cognitive and perceptual rehabili­ • Outcome 2: Following cognitive rehabili­
tation has been plagued by a lack of well-designed tation, Mary has no detectable changes on the
clinical trials demonstrating positive outcomes. standardized memory scale (stable impair­
A starting point is to decide what is considered ment) but changes are detected on mea­
an appropriate, meaningful, and ideal outcome to sures of IADL and QOL (decreased activity
measure. This decision will help guide interventions ­limitations/participation restrictions).
as well. The preceding paragraphs have already dis­ • Outcome 3: Following cognitive rehabili­
cussed the importance of keeping a client-centered tation, Mary has detectable changes on
focus during the rehabilitation process. A client- the standardized memory scale (decreased
centered focus is paramount when considering out­ impairment) as well as changes that are
comes as well. The following case illustrates various detected on measures of IADL and QOL
possible outcomes: (decreased ­ activity limitations/­participation
Mary is a 32-year-old woman who survived an restrictions).
anoxic event that has resulted in moderate/severe Out of the three outcome scenarios, outcome 1 is
short term memory impairments. Mary is a sin­ the least desirable. In the past this type of outcome
gle mother of a 5-year-old boy. She works from may have been considered successful (i.e., “Mary’s
home (desktop publishing). Mary’s days were quite memory has improved”). This outcome may be
­structured before her brain injury. Mornings were indicative of an intervention plan that is over­
characterized by basic self-care followed by tasks focused on attempts to remediate memory skills
Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 

(e.g., memory drills, computerized ­ memory pro­ changes in these measures are more relevant than
grams) without consideration of generalization an isolated change on an impairment measure—
to real-life scenarios. If a change at the impair­ the impairment change must be associated with a
ment level of function does translate or general­ change in other health domains. Individuals receiv­
ize to improved ability to engage in meaningful ing ­services, family members, and third-party pay­
activities, participate successfully in life roles, or ers alike are likely to be more satisfied with changes
enhance quality of life, the importance of the at these arguably more meaningful levels of func­
intervention needs to be reconsidered. Outcomes tion. The following standardized, valid, and reli­
2 and 3 are more clinically relevant, arguably more able measurement instruments are suggested to
meaningful to Mary and her family, and repre­ document successful clinical and research out­
sent more optimal results of structured rehabilita­ comes related to improving function in those with
tion services. Outcome 2 may have been achieved functional limitations secondary to the presence of
by focusing interventions on Mary’s chosen tasks. cognitive and perceptual impairments.
Interventions such as teaching compensatory strat­ For a thorough review of performance-based
egies including the use of assistive technology may measures, refer to Law and associates.39 Unless oth­
have been responsible for this outcome. Mary is erwise indicated, they are not impairment-specific
able to engage in chosen tasks despite the presence evaluations; therefore, they have high use when
of stable memory impairments. working with this population.
Finally, outcome 3 represents improvement
(decreased impairment, improved activity perfor­
Quality of Life Measures
mance, and improved quality of life) across mul­
tiple health domains. Although this outcome may The construct of quality of life is broad and com­
be considered the most optimal, the relationships plicated. In her paper “What Is Quality of Life?”
among the three measures are not clear. Clinicians Donald17 summarizes several issues related to qual­
may assume that the improved status detected by ity of life:
the standardized measure of memory was also • “Quality of life is a descriptive term that refers
responsible for Mary’s improved ability to per­ to people’s emotional, social and physical well-
form household chores and childcare. This reason­ being, and their ability to function in the ordi­
ing is not necessarily accurate. The changes within nary tasks of living.
the health domains may in fact be independent of • Health-related quality of life analyses measure
each other. In other words, Mary’s improved abil­ the impact of treatments and disease processes
ity to manage her household after participating in on these holistic aspects of a person’s life.
treatment may be related to the fact that interven­ • Quality of life is measured using specially
tions included specifically teaching Mary strate­ designed and tested instruments, which measure
gies to manage her household. Similar to outcome people’s ability to function in the ordinary tasks
2, this positive change may have occurred with or of living.
without a documented improvement in memory • Quality of life analyses are particularly helpful
skills. for investigating the social, emotional, and physi­
Traditionally clinicians and researchers involved cal effects of treatments and disease processes on
in working with those living with cognitive and per­ people’s daily lives; analyzing the effects of treat­
ceptual impairments use standardized measures of ment or disease from the client’s perspective;
cognitive-perceptual impairment (i.e., standardized and determining the need for social, ­emotional,
tests of attention, memory, apraxia, neglect) as the and physical support during illness.
primary outcome measure to document effective­ • Quality of life measures can therefore help to
ness of interventions. Although this is one impor­ decide between different treatments, to inform
tant level of measurement and following chapters clients about the likely effects of treatments, to
will review specific cognitive-perceptual measures monitor the success of treatments from the cli­
in detail, it is not sufficient to use these measures ent’s perspective, and to plan and coordinate
as the sole or important indicator of successful care packages.”
interventions. It is critical that clinical programs Clinicians and researchers should consider
and research protocols not only include but also improving quality of life as an overarching theme
focus on measures of activity, participation, and related to rehabilitation in general. Specific assess­
quality of life as a key outcome. As stated, positive ments are reviewed below.
 cognitive and perceptual rehabilitation: Optimizing function

Medical Outcomes Study Short Form-36 Reintegration to Normal Living

The Medical Outcomes Study Short Form-36 (SF- The Reintegration to Normal Living (RNL)66,67
36)59 is a widely used survey instrument for assess­ assessment is used to document reentry into every­
ing a client’s health-related quality of life. The SF-36 day life following a sudden illness or event. This
measures eight domains: physical functioning, role functional status measure quantitatively assesses the
physical, bodily pain, general health, vitality, social degree of reintegration to normal living achieved
functioning, role emotional, and mental health, by clients after illness or trauma and is useful. This
and has two summary scores (physical and men­ tool assesses global function and the individual’s
tal). The SF-36 has demonstrated its reliability and satisfaction with basic self-care, in-home mobility,
validity in multiple populations and can be admin­ leisure activities, travel, and productive pursuits.
istered in various ways. The SF-1258 and SF-2060 are Clients are provided with 11 statements to which
abbreviated versions of the SF-36 health profile. they respond. The test can be completed using a
pen-and-paper format or an interview format.
Sickness Impact Profile
The Sickness Impact Profile (SIP)11 is used to evalu­ Satisfaction with Life Scale
ate the effect of disease on physical and emotional The Satisfaction with Life Scale (SWLS)16 is a 5-
functioning. The measure includes two overall item scale that uses a 7-point Likert scale response
domains: physical and psychosocial. The measure format. Individual scores are added to create a total
has 12 categories including sleep and rest, eating, score ranging from 5 to 35. A score of 20 represents
work, home management, recreation and pastimes, a neutral point at which the respondent is equally
ambulation, mobility, body care and movement, satisfied and dissatisfied. The items in the SWLS are
social interaction, alertness behavior, emotional limited to general life satisfaction.
behavior, and communication. The instrument
yields an overall score, 2 domain scores, and 12
Activity and Participation Measures
category scores; items are weighted according to a
standardized weighting scheme. A stroke-specific Outcomes related to cognitive perceptual rehabilita­
version (Stroke Adapted Sickness Impact Profile) is tion must be detectable and evidenced by decreasing
available.57 activity limitations and participation restrictions. Out­
comes are individualized and based on the activities
Nottingham Health Profile (basic activities of daily living [ADL], IADL, paid
The Nottingham Health Profile (NHP)27,28 was and unpaid work, and play and leisure) that clients
developed to be used in epidemiologic studies of want to be able to do or need to do to live a safe and
health and disease and consists of two parts. Part productive life. Measurement instruments that focus
1 contains 38 yes/no items in six dimensions: pain, on the activity and participation levels are critical to
physical mobility, emotional reactions, energy, document the effectiveness of cognitive-perceptual
social isolation, and sleep. Part 2 contains 7 gen­ rehabilitation interventions. Examples follow.
eral yes/no questions concerning daily living prob­
lems including paid employment, jobs around the Community Integration Questionnaire
house, personal relationships, social life, sex life, The Community Integration Questionnaire (CIQ)62-64
hobbies, and holidays. The two parts may be used consists of 15 items relevant to home integration, social
independently. integration, and productive activities. It is scored to
provide subtotals for each of these, as well as for com­
Stroke Impact Scale munity integration overall. Scoring is primarily based
The Stroke Impact Scale (SIS)19,33 is a stroke-specific on frequency of performing activities or roles, with
measure that provides information on function and secondary weight given to whether activities are done
quality of life. This self report measure including 59 jointly with others, and the nature of these other per­
items that form eight subgroups including strength, sons. The CIQ can be completed, by either the client or
hand function, basic and instrumental activities of a proxy, in about 15 minutes.
daily living, mobility, communication, emotion,
memory and thinking, and participation. The SIS Craig Handicap Assessment and
is valid, reliable, and sensitive to change in stroke Reporting Technique
populations and is reliable when responses are The Craig Handicap Assessment and Reporting
­provided by proxy. Technique (CHART)61 measures the degree to
Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 

which impairments and activity limitations result in In ­addition, an adolescent as well as child version is
decreased participation. The original CHART had in development.25
27 questions and included the following domains:
(1) physical independence: ability to sustain a Canadian Occupational Performance Measure
customarily effective independent existence; (2) The Canadian Occupational Performance Measure
mobility: ability to move about effectively in one’s (COPM)12,36 is a self-report measure used to assess
surroundings; (3) occupation: ability to occupy a client’s perception of recovery and goals. This
time in the manner customary to that person’s sex, client-centered assessment allows the recipient of
age, and culture; (4) social integration: ability to treatment (or a caretaker) to identify activities that
participate in and maintain customary social rela­ are difficult, rate the importance of each activity,
tionships; and (5) economic self-sufficiency: ability rate own level of performance for each identified
to sustain customary socioeconomic activity and activity, and rate satisfaction with current perfor­
independence. mance. Overall areas of assessment include self-care,
The revised CHART46 (32 questions) contains a leisure, and productivity. The tool is not diagnosis
sixth domain designed to assess orientation: cog­ specific and can be used with children, adolescents,
nitive independence. Each of the domains or sub­ and adults. To be used with success, the client must
scales of the CHART has a maximum score of 100 be able to understand a 10-point Likert scale scor­
points. High subscale scores indicate less handicap, ing format. If this is not possible, a caregiver may be
or higher social and community participation. The involved in the assessment process (Figure 1-3).
CHART can be administered by interview, either in
person or by telephone, and takes approximately Barthel Index
15 minutes to administer. Participant-proxy agree­ The Barthel Index (BI)44 is a measure of basic activ­
ment across disability groups on the CHART has ities of daily living and mobility. It is scored from
provided evidence in support of the use of proxy 0 to 100, with higher scores indicative of increased
data for people with various types of disabilities. function. The specific items measured include feed­
A shorter version of the instrument, the CHART ing, bathing, grooming, dressing, bowel control,
Short Form, has 19 items that yield the same bladder control, toilet use, transfers, mobility on
­subscales as the original CHART. even surfaces, and stairs.

Activity Card Sort Functional Independence Measure

The Activity Card Sort (ACS)9,30 uses a Q-sort The Functional Independence Measure (FIM)31
methodology to assess participation in 80 instru­ is a widely accepted functional assessment mea­
mental, social, and high and low physical demand sure used during inpatient rehabilitation. The FIM
leisure activities. Clients sort the cards into different is an 18-item ordinal scale, used with all diagno­
piles to identify activities that were done prior to ses within a rehabilitation population. FIM scores
insult or injury, those activities they are doing less, range from 1 to 7 (1 = total assist and 7 = com­
and those they have given up since their injury. The plete independence). Scores falling below 6 require
ACS uses cards with pictures of tasks that people do another person for supervision or assistance. The
every day. There are different versions of the card FIM measures independent performance in self-
sort based on where interventions are taking place. care, sphincter control, transfers, locomotion, com­
An institutional version sorts the cards into cate­ munication, and social cognition. By adding the
gories of done prior to illness and not done. The points for each item, the possible total score ranges
recovering version identifies activities not done in from 18 (lowest) to 126 (highest) level of inde­
the past 5 years, those given up because of illness, pendence. During rehabilitation, admission and
those beginning to do again, and those activities the discharge scores are rated by a multidisciplinary
client is doing now.25 team while observing client function. Functioning
In all versions, a current activity level is deter­ postdischarge can be accurately assessed using a
mined. This assessment takes approximately 30 telephone version of FIM when administered by
minutes to administer and results in a score of qualified interviewers.
percent of activities retained. The ACS has been
found to be a reliable and valid measure with indi­ Revised Observed Tasks of Daily Living
viduals with cognitive loss9 as well as stroke30 and The Revised Observed Tasks of Daily Living
is available in several culture-specific formats. (OTDL-R)15 is a performance-based test of ­everyday
10 cognitive and perceptual rehabilitation: Optimizing function


Personal Care
(e.g., dressing, bathing,
feeding, hygiene)

Functional Mobility
(e.g., transfers,
indoor, outdoor)

Community Management
(e.g., transportation,
shopping, finances)

STEP 1B: Productivity

Paid/Unpaid Work
(e.g., finding/keeping
a job, volunteering)

Household Management
(e.g., cleaning, doing
laundry, cooking)

(e.g., play skills,

STEP 1C: Leisure

Quiet Recreation
(e.g., hobbies,
crafts, reading)

Active Recreation
(e.g., sports,
outings, travel)

(e.g., visiting, phone calls,
parties, correspondence)

Figure 1-3  Canadian Occupational Performance Measure (identifying occupations and rating importance). (From Park S: Enhancing
engagement in instrumental activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach,
ed 2, St Louis, 2004, Elsevier/Mosby.)

problem solving and competence. The test was administered in bed. The tool has been used with
designed with a focus on cognitive IADL. The test community-dwelling older adults, older adults liv­
includes nine tasks in the categories of medication ing in nursing homes or assisted living facilities,
use, telephone use, and financial management. The individuals with schizophrenia, and individuals
test does not require special equipment and can be with brain injuries.24
Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 11

Lawton Instrumental Activities of Daily Living Scale a three-point scale: independent, assistance needed,
The Lawton Instrumental Activities of Daily Living or dependent. Client self-report and informant (i.e.,
Scale40 includes the following items: use of the tele­ clinician or family member) versions are available.
phone (look up numbers, dial, answer), traveling Table 1-3 gives more choices of standardized IADL
via car or public transportation, food or clothes assessments.
shopping (regardless of transport), meal prepara­
tion, housework, medication use (preparing and Nottingham Leisure Questionnaire
taking correct dose), management of money (write The Nottingham Leisure Questionnaire18 was
checks, pays bills). Each criterion is graded on ­ developed to measure the leisure activity of stroke

Table 1-3 Instrumental Activities of Daily Living Standardized Assessments

of Daily Adelaide Nottingham
Living (ADL) Activities Frenchay Extended ADL Instrumental
Assessment Profile Activities Index Scale Activity Measure

Authors Whiting and Bond and Clark Holbrook and Nouri and Lincoln Grimby et al
Lincoln (1980) (1998) Skillbeck (1983) (1987) (1996)
Rating scale 3-level 4-level 4-level 4-level 7-level
Focus Degree of Degree of Degree of Degree of Degree of
assistance in participation in participation in difficulty and assistance in
performance activities activities assistance performance
activities engaging in activities
Format Observation Interview Interview Self-report Observation
Country of origin United Kingdom Australia United Kingdom United Kingdom Sweden

Assessment Items
Meal preparation Prepare a meal Prepare main Prepare main Make a hot drink Cook a main
Prepare a hot drink meal meal Make a hot snack meal
Prepare a snack Wash dishes Wash dishes Wash dishes Prepare a simple
Take hot drinks meal
between rooms
Domestic activities Heavy cleaning Heavy housework Heavy housework Housework Cleaning house
Light cleaning Light housework Light housework Wash small Washing clothes
Hand wash clothes Wash clothes Wash clothes clothing items
Iron clothes Household or car Household Full clothes wash
Hang out washing maintenance or car
Make bed maintenance
Gardening — Light gardening Gardening Manage own —
Heavy gardening garden
Productive — Voluntary or paid Gainful work — —
activities employment
Shopping/ Carry shopping Household Local shopping Shopping Large-scale
community Cope with money shopping Manage own shopping
activities Personal money Small-scale
shopping shopping
Transportation Use public Drive a car or Drive car or go Travel on public Use public
transport—bus organize on bus transport transportation
Transport self to transport Travel outings or Drive a car
shop car rides

12 cognitive and perceptual rehabilitation: Optimizing function

Table 1-3 Instrumental Activities of Daily Living Standardized Assessments­—Cont’d

of Daily Adelaide Nottingham
Living (ADL) Activities Frenchay Extended ADL Instrumental
Assessment Profile Activities Index Scale Activity Measure

Leisure/social — Community social Social occasions Go out socially —

activities activities Hobby Use the telephone
Outdoor social Reading books Read newspapers
activity or books
Invite guests to Write letters
Telephone calls to
Attend religious
recreation or
sporting activity
Mobility: outdoors Outdoor mobility Walk outdoors Walking outside Walk outside Locomotion
Crossing roads Cross roads outdoors
Get in and out Get in and out
of car of car
Walk on uneven
Mobility: indoors Indoor mobility — — Climb stairs —
Mobility to lavatory
Move bed to chair
Move floor to chair
Basic self-care Drink — — Feed self —
Clean teeth
Comb hair
Wash face and
Put on makeup or
Wash in bath, get in
and out of bath
Overall wash

Studies cited: Whiting S, Lincoln NB: An ADL assessment for stroke patients, Br J Occup Ther 43:44, 1980; Bond MJ, Clark MS: Clinical applications of
the Adelaide activities profile, Clin Rehabil 12(3):228-237, 1998; Holbrook M, Skillbeck CE: An activities index for use with stroke patients, Age Ageing
12(2):166-170, 1983; Nouri FM, Lincoln NB: An extended activities of daily living scale for stroke patients, Clin Rehabil 4:123, 1987; and Grimby G, Andren
E, Holmgren E, et al: Structure of a combination of functional independence measure and instrumental activity measure items in community-living persons:
a study of individuals with cerebral palsy and spina bifida, Arch Phys Med Rehabil 77(11):1109-1114, 1996. From Park S: Enhancing engagement in instru-
mental activities of daily living: an occupational therapy perspective. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach,
ed 2, St Louis, 2004, Elsevier.

c­ lients. The results for the interrater reliability study collapsed (five to three categories) in order to make
were “excellent” and “excellent” or “good” for the it suitable for mail use.
test retest reliability study. They suggested that the
tool has potential for clinical use. More recently the Leisure Competence Measure
Nottingham Leisure Questionnaire has been short­ The Leisure Competence Measure32 provides infor­
ened (37 to 30 items) and the response categories mation about leisure functioning as well as ­measure
Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 13

change in leisure function over time. The tool therapist to detect impairments that interfere with
includes nine areas: social contact, community par­ task performance to understand factors underlying
ticipation, leisure awareness, leisure attitude, social activity limitations. It is used with clients who are
behaviors, cultural behaviors, leisure skills, inter­ 16 years and older and are living with functional
personal kills, and community integration skills. limitations secondary to central nervous system
Items are rated on a seven-point Likert scale. dysfunction such as stroke, traumatic brain injury,
dementia, and multiple sclerosis.
Leisure Diagnostic Battery The A-ONE aids the therapist in analyzing the
The original version of the Leisure Diagnostic nature or cause of a functional problem requiring
Battery65 includes 95 items, whereas the newer intervention. Subsequently, therapists can speculate
shorter version includes 25 items.13 Items are scaled about the best intervention for activity limitation
on three-point scale. Assessment areas include play­ and impairments. The A-ONE is a performance-
fulness, competence, barriers, knowledge, and so on. based tool that uses structured observations of
upper and lower body dressing, grooming, hygiene,
feeding, transfers, mobility and communication to
Measures That Simultaneously Assess
detect the underlying impairments that interfere
Activity/Participation and Underlying
with function (Box 1-1).
Impairments or Subskills
Impairments detected during the observation
There is a short list of available assessments that are of these tasks include motor apraxia, ideational
highly recommended because they are unique in apraxia, unilateral body neglect, somatoagnosia,
their ability to simultaneously assess more than one spatial relations, unilateral spatial neglect, impaired
level of function such as activity limitations and the motor control, perseveration, and organization and
impairments responsible for the limitations. These sequencing. In addition pervasive impairments such
assessments provide clinicians with critical and as agnosias, memory loss, disorientation, confabu­
substantial information via skilled observation of lation, and affective disturbances can be detected
functional tasks. throughout the observations. Figure 1-4 shows an
example of the dressing domain of the A-ONE. Note
Árnadóttir OT-ADL Neurobehavioral Evaluation that the instrument includes two scales; the Indepen­
The Árnadóttir OT-ADL Neurobehavioral Evalua­ dence Score ­ measures each activity in terms of
tion (A-ONE)3–5,22 is an instrument that allows the functional independence, and the Neurobehavioral

Box 1-1 Items Included on the Árnadóttir OT-ADL Neurobehavioral Evaluation (A-ONE)
The A-ONE uses standardized and structured observations • Unilateral body neglect
as the method of assessment during the following daily • Somatoagnosia
­living skills: • Spatial relations dysfunction
• Feeding • Unilateral spatial neglect
• Grooming and hygiene (upper body washing, oral/hair • Perseveration
care, shaving, etc.) • Organization and sequencing dysfunction
• Dressing (upper and lower body) • Topographic disorientation
• Transfers and mobility (bed mobility, transfers, • Motor control impairments
maneuvering in a wheelchair or during ambulation) In addition, the following pervasive impairments can be
• Functional communication (comprehension and detected and objectified:
expression) • Agnosias (visual object, associative visual object,
Using standardized procedures and uniform conceptual visuospatial)
and operational definitions as guidelines the following spe- • Anosognosia
cific impairments are evaluated in the context of functional • Body scheme disturbances
skills: • Emotional/affective disturbances
• Ideational apraxia • Impaired attention and alertness
• Motor apraxia • Memory loss

Data from Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby; Árnadóttir G: Impact
of neurobehavioral deficits of activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach, ed 2, St Louis,
2004, Elsevier/Mosby; and Árnadóttir G: Rasch analysis of the ADL scale of the A-ONE, Am J Occup Ther (in press).
14 cognitive and perceptual rehabilitation: Optimizing function

Functional Independence Scale and

Neurobehavioral Specific Impairment Subscale

Ms. Wilson 6/13/03

Date _________________________

Independence Score (IP): Neurobehavioral Score (NB):

4 = Independent and able to transfer activity to 0 = No neurobehavioral impairments observed.
other environmental situations. 1 = Able to perform without additional
3 = Independent with supervision. information, but some neurobehavioral impairment
2 = Needs verbal assistance. is observed.
1 = Needs demonstration or physical assistance. 2 = Able to perform with additional verbal assistance, but
0 = Unable to perform. Totally dependent on assistance. neurobehavioral impairment can be
observed during performance.
3 = Able to perform with demonstration or
minimal to considerable physical assistance.
4 = Unable to perform due to neurobehavioral impairment.
Needs maximum physical assistance.

List helping aids used:

•Nonslip for soap and plate
•Adapted toothbrush
•Velcro fastening on shoes



Shirt (or Dress) 4 3 2 1 0 Include one armhole, fix shoulder

Pants 4 3 2 1 0 Find correct leghole
Socks 4 3 2 1 0 One-handed technique, balance
Shoes 4 3 2 1 0 Balance
Fastenings 4 3 2 1 0 Match buttonholes, Velcro through loop


Motor Apraxia 0 1 2 3 4
Ideational Apraxia 0 1 2 3 4
Unilateral Body Neglect 0 1 2 3 4 Leaves out left body side
Somatoagnosia 0 1 2 3 4
Spatial Relations 0 1 2 3 4 Finding correct holes, front/back
Unilateral Spatial Neglect 0 1 2 3 4 Leaves out items in left visual field
Abnormal Tone: Right 0 1 2 3 4
Abnormal Tone: Left 0 1 2 3 4 Sitting balance/bilateral manipulation
Perseveration 0 1 2 3 4
Organization/Sequencing 0 1 2 3 4 For activity steps

Note: All definitions and scoring criteria for each deficit are in the Evaluation Manual.
Figure 1-4  Example of the dressing domain and summary of findings from the Árnadóttir OT-ADL Neurobehavioral Evaluation (A-ONE)
for a client with a right cerebrovascular accident (CVA). (From Árnadóttir G: Impact of neurobehavioral deficits on activities of daily living.
In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach, ed 2, St Louis, 2004, Elsevier.)
Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 15

Score ­measures the individual impairments that are basic and IADL with an emphasis placed on
affecting function. In this example Ms. Wilson has IADL tasks. The AMPS is not diagnosis specific.
sustained a right cerebrovascular accident (CVA); It is appropriate for clients who are 3 years old
unilateral body neglect, spatial relations impair­ and up and who are experiencing functional limi­
ment, unilateral spatial neglect, organization and tations. The AMPS entails the client choosing to
sequencing problems, and left hemiplegia inter­ perform two or three tasks in collaboration with
fere with the dressing performance as indicated by a therapist from a list of more than 80 standard­
scores on the Neurobehavioral Specific Impairment ized tasks.
Subscale of the A-ONE. To be administered reliably, In addition, although it does not detect the
the A-ONE requires a training course. client’s underlying impairments it does evaluate
motor and processing skills that affect function.
Assessment of Motor and Process Skills Motor skills are observable actions a person uses
The Assessment of Motor and Process Skills (AMPS)21 to move the body or objects during all ADL task
is a client-centered performance assessment of both performance. Process skills are observable actions

Árnadóttir OT-ADL
Neurobehavioral Evaluation
Ms. Wilson
Name _____________________________________________ 6–13–03
Date ________________________________________
Birthdate __________________________________________ 60
Age _________________________________________
Gender ____________________________________________ Caucasian
Ethnicity _____________________________________
Dominance ________________________________________ Dressmaker
Profession ___________________________________

Medical Diagnosis:
Right CVA 6/20/03. Ischemia.


Social Situation:
Lives alone in an apartment building on third floor
Has two adult daughters

Summary of Independence:
Needs physical assistance with dressing, grooming, hygiene, transfer, and mobility tasks
because of left-sided paralysis and perceptual and cognitive impairments. Is more or less
able to feed herself if meals have been prepared. No problems with personal communication,
although perceptual impairments will affect reading and writing skills. Also has lack of
judgment and memory impairment, which affect task performance. Is not able to live alone at
this stage. If personal home support becomes available, will need a home evaluation because
of physical limitation and wheelchair use. Needs recommendations regarding removal of
architectural barriers or suggestions for alternative housing. Unable to return to previous
job as a dressmaker.


Dressing 1,1,1,1,1= 5/20
Grooming and Hygiene 1,2,1,1,3,0= 8/24
Transfer and Mobility 1,1,1,1,1= 5/20
Feeding 4,4,4,3= 15/16
Communication 4,4= 8/8

Figure 1-4—Cont’d
16 cognitive and perceptual rehabilitation: Optimizing function



Motor Apraxia Astereognosis Restlessness
Ideational Apraxia Visual Object Agnosia Concrete Thinking
Unilateral Body Neglect Visual Spatial Agnosia Decreased Insight
Somatoagnosia Associative Visual Agnosia Impaired Judgment
Spatial Relations Anosognosia Confusion
Unilateral Spatial Neglect R/L Discrimination Impaired Alertness
Abnormal Tone: Right Short-Term Memory Impaired Attention
Abnormal Tone: Left Long-Term Memory Distractibility
Perseveration Disorientation Impaired Initiative
Organization Confabulation Impaired Motivation
Topographic Disorientation Lability Performance Latency
Other Euphoria Absent Mindedness
Sensory Aphasia Apathy Other
Jargon Aphasia Depression Field Dependency
Anomia Aggressiveness
Paraphasia Irritability
Expressive Aphasia Frustration

Use ( ) for presence of specific impairments in different ADL domains (D = dressing, G = grooming, T =transfers, F = feeding,
C = communication) and for presence of pervasive impairments detected during the ADL evaluation.

Summary of Neurobehavioral Impairments:

Needs physical assistance for most dressing, grooming, hygiene, transfer, and mobility tasks
because of left-sided paralysis, spatial relations impairments (e.g., problems dif-
ferentiating back from front of clothes and finding armholes and legholes), and unilateral
body neglect (i.e., does not wash or dress affected side)finding. Does not attend to objects in
the left visual field and needs verbal cues for performance. Also needs verbal cues for
organizing activity steps. Does not know her way around the hospital. Does not have insight
into how the CVA affects her ADL and is thus unrealistic in day-to-day planning. Has
impaired judgment resulting in unsafe transfer attempts. Leaves the water running after
hygiene and grooming activities if not reminded to turn it off. Is emotionally labile and
appears depressed at times. Is not oriented regarding time and date. Presents with impaired
attention, distraction, and defective short-term memory requiring repeated verbal instruc-
Treatment Considerations:

Occupational Therapist:

A-ONE Certification Number:

Figure 1-4—Cont’d

a person uses to (1) select, interact with, and use figure-ground skills, problem solving, intact visual
tools and materials, (2) carry out ­individual actions fields, and so on. The AMPS detects the behavioral
and steps, and (3) modify performance when prob­ output of these subskills. Following the skilled obser­
lems are encountered. Process skills should not be vation of each ADL task, the client is rated on 16
confused with cognitive or ­perceptual skills. motor and 20 process skill items for each task per­
For example, one process skill included on the formed using a four-point Likert scale. Once the
AMPS is the ability “search and locate.” Searching for items are scored for each task, the results are entered
and locating necessary items to perform a task relies in the AMPS computer scoring program. The pro­
on multiple underlying skills such as visual ­attention, gram generates a summary report (Figure 1-5, A).
Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 17

In addition, the computer analysis of the motor and within 60 minutes. A study42 found that the AMPS
process skill scores results in ADL motor ability and may give a better indication of the client’s ability
ADL process ability measures. The measures repre­ to resume independent living than neuropsycho­
sent the placement of the person on a continuum of logical testing alone. The occupational therapy
motor or process ability (Figure 1-5, B). practitioner who uses the AMPS must attend a
The AMPS requires no specialized equipment 5-day AMPS training course to become certified
and can be conducted in any ADL-relevant setting in its use.


Caution: Item and total raw scores are not valid representations of client performance, and they cannot be used for
documentation or statistical analyses. Raw scores must be analyzed using the AMPS computer-scoring software to
create ADL ability measures. Only ADL ability measures are valid for measuring change.

Client: John S Evaluation date: 01/10/2005

ID: 1111JS Occupational therapist: Kim A

Task 1: A-3: Pot of boiled/brewed coffee or tea (Average)

Task 2: F-2: Luncheon meat or cheese sandwich (Average)

Overall performance in each skill area is summarized below using the following scale:
A = Adequate skill, no apparent disruption was observed
I = Ineffective skill, moderate disruption was observed
MD = Markedly deficient skill, observed problems were severe enough to be unsafe or to require therapist

MOTOR SKILLS: Skills observed when client moved self and objects A I MD
during task performance

Body Position
STABILIZES: does not lose balance when interacting with task objects X
ALIGNS: does not persistently support oneself during task performance X
POSITIONS the arm or body effectively in relation to task objects X
Obtaining and Holding Objects
REACHES effectively for task objects X
BENDS or twists the body appropriate to the task X
GRIPS: securely grasps task objects X
MANIPULATES task objects as needed for task performance X
COORDINATES two body parts to securely stabilize task objects X
Moving Self and Objects
MOVES: effectively pushes/pulls task objects and opens/closes doors or drawers X
LIFTS task objects effectively X
WALKS effectively about the task environment X
TRANSPORTS task objects effectively from one place to another X
CALIBRATES the force and speed of task-related actions X
FLOWS: uses smooth arm and hand movements when interacting with task objects X
Sustaining Performance
ENDURES for the duration of the task performance X
PACES: maintains an effective rate of task performance X

Figure 1-5  A, Assessment of Motor and Process Skills (AMPS) summary.

18 cognitive and perceptual rehabilitation: Optimizing function


Caution: Item and total raw scores are not valid representations of client performance, and they cannot be used for
documentation or statistical analyses. Raw scores must be analyzed using the AMPS computer-scoring software to
create ADL ability measures. Only ADL ability measures are valid for measuring change.

Client: John S Evaluation date: 01/10/2005

ID: 1111JS Occupational therapist: Kim A

Task 1: A-3: Pot of boiled/brewed coffee or tea (Average)

Task 2: F-2: Luncheon meat or cheese sandwich (Average)

Overall performance in each skill area is summarized below using the following scale:
A = Adequate skill, no apparent disruption was observed
I = Ineffective skill, moderate disruption was observed
MD = Markedly deficient skill, observed problems were severe enough to be unsafe or to require therapist

PROCESS SKILLS: Skills observed when client (a) selected, interacted A I MD

with, and used task tools and materials; and (b)
modified task actions, when needed, to complete the

Sustaining Performance
PACES: maintains an effective rate of task performance X
ATTENDS: does not look away from task performance X
HEEDS the goal of the specified task X
Applying Knowledge
CHOOSES appropriate tools and materials needed for task performance X
USES task objects according to their intended purposes X
HANDLES task objects with care X
INQUIRES: asks for needed task-related information X
Temporal Organization
INITIATES actions or steps of task without hesitation X
CONTINUES task actions through to completion X
SEQUENCES the steps of the task in a logical manner X
TERMINATES task actions or steps appropriately X
Organizing Space and Objects
SEARCHES and effectively LOCATES task tools and materials X
GATHERS tools and materials effectively into the task workspace X
ORGANIZES tools and materials in an orderly and spatially appropriate fashion X
RESTORES: puts away tools and materials and cleans the workspace X
NAVIGATES: maneuvers the hand and body around obstacles in the task environment X
Adapting Performance
NOTICES and RESPONDS to task-relevant cues from the environment X
ADJUSTS: changes workplaces or adjusts switches and dials to overcome problems X
ACCOMMODATES: modifies one's actions to overcome problems X
BENEFITS: prevents task-related problems from persisting X

Figure 1-5—Cont’d
Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 19


(Results and Interpretation of an Assessment of Motor
and Process Skills (AMPS) Evaluation)

Therapist: Kim A, OTR

Client: John S
Age: 72
Date of Evaluation: 01/10/2005
The Assessment of Motor and Process Skills (AMPS) was administered to John S as a means of evaluating his ability to perform
activities of daily living (ADL) tasks. As part of the AMPS assessment, the occupational therapist conducted an interview to gain
a better understanding of the everyday tasks (occupations) that have been presenting a challenge for him, as well as those
everyday tasks that he has been performing with little difficulty. He was offered a choice of familiar and relevant tasks that he had
identified as presenting problems in everyday life. He chose to perform 2 of the tasks that were offered: Pot of boiled/brewed
coffee or tea, and Luncheon meat or cheese sandwich. When the AMPS was administered, the occupational therapist assessed
the amount of effort, independence, efficiency, and safety that he exhibited during the performance of these tasks.
John showed evidence of moderately unsafe, markedly effortful, and moderately inefficient ADL task performance and he needed
frequent assistance to complete the 2 ADL tasks.


More specifically, John's performance of the above noted ADL tasks was limited by:
• Momentary or transient loss of balance and/or the need to support himself on external objects while moving through the
environment or interacting with task objects (Stabilizes)
• Difficulty positioning body in relation to the workspace (Positions)
• Increased effort when reaching for or placing task objects (Reaches)
• Increased effort propelling the wheelchair (Moves)
• Ineffective walking or ambulating skill; instability when walking (Walks)
• Increased effort and/or instability when transporting task objects from one place to another
• Difficulty completing tasks without obvious evidence of physical fatigue (Endures)
• Failure to maintain a consistent and effective rate of performance (Paces)
• Pauses during actions or task steps, delaying task progression (Continues)
• Decreased skill accommodating for and preventing problems from occurring, and problems
persisted or recurred during task performances (Accommodates and Benefits)
ADL motor ability is an overall measure of a person's observed skill when moving oneself or task objects as needed for ADL task
performance. John's ADL motor ability measure of -0.38 logits is plotted in relationship to the AMPS motor cutoff measure on the
AMPS Graphic Report. His ADL motor ability is below the AMPS motor cutoff. This indicates that he has increased effort when he
performs ADL tasks. To put this in perspective, approximately 95% of well, healthy persons of John's age have ADL motor ability
measures between 1.07 and 3.27 logits. This indicates that his ADL motor performance is lower than age expectations.
ADL process ability is a global measure of a person's observed skill in efficiently (a) selecting, interacting with, and using tools and
materials; (b) carrying out individual task actions and steps; (c) and modifying performance when problems are encountered.
On the AMPS Graphic Report, John's ADL process ability measure of 0.27 logits is below AMPS process scale cutoff.
This indicates that he is experiencing decreased safety, independence and/or efficiency when he performs familiar ADL tasks.
As a basis for comparison, 95% of well, healthy persons of John's age have ADL process ability measures between 0.59 and 2.55
logits, thus his ADL process ability measure is lower than age expectations.
• John's ADL motor and ADL process ability measures are both below the AMPS process cutoff and below age expectations,
indicating that he is experiencing increased effort, decreased efficiency, decreased safety, and/or the need for assistance when
performing chosen, familiar, and life relevant ADL tasks.
• Occupational therapy services may be indicated to enhance and/or prevent further decline
of John's ADL task performance.
If there are any questions regarding this evaluation, please do not hesitate to contact me.
Kim A, OTR
Figure 1-5—Cont’d
20 cognitive and perceptual rehabilitation: Optimizing function



Client: John S Date MOTOR PROCESS

Occupational therapist: Kim A Evaluation 1 01/10/2005 −0.38 0.27


4 3

Less physical More likely to be safe and ADL performance

effort independent living in the more efficient
performing community
ADL 3 2

Motor Process
2 < Cutoff 1 < Cutoff

Some Some concerns for safe Some inefficiencies;

increased and/or independent living in 1 93% of persons
physical effort 1 the community 0 below cutoff need
performing assistance

0 −1

−1 −2

More physical Less likely to be safe and/or ADL performance

effort independent living in the less efficient
performing community
−2 −3

−3 −4

The numbers on the ADL motor and ADL process scales are units of ADL ability (logits). The results are reported as ADL motor
and ADL process measures plotted in relation to the AMPS scale cutoffs. Measures below the cutoffs indicate that there was
diminished quality or effectiveness of performance of instrumental and/or personal activities of daily living (ADL). See the AMPS
Narrative Report for further information regarding the interpretation of a single AMPS evaluation.
Figure 1-5—Cont’d  B, Computer-generated graphic report of AMPS. (From Fisher AG: Overview of performance skills and client factors.
In Pendleton H, Schultz-Krohn W, editors: Pedretti’s occupational therapy: practice skills for physical dysfunction, ed 6, St Louis, 2006,

Executive Function Performance Test and Kitchen ability to initiate the task when asked, organize
Task Assessment the task, perform the necessary steps of the task,
The Executive Function Performance Test sequence the steps in a logical order, develop
(EFPT)10 was developed subsequently to the awareness related to safety and judgment, and
Kitchen Task Assessment (KTA).8 Both measures recognize completion of the task. Cueing is sys­
are standardized performance-based assessments tematic and includes visual, ­gestural, and ­physical
that examine cognitive functioning through the cues that are provided in a hierarchic fashion.
observation of cues needed for a person to carry These cues provide support to the client when
out a functional task. Specifically observed is the task execution begins to fail.
Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 21

The original KTA was completed by observ­ wide range of client impairment that was devel­
ing one task, making store-bought pudding on a oped subsequently to the Multi-level Action Test. It
stovetop. The KTA was validated on those living is based on research demonstrating that ­recovering
with dementia. More recently the EFPT was devel­ stroke and brain injury clients and those with pro­
oped using the same cueing system from the KTA. gressive dementia are highly prone to errors of
The tasks have been expanded to include preparing action when performing routine ADL. The NAT
or heating up a light meal (cooked oatmeal), man­ is a ­ performance-based test of naturalistic action
aging medications, using the telephone, and paying in which the tasks are associated with disorders
bills. The tool has been used for those with stroke of higher cortical function. The materials, layout,
and was recently found to be sensitive to the cogni­ and cueing procedures are standardized. Scoring
tive difficulties experienced in everyday life for those is simple and objective and can be performed
living with multiple sclerosis (see Chapter 10). reliably with little formal training. Tasks that are
observed include making toast with butter and jelly
Performance Assessment of Self-Care Skills and instant coffee with cream and sugar, wrapping
The Performance Assessment of Self-Care Skills a gift, and preparing and packing a child’s lunch­
(PASS)20,26,51 is also a performance-based observa­ box and schoolbag. Instructions are spoken and
tional test with a home and clinic version. The PASS ­reinforced with ­ drawings. Items are scored for
is composed of 26 core tasks within four functional accomplishment of necessary steps, and this score
domains: is combined with an error score that tracks 12 com­
• Functional mobility (5 tasks) mission errors. The test has been validated on those
• Personal self-care (3 tasks) with right and left strokes and those with traumatic
• IADL with a cognitive emphasis (14 tasks: shop­ brain injury.
ping, bill paying, check writing, balancing a
checkbook, mailing, telephone use, medication Structured Observational Test of Function
management, 2 tasks related to obtaining infor­ The Structured Observational Test of Function
mation from the media, small home repairs, (SOTOF)34,35 is a valid and reliable tool that assesses
home safety, playing bingo, oven use, stove use, the following:
and use of sharp utensils) • Occupational performance (deficits in simple
• IADL with a physical emphasis ADL)
Performance is rated for independence, safety, and • Performance components (perceptual, cogni­
adequacy. If an individual requires assistance to com­ tive, motor, and sensory impairment)
plete a task, the PASS provides a hierarchy of prompts. • Behavioral skill components (reaching, scan­
The types of prompts, beginning with the least assis­ ning, grasp, sequence)
tive and progressing to the most assistive are (1) ver­ • Neuropsychological deficits (spatial relations
bal supportive, (2) verbal nondirective, (3) verbal apraxia, agnosia, aphasia, spasticity, memory loss)
directive, (4) gestures, (5) task object or environmen­ Impairments are detected by the structured
tal rearrangement, (6) demonstration, (7) physical observation of simple ADL (e.g., eating from a
guidance, (8) physical support, and (9) total assist. bowl, pouring a drink and drinking, upper body
The PASS is criterion referenced and may be dressing, washing and drying hands).
given in total, or selected tasks may be used alone This relative quick tool aims to answer the fol­
or in combination. The PASS can be used with ado­ lowing questions:
lescents and adults with various diagnoses includ­ 1. How does the subject perform ADL tasks?
ing stroke, head injury, and multiple sclerosis. The 2. What behavioral skill components are intact?
interactive assessment used when administering the Which have been affected by neurologic damage?
PASS allows clinicians to identify the point of task 3. Which perceptual, cognitive, motor, and sensory
breakdown and the types of assistance that enable impairments are present?
improvement in task performance. Self-report, 4. Why is function impaired?
proxy-report, and clinical judgment versions of the
PASS are available.
Overview of Models That
Naturalistic Action Test Guide Practice
The Naturalistic Action Test (NAT)53 is a measure­ Various models that guide this practice area have
ment of naturalistic action production across a been described in the literature. The reader is
22 cognitive and perceptual rehabilitation: Optimizing function

referred to Katz29 for comprehensive descriptions of when there is a match between all three variables.
these models. The following paragraphs are sum­ Assessment and treatment reflect this dynamic
maries of commonly used approaches. view of cognition.” This approach may be used with
adults, children, and adolescents.
Toglia used the Dynamic Interactional Model to
Dynamic Interactional Approach
develop the Multicontext Treatment Approach.54,55
The Dynamic Interactional Approach55 views cog­ Combining both remedial and compensatory strat­
nition as a product of the interaction among the egies, this approach focuses on teaching a par­
person, activity, and environment. Therefore, per­ ticular strategy to perform a task and practicing
formance of a skill can be promoted by changing this strategy across different activities, situations,
either the demands of the activity, the environ­ and environments over time. Toglia summarizes
ment in which the activity is carried out, or the the components of this approach to include the
person’s use of particular strategies to facilitate following:
skill performance. To illustrate the interaction • Awareness training or using structured expe­
among the three factors (person, activity, and riences in conjunction with self-monitoring
environment), the reader is encouraged to think techniques so that clients may redefine their
about how the efficiency and effectiveness of skill knowledge of their strengths and weaknesses
performance vary based on the following task (see Chapter 4).
descriptions: • Personal context. Treatment activities are chosen
• Driving your own automatic transmission mid­ based on client’s interest and goals. A particular
size car versus renting and driving a standard emphasis is placed on the relevance and purpose
transmission pickup truck of the activities. Managing monthly bills may be
• Performing a morning self-care routine in your an appropriate activity for a single person living
own home versus the same routine carried out alone, whereas crossword puzzles may be used as
in a hotel room an activity for a retiree who previously enjoyed
• Cooking a meal versus cooking a meal while this activity.
simultaneously babysitting twin 2-year-old boys • Processing strategies are practiced during a vari­
Toglia55 describes several constructs associated ety of functional activities and situations. Toglia
with this model including the following: defines processing strategies as strategies that
• Structural capacity or the physical limits in the help a client to control cognitive and percep­
ability to process and interpret information tual symptoms such as distractibility, impulsiv­
• Personal context or characteristics of the person ity, inability to shift attention, disorganization,
such as coping style, beliefs, values, and lifestyle attention to only one side of the environment,
• Self-awareness or understanding your own or a tendency to over focus on one part of an
strengths and limitations, as well as metacog­ activity.
nitive skills such as the ability to judge task • Activity analysis is used to choose tasks that
demands, evaluate performance, and anticipate systematically place increased demands on the
the likelihood of problems (see Chapter 4) ability to generalize strategies that enhance
• Processing strategies or underlying components performance.
that improve task performance such as atten­ • Transfer of learning occurs gradually and sys­
tion, visual processing, memory, organization, tematically as the client practices the same strat­
and problem solving egy during activities that gradually differ in
• The activity itself considering the demands, physical appearance and complexity.
meaningfulness, and how familiar the activity is • Interventions occur in multiple environments to
• Environmental factors such as the social, physi­ promote generalization of learning.
cal, and cultural aspects.
Toglia55 summarizes that “to understand cog­
Quadraphonic Approach
nitive function and occupational performance,
one needs to analyze the interaction among per­ The Quadraphonic Approach was developed by
son, activity, and environment. If the activity and Abreu and colleagues1 for use with those living
environmental demands change, the type of cog­ with cognitive impairments after brain injury. This
nitive strategies needed for efficient performance approach is described as including both a “micro”
changes as well. Optimal performance is observed perspective (i.e., a focus on the remediation of
Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 23

subskills such as attention, memory, etc.) and a ing cause of the functional limitation but focuses
“macro” perspective (i.e., a focus on functional skills directly on retraining the skill itself.
such as ADL, leisure, etc.). The approach supports the
use of remediation as well as compensatory strategies.
Patterns of Cognitive-Perceptual
The micro perspective incorporates four
Impairments Based on Diagnoses
and Area(s) of Brain Pathology
1. Teaching-learning theory is used to describe
how clients use cues to increase cognitive aware­ A critical aspect of the evaluation process involves
ness and control. determining the impairment(s) that are interfering
2. Information-processing theory describes how with an individual’s ability to participate in mean­
an individual perceives and reacts to the envi­ ingful activities. Several clients may have similar
ronment. Three successive processing strategies activity level scores, but the impairments causing
are described including detection of a stimulus, the limitations may be quite different (Table 1-4).
discrimination and analysis of the stimulus, and Identifying the correct impairment(s) will help cli­
selection and determination of a response. nicians determine which interventions are required
3. Biomechanical theory is used to explain the including necessary adaptations, which strategy
client’s movement, with an emphasis on the choices are appropriate, and to begin to determine
integration of the central nervous system, mus­ the focus of rehabilitation. Depending on the diag­
culoskeletal system, and perceptual-motor skills. noses, clinicians can begin to expect usual pre­
4. Neurodevelopmental theory is concerned with sentations of patterns of cognitive and perceptual
quality of movement. impairments although variations from these typical
The macro perspective is based on narrative and patterns may occur.
functional analysis to explain behavior based on the
following four characteristics:
1. Lifestyle status or personal characteristics related
to performing everyday activities If neuroimaging data are available they may provide
2. Life-stage status such as childhood, adolescence, information related to which structures are compro­
adulthood, and married mised. Using knowledge of neuroanatomy and neuro­
3. Health status such as the presence of premorbid logic processing, the clinician may begin to hypothesize
conditions which impairments will be present and how they
4. Disadvantage status or the degree of functional interfere with function (Tables 1-5 and 1-6).
restrictions resulting from impairment Even a basic understanding of cortical func­
tion related to understanding the various functions
associated with different areas of the brain can help
Cognitive-Retraining Model
clinicians in the clinical reasoning process associ­
The Cognitive-Retraining Model7 is used for ado­ ated to identifying impairments that affect daily
lescents and adults living with neurologic and functioning (Tables 1-7 and 1-8).3,4
neuropsychological dysfunction. Based on neuropsy­
chological, cognitive, and neurobiologic rationales,
Multiple Sclerosis
this model focuses on cognitive training by enhanc­
ing remaining skills, and by teaching cognitive strate­ Those living with multiple sclerosis may experience
gies, learning strategies, or procedural strategies. slowed information processing, decreased atten­
tion, decreased concentration, difficulty shifting
attention, difficulty dividing attention, decreased
Neurofunctional Approach
explicit memory, decreased episodic memory,
The neurofunctional approach23 is applied to those loss of executive functioning (concept forma­
living with severe cognitive impairments secondary tion, reasoning, problem solving, planning, and
to brain injuries. The approach focuses on train­ sequencing.14,52
ing clients in highly specific compensatory strate­
gies (not expecting generalization) and specific task
Parkinson’s Disease
training. Contextual and metacognitive factors are
specifically considered during intervention plan­ In general, individuals living with Parkinson’s dis­
ning. The approach does not target the underly­ ease often present with normal or only slightly
24 cognitive and perceptual rehabilitation: Optimizing function

Table 1-4 Clinical Situation: A Client Requires Moderate Assistance for Grooming Tasks
Based on the Functional Independence Measure (FIM)
Behaviors Interfering with
Client Diagnosis Potential Impairments Function

A Right frontoparietal stroke Unilateral neglect, figure-ground Inability to “find” grooming items
impairment, spatial relations on the left side of the sink,
dysfunction, distractibility inability to integrate the left
water faucet, inability to locate
white soap on the white sink,
incorrect endpoint (overshooting
or undershooting) when placing
the toothbrush under the running
water, distracted by irrelevant
environmental stimuli
B Left frontoparietal stroke Motor planning deficits, ideational Uses grooming objects incorrectly
apraxia, impaired organization and (eats soap), brushes teeth
sequencing without turning on the water,
cannot manipulate grooming
tools in hand, doesn’t initiate task

Data from Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby; and Árnadóttir
G: Impact of neurobehavioral deficits of activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach, ed 2,
St Louis, 2004, Elsevier/Mosby.

Traumatic Brain Injury

decreased performance in language, gnosis, and
praxis functions, although memory and executive Severe cognitive and perceptual deficits are
functions more prominently affected. More specifi­ common after traumatic brain injury (TBI)
cally, attention functions are commonly decreased. including deficits of attention, memory, infor­
In addition free recall (immediate and delayed) mation-­processing speed, and problems in self-
is impaired as is visuospatial processing, motor perception. In addition posttrauma for anxiety,
­planning, shifting attention, alternating tasks, and expressive deficit, emotional withdrawal, depres­
­verbal fluency.45 sive mood, hostility, suspiciousness, fatigabil­
ity, hallucinatory behavior, motor retardation,
unusual thought content, lability of mood, and
Huntington’s Disease
comprehension deficits have been documented.
In this disease, selective cognitive abilities are pro­ A recent longitudinal study43 of those with severe
gressively impaired, whereas others remain intact. TBI documented a tendency of improvement
Abilities affected include executive function (plan­ for inattention, somatic concern, ­disorientation,
ning, cognitive flexibility, abstract thinking, rule guilt feelings, excitement, poor planning, and
acquisition, initiating appropriate actions, and articulation deficits. In addition, for the impair­
inhibiting inappropriate actions), psychomotor ments of conceptual disorganization, disinhi­
function (slowing of thought processes to con­ bition, memory deficit, agitation, inaccurate
trol muscles), perceptual and spatial skills of self self-appraisal, decreased initiative, blunted affect,
and surrounding environment, selection of cor­ and tension the authors noted a tendency for fur­
rect methods of remembering information (but ther deterioration in the posttraumatic follow-
not actual memory itself), and ability to learn new up. Changes between 6 and 12 months post-TBI
skills. Problems in attention, working memory, were statistically significant for disorientation
verbal learning, verbal long-term memory, and (improvement), inattention or reduced alertness
learning of random associations are the earliest ­(improvement), and ­ excitement (deterioration).
cognitive manifestations.41 The authors concluded that neurobehavioral
Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 25

Table 1-5 Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment
Artery Location Possible Impairments

Dysfunction of either hemisphere

Middle cerebral artery: Lateral aspect of frontal and Contralateral hemiplegia, especially of the face and the
upper trunk parietal lobe upper extremity
Contralateral hemisensory loss
Visual field impairment
Poor contralateral conjugate gaze
Ideational apraxia
Lack of judgment
Field dependency
Impaired organization of behavior

Right hemisphere dysfunction

Left unilateral body neglect
Left unilateral visual neglect
Visuospatial impairment
Left unilateral motor apraxia

Left hemisphere dysfunction

Bilateral motor apraxia
Broca’s aphasia
Middle cerebral artery: Lateral aspect of temporal
lower trunk and occipital lobes Dysfunction of either hemisphere
Contralateral visual field defect
Behavioral abnormalities

Right hemisphere dysfunction

Visuospatial dysfunction

Left hemisphere dysfunction

Wernicke’s aphasia

Middle cerebral artery: Lateral aspect of the involved Impairments related to both upper and lower trunk
both upper and lower hemisphere dysfunction as listed in previous two sections

(Continued )
26 cognitive and perceptual rehabilitation: Optimizing function

Table 1-5 Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment—Cont’d
Artery Location Possible Impairments

Anterior cerebral artery Medial and superior aspects of Contralateral hemiparesis, greatest in foot
frontal and parietal lobes Contralateral hemisensory loss, greatest in foot
Left unilateral apraxia
Inertia of speech or mutism
Behavioral disturbances

Internal carotid artery Combination of middle cerebral Impairments related to dysfunction of middle and
artery distribution and anterior anterior cerebral arteries as listed above
cerebral artery
Anterior choroidal artery, Globus pallidus, lateral geniculate Hemiparesis of face, arm, and leg
a branch of the internal body, posterior limb of the Hemisensory loss
carotid artery internal capsule, medial Hemianopsia
temporal lobe

Dysfunction of either side

Posterior cerebral artery Medial and inferior aspects of Homonymous hemianopsia
right temporal and occipital Visual agnosia (visual object agnosia, prosopagnosia,
lobes, posterior corpus color agnosia)
callosum and penetrating Memory impairment
arteries to midbrain and Occasional contralateral numbness

Right side dysfunction

Cortical blindness
Visuospatial impairment
Impaired left-right discrimination

Left side dysfunction

Finger agnosia
Basilar artery proximal Pons Bilateral asymmetric weakness
Bulbar or pseudobulbar paralysis (bilateral paralysis of
face, palate, pharynx, neck, or tongue)
Paralysis of eye abductors
Cranial nerve abnormalities
Occipital headache
Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 27

Table 1-5 Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment—Cont’d
Artery Location Possible Impairments

Basilar artery distal Midbrain, thalamus, and caudate Papillary abnormalities

nucleus Abnormal eye movements
Altered level of alertness
Memory loss
Vertebral artery Lateral medulla and cerebellum Dizziness
Pain in ipsilateral eye and face
Numbness in face
Clumsiness of ipsilateral limbs
Hypotonia of ipsilateral limbs
Gait ataxia
Systemic hypoperfusion Watershed region on lateral side Coma
of hemisphere, hippocampus Dizziness
and surrounding structures in Confusion
medial temporal lobe Decreased eoncentration
Memory impairment
Visual abnormalities caused by disconnection from
frontal eye fields
Impaired eye movements
Weakness of shoulder and arm
Gait ataxia

From Árnadóttir G: Impact of neurobehavioral deficits of activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based
approach, ed 2, St Louis, 2004, Elsevier/Mosby.

Table 1-6 Cerebrovascular Dysfunction in Noncortical Areas: Patterns of Impairment

Location Possible Impairments

Anterolateral thalamus, either side Minor contralateral motor abnormalities

Long latency period
Right side
Visual neglect
Left side
Lateral thalamus Contralateral hemisensory symptoms
Contralateral limb ataxia
Bilateral thalamus Memory impairment
Behavioral abnormalities
Internal capsule or basis pontis Pure motor stroke
Posterior thalamus Numbness or decreased sensibility of face and arm
Choreic movements
Impaired eye movements

(Continued )
28 cognitive and perceptual rehabilitation: Optimizing function

Table 1-6 Cerebrovascular Dysfunction in Noncortical Areas: Patterns of Impairment—Cont’d

Location Possible Impairments

Posterior thalamus—Cont’d Decreased consciousness

Decreased alertness
Right side
Visual neglect
Visuospatial abnormalities
Left side
Jargon aphasia
Good comprehension of speech
Caudate Dysarthria
Lack of initiative
Poor memory
Contralateral hemiparesis
Ipsilateral conjugate deviation of the eyes
Putamen Contralateral hemiparesis
Contralateral hemisensory loss
Decreased consciousness
Ipsilateral conjugate gaze
Motor impersistence
Right side
Visuospatial impairment
Left side
Pons Quadriplegia
Impaired eye movement
Cerebellum Ipsilateral limb ataxia
Gait ataxia
Impaired eye movements

From Árnadóttir G: Impact of neurobehavioral deficits of activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based
approach, ed 2, St Louis, 2004, Elsevier/Mosby.

deficits after TBI do not show a general tendency to 2. What are the expected patterns of cognitive or
disappear over time and that some aspects related perceptual impairments if a person presents
to self-appraisal, conceptual ­disorganization and with a right middle cerebral artery stroke? Left
affect may even deteriorate. middle cerebral artery stroke?
3. How can the principles of client-centered prac­
tice be integrated into the development of an
Review Questions
intervention plan for a person with attention
1. Name and describe three assessments that may deficits after a brain injury?
be used to document improvements in quality 4. Give two examples of how the ICF levels of func­
of life and participation. tion are interrelated.
Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 29

Table 1-7 Typical Impairments Based on Damage to the Right Versus Left Hemispheres
Hemisphere Typical Impairments

Right hemisphere Attention deficits

Unilateral spatial neglect
Unilateral body neglect
Visuospatial impairments
Left visual field cut
Left-sided motor apraxia
Loss of left-sided motor control
Loss of left-sided sensation
Reduced insight
Left hemisphere Expressive aphasia
Receptive aphasia
Bilateral motor apraxia Ideational apraxia
Decreased organization and sequencing
Loss of right sided motor control
Loss of right-sided sensation
Right visual field cut

Table 1-8 Typical Functions Based on the Cortical Lobes

Lobe Typical Functions

Frontal Ideation, planning, executive functions in general, organizing, problem solving, selective
attention, speech (left: Broca’s area), motor execution, short-term memory, motivation,
judgment, personality, and emotions
Temporal Emotion, memory, visual memory (right), verbal memory (left), interpretation of music
(right), receptive language (left: Wernicke’s area)
Occipital Visual reception, visual recognition of shapes and colors
Parietal Visual-spatial functions (right), reception and recognition of tactile information, praxis (left)

7. Averbuch MA, Katz N: Cognitive rehabilitation:

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A stroke-adapted 30-item version of the sickness
Chapter 2
General Considerations: Evaluations and Interventions
for Those Living with Functional Limitations Secondary
to Cognitive and Perceptual Impairments

Key Terms
Adaptation Generalization Top-down Approaches
Bottom-up Approaches Performance Based Assessments Validity
Compensation Reliability
Ecologic Validity Remediation

Learning Objectives
At the end of this chapter readers will be able to: 4. Discuss the issue of generalization of clinical inter-
1. Understand the differences between top-down and vention strategies to everyday function.
bottom-up approaches to assessment and evaluation. 5. Understand the interplay of the environmental con-
2. Constructively critique the use of pen-and-paper text and task performance as it relates to assessment
(tabletop) assessment procedures. and interventions.
3.  Be able to differentiate among various forms of reli-
ability and validity.

“Therapists involved in the assessment and treatment of patients with neurobehavioral dysfunctions
have an ethical responsibility to assure themselves that they are using the most effective methods.…
To establish the effectiveness of evaluation and treatment, valid and reliable tools are necessary. Such
tools are also necessary in order to identify the dysfunctions that cause impaired independence, which
is a prerequisite for goal formation and for choosing the most pertinent treatment.”3

have been described in the literature39 and are appli-

Approaches to Evaluation Procedures
cable to those living with cognitive and perceptual
Evaluation procedures can be broadly defined by two impairments.
categories: top-down approaches and bottom-up Principles of a top-down approach include the
approaches. Both approaches to evaluation process following procedures.39 Using standardized and non-

Chapter 2  General Considerations: Evaluations and Interventions 33

standardized instruments (checklists, interviews, apraxia, or other ­impairments. Determining which

etc.), the therapist obtains information regarding impairment is affecting ­mealtime will further dic-
role competency and meaningfulness as the start- tate the treatment (e.g., illumination, providing
ing point for evaluation. Roles (e.g., student, vol- contrast, and magnification versus using tactile
unteer, homemaker, parent, boyfriend, baseball information to recognize objects, etc.). In these
team member, etc.) that comprised an individu- cases, a bottom-up approach may be used to glean
al’s life before his or her neurologic event become information related to the presence or absence
the starting point for assessment. Discrepancies and effect of ­ various impairments. See Chapter 1
between past and present performance are deter- for infor­mation regarding recommended stan-
mined, and this information is used to guide dardized assessments (e.g., Árnadóttir OT-ADL
treatment. Neurobehavioral Evaluation [A-ONE], Assessment
Once an individual’s roles are defined, the spe- of Motor and Process Skills [AMPS], Executive
cific tasks that define a person’s life and those Functions Performance Test, etc.) that simultane-
required to engage in these roles are identified (e.g., ously assess functional activities in addition to the
making a shopping list, managing bills, keeping underlying impairments or processing dysfunction
score, taking notes, reading a newspaper, respond- that affects functional performance.
ing to e-mail on a computer) and evaluated by
standardized and nonstandardized direct observa-
Psychometric Properties of
tion and self-report methods. If a person cannot
Measurement Instruments
perform a particular task, the level and type of sup-
port required to perform the task is determined. Although multiple standardized measurement
The reasons that a task cannot be performed are instruments are available to evaluate those living
then determined (e.g., apraxia, memory loss, visuo- with cognitive and perceptual impairments (see
spatial dysfunction). In other words, a connection Chapter 1 and all subsequent chapters), it is all too
is determined between the components of function common for clinicians to use only nonstandard-
and task performance. ized observations, piecemeal assessments (choos-
In contrast, a bottom-up approach first focuses ing one or two items from a variety of tests and
on an evaluation of specific cognitive and percep- combining them for use based on a clinics needs),
tual impairments using standardized assessments nonstandardized procedures to administer a stan-
and nonstandardized observations. This is fol- dardized assessment, or a valid and reliable assess-
lowed by an assessment of functional limitations. ment for a population or diagnostic category for
Using this approach exclusively makes it difficult to which the instrument has not been formally tested.
determine the clinical and functional connection Whereas nonstandardized observations are com-
between the underlying impairments and noted monly used and may help clinicians determine an
performance deficits.39 individual’s needs, they must be used in conjunc-
A comprehensive evaluation dictates that a tion with a standardized measure that is both valid
­clinician must use both top-down and bottom-up and reliable.
approaches. In general, it is recommended that A valid test measures what it was intended to
the starting point of the evaluation process should measure. A reliable test yields consistent results.
focus on top-down procedures. This allows the A test may reliable and valid, valid or reliable, or
therapist to collect critical information related to the neither valid nor reliable. Box 2-1 reviews types of
functional areas that are targeted for change, allows validity and reliability.
the individual who is receiving services to under- A particular emphasis should be placed on the
stand the focus of interventions and outcomes, and ecologic validity of an instrument. This term refers
provides the clinician with ideas related to integrat- to the degree to which the cognitive demands
ing functional activities into the intervention plan. of the test theoretically resemble the cognitive
That being said, in many cases it is difficult to differ- demands in the everyday environment, some-
entiate among impairments, thus making treatment times termed functional cognition. A test with high
planning difficult. For example, if an individual ecologic validity identifies difficulty in perform-
is observed to have difficulty identifying or using ing real-world functional and meaningful tasks.
objects required to eat a meal independently, it is Ecologic validity also refers to the degree to which
necessary to determine if the problem is related to existing tests are empirically related to measures of
decreased visual acuity, visual agnosia, ideational everyday functioning via a statistical analysis.11
34 cognitive and perceptual rehabilitation: Optimizing function

Box 2-1 Quick Review of Validity and Reliability

Validity Convergent validity: The measure associates with related
Face validity: Does the instrument appear to measure constructs.
what it’s supposed to measure? Is the content appropri- Ecologic validity: The degree to which the cognitive demands
ate for the purpose of the instrument? Do the items look of the test theoretically resemble the cognitive demands in
like they test what they are supposed to? Is the test a good the everyday environment. “Functional cognition” identifies
translation of the construct being measured? Determining difficulty in performing real world tasks or the degree to which
face validity depends on intuitive judgment. existing tests are empirically related to measures of everyday
Content validity: Usually determined via expert review functioning.
and literature reviews, and refers to whether the full con-
tent of a construct’s definition is included or represented Reliability (Determined Quantitatively)
in the measure. Interrater/interobserver: Refers to consistent results
Criterion validity: Is the measure consistent with what we between various testers.
already know and what we expect? Is the instrument valid Test-retest: Refers to the stability of the test over time. If a
against a known external criterion? Includes two subcatego- test is administered at two different times without an inter-
ries of validity: predictive and concurrent. vention in between, it should yield the same results.
Predictive validity: Predicts a known association Parallel forms: Used to assess the consistency of the
between the construct you’re measuring and something results of two forms or versions of a test constructed in the
else. Determines how someone will do in the future on the same way from the same content domain. Parallel forms
basis of a particular instrument. are used to control for a testing effect or practice effect;
Concurrent validity: Associated with preexisting indica- in other words controlling for participants gaining knowl-
tors; something that already measures the same concept. edge from the testing procedure itself, which may influence
Construct validity: Refers to whether the measure relates outcomes.
to a variety of other measures as specified in a theory. Internal consistency: Refers to the extent to which tests
Subcategories: discriminant and convergent validity assess the same construct, skill, or quality. Used to assess
Discriminant validity: The measure does not associate the consistency of results across items within a test.
with constructs that shouldn’t be related.

Data from Chaytor N, Schmitter-Edgecombe M: The ecological validity of neuropsychological tests: a review of the literature on everyday cognitive skills,
Neuropsychol Rev 13:181-197, 2003, and Gliner JA, Morgan GA: Research methods in applied settings: an integrated approach to design and analysis,
Mahwah, NJ, 2000, Lawrence Erlbaum.

­ icture cards predict the ability to plan, cook, and

Performance-Based Assessment
clean up a family meal? Does failure to accurately
Compared with Pen-and-Paper or Tabletop
create a three-dimensional block design from a two-
Assessment Procedures
dimensional cue card mean that an individual won’t
Even after a cursory review of the items included on be able to dress or bathe independently?
assessments that evaluate cognitive and perceptual The use of this type of assessment procedure as
impairments after a neurologic event, it becomes the basis for clinical assessment needs to be ques-
clear that two approaches to assessment are used in tioned if the goal of the cognitive and perceptual
both clinical and research settings. Pen-and-paper assessment is to determine if or how impairment(s)
or tabletop assessments most typically include items will affect functioning in the real world. This type
that attempt to detect the presence of a particular of assessment does not give enough detail to be able
impairment (i.e., they are deficit specific). Test items to predict what kinds of daily life problems will
are usually contrived and nonfunctional tasks such be encountered or provide information regarding
as copying geometric forms, creating pegboard con- the nature and frequency of problems.43 Kingstone
structions, constructing block designs, matching and colleagues ask “to what extent does the sim-
picture halves, performing drawing tasks, sequenc- ple, impoverished, and highly artificial experi-
ing pictures, remembering number strings, per- mental task…have to do with the many complex,
forming cancellation tasks, identifying overlapping rich, real life experiences that people share?”22
figures, completing body puzzles, and so on. It may Particular concerns related to this type of assess-
be argued that this type of test has low ­ ecologic ment are addressed in the following paragraphs. In
validity. Does the ability to sequence a series of contrast, a performance-based test uses common
Chapter 2  General Considerations: Evaluations and Interventions 35

daily ­functional activities as the method of assess-

ment. The use of structured observations to detect
Table 2-1 A Comparison of Test Items
underlying impairments is a not only clinically
Included on Common
valid3,4,32,35,41 but also provides the clinician with
Cognitive and Perceptual
detailed information regarding how the underly-
ing impairments directly affects task performance. Type of
Assessment Examples
For instance, Sunderland and associates used struc-
tured observations of action errors during dress- Tabletop/pen-and- Block designs
ing performance of those living with stroke.35 They paper assessments Pegboards
found that for those with right hemispheric damage, Puzzles
dressing was disrupted by visuospatial problems or Matching pictures
poor sustained attention, whereas those with left Gesture copying
hemisphere damage and ideomotor apraxia were Memorizing word lists or number
unable to learn the correct procedure to compen-
Matchstick designs
sate for hemiparesis when dressing. Specific find-
Leather lacing
ings from these observations were then used to Drawing pictures
develop individualized intervention plans. The Drawing geometric designs
authors concluded that observation of a naturalistic Bisecting lines
but controlled task (dressing with a standard item Cancellation tests
of clothing) allows greater insight into the effect of Identifying overlapping figures
specific ­neuropsychological deficits. Sequencing picture cards
When examining test items it is clear that the items Performance-based Dressing
included in pen-and-paper or tabletop assessments assessments Feeding
use novel tasks (i.e., not related to a person’s habits Grooming
Bed mobility
and routines) as the focus of assessment (Table 2-1).
In general, task performance is degraded during
Hot and cold meal preparation
novel tasks as compared with previously learned or Table setting
overlearned tasks. Performance of novel tasks requires Sweeping
increased attentional control, compromises second- Shopping
ary task performance (e.g., memory), preempts the Managing medications
ability to use proceduralized control, and decreases Menu reading
overall task performance.6 Using novel tasks as the Repotting a plant
starting point or basis of assessment for those living Writing on a computer
with neurologic impairments may not provide an Telephone use
accurate clinical picture of functional status. Instead, Telling the time
Managing money
responses to novel tasks may be better used for indi-
Reading an article
viduals who are living with milder impairments or
Finding a number in a phone book
during later stages of the assessment process. Keeping score during a game
Pen-and-paper or tabletop assessments attempt Remembering and navigating a new
to isolate and diagnose the presence or absence of environment
a particular cognitive or perceptual impairment;
therefore, by definition they do not allow integra-
tion of motor, visual, cognitive, or perceptual skills.
Engaging in daily activities successfully requires the system, our ability to interpret spatial information,
ability to perform multiple cognitive, perceptual, motor planning skills, ­ sustained attention skills,
and motor functions at the same time (e.g., remem- and so on. Clinicians must decide if deficit specific
bering a recipe while maneuvering around a grocery pen-and-paper tests that do not simultaneously chal-
store, conversing while driving, taking notes when lenge motor or postural control or other ­cognitive-
getting directions over the phone, managing a ­laptop ­perceptual skills can provide accurate information
computer while teaching, etc). Similarly, daily living regarding real-life function. Performing a cognitive
tasks require one to process, integrate, use, and adapt or motor task in isolation does not ensure ­concurrent
to multiple different types of information simulta- performance. Findings from dual task performance
neously. Wrapping a gift puts demands on our visual research must be considered.
36 cognitive and perceptual rehabilitation: Optimizing function

Haggard and coworkers20 analyzed the ­ability of of the visual cancellation test and letter fluency.
those living with stroke, subarachnoid ­hemorrhages, The authors concluded that those with cognitive
and head injuries to perform cognitive tasks (spo- impairment incurred significantly greater dual-task
ken word generation, mental calculations, remem- costs (i.e., degraded performance while performing
bering the order of paired words, and visuospatial both tasks) compared with control groups.
tasks) and motor tasks in isolation and then simul- To summarize, in healthy older adults, peo-
taneously. The authors documented decrements in ple living with a variety of neurologic diagnoses,
both cognitive and motor function in subjects with adults with cognitive impairments, and those living
CNS dysfunction during dual task conditions as with apraxia, levels of cognitive function decrease
compared to performing a single cognitive or motor when they are involved in tasks that place demands
task. In other words, evaluating cognitive and motor on more than one underlying skill. One can argue
function separately (which commonly occurs in the that typical daily living tasks such as cooking, driv-
clinical setting), yields different results as compared ing, a morning self-care routine, childcare, and so
to evaluating these skills simultaneously. When on are even more demanding than the dual-task
performed simultaneously, ­ performance may be conditions that are examined in highly controlled
degraded. research protocols. Therefore clinicians need to
Lindenberger and colleagues examined the dual reconsider if the results from a highly controlled
task of memorizing while walking in healthy adults deficit specific (single task) test can be general-
classified as young (ages 20 to 30 years), middle-aged ized to a real-world setting. Holtzer and colleagues
(40 to 50 years), and older (60 to 70 years) adults.23 summarized that dual-task measures were accurate
Dual-task costs increased with age in both ­cognitive and better than the traditional neuropsychological
and motor function. Specifically, with advancing age, measures at discriminating cognitive impairments
participants showed greater reductions in memory from normal controls.21 They further concluded
accuracy when they were walking. that dual-task measures can provide additional and
Similarly Baddeley and associates examined important information regarding cognitive status
older adults with cognitive impairment performing that is not available from routinely used standard-
a visual search task and auditory processing task ized neuropsychological measures. In further con-
separately and then simultaneously.5 The authors trast, a performance-based measure that uses daily
documented a similar trend as the previously men- living tasks as test items not only increases the eco-
tioned studies (i.e., older adults had a decreased abil- logic validity of the test but also may provide even
ity to perform visual and auditory processing tasks more accurate information related to real-life func-
simultaneously as compared with performing the tional performance as compared with the exclusive
tasks separately). This same paper examined single- use of deficit-specific pen-and-paper tests.
task performance of motor task and digit span task The focus of a tabletop examination is on diag-
followed by simultaneously dual-task performance. nosing the impairment as opposed to determining
During dual-task conditions, adults with cognitive the effect of a deficit on a particular living skill as
impairments demonstrated decreased performance is the focus of a performance-based test. The diag-
on both tasks. nostic abilities of a pen-and-paper test also may be
Southwood and Dagenais examined the single- questioned.3,4 For example, body puzzles have been
task versus dual-task performance in adults with suggested to diagnose the presence of body scheme
apraxia.34 Single tasks consisted of a manual motor disorders. Failure to accurately complete the puzzle
reaction time task and a voice reaction time task, may be caused by a variety of reasons beyond the
followed by dual-task performance. The authors loss of a body scheme. Visuospatial impairments,
documented an increase in apraxic errors during loss of sustained attention, decreased visual acuity,
dual-task conditions. decreased arousal, or lack of motivation to engage
Holtzer and colleagues examined dual-task per- in a task that is not meaningful all may contribute to
formance in older adults with cognitive impair- poor performance. A similar problem involves tests
ments.21 Specifically, they used two sets of tasks that that detect impairments via two-dimensional test
challenged different perceptual processing skills. items, particularly tests of visual perception, and
The first set of tasks consisted of a visual cancel- attempt to provide information related to ­living in
lation test and an auditory digit span examined a three-dimensional world.
under single and dual task conditions. The sec- The previous paragraphs question the assumed
ond set of tasks was composed of a parallel form relationship between findings on deficit-specific
Chapter 2  General Considerations: Evaluations and Interventions 37

novel pen-and-paper tasks and real-world function. ties of daily living (IADL) performance of older
Findings from published empirical research continue adults.28 Twenty older adults living in the commu-
to question this relationship as well. These studies nity were evaluated in their homes and in an occu-
have attempted to clarify the relationships between pational therapy clinic with the Assessment of Motor
impairments and activity limitations and impair- and Process Skills (AMPS) (see Chapter 1). The
ments and participation restrictions. Reviews of the motor and process ability measures were compared
literature10,24,42 have determined that these relation- between the two settings. The authors found that the
ships are small to moderate, ranging from Pearson subjects’ motor ability measures tended to remain
correlations of 0.2 to 0.5, at best. Other specific rela- stable from clinic to home settings, but the process
tionships that have been examined and determined to ability measures tended not to remain stable from
have a limited relationship include impaired execu- clinic to home settings. The authors concluded that
tive functions as tested by deficit-­specific impairment process skill abilities are affected by the environment
measures and activity limitations or participation to a greater degree than are motor skill abilities. In
restrictions,27 as well as poor attention span as assessed this particular study the familiar home environment
via digit span and tests of everyday attention.19 Finally, tended to support IADL performance (i.e., improved
impairment based measures of neuropsychological performance was noted in familiar home settings).
function have been found to be generally poor pre- Gillen and Wasserman examined the effect of
dictors of vocational functioning in those living with the environment on functional mobility (specifi-
traumatic brain injury.18 cally the ability to transfer) in individuals with a
Overall, the ecologic validity of deficit specific test central nervous system (CNS) disorder within two
results has not been well examined. Findings from varying environments.17 The two environmental
this type of assessment may underestimate7 or overes- conditions were a traditional clinic setting, and a
timate36 the degree of impairment. Generalizing test more naturalistic simulated apartment. Overall,
findings to compromised real-world function should 100 transfer observations were objectively mea-
be done with restraint.36 In other words, predicting sured using the Functional Independence Measure
real-world function based on a pen-and-paper assess- (FIM) method. Forty-four percent (44%) of the
ment, if done at all, should be done with extreme participants performed better in the clinic setting;
­caution if the particular functional skill in ques- 20% performed better in the simulated apartment.
tion has not been observed by the clinician. Bennett Analysis of FIM data revealed that 36% of the par-
summarizes that “the ecological validity…can be ticipants transferred consistently in both environ-
extended by observing the patient’s approach to tasks ments. However, overall 64% of the participants
in the assessment environment and by ­observing the were inconsistent in the same transfer task across
patient in his or her normal activities.”7 the two environments. This research further sup-
ports the concept that the environment affects
functional performance. Performance of activi-
The Influence of the Environment on Functional
ties of daily living (ADL) and functional mobility
Performance and Assessment Outcomes
tasks such as transfers may differ across various
There is a dynamic interplay between a person, his environmental contexts.
or her impairments, task(s) being evaluated, and the Brown and coworkers examined 20 people with
environment in which the evaluation takes place.13 severe mental illness on two tasks (making a pur-
For example, the severity of left spatial neglect and chase in a store and using the bus).9 The partici-
the presence of extinction (see Chapter 6) is increased pants were evaluated on each task with two methods
in a situation in which distracters in the right visual of assessment: interview or simulation (using the
field must be processed.16 Those living with right Kohlman Evaluation of Living Skills) and observa-
brain damage and concurrent attention deficits typi- tion in the natural environment. Results demon-
cally present with degraded functional performance strated inconsistent performance across assessment
in environments that provide increased ­sensory stim- approaches and task performance. The research-
ulation (e.g., a quiet reading room ­versus a cafeteria). ers highlighted the importance of considering the
The relationship between task performance, under- influence of the environment when evaluating the
lying skills, and the environment in which the task complexity of real-world performance. Of particu-
has been ­performed has been empirically tested. lar concern was a trend toward false positives that
Park and colleagues examined the effect of home was found when participants were judged indepen-
versus clinical settings on the instrumental activi- dent on the standardized assessment but could not
38 cognitive and perceptual rehabilitation: Optimizing function

perform the same tasks in the natural environment. nician provides multiple cues for task progres-
The authors concluded that clinicians “should be sion and the tests tend to include discrete items
cautious when making judgments of independence that are performed one at a time as opposed to a
on the basis of interview and observation of simu- sequence of events7.
lated tasks. Evaluating IADL performance in the
persons’ natural environment may provide more
Intervention Overview
accurate information.”
Sbordone emphasized that the typical assess-
General Approaches to Intervention:
ment environment (a quiet room without environ-
Remediation and Compensation or Adaptation
mental distracters) is not the real world. Specific
concerns with a typical testing environment include Common interventions for those living with cog-
the following31: nitive and perceptual impairments are grossly
• The conditions of testing are set up in such a way classified as those focused on remediation of an
as to optimize performance. underlying impairment or compensatory or adap-
• The environment in which testing occurs tends tive strategies used to function despite the effect of
to be distraction-free. cognitive perceptual deficits (Table 2-2).
• The tasks used are highly structured. Although describing and critiquing specific
• The person administering the test provides clear interventions is the focus of the rest of this book, in
and immediate feedback. general, there is little research in the published lit-
• Time demands are minimized. erature that supports the sole use of a remediation
• Repeated and clarified instructions are used to program. Traditionally, the remediation and adap-
optimize performance. tive approaches have been viewed as completely
• Problems with task initiation, organization, separate approaches, and clinicians had to make a
and follow-through are minimized as the cli- decision as to which one to choose when develop-

Table 2-2 Traditional Classifications of Interventions

Remediation Adaptation

Also known as a restorative or transfer of training approach Also known as a functional approach
Focused on decreasing the severity of impairment(s) Focused on decreasing activity limitations and participation
Focused on the cause of the functional limitation. Assumes Focused on the symptoms of the problem
cortical reorganization takes place.
Typically uses deficit specific cognitive and perceptual Typically uses functional activities chosen based what the
retraining activities chosen based on the pattern of clients receiving services want to do, need to do, or have to
impairment do in their own environment
Examples of interventions: cognitive and perceptual tabletop Examples of interventions: meal preparation, dressing,
“exercises,” parquetry blocks, specialized computer generating a shopping list, balancing a checkbook, finding
software programs, cancellation tasks, block designs, a number in the phonebook. Environmental adaptations
pegboard design copying, puzzles, sequencing cards, (e.g., placing all necessary grooming items on the right
gesture imitation, picture matching, design copying, etc. side of the sink for a person with neglect), compensatory
strategy training approaches (e.g., using a scanning
strategy such as the “lighthouse strategy” to improve
attention to the left side of the environment for those living
with unilateral neglect; an alarm watch to remember to
take a medication for those with memory impairment).
Requires the ability to learn and generalize the intervention A compensatory strategy requires insight to the functional
strategies to a real-world situation deficits and accepting that the impairment is relatively
permanent. Environmental modifications do not require
insight or learning on the part of the person receiving
Assumes that improvement in a particular cognitive- Does not assume that the underlying impairment is even
perceptual activity will “carry over” to functional activities affected by the intervention
Chapter 2  General Considerations: Evaluations and Interventions 39

ing an intervention plan. More recently this dichot- A limitation of this approach is that the success of
omy has been challenged, with newer approaches performing a skill is dependent on approaching the
embracing the use of both approaches.1,2 In a study task exactly the same way in the same environment
comparing remedial and compensatory interven- each time.
tions for those living with brain injury, it was found Abreu and colleagues proposed an integrated
that 80% of the participants used compensatory functional approach to treatment in which princi-
strategies regardless of intervention (remediation ples from both remediation and adaptive approaches
or compensatory). In this study, those who used are used simultaneously.2 In this approach, mean-
these strategies demonstrated better performance ingful and functional activities challenge underly-
than those who did not.12 Clinicians must also con- ing cognitive and perceptual impairments. With this
sider that focusing interventions on adaptations or integrated functional approach, interventions may
strategy training does not necessarily mean reme- be focused on a specific impairment such as sus-
diation will not occur.15 Although the remedia- tained attention, but relevant tasks are used as the
tion approach assumes that perceptual retraining modality to affect change. Brockmann-Rubio and
activities may affect functional performance (even Gillen use the example of self-feeding as a task that
though as stated above empirical support for this may improve sustained attention to task.8 Mealtime
relationship is quite weak), engagement in func- is often distracting. Eating can be a difficult task if
tional activities most likely affects cognitive and attention deficits are present. A system of vanish-
perceptual processing as well.14 An intervention ing cues and a gradual increase in the amount of
study for apraxia40 illustrates this point. The focus environmental distraction can address inattention
of the intervention was a strategy-training approach to task and activity participation. Most functional
to improve functional performance despite the tasks can address multiple impairments. A detailed
­presence of apraxia (see Chapter 5). The emphasis task analysis is required when evaluating an activity
of the intervention was on task performance and for its effectiveness in addressing particular cogni-
not explicitly focused on improving praxis. The tive or perceptual deficits (Box 2-2 and Figure 2-1).
outcome demonstrated a large effect size related to
improving the performance of functional skills in
Issues Regarding Generalization of Task
addition to a small to moderate effect size related to
Performance and Strategy Training
measures of apraxia and motor function. Note: the
improvement in functional skills should be consid- One of the biggest challenges to providing interven-
ered the more clinically relevant outcome. tions to this population is the issue of generalizing
Choosing the appropriate intervention approach or transfer of what is learned in therapy sessions to
relies on the results of the assessment. Brockmann- other real-world situations. Examples include gen-
Rubio and Gillen suggest that the following questions eralizing the skills learned on an inpatient rehabili-
should be answered prior to choosing an approach8: tation unit related to meal preparation to making a
• Does the person receiving services have the meal at home upon discharge, ­generalizing a scan-
potential to learn? ning strategy used to read a newspaper article to
• Is he or she aware of errors during task ­locating an item of clothing in a closet, and gen-
performance? eralizing tactile feedback to identify objects on a
• If so, does he or she have the potential to seek meal tray to using this strategy when shopping for
solutions to those errors? grooming items. The consistent perspective on the
If poor learning potential is exhibited, insight idea of generalization is that it will not occur spon-
to deficits do not respond to metacognitive train- taneously but instead needs to be addressed explic-
ing (see Chapter 4), and the use of cues and task itly in an intervention plan.26,33,37,38
performance strategies is not effective or ­consistent, Suggestions have been made in the literature to
a strictly functional approach involving task-­specific enhance generalization of cognitive and perceptual
training may be recommended. This approach rehabilitation techniques.
requires little or no transfer of learning and involves • Avoid repetitively teaching the same activity in
repetitive performance of a specific functional task the same environment.37,38 Consistently practic-
using a system of vanishing cues or cues that are ing bed mobility and wheelchair transfers in a
provided at every step of task performance but then person’s hospital room does not guarantee that
gradually removed.8 The goal is to maximize task the skill will generalize to the ability to transfer
performance with a minimum number of cues. to a toilet in a shopping mall.
40 cognitive and perceptual rehabilitation: Optimizing function

Box 2-2 Toothbrushing Task: Used to Challenge Underlying Impairments

Spatial Relations and Spatial Positioning Organization and Sequencing
Positioning of toothbrush and toothpaste while applying Sequencing of task (removal of cap, application of tooth-
paste to toothbrush paste to toothbrush, turning on water, and putting tooth-
Placement of toothbrush in mouth brush in mouth)
Positioning of bristles in mouth Continuing task to completion
Placement of toothbrush under faucet
Spatial Neglect Attention to task (for greater difficulty, distractions such as
Visual search for and use of toothbrush, toothpaste, and conversation, flushing toilet, or running water may be
cup in affected hemisphere added)
Visual search and use of faucet handle in affected Refocus on task after distraction
Body Neglect Distinguishing white toothbrush and toothpaste from sink
Brushing of affected side of mouth
Initiation and Perseverance
Motor Apraxia Initiation of task on command
Manipulation of toothbrush during task performance Cleaning parts of mouth for appropriate period of time and
Manipulation of cap from toothpaste then moving bristles to another part of mouth
Squeezing toothpaste onto toothbrush Discontinuation of task when complete

Ideational Apraxia Visual Agnosia

Appropriate use of objects (toothbrush, toothpaste, cup) Use of touch to identify objects
during task
Problem Solving
Search for alternatives if toothpaste or toothbrush is

From Brockmann-Rubio K, Gillen G: Treatment of cognitive-perceptual impairments: a function-based approach. In Gillen G, Burkhardt A, editors: Stroke
rehabilitation: a function-based approach, ed 2, p. 430, St Louis, 2004, Elsevier Science/Mosby.

• Practice the same strategy across multiple tasks.29 of learning from those that are very similar to those
For example, if the “lighthouse strategy”(see that are very different. Toglia’s criteria for transfer
Chapter 6) is successful during the treatment of include the following37,38:
an individual with spatial neglect to accurately • Near transfer: Only one or two of the character-
read an 8½ by 11–inch menu, the same strategy istics are changed from the originally practiced
should consistently and progressively ­ practiced task. The tasks are similar. Toglia gives the exam-
to read a newspaper, followed by ­ reading the ple of making coffee as compared with making
labels on spices in a spice rack, followed by hot chocolate or lemonade.38
a street sign, and so on. • Intermediate transfer: Three to six characteristics
• Practice the same task and strategies in multiple are changed from the original task. The tasks are
natural environments.37,38 Practice of organized somewhat similar, such as making coffee as com-
visual scanning for an inpatient should be done pared with making oatmeal.
in the therapy clinic, in the person’s hospital • Far transfer: The tasks are conceptually ­ similar
room, in the facility’s lobby and gift shop, in the but share only one similarity. The tasks are
therapist’s office, and so on. ­different, such as making coffee as compared
• Include metacognitive training in the interven- with making a sandwich.
tion plan to improve awareness (see Chapter 4). • Very far transfer: The tasks are very different,
Toglia has identified a continuum related to the such as making coffee as compared with setting
transfer of learning and emphasizes that general- a table.
ization is not an all-or-none phenomenon.37,38 She Neistadt has suggested, based on her research and
­discusses grading tasks to promote generalization review of the literature, that only those ­individuals
Chapter 2  General Considerations: Evaluations and Interventions 41

Possible behavioral deficits interfering with function

Premotor perseveration: pulling up sleeve
Spatial-relation difficulties: differentiating front from back on shirt
Spatial-relation difficulties: getting an arm into the right armhole
Unilateral spatial neglect: not seeing shirt located on neglected side (or a part of the shirt)
Unilateral body neglect: not dressing the neglected side or not completing the dressing on that side
Comprehension problem: not understanding verbal information related to performance
Ideational apraxia: not knowing what to do to get shirt on or not knowing what the shirt is for
Ideomotor apraxia: having problems with the planning of finger movements in order to perform
Tactile agnosia (astereognosis): having trouble buttoning shirt without watching the performance
Organization and sequencing: dressing the unaffected arm first and getting into trouble with dressing the affected
  arm; inability to continue the activity without being reminded
Lack of motivation to perform
Distraction: becomes interrupted by other things
Attention deficit: difficulty attending to task and quality of performance
Irritated or frustrated when having trouble performing or when not getting the desired assistance
Aggressive when therapist touches client in order to assist (tactile defensiveness)
Difficulties recognizing foreground from background or a sleeve of a unicolor shirt from the rest of the shirt

Figure 2-1  Putting on a shirt. (From Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of daily living,
St Louis, 1990, Mosby.)

who have the ability to perform far and very far give clinicians guidelines related to intervention
transfers of learning are candidates for the reme- planning.
dial approach to cognitive and perceptual reha-
bilitation.26 But she suggests that those who are
Evidence-Based Practice and Levels of Evidence
only capable of near and intermediate transfers of
learning are candidates for the adaptive approach In the recent past, many of the interventions com-
as described earlier. Similarly, near transfers seem monly used with this population were anecdotal
to be possible for all individuals regardless of sever- in nature only. For instance, the transfer of train-
ity of brain damage, whereas intermediate, far, and ing approach (as described earlier) was consistently
very far transfers may be possible only for those recommended and applied in clinic settings despite
with localized brain lesions, preserved abstract there being little evidence to support its use, par-
thinking, and with those who have been ­explicitly ticularly related to the effect it has on daily perfor-
taught to generalize.25 Although these statements mance. Fortunately, a recent focus on evidence-based
should continue to be tested empirically, they ­practice continues to provide clinicians with more
42 cognitive and perceptual rehabilitation: Optimizing function

­ bjective data regarding interventions that are effec-

o the intervention is effective. A specific focus must be
tive (these interventions are reviewed ­ throughout on outcomes that objectify a meaningful decrease in
the rest of this text). Evidence-based practice can be activity limitations and participation restrictions as
defined as “the conscientious, explicit, and judicious well as document an improvement in quality of life.
use of current best evidence in making decisions
about the care of individual patients. The practice of
Considerations Related to Aphasia
evidence-based medicine means integrating individ-
ual clinical expertise with the best available ­external The presence of language impairments (particu-
clinical evidence from systematic research.”30 larly receptive language deficits) results in consistent
When interpreting research that has examined problems related to both assessment and interven-
various interventions, it important to understand tions for this population. Problems particularly arise
that there are different levels of evidence. Sackett when novel tasks are used to asses impairments and
outlined the following levels of evidence to rank when novel and contrived tasks are used for attempts
research articles30: at remediation. Consistent with the previous para-
• Level I: Large randomized controlled trials graphs, both assessment and interventions should
(RCTs) with low false positives. be consistent of meaningful and familiar tasks per-
• Level II: Small RCTs with high false positives. formed in context. This approach will begin to con-
• Level III: Nonrandomized concurrent cohort trol for aphasia by decreasing the need to verbally
comparisons between subjects that did and did explain the task at hand. For example, an attention
not receive intervention. task that requires the person to cancel or cross out
• Level IV: Nonrandomized historical cohort the letter “R” on a sheet of paper requires a verbal or
comparisons between current subjects who did written explanation because of its novelty. Another
receive intervention with former subjects who approach is to use morning grooming tasks at the
did not. sink followed by observation during breakfast to
• Level V: Case series without controls. ascertain levels of attention. If the tasks are provided
Another consideration when reviewing the at the correct time of day and the person’s own
­evidence related to cognitive and perceptual reha- grooming items are used, the task “speaks for itself ”
bilitation interventions is related to the type of and the need for verbal explanation is decreased.
outcome measure. Three categories of assessments
with varying levels of ecological validity have been
Review Questions
utilized in the published empirical research:
• Impairment based measures composed of 1. What factors are examined to determine if an
contrived tabletop or pen and paper tasks. assessment has high ecologic validity?
Examples include cancellation tasks, draw- 2. What are three interventions that promote gen-
ing tasks, block designs, memorizing number eralization of a strategy used to improve basic
strings, etc. (See Chapter 1.) ADL for someone living with unilateral neglect
• Simulated activity performance measures such in the clinic to a home environment?
as the Baking Tray Task and the Behavioral 3. What is the sequence of evaluation when using a
Inattention Test. (See Chapter 6.) top-down approach versus a bottom-up approach
• Sructured observations of tasks in con- to assessment?
text such as the A-ONE and the AMPS (see 4. How does the dual-task paradigm apply to
Chapter 1) and the Catherine Bergego Scale assessment of those living with cognitive and
(see Chapter 6). perceptual impairments?
The majority of studies that have been ­published 5. What are three concerns related to the exclusive
have only examined changes at the impairment use of tabletop assessments to form functional
level (e.g., improved ability to perform a cancella- goals?
tion task for a clinical trial designed for those with
neglect). As stated in Chapter 1, these studies must
be interpreted with caution because the results can- References
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Chapter 2  General Considerations: Evaluations and Interventions 43

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Chapter 3
Managing Visuospatial Impairments to Optimize Function

Key Terms
Accommodation Hemianopsia Stereopsis
Diplopia Orthoptics Strabismus
Field cut Pursuits Vergence
Fixation Saccades
Figure Ground Impairment Spatial Relations

Learning Objectives
At the end of this chapter, readers will be able to: 3. Be aware of procedures to perform a visual screen-
1. Understand how visual information is processed by ing after a brain injury.
the central nervous system. 4. Implement at least five intervention strategies
2. Understand how everyday living is affected if visual focused on decreasing activity limitations and par-
and spatial impairments are present. ticipation restrictions for those living with visual
and spatial impairments.

“Vision is our dominant sense: More than just sight is measured in terms of visual acuity; vision
is the process of deriving meaning from what is seen. It is a complex, learned, and developed set of
functions that involve a multitude of skills. Research estimates that eighty to eighty five percent of our
perception, learning, cognition and activities are mediated through vision.”41

on. In order for one to use vision to support partici-

Visual Processing During
pation in daily activities, visual information must
Functional Activities
be correctly received and recognized.
The visual system is commonly impaired after brain The ultimate function of visual processing is to
damage. Typical visual impairments include visual support participation in daily activities via appro-
field deficits, loss of ocular alignment or control, priate motor and/or cognitive response. There
diplopia, and changes in visual acuity.2,47 Further exists a relationship between visual impairments
complex impairments include spatial relations after acquired brain damage and difficulties with
impairments as is discussed later, visual agnosia activities of daily living (ADLs), increased risk of
(see Chapter 7), neglect of visual information con- falls, and poor rehabilitation outcome.17 Visual pro-
tralateral to the brain injury (see Chapter 6), and so cessing involves a complex system of peripheral

46 cognitive and perceptual rehabilitation: Optimizing function

and central structures. Compromised integrity of The frontal eye fields within the premotor cor-
any of the structures impedes functional perfor- tex support visual search as well guide gaze shifts.
mance. To illustrate this complexity, the following The image “lands” on the nasal hemiretina of the
examination of processing visual information is left eye and the temporal hemiretina in the right eye
based on the example of searching for a gallon of once the milk is located in the left visual field. The
milk that is stored in the left side of the refrigerator. information is mobilized posteriorly via the optic
Figure 3-1 outlines the visual pathways within the nerve. At the point of the optic chiasm, information
central ­nervous system. from the right eye’s temporal hemiretina remains
Once the refrigerator is opened, a variety of eye ipsilateral in the right hemisphere, and the infor-
movements occur to locate the milk. This usually sys- mation from the left eye’s nasal hemiretina crosses
tematic visual search is supported by rapid intermit- into the right hemisphere.2,58 Therefore visual infor-
tent eye movements (saccades) that occur when the mation from the left visual field is processed in the
eyes fix on one point after another in the visual field. right hemisphere. The optic tract projects to the lat-
Each eye is controlled by six muscles (Figure 3-2). eral geniculate nucleus of the thalamus because the
These muscles in turn are controlled by three cranial lateral geniculate nucleus is the principal subcorti-
nerves (cranial nerve III or oculomotor, IV or troch- cal structure that carries visual information to the
lear, VI or abducens). cortex.58 The optic radiation “fans out” and carries

Visual field
Right visual Left visual
hemifield hemifield

Temporal Temporal
hemiretina of the eye hemiretina of the eye

Optic nerve Optic nerve

Optic tract Optic chiasm

Lateral Optic tract

geniculate body

Optic radiation Lateral

geniculate body
Posterior corpus
callosum Optic radiation

Occipital cortex: Occipital cortex:

right hemisphere left hemisphere
Superior optic
Visual radiation

Primary visual Central Inferior Visual

cortex Peripheral optic stimulus
B field radiation
Figure 3-1  The visual pathways. A, Inferior view depicting flow of information from the visual fields to the visual cortex (visual fields =
180 degrees). B, Medial view of components of the visual cortex and visual processing. (A, From Aloisio L: Visual dysfunction. In Gillen G,
Burkhardt A, editors: Stroke rehabilitation: a function-based approach, ed 2, St Louis, 2004, Mosby. B, From Árnadóttir G: The brain and
behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby.)
Chapter 3  Managing Visuospatial Impairments to Optimize Function 47

Figure 3-2  The origins and insertions of the extraocular muscles. A, Lateral view of the left eye with the orbital wall cut away. B, Superior
view of the left eye with the roof of the orbit cut away. (From Goldberg ME: The control of gaze. In Kandel ER, Schwartz JH, Jessell TM,
editors: Principles of neural science, ed 4, New York, 2000, McGraw-Hill.)

the visual information to the primary visual cortex pathways allow for sophisticated examination of
around the calcarine fissure in the occipital lobe. incoming visual information2,3,5,58:
During the radiation, fibers carrying informa- 1. The ventral stream or inferior occipitotempo-
tion from the inferior visual field run posteriorly ral pathway functions include object recognition
through the parietal lobe, whereas fibers carrying via vision, perception of color (e.g., the milk is
information from the superior visual field loop in a red container), recognition of shapes and
around the temporal lobe on their way to the visual forms (the milk is in a rectangular carton), and
cortex in the occipital lobe.2,58 Any lesion in this ret- size discrimination (a quart of milk is smaller
ino-geniculate-cortical pathway will result in a loss than a half gallon). Information from this path-
of visual fields (Figure 3-3). The distribution (e.g., way helps to answer the question, “What am I
nasal, temporal, inferior, superior, homonymous, looking at?”
etc.) of the visual field loss is usually determined 2. The dorsal stream or the superior occipitopa-
by the point of injury. The function of the pathway rietal pathway functions include visuospatial
discussed thus far is to move the visual information perception (the milk is on the top shelf toward
from the retina to the cortex, and the direction of the left and behind the butter) and detection of
flow is primarily anterior to posterior. movement. Information from this pathway helps
At this point the visual information has reached to answer the question: “Where is the object
the primary visual cortex in the occipital lobe located?”
around the calcarine fissure involved in reception
of the visual information. If damage occurs bilater-
Visual Screening
ally around the calcarine fissure, the presentation
is usually that of cortical blindness.3,5 Those living Several authors have described the components of a
with cortical blindness can usually detect lights and vision screening.2,55,56 Prior to developing an interven-
movement but otherwise the visual impairment tion plan, a clinician must determine whether difficul-
is severe. Following the processing that occurs in ties engaging in functional activities are the result of
the primary visual cortex, the visual information a visual deficit, a cognitive or perceptual deficit, or a
is mobilized to the visual association cortex. Two combination of both. Many dysfunctional ­ behaviors
48 cognitive and perceptual rehabilitation: Optimizing function

Defects in
visual field of
Left eye Right eye

Left Right

1 2
2 Optic nerve
Optic chiasm
3 Optic
tract 3

Optic Lateral
radiation geniculate
5 5


Figure 3-3  Deficits in the visual field produced by lesions at various points in the visual pathway. The level of a lesion can be determined
by the specific deficit in the visual field. In the diagram of the cortex the numbers along the visual pathway indicate the sites of lesions. The
deficits that result from lesions at each site are shown in the visual field maps on the right as black areas. Deficits in the visual field of the left
eye represent what an individual would not see with the right eye closed rather than deficits of the left visual hemifield. (1) A lesion of the
right optic nerve causes a total loss of vision in the right eye. (2) A lesion of the optic chiasm causes a loss of vision in the temporal halves
of both visual fields (bitemporal hemianopsia). Because the chiasm carries crossing fibers from both eyes, this is the only lesion in the
visual system that causes a nonhomonymous deficit in vision (i.e., a deficit in two different parts of the visual field resulting from a single
lesion). (3) A lesion of the optic tract causes a complete loss of vision in the opposite half of the visual field (contralateral hemianopsia). In
this case, because the lesion is on the right side, vision loss occurs on the left side. (4) After leaving the lateral geniculate nucleus the fibers
representing both retinas mix in the optic radiation. A lesion of the optic radiation fibers that curve into the temporal lobe (Meyer’s loop)
causes a loss of vision in the upper quadrant of the opposite half of the visual field of both eyes (upper contralateral quadrantic anopsia).
(5) and (6) Partial lesions of the visual cortex lead to partial field deficits on the opposite side. A lesion in the upper bank of the calcarine
sulcus (5) causes a partial deficit in the inferior quadrant of the visual field on the opposite side. A lesion in the lower bank of the calcarine
sulcus (6) causes a partial deficit in the superior quadrant of the visual field on the opposite side. A more extensive lesion of the visual
cortex, including parts of both banks of the calcarine cortex, would cause a more extensive loss of vision in the contralateral hemifield.
The central area of the visual field is unaffected by cortical lesions (5) and (6), probably because the representation of the foveal region
of the retina is so extensive that a single lesion is unlikely to destroy the entire representation. The representation of the periphery of the
visual field is smaller and hence more easily destroyed by a single lesion. (From Wurtz RH, Kandel ER: Central visual pathways. In Kandel
ER, Schwartz JH, Jessell TM, editors: Principles of neural science, ed 4, New York, 2000, McGraw-Hill.)

observed or mistakes made during attempts at per- container may be presenting with a spatial relations
forming a functional activity can be attributed to one impairment related to judging depth or distance versus
or several underlying impairments that must be differ- living with diplopia (double-vision) versus living with
entiated. A person who is having difficulty searching monocular vision (information is only obtained via
for paperclips in a cluttered drawer may be present- one eye). Finally, not being able to identify an object on
ing with poor visual acuity (a decrease in the clarity a bathroom sink by vision alone may be an issue related
of vision) versus living with figure-ground impair- to decreased visual acuity versus living with a figure-
ment (the inability to differentiate foreground from ground impairment (e.g., not able to identify a white
background), necessitating visual acuity testing prior bar of soap on a white sink) versus living with poor
to developing an intervention plan. Similarly, a per- contrast sensitivity versus not recognizing the visual
son who misses the glass when pouring juice from a information received by the cortex (visual agnosia).
Chapter 3  Managing Visuospatial Impairments to Optimize Function 49

A correlation study of adults receiving occupa- skills. The authors further concluded that the results
tional therapy who sustained a stroke examined the suggest that evaluation of visual-perceptual process-
relationship between basic visual functions (defined ing skills must begin with assessment of basic visual
as acuity, visual field deficits, oculomotor skills, and functions so that the influence of these basic visual
visual attention or scanning) and higher level visual- functions on performance in more complex tests
perceptual processing skills such as visual closure and can be taken into consideration.47 Therefore it is rec-
figure-ground discrimination. The study suggested ommended that a visual screening occur prior to or
that a positive relation exists (r = 0.75) between basic in conjunction with a full cognitive and perceptual
visual functions and visual-perceptual processing evaluation (Box 3-1). Examples of components of a

Box 3-1 Components of a Vision Screening

The following is a description of vision screening processes, 3. Ocular Mobility
which should be administered in a well-illuminated room Equipment: Penlight
free of glare and reflection. Setup: Have client sit facing therapist. Penlight should
1. Distance Visual Acuity be approximately 12 inches from the eyes. Do not
Equipment: Distance acuity chart (Snellen chart), shine the light directly into the eyes; instead direct
occluder or eyepatch, 20-foot measure the light so that it is pointing slightly above eye level
Setup: Fixate distance acuity chart on a well-lighted wall at the brow.
at client’s eye level 20 feet away. Procedure: Ask the client to follow the penlight and move
Procedure: Cover the client’s left eye with occluder or it in a large H pattern to the extremes of gaze. Then
patch. Ask the client to identify letters on the 20/40 move the penlight in a large O pattern. Allow the client
line. If the client appears confused by the lines and to fixate on the light for 10 seconds before moving it.
letters, cover all other lines on the chart and expose Functional implications: Observation of pursuits
only the line being used. If necessary, expose only should be smooth and precise without anticipating
one letter at a time. If the client continues to have responses. Note visual fatigue or stress and whether
problems, attempt to test visual acuity using the Lea the client reports diplopia (double vision). Observe
Symbols Test. Continue until the individual misses whether the client looks away, loses the target, or
more than 50% of the letters on a line. Cover the squints or blinks excessively. Inability to attend to
client’s right eye with occluder or patch and repeat visual tasks, difficulty reading or completing writing
the steps. Record acuity as last line in which the tasks, and problems with spatial orientation during
individual can successfully identify more than 50% walking may be displayed.
of the letters. 4. Near Point of Convergence
Functional implications: If visual acuity is poorer than Equipment: Penlight and ruler
20/40 or if a two-line difference or more is evident Setup: Practice this procedure on a partner to deter-
between the two eyes, a referral is necessary and mine when the penlight is positioned at 2, 4, and 6
corrective lenses may need to be prescribed. inches from an individual’s eyes.
2. Near/Reading Visual Acuity Procedure: Slowly move the penlight toward the client
Equipment: Near acuity chart, occluder or eyepatch, at eye level and between the eyes, making sure not
16-inch measure. to shine the light in the eyes. Ask the client to keep
Setup: Hold a near acuity chart in a well-lit room the eyes on the light and state when two lights are
16 inches away. seen. After this occurs, move the light another inch
Procedure: The test card is held 16 inches from the or two closer and then begin to move it away. Ask
person being tested. The test is performed with the the client to state when only one light is seen. Watch
client wearing his or her corrective lenses if they are the eyes carefully and observe whether they stop
normally used. Binocular vision is tested. The small- working together as a team—one eye may drift out-
est size able to be read correctly is recorded. ward. Record the distance at which the client reports
Functional implications: The results of the test will give double vision and the recovery to single vision.
an idea of the detail that can be discriminated. Near Functional implications: Double vision should occur
tasks include craft and leisure activities, personal within 2 to 4 inches of the eyes. A recovery to single
care and hygiene, some work tasks, and reading. vision should occur within 4 to 6 inches. A client with

(Continued )
50 cognitive and perceptual rehabilitation: Optimizing function

Box 3-1 Components of a Vision Screening—Cont’d

a binocular vision problem may not report double A 45-year-old adult:
vision because the eye that turns out is suppressed.
Thus all eye movements should be observed before Expected amplitude =18 − (1/3 [45])
screening. Expected amplitude = 18 − 15 = 3 diopters
5. Stereopsis
Functional implications: The amplitude of accommo-
Equipment: Viewer-free random dot test
dation should be 2 diopters of the expected finding
Setup: Individual’s head position should be vertical. If
for the client to pass the screening test. Observe all
any head tilt occurs, it negates this screening.
eye movements. Problems include blurred vision,
Procedure: Hold the viewer-free random dot test 16
poor concentration, inattention, visual fatigue, and
inches from the client’s eyes and ask the client to
describe what is seen. A person with stereopsis
7. Saccades
should report seeing a square box in the upper left,
Equipment: Two fixators with red and green targets and
an E on the upper right, a circle on the lower left,
scanning chart
and a blank box on the lower right. Give the client
Setup: Have the client keep the head erect and vertical.
about 20 to 30 seconds to observe targets. If the cli-
Procedure: Hold two tongue depressors (one with a red
ent has difficulty, try tilting the target slightly to the
target and one with a green target) 16 inches from
left or right.
the client’s face and about 4 inches from the midline.
Functional implications: The client should be able to
Give the following instructions: “When I say red, look
identify all three symbols correctly. A client with
at the red target. When I say green, look at the green
constant strabismus is unable to identify any of the
target. Do not look until I tell you.” Have the client
shapes. Clients with less severe strabismus or pho-
look from one target to the other five round-trips or
ria may have normal responses. Some people may
a total of 10 fixations.
report double vision on this task, which suggests
Functional implications: Adults without visual impair-
ment should perform perfectly. Any mistake denotes
6. Accommodation
problems with saccadic function, and the client will
Equipment: Isolated letters and occluder or eyepatch
require further evaluation. Poor saccades result in
Setup: Make a target by photocopying the near visual
poor concentration and attention and difficulty read-
acuity chart, cutting out the 20/30 targets, and tap-
ing and writing.
ing them to a tongue depressor. Place one target on
8. Visual Fields: The Confrontation Test
each side of the tongue depressor so that you have
Equipment: Occluder or eyepatch, black dowels with
two screening targets.
white targets (are other contrasting colors) on the
Procedure: Patch the left eye. Hold the tongue depres-
ends or a wiggling finger
sor with the 20/30 target about 1 inch in front of the
Setup: Make sure the client is seated facing the examiner.
right eye. The client should be unable to identify the
stimulus on the tongue depressor at this distance.
1. One-examiner presentation—The client holds the
Slowly move the target away and ask the client to
occluder over the left eye. Wiggle a finger out to
report as soon as the target is identifiable. Using a
the side and ask the client to say “now” when the
ruler, measure and record the distance at which the
movement of the wiggling finger is first detected.
person is able to identify the stimulus. Divide 40 by
The client should look at your nose the entire time
the measurement to determine the amplitude of
and ignore any arm movement. Begin with the hand
accommodation. If the client is able to identify the
slightly behind the client about 16 inches away from
target at 8 inches, divide 40 by 8, which equals 5
the head. Slowly bring the hand forward while wiggling
diopters. To compare the amplitude of accommoda-
a finger. Continue randomly testing different sections
tion to the expected amplitude for the client’s age,
of the visual field in 45-degree intervals around the
use the following formula: expected amplitude =
visual field. Proceed to the left eye, asking the client
18 – one third the client’s age. The following are
to occlude the right eye. If using the dowel technique,
examples of the way to use this equation:
slowly bring it in from the side until the client reports
A 9-year-old child:
seeing the small pin at the end of the dowel.
Expected amplitude = 18 − (1/3 [9]) 2. Two-examiner presentation—Examiner one stands
Expected amplitude = 18 − 3 = 15 diopters behind the seated client and examiner two sits facing
Chapter 3  Managing Visuospatial Impairments to Optimize Function 51

Box 3-1 Components of a Vision Screening—Cont’d

the client about 30 inches in front so that the face of   Examiner one presents one or two fingers
the examiner and client are at the same level. randomly for a 1-second duration to each quadrant
  Test each eye individually, being careful to patch of the visual field of the client’s unpatched eye.
the other eye. Examiner two closes one eye and The fingers in the upper quadrant point down, and
instructs the client to “fixate and keep looking at my those in the lower quadrant point up. The fingers
open eye. Examiner one will be showing you one are presented 18 inches from the client and at
or more fingers very quickly. Don’t try to look at the approximately 20 degrees from the line of fixation.
fingers. Keep looking at my open eye and when you
see a finger or fingers, tell me how many you see.”

Data from Aloisio L: Visual dysfunction. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach, ed 2, St Louis, 2004, Mosby;
Gianutsos R, Suchoff IB: Visual fields after brain injury: management issues for the occupational therapist. In Scheiman M, editor: Understanding and man-
aging vision deficits: a guide for occupational therapists, Thorofare, NJ, 1997, Slack; Gutman SA, Schonfeld AB: Screening adult neurologic populations,
Bethesda, Md, 2003, AOTA Press; and Warren M: Evaluation and treatment of visual deficits following brain injury. In Pendleton H, Schultz-Krohn W, editors:
Pedretti’s occupational therapy: practice skills for physical dysfunction, ed 6, St Louis, 2006, Elsevier Science/Mosby.

visual screening include near and far acuity, visual • Visual acuity (distant and reading)
field testing, ocular range of motion or control, ocu- • Contrast sensitivity function
lar alignment, contrast sensitivity, and the like. These • Visual field
skills are often considered the foundation skills for • Oculomotor function
visual processing.2,53,54 • Visual attention and scanning
Specific visuomotor abilities that should be
assessed include the following:
Managing Visual Acuity Impairments
• Fixation: The ability to steadily and accurately
gaze at an object of regard (e.g., examining the Assessment of visual acuity has been described in
detail of a painting in a museum). Box 3-1. Visual acuity refers to clarity and sharp-
• Pursuits: The ability to smoothly and accurately ness of sight. It is commonly measured using the
track or follow a moving object (e.g., watching Snellen chart (or text cards for near acuity) and
your dog run through the yard). noted, for example, as 20/20, 20/60, 20/200, and
• Saccades: The ability to quickly and accurately so on. Modifications such as using picture charts
look or scan from one object to another (e.g., or a “tumbling E” chart are available for those
reading or watching a soccer game and trying to with aphasia. A visual acuity of 20/20 means that
locate a certain player). a person can see detail from 20 feet away the same
• Accommodation: The ability to accurately focus as a person with normal eyesight would see from
on an object of regard, sustain focusing of the the same distance. If a person has a visual acuity
eyes, and change focusing when looking at dif- of 20/60, that person is said to see detail from 20
ferent distances (e.g., maintaining focus when feet away the same as a person with normal eye-
you look from up from a textbook to a clock and sight would see it from 60 feet away. Visual acuity
back to the textbook). becomes impaired in various refractive conditions
• Vergence: The ability to accurately aim the eyes (i.e., impaired focusing of the image on the retina),
at an object of regard and to track an object as the most typical being myopia (nearsighted), hyper-
it moves toward and away from the person (e.g., opia (farsighted), astigmatism (mixed), and pres-
watching people walking toward you [conver- byopia (age-related decrease in acuity).2 Chia and
gence] and away from you [divergence] in the associates9 found that noncorrectable visual acuity
mall). impairment (defined as acuity less than 20/40) was
The Brain Injury Visual Assessment Battery associated with reduced functional status and well-
for Adults (biVABA)55 is an example of a battery being as measured by the Medical Outcomes Study
that includes standardized assessments for evalu- Short Form-36 (SF-36) (a measure of quality of life,
ation of the visual functions important in ensur- see Chapter 1). Tsai and colleagues51 documented a
ing that visual perceptual processing is accurately relationship between poor visual acuity and depres-
completed: sion using the Geriatric Depression Scale. Visual
52 cognitive and perceptual rehabilitation: Optimizing function

impairment was specifically associated with feelings • The visual fields are essential areas of the visual
of worthlessness and hopelessness. system that allow the individual to orient effec-
A decrease in visual acuity can result in multi- tively to stimuli in specific areas of space.
ple difficulties in all functional domains. Examples • In terms of function, they are used when ­driving,
include difficulty reading labels on pill bottles, doing walking, reading, eating, and in all daily living
crosswords, unsafe driving, increased fall risk, and skills.
so on. A focus on this impairment is warranted to • In terms of impairment, inferior field loss causes
improve participation in daily activities. In general if difficulty with mobility, including poor balance,
visual acuity is worse than 20/40, a referral to an eye tendency to trail behind others when walking,
care specialist is warranted for evaluation of prescrip- walking next to walls and touching them for bal-
tive lenses.2 Other interventions are in line with low- ance, trouble seeing steps or curbs, shortened
vision rehabilitation techniques. They are pragmatic and uncertain stride while walking, and trouble
yet effective and have been outlined by Warren56: identifying visual landmarks. In addition, supe-
• Increase illumination: In general increasing the rior field deficit causes difficulty in seeing signs,
amount of light can improve function. Particular reading and writing; misreading of words, poor
attention should be placed on areas of high risk, accuracy, slow reading rate, inability to follow
where activities requiring precision are per- lines of text, and inaccurate check writing are
formed such as cooking, sorting pills into a pill additional difficulties.
box, and needlework. Task-specific lighting is Hemianopsia, or hemianopia or hemiopia,
recommended. Warren warns a about maintain- means “half-blindness” or a loss of half the fields
ing the balance between increasing the amount of vision in both eyes.38 Homonymous visual field
and intensity of illumination while not increas- impairments are seen frequently in the clinic after
ing glare and recommends halogen, fluorescent, an acquired brain injury. Thirty percent of all cli-
and full-spectrum lights to eliminate casting ents with stroke and 70% of those with a stroke
shadows. involving the posterior cerebral artery present
• Increase contrast: Specifically background col- with hemianopsia. In addition, those with sub-
ors that contrast with objects used for function. arachnoid hemorrhages, intracerebral bleeds, and
Examples are purchasing colored soap to place head trauma also commonly present with this
on a white sink, using dark placemats and white impairment.34
dishes, and placing strips of colored tape on the Zhang and coworkers60 examined the medi-
edge of steps. cal records of more than 900 people present-
• Decrease background pattern: Increased patterns ing with visual field loss. The authors found that
on household objects can further increase the 37.6% were complete homonymous hemianopsias,
difficulty of finding necessary objects. For exam- whereas 62.4% were incomplete. Homonymous
ple, finding a white sock on a patchwork quilt is quadrantanopsia (29%) was the most common
much more difficult than finding the same sock type of incomplete hemianopsia, followed by
on a solid colored bedspread. homonymous scotomatous defects (13.5%), par-
• Decrease clutter and organize the environment: tial homonymous hemianopsia (13%), and hom-
A focus should be placed on a having necessary onymous hemianopsia with macular sparing
objects placed out neatly and not overlapping. (7%). The causes of homonymous hemianopsias
• Increase size: Commercially available magnifica- included stroke (69.6%), head trauma (13.6%),
tion devices, labeling with bold markers, reprint- tumor (11.3%), after brain surgery (2.4%), demy-
ing instructions or daily planners in larger fonts, elination (1.4%), other rare causes (1.4%), and
changing personal computer settings to a larger unknown etiology (0.2%). The authors found
font are just a few example of this intervention. that the lesions were most commonly located in
the occipital lobes (45%) and the optic radiations
(32.2%). Almost every type of hemianopsia was
Managing Visual Field Deficits with
found in all lesion locations along the retrochias-
an Emphasis on Hemianopsia
mal visual pathways.
The visual fields extend approximately 65 degrees The amount and distribution of visual field loss
upward, 75 degrees downward, 60 degrees inward, (nasal, temporal, inferior, superior, homonymous,
and 95 degrees outward when the eye is in the for- etc.) depends on the location of the lesion. If the
ward position.15 Aloisio2 summarizes that: optic nerve itself is damaged (i.e., the area between
Chapter 3  Managing Visuospatial Impairments to Optimize Function 53

the retina and the optic chiasm), the presentation is seated and looking straight ahead at a central
will be that of monocular visual loss. Damage to the target. The person is instructed to press a buzzer
optic tract will result in contralateral hemianopsia. when he or she becomes aware of a small light
If damage occurs posterior to the lateral genicu- within the visual field. The accuracy of the test
late body, the typical presentation is that of either depends on the person’s being alert and able to
quadrantanopsia or hemianopsia depending on the concentrate on the central target. The results from
lesion site (see Figure 3-3). Although the character- this test are printed out by the computer, objectively
istics of visual field defects can be helpful in lesion mapping blind spots in the visual field. A screening
location, specific visual field defects do not always technique that grossly measures the visual fields is
indicate specific brain locations.60 a confrontation test, which is described in Box 3-1.
Zihl62 summarized that those living with hemi- Although it is common for hemianopsia to occur
anopsia cannot process visual information as com­ in conjunction with neglect, there exists a double
pared with those with intact visual fields. Specifically, dissociation between the two impairments—each
they demonstrate numerous visual refixations, have can occur separately or coexist (see Chapter 6). As
inaccurate saccades and disorganized scanning, compared with those living with neglect, awareness
require longer visual search times, and omit relevant of visual filed deficits tends to be better. Nonetheless,
objects in the environment. In addition, they focus on clients may benefit from awareness training to
their intact hemifield; their saccades are less regular, make connections between how this impairment
less accurate, and too small to allow rapid, organized will affect a variety of functional activities as well as
scanning or reading.35 The majority of basic and understand the importance of compensating for it
instrumental activities of daily living (IADL) have (see Chapter 4).
the potential to be adversely affected without proper Several interventions are available to those living
intervention. Reading may be particularly problem- with visual field loss. The methods are compensa-
atic. For example, in those living with a complete tory in nature. These methods include learning ocu-
right homonymous hemianopsia, rightward sac- lomotor compensation strategies, strengthening the
cades during text reading are disrupted (“hemianop- person’s attention to the blind hemifield, improv-
sic alexia”), which disrupts the motor preparation of ing the ability to direct gaze movements toward the
reading saccades during text reading.25 involved side, exploring the involved side more effi-
In terms of recovery, Zhang and coworkers59 lon- ciently, improving saccadic exploration toward the
gitudinally followed 254 clients with homonymous blind hemifield, using prisms, and so on.*
hemianopsia secondary to a variety of brain lesions. Some of the most useful approaches to the treat-
The authors documented spontaneous visual field ment of hemianopsia are based on compensating
deficit recovery in less than 40% of the cases. They for visual field loss by oculomotor compensation.
also noted that the likelihood of spontaneous recov- This training involves psychophysical techniques
ery decreased with increasing time from injury to aimed at strengthening the client’s attention to
initial visual field testing (p = 0.0003). The prob- the blind hemifield and improving their ability to
ability of improvement was related to the time since explore the visual field with saccadic movement.6
injury (p = 0.0003) with a 50% to 60% chance of Kerkhoff18 suggests three types of saccadic train-
improvement for cases tested within 1 month after ing: train people to make broader searches (“visual
injury. This chance for improvement decreased to search field”) in the blind hemifield, train people to
about 20% for cases tested at 6 months after sur- make large-scale eye movements toward the blind
gery. In most cases, the improvements occurred hemifield, and train people to make small-scale eye
within the first 3 months after injury. The authors movements with the goal of improving reading.
warned that spontaneous improvement after 6 In terms of specifically training reading, the
months should be interpreted with caution because minimum visual field that is required for reading is
it may be secondary to improvement of the disease 2 degrees to the left and right of fixation. This is the
or to improvement in the client’s ability to perform area where the text is seen clearly and covers 10 to 12
visual field testing reliably. They recommended that letters of print at a distance of 25 cm. For fluent read-
visual field rehabilitation strategies should most ing, the visual span must be extended in the reading
likely be initiated early after injury. direction up to 5 degrees or 15 letters. People with
The most objective test for mapping the hemianopsia need a minimum of 5 degrees to both
available field is perimetry. This automated test is
usually conducted while the person being tested *References 18, 34, 35, 56, 61, 62.
54 cognitive and perceptual rehabilitation: Optimizing function

sides of fixation to read normally. Less than that visual search with practice and that the underlying
amount affects people differently based on whether mechanism may involve the adoption of compensa-
they are living with a right or a left hemianopsia. tory eye movement strategies.
Less than 5 degrees preempts proper reading of a Compensatory visual field training has been
given line of text by those with right hemianopia tested by Nelles and colleagues.31 The authors exam-
and decreases the ability to locate the beginning of ined 21 subjects with hemianopsia. Compensatory
the next line of text by those with left hemianop- visual field training was accomplished using a 1.25
sia.48–50 Those with right hemianopsia tend to per- by 3.05–m training board with right and left side-
form worse on reading tasks and take longer to wings. Forty red lights were distributed across the
respond to treatment. Pambakian and Kennard35 board in four horizontal lines with 10 lights in
suggest teaching to perceive each word as a whole each line. Clients sat 1.5 m away from the board
before reading it. They specifically suggest that those so that visual fields of subjects were filled out by
with left hemianopsia should shift their gaze first to the board. The subject’s heads were kept midline.
the beginning of the line and the first letter of every When the stimulus of the light was presented, the
word in that line. In contrast, those with right-sided subjects reacted by pressing a button. Training was
hemianopsia are discouraged to read a word before carried out under two conditions: (1) subjects were
they have shifted their gaze to the end of it. Wang57 required to fixate on a central point on the board
reported the case of a 65-year-old woman who pre- and to react to single visual stimuli and (2) multi-
sented with a right homonymous hemianopsia sec- ple stimuli were randomly presented on the board.
ondary to a left occipital lobe tumor. She was most Clients were asked to identify a target stimulus
concerned about her inability to read sheet music (e.g., square of four lights) in each hemifield with
and developed an effective compensatory strategy use of exploratory eye movements, but without
to improve her reading ability. By turning her sheet head movements. Detection of and reaction time to
at right angles (i.e., left-to-right became above-to- visual stimuli were measured during the two con-
below) she was able to read a line almost as prior to ditions. The subjects showed an improvement of
the loss of vision. Another possible intervention to detection and reaction time during condition two,
assist those with hemianopsia to participate fully in but minimum or no change during condition one.
reading tasks is to teach the use of a ruler to assist Improvements were maintained 8 months after
in keeping track of each line of reading and using training. Activity of daily living skills also improved
the ruler to increase the ­accuracy of the saccadic eye in all clients. Of note was that the size of scotoma
movements. (blind area) on computerized perimetry remained
Specifically training visual search strategies is stable. Training improved detection of and reaction
also recommended. Pambakian and associates36 to visual stimuli without a change of the visual field
examined 29 subjects with homonymous visual field impairment.
deficits. Using a videotape, visual search images were Pambakian and coworkers34 suggest three steps
projected on a television in subjects’ homes for 20 to improving visual exploration. People with hemi-
sessions over a 1-month period. Prior to beginning anopsia should first practice making large, quick
the search, subjects fixated on a target in the mid- saccades (of amplitude 30 to 40 degrees) into their
dle of the screen. Random targets were projected blind field, to enhance the overshoot of the target.
among distracters and subjects indicated when they They are then taught to scan for targets among dis-
appeared. During the training they were encour- tracters in a systematic way. Finally these strategies
aged to not move their heads. The researchers found are practiced during real-world activities. These
that the subjects had significantly shorter mean strategies have been tested by Zihl,61 whose subjects
reaction times related to visual search after train- increased their visual field searches from 10 to 30
ing (p < 0.001). The improvements were confined degrees after four to eight sessions. More recently,
to the training period and maintained at follow-up. Kerkhoff and colleagues19 had similar findings after
In addition, subjects performed ADL tasks signifi- examining 92 people with hemianopsia and 30 with
cantly faster after training and reported significant additional neglect. Treatment focused on the prac-
subjective improvements. The researchers found no tice of large saccades to targets in their blind hemi-
enlargement of the visual field, but there was a small field. Additional focus was on adopting a systematic
but significant enlargement of the visual search scanning strategy, either horizontal or vertical scan-
fields. Findings led the authors to conclude that ning. In addition, the subjects practiced search-
people with homonymous field deficits can improve ing for targets on projected slides. Training was
Chapter 3  Managing Visuospatial Impairments to Optimize Function 55

c­ arried for 30 sessions and the mean search field

Managing Diplopia
size increased from 15 to 35 degrees in those liv-
ing with hemianopsia. Those with neglect required Diplopia, or double vision, is an all too common
25% more training over 2 to 3 months to achieve visual impairment after a neurologic event. During
a similar result. At follow-up, almost 2 years later, intact processing of visual information, when we
there were no further significant changes. The effect look at an object with both eyes, the visual image
of the treatment was independent of variables such falls on the fovea (a spot located in the center of
as time since lesion, type of field defect, field spar- the macula, which is responsible for sharp central
ing, and client age. Two noteworthy findings were vision) in each eye and a single image is perceived.
that those with more severe impairments benefited When the eyes are not in alignment, the object we
most from training and that the mean number of are looking at falls on the fovea in one eye and on
required treatment sessions increased dramatically an extrafoveal location in the other eye. When this
with the frequency and extent of head movements occurs two images are perceived (i.e., binocular
during training. Pambakian and Kennard35 note diplopia).37,44 Diplopia typically resolves completely
that this finding contradicts the assumption that with monocular vision (i.e., covering one eye). If
head movements are helpful to the compensatory diplopia is present with monocular viewing, it is
mechanisms for those with hemianopsia as is some- unlikely to be neurologic in origin.44 Diplopia may
times claimed. The concept of using excessive head present as the following11,44:
movements to compensate for a visual field deficit • Horizontal (secondary to impaired abduction
warrants further investigation. or adduction of an eye involving the lateral or
Optical devices such as prisms also have been medial rectus or both)
used for those with visual field loss. When a prism • Vertical (secondary to impaired elevation or
is applied to glasses it shifts the peripheral image depression of the eye)
toward the central area of the retina. Rossi and asso- • Worse in a particular directional gaze (sugges-
ciates43 examined the effects of using 15-diopter tive of ocular motility being impaired in that
press on Fresnel prisms on subjects with homony- direction)
mous hemianopsia and neglect. They found signifi- • Worse while viewing objects far away (usually
cant improvements on impairment tests of visual found in conjunction with impaired abduction
perception such as the Motor Free Visual Perception or divergence of the eyes)
Test, Line Bisection, and Letter Cancellation tests. • Worse while viewing near objects (usually found
They found no difference in ADL and mobility in conjunction with impaired adduction or
scores as measured by the Barthel Index. These convergence)
findings make sense because the improvements Binocular diplopia is most likely caused by “ocu-
were found only in tabletop measures (i.e., mea- lar misalignment” that can be gross or subtle and
sures that by definition do not encompass large warrants investigation as to the cause by an optom-
visual fields). The visual image is only subtly shifted etrist or neuro-ophthalmologist. The most com-
when wearing a prism, perhaps not enough to make mon causes of misalignment of the visual axes are
a positive change in activities such as gait or wheel- extraocular muscle dysfunction (see Figure 3-2).11
chair mobility, which require broader visual scans. Ocular alignment should be evaluated in those
Tabletop ADL have not been objectively tested, but living with diplopia. Strabismus, or tropia, is a vis-
based on these findings perhaps activities such as ible turn of one and may result in double vision.
balancing a checkbook, doing a crossword puzzle, The person is unable to keep the eye straight with the
or leisure reading may be positively affected. On the power of fusion. In strabismus one eye may turn out-
other hand, several problems are related to wearing ward (exotropia), inward (esotropia), upward (hyper-
prisms including double vision, a potential blocking tropia), or downward (hypotropia).2 Stra­bismus may
of the central field, discomfort, disturbances in spa- be noncomitant strabismus (the amount of mis-
tial orientation, and confusion from the distorted alignment depends on which direction the eyes are
visual image. Prisms may consist of a straight-edged pointed) or comitant (the amount of turn is always
segment of press-on prism applied to the side of the the same regardless of whether the person is look-
field loss on both lenses or round prisms applied to ing up, down, right, left, or straight ahead). Newly
the lens over one eye. Consultation with an optom- acquired strabismus from a neurologic insult is usu-
etrist, ophthalmologist, or neuro-ophthalmologist ally noncomitant (i.e., the eye turn changes depend
is mandatory. on the direction in which the eyes are looking).
56 cognitive and perceptual rehabilitation: Optimizing function

Aloiso2 states that “strabismic disorder may result is living with an ocular misalignment, only one of the
in an inability to judge distance, underreaching or eyes fixates on the particular object while the other
overreaching for objects, covering or closure of one eye deviates. If the fixating eye is covered, the deviat-
eye, double vision, head tilt or turn, “spaced-out” ing eye must refixate in order to be aligned with the
appearance, difficulty reading, and avoidance of particular object. In the cover-uncover test, the per-
near tasks.” The term phoria is used when there is son fixates on a distant object, then covers one eye.
tendency for the eye to deviate but is controlled with The examiner observes whether the uncovered eye
muscular effort. It is not noticeable when a person is makes a fixational movement, and notes the direc-
focusing on an object.56 The eyes remain straight as tion of the movement. Then the occluder is removed
long as fusion is present. and placed in front of the other eye. Again the exam-
In terms of assessing diplopia, scanning assess- iner observes for fixational movements of the uncov-
ments such as convergence and ocular range of ered eye. If both eyes are aligned, no movement will
motion or ocular mobility should be examined to be seen during the cover-uncover test (i.e., the test is
help determine the weak ocular muscle(s).2,15 Ocular negative). A positive test is documented if the uncov-
mobility and convergence assessments as described ered eye moves to take up fixation. If refixation is
in Box 3-1 should be evaluated to determine the observed, it can be assumed that under binocular
available ocular range of motion and the observed viewing conditions the eye is not aligned with fixa-
range of motion lags. During the assessment the cli- tion, and a deviation is present. Based on the direction
nician should be aware of the corresponding mus- of the affected eyes, movement when the nonaffected
cles responsible for the patterns of movements: eye is covered can indicate the type of misalignment.
• The medial rectus adducts and rotates the eyes Inward movement of the uncovered eye indicates an
inward. exotropia, whereas an outward movement is an eso-
• The lateral rectus abducts and rotates the eyes tropia. A vertical deviation may be either a hypotro-
outward. pia or a hypertropia, depending on whether the eye
• The superior rectus uses elevation and intorsion moves up or down.2,11,56 The Alternate Cover Test is
to move the eyes upward. more dissociating than the cover-uncover test and it
• The inferior rectus uses depression and extor- may demonstrate phoria more readily.11 In the alter-
sion to move the eyes downward. nate cover test, the eyes are rapidly and alternately
• The superior oblique uses depression and intor- occluded—from one eye to the other and then back
sion to rotate the eye downward and outward. again. This procedure causes breakdown of the bin-
• The inferior oblique uses elevation and extor- ocular fusion mechanism and will reveal refixation
sion to rotate the eye upward and outward (see movements of each eye at the moment of uncover-
Figure 3-2).2,14 ing. If no tropia is present and the uncovered eye
In addition, the cranial nerves that innervate the shows refixation during the ­alternate cover test, the
various muscles should be considered. The lateral client presents with phoria.
rectus is innervated by the abducens nerve (cranial Holmes and coworkers16 developed a valid, reli-
nerve VI). The medial, inferior, and superior recti able, and responsive questionnaire to quantify
and the inferior oblique muscles are innervated diplopia. This self-report measure asks, “Do you
by the ocular motor nerve (cranial nerve III). The always, sometimes, or never see double?” for seven
superior oblique muscle is innervated by the troch- gaze positions (straight ahead, up, downstairs, right,
lear nerve (cranial nerve IV).2,14 left, reading, any position). The diplopia question-
Involvement of cranial nerve III results in exotro- naire score then ranges from 0 (no diplopia) to 25
pia, exophoria, convergence insufficiency, accommo- (constant diplopia everywhere) and can easily be
dative insufficiency, ptosis, and a fixed and dilated rescaled to 0 to 100 by multiplying the score by 4
pupil. The affected eye is in a down and out position. (Figure 3-4).
Damage to the cranial nerve IV results in hypertropia, In terms of interventions, the overall goal of
vertical diplopia, and limited downward gaze. Finally managing diplopia is to establish clear and comfort-
damage to cranial nerve VI manifests as esotropia, able binocular single vision to support engagement
esophoria, divergence insufficiency, horizontal diplo- in meaningful activities. A typical way to manage
pia, and limited abduction of the affected eye.2,11 diplopia is to apply a patch (i.e., full occlusion or
In terms of assessment, the Cover-Uncover Test is “pirate patching”) over one eye. This technique
based on evoking a fixational eye movement and is does in fact result in single vision but causes sev-
appropriate for those living with diplopia. If a ­person eral other problems: issues related to cosmesis and
Chapter 3  Managing Visuospatial Impairments to Optimize Function 57

Gaze position
Score if Score if Score if
Always Sometimes Never Score
For example, if the person closes the right eye and
Straight ahead in distance 6 3 0
the left can still see the target through the hole, the
Up 2 1 0
left eye is dominant. When the same person closes
Downstairs 4 2 0 the left eye while looking through the paper, the
Right 4 2 0 ­target will not be seen with the right eye. Both ver-
Left 4 2 0 sions of partial visual occlusion warrant further
Reading 4 2 0 empirical investigation (Figure 3-5).
Any position 1 1 0 Optical aids such as prisms have been suggested for
If "always," to all above, can you get −1 those with diplopia. Fresnel press-on plastic prisms
rid of it?
may be helpful for clients with binocular diplopia
up to 40 prism diopters in magnitude. The prisms
Figure 3-4  Diplopia questionnaire. (From Holmes JM, Leske DA,  are available in 1-diopter increments from 1 to 10
Kupersmith MJ: New methods for quantifying diplopia, Ophthal­ and then in 12, 15, 20, 25, 30, 35, and 40 diopters.44
mology 112[11]:2035-2039, 2005.) Rucker and Tomsak recommend placing the Fresnel
prism in front of the paretic eye and on only one lens
of a person’s glasses to minimize blurring of vision.
Prisms can be temporary (press-on plastic versions)
self-image, imposed loss of peripheral vision, eye or permanent (ground into the lens) depending on
fatigue, rendering the person monocular, mobility the trajectory of recovery. Further empirical testing
impairments, and safety concerns. Therefore this of this intervention related to diplopia that occurs
technique is not recommended for long-term use. secondary to brain injury is necessary.
More recently partial visual occlusion has been The support for eye exercises (orthoptics) in the
used. Proper use of partial occlusion can result in literature is limited to improving convergence insuf-
comfortable single vision without the negative ficiency.20,45 Scheiman and associates45 ­ compared
side effects of full occlusion, particularly preserv-
ing peripheral vision. The “spot patch” is a type of
partial visual occlusion. It is a round patch made of
translucent tape that is placed on the inside of the
client’s glasses (corrective or nonprescriptive lens)
and directly in the line of sight. The size of the spot
patch is approximately 1 cm in diameter but this
varies based on clinical presentation. In general,
use the smallest size possible that decreases dou-
ble vision. The spot patch is effective in eliminating
double vision because it blurs central vision in the
partially occluded eye.40
Another suggested method for partial visual
occlusion is to apply a strip of opaque material such
as surgical tape to the nasal field of one eye (i.e., the
peripheral field is left unoccluded) over prescrip-
tive or nonprescriptive glasses.56 Similar to the spot
patch, this technique results in single vision while
sparing the peripheral field. The clinician applies
strips of tape systematically to a pair of glasses start-
ing at the nasal field and progressively toward the
center until a single image is obtained. In general,
when using occlusion as an intervention strategy,
Figure 3-5  Visual occlusion techniques for diplopia. Top: Full
the nondominant eye is occluded.56 To determine
visual occlusion (e.g., “pirate patch”) will result in the person
the nondominant eye, have the person focus on a seeing one image but secondary complications include loss of
far target through a 1-inch-diameter hole cut in the peripheral vision, body image issues, and so on. Middle and lower
center of a piece of white paper. Ask the person to figures represent partial visual occlusion such as spot patching
close one eye at a time. Depending on which eye is with translucent tape (middle) and occluding the nasal field of the
closed, the target will be visible through the hole. nondominant eye.
58 cognitive and perceptual rehabilitation: Optimizing function

vision therapy/orthoptics, pencil pushups, and pla- vision therapy/orthoptics, 31% in office-based placebo
cebo vision therapy/orthoptics as treatments for vision therapy/orthoptics, and 20% in home-based
symptomatic convergence insufficiency in adults pencil push-ups. Although the vision therapy/orthop-
ranging from 19 to 30 years of age by way of a ran- tics group was the only treatment that produced clini-
domized multicenter trial. The intervention lasted cally more than half of the clients in this group were
12 weeks. There were three arms of the trial. The still symptomatic at the end of treatment, although
first arm was pencil pushups, in which the sub- their symptoms were significantly reduced.
ject was instructed to hold a pencil at arm’s length Rawstron and colleagues42 systematically reviewed
directly between his or her eyes, and an index card the current evidence regarding the efficacy of eye
was placed on the wall 6 to 8 feet away. Each subject exercises. The authors reviewed 43 refereed stud-
was instructed to look at the tip of the sharpened ies (14 were clinical trials [10 controlled studies], 18
pencil and to try to keep the pencil point single while review articles, 2 historical articles, 1 case report, 6
moving it toward the nose. If one of the cards in the editorials or letters, and 2 position statements from
background disappeared, the person was instructed professional colleges). Based on their review, the
to stop moving the pencil and blink his or her eyes authors summarized that “eye exercises have been
until both cards were present. The client was told to purported to improve a wide range of conditions
continue moving the pencil slowly toward the nose including vergence problems, ocular motility dis-
until it could no longer be kept single and then to orders, accommodative dysfunction, amblyopia,
try to regain single vision. If the person was able to learning disabilities, dyslexia, asthenopia, myopia,
regain single vision, he or she was asked to continue motion sickness, sports performance, stereopsis,
moving the pencil closer to the nose. If single vision visual field defects, visual acuity, and general well-
could not be regained, the client was instructed to being. Small controlled trials and a large num-
start the procedure again. The exercises were per- ber of cases support the treatment of convergence
formed 20 times, three times per day (approximately insufficiency. Less robust, but believable, evidence
15 minutes per day) for 12 weeks. indicates visual training may be useful in develop-
In the second arm, the vision therapy/orthoptics ing fine stereoscopic skills and improving visual
group received therapy administered by a trained field remnants after brain damage. As yet there is
therapist during a weekly, 60-minute office visit, no clear scientific evidence published in the main-
with additional procedures to be performed at stream literature supporting the use of eye exercises
home for 15 minutes a day, five times per week for in the remainder of the areas reviewed, and their
12 weeks. The exercise protocol46 included accom- use therefore remains controversial.”
modative facility, Brock string exercises, vecto-
grams, computer-assisted orthoptics, and so on.
Visuospatial and Spatial Relations Impairments
In the third arm—the placebo office-based vision
therapy/orthoptics—clients received therapy admin- Participating in daily living tasks in a meaningful
istered by a trained therapist during a 60-minute and safe manner relies on higher-order visual pro-
office visit and were prescribed procedures to be per- cessing such as perceiving depth, interpreting spa-
formed at home, 15 minutes, five times per week for tial relations, and differentiating foreground from
12 weeks. The procedures were designed to simulate background, for example. (Table 3-1). Visuospatial
real vision therapy/orthoptics procedures without impairments have been reported to be one of the
the expectation of affecting vergence, accommoda- most common impairments observed after stroke
tion, or saccadic function. Examples included using with a prevalence reported as high as 38%.32 These
stereograms monocularly to simulate vergence ther- deficits have also been reported in those living with
apy, computer vergence therapy with no vergence Huntington’s disease,26 Parkinson’s disease,28 trau-
changes, and monocular prism (instead of plus and matic brain injury,30 and multiple sclerosis.39
minus lenses) to simulate accommodative treatment. The presence of visuospatial impairments has
The authors found that only clients in the vision been associated with a significant increase in falls,33
therapy/orthoptics group demonstrated statistically decreased performance of basic ADL and mobil-
and clinically significant changes in the near point ity after stroke as measured by the Barthel Index,32
of convergence (p = 0.002) and positive fusional ver- impairments in both ADL and motor function in
gence (p = 0.001). In addition, clients in all three treat- those living with Parkinson’s disease,27 and difficul-
ment groups demonstrated statistically significant ties with dressing such as putting one’s arm in the
improvement in symptoms with 42% in ­office-based correct sleeve52 (Figure 3-6).
Chapter 3  Managing Visuospatial Impairments to Optimize Function 59

Table 3-1 Visual-Spatial (Visuospatial) Skills and Their Relationship to Function

Functional Activities
Skill Definition Requiring the Skill Comments

Depth perception The processes of the visual Pouring water into a glass, Relies primarily on binocular
(stereopsis) system that interprets catching a ball, stepping vision but also relies on
depth information from a up or down a curb, monocular cues (light and
viewed scene and builds reaching for cooking shading, color, relative
a three-dimensional equipment with accuracy size).
understanding of that during meal preparation, Those living with monocular
scene parking a car, etc. vision and strabismus will
have difficulty perceiving
Spatial relations Ability to process and Orienting clothing to your Rule out ideational and motor
interpret visual body, applying paste to apraxia (see Chapter 5)
information about where a toothbrush, orienting/
objects are in space; aligning your body in
the process of relating space during a transfer,
objects to each other and orienting dentures and
the self glasses to your body
Indoor and outdoor mobility
during wayfinding,
performing math tasks
and calculations
Right/left discrimination Ability to use/apply the Following directions related Differentiate between
concepts of left and right to personal space (i.e., personal and extrapersonal
“Dress your right arm confusion related to
first”), applying concepts right/left
during mobility (“Make
a left turn after the
occupational therapy
Topographic The ability to use Finding your way via See Chapter 7
orientation visuospatial (and ambulation, wheeled
memory) skills to support mobility, or driving in
wayfinding or route familiar environments;
finding learning new routes
Figure-ground Inability to distinguish Locating a white napkin Rule out decreased visual
discrimination objects in the foreground on a white table, acuity and related basic
(foreground from objects in the finding a scissors in visual skills
from background background a cluttered drawer,
discrimination) locating a shirtsleeve
on a monochromatic
shirt, finding a person
in a crowded room,
stair climbing (i.e.,
differentiating when one
step ends)

Data from Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby; Árnadóttir G: Impact
of neurobehavioral deficits on activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach, ed 2, St Louis,
2004, Mosby; Greene JD: Apraxia, agnosias, and higher visual function abnormalities, J Neurol Neurosurg Psychiatry 76(Suppl 5):25-34, 2005; Gutman SA,
Schonfeld AB: Screening adult neurologic populations, Bethesda, Md, 2003, AOTA Press; Mazzocco MM, Singh BN, Lesniak-Karpiak K: Visuospatial skills and
their association with math performance in girls with fragile X or Turner syndrome, Child Neuropsychol 12(2):87-110, 2006; Nori R, Grandicelli S, Giusberti,
F: Visuo-spatial ability and wayfinding performance in real-world, Cogn Processing 7(5):135-137, 2006.
60 cognitive and perceptual rehabilitation: Optimizing function

Figure 3-6  Spatial impairments: the effect on everyday living. A, Difficulties in differentiating foreground from background. The client
has trouble finding the sleeve of a unicolor shirt. B, The client is unable to find the right armhole. C, The client may start at the wrong
hole, placing her arm through the neckhole instead of the left sleeve. D, The client is unable to guide the paralyzed arm into the right
hole. Pulling more on the shirt at the top of the arm than under it will result in the arm going past the right hole. This deficit can also be
related to perseveration.
Chapter 3  Managing Visuospatial Impairments to Optimize Function 61

Figure 3-6—Cont’d  E, The client’s arm goes through the neckhole instead of the armhole. F, The client matches buttons incorrectly with
buttonholes. G, The client puts both legs through the same leghole. H, The client notices that the pants are turned wrong front to back,
with the label at the front, and attempts to correct the mistake by turning the pants with the leg in the leg hole. Ideation also interferes with
the client’s performance in attempting to correct for the error. See chapter 5.
62 cognitive and perceptual rehabilitation: Optimizing function

Figure 3-6—Cont’d  I, The client puts the glasses on upside down. J, The client leans backward instead of forward while the therapist is
attempting to transfer her to a wheelchair. Such a client can be dangerous for the therapist if she is unaware of the problem because the
client’s actions are unpredictable and often the opposite of what is expected. K, Spatial-relation difficulties manifested in underestimation
of distances when reaching for the cup. (From Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of
daily living, St Louis, 1990, Mosby.)

A qualitative study22 of those living with visuo- experiences of being an individual “self-­person.”
spatial impairments documented “three main Specific everyday problems that the participants
themes comprising six characteristics of how the reported included confusion related to space and
physical world was experienced in a new, unfamil- objects, difficulty reaching for objects, feelings
iar, and confusing way that interfered with the par- that one’s arms were too short, not being able to
ticipants’ occupational performance and with their figure out how to get one’s body into a car, feeling
Chapter 3  Managing Visuospatial Impairments to Optimize Function 63

unsafe, familiar objects now being unfamiliar, diffi- • Occupational performance (deficits in simple
culty finding everyday objects, and difficulties with ADL)
wheelchair maneuvering, for example. • Performance components (perceptual, cogni-
The majority of common instruments to mea- tive, motor, and sensory impairment)
sure the presence of spatial dysfunction use two- • Behavioral skill components (reaching, scan-
dimensional contrived tasks such as overlapping ning, grasp, sequence)
figures, design copying, and so on. The Motor Free • Neuropsychological deficits (spatial relations
Visual Perception Test (MVPT)10 is only one exam- apra­xia, agnosia, aphasia, spasticity, memory
ple of this level of impairment testing. The abil- loss)
ity of these types of test to predict performance of • Specific visual and spatial impairments (in
everyday tasks performed in context is not clear, addition to the above impairments), includ-
and results should be interpreted with caution.8,29 ing figure-ground discrimination, position in
Specifically validity data have not been collected space, form constancy, spatial relations, depth
comparing MVPT scores with real-world tasks and distance perception, visual acuity, visual
requiring visual perception (see Chapters 1 and 2).29 attention, visual scanning, visual filed loss, and
For example, a retrospective study examined 269 neglect. These impairments are detected by the
individuals living with a stroke who completed the structured observation of simple ADL (eat-
MVPT and an on-road driving evaluation. The ing from a bowl, pouring a drink and drink-
MVPT scores ranged from 0 to 36, with a higher ing, upper body dressing, washing and drying
score indicating better visual perception. A struc- hands).
tured on-road driving evaluation was performed This relatively quick tool aims to answer the fol-
to determine fitness to drive. A pass or fail out- lowing questions:
come was determined by the examiner based on • How does the subject perform ADL tasks?
driving behaviors. The author’s results indicated • What behavioral skill components are intact?
that using a score on the MVPT of less than or Which have been affected by neurologic
equal to 30 to indicate poor visual-perception damage?
and more than 30 to indicate good visual percep- • Which perceptual, cognitive, motor, and sensory
tion, the positive predictive value of the MVPT in impairments are present?
identifying those who would fail the on-road test • Why is function impaired?
was 60.9%. The corresponding negative predictive Although presented here, the SOTOF is appro-
value was 64.2%. The authors concluded that the priate for a variety of the problem areas discussed
predictive validity of the MVPT is not sufficiently in future chapters as well.
high to warrant its use as the sole screening tool in Despite the prevalence of these impairments
identifying those who are unfit to undergo an on- and the substantial effect on function, little empir-
road evaluation.21 ical evidence is available to guide interventions
An error analysis approach has been suggested to focused on decreasing activity limitations and par-
document the effects of impairments on daily living ticipation restrictions. It has been suggested that a
skills.3,5,52 The Árnadóttir OT-ADL Neurobehavioral functional approach is the most appropriate inter-
Evaluation (A-ONE)3–5 is one of a select group vention for this population.4,52 This may consist of
of standardized assessments that document the task-specific training, strategy training, and envi-
effects of spatial impairments on daily living tasks ronmental modifications (Table 3-2). It also has
such as mobility, feeding, grooming, and dress- been suggested that interventions that consist of
ing. Specific impairment test items that are scored engaging clients in everyday occupations that are
based on functional observations include spa- presented to challenge the underlying impairment
tial relations, visuospatial agnosia, impaired right should be incorporated into treatment.1,4,7 Abreu
and left discrimination, and topographic orienta- and colleagues1 have proposed an integrated func-
tion. The Assessment of Motor and Process Skills tional approach. In this approach, areas of occupa-
(AMPS)12,13 may be used to document functional tion and context are used to challenge processing
limitations of those living with a variety of impair- skills. With this integrated functional approach,
ments including visual and spatial impairments treatment may be focused on a subcomponent
(see Chapter 1). The Structured Observational Test skill such as spatial, but daily occupations are used
of Function (SOTOF)23,24 is a valid and reliable tool as the modality. Box 3-2 lists potential activity
that assesses the following: choices.
64 cognitive and perceptual rehabilitation: Optimizing function

Table 3-2 Potential Strategies to Improve Function in Those Living with

Visuospatial Impairments
Domain of Function Potential Interventions*

Dressing Deemphasize visual demonstrations during dressing training. Focus on verbal descriptions to
retrain the task.
Decrease the use of spatial-based language (i.e., “under,” “over,” “right,” “left,” “behind,”
etc.) when teaching dressing skills. For example, instead of saying “Your left arm is in the
right sleeve” say “Wrong sleeve” or “Other sleeve.”
Use cues that facilitate insight into the spatial impairment and that assist in strategy
development (see Table 4-7). For example, if a person puts on the shirt backward, start
with a general cue such as, “Are you sure you are finished?”, then progress to more
specific cues.
Use clothing that provides cues that can be used to orient the article of clothing to the body.
A monochromatic blue T-shirt may be more difficult to orient correctly compared with a
baseball jersey in which the sleeves are a different color than the body of the shirt.
Teach spatial orientation strategies before the client starts to dress, for example, using the
label to differentiate front from back or finding a decal on the front shirt.
Use an audiotape (i.e., does not rely on visual skills) to cue the sequence of dressing.
The therapist should sit next to and parallel to the person that is relearning how to dress so
that they are working in the same spatial plane.
Meal preparation Use tactile feedback to increase accuracy when reaching for needed objects (e.g., slide hand
across the counter to reach for a pot).
Decrease clutter. Keep drawers organized to improve foreground from background
Use contrasting colors such as dark dishes on a white counter and vice versa.
Label or color code needed items or ingredients that are difficult to recognize.
Organize the kitchen so that cooking equipment is always in the same place. This decreases
the amount of time spent search and locating objects.
Place a piece of colored tape at the edge of the countertop.
Place colored tape on the handle of the refrigerator and stove controls to ease in spatial
Use tactile cues before pouring. For example, find the lip of the measuring cup by touch
before pouring oil into it.
Encourage the person to work slowly to ensure safety.
Label cabinets based on contents.

*May be applied to other functional domains as well; all require further empirical testing.

Box 3-2 Examples of Functional Activities Presumed to Challenge Visuospatial Skills* Based
on Activity Analysis
Wrapping a gift Folding clothing
Dressing Board games such as checkers
Reaching for groceries on shelves of varying distances Stair climbing
Wayfinding/route finding in familiar and new Sports activities such as playing catch, basketball, or golf
environments Sorting silverware or coins
Setting a table Using a mouse on a computer
Watering plants Playing videogames
Making a bed Crossword puzzles
Sorting laundry Organizing a workspace such as desk or kitchen counter

*Note: This relationship requires further empirical testing.

Chapter 3  Managing Visuospatial Impairments to Optimize Function 65

Review Questions 11. Danchaivijitr C, Kennard C: Diplopia and eye

movement disorders. J Neurol Neurosurg Psychiatry
1. Name three compensatory interventions that 75(Suppl 4):24-31, 2004.
may be used for a person with decreased per- 12. Fisher AG: Assessment of motor and process skills.
formance in grooming secondary to spatial vol. 1: development, standardization, and administra-
impairment. tion manual, ed 5, Fort Collins, Colo, 2003, Three
2. What are the components of a visual screening? Star Press.
3. Describe the clinical reasoning process to deter- 13. Fisher AG: Assessment of motor and process skills. vol. 2:
mine why a person cannot locate a spoon in a user manual, ed 5, Fort Collins, Colo, 2003, Three
Star Press.
utensil drawer.
14. Goldberg ME: The control of gaze. In Kandel ER,
4. Describe three different methods of visual occlu-
Schwartz JH, Jessell TM, editors: Principles of neural
sion that may be used with a person presenting science, ed 4, New York, 2000, McGraw-Hill.
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17. Jones SA, Shinton RA: Improving outcome in stroke
patients with visual problems, Age Ageing 35:560-565,
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Chapter 4
Self-Awareness and Insight: Foundations for Intervention

Key Terms
Anosognosia Emergent Awareness Online Awareness
Anticipatory Awareness Insight Self-awareness
Awareness Intellectual Awareness
Denial Metacognition

Learning Objectives
At the end of this chapter, readers will be able to: 4. Be aware of various methods to objectively docu-
1. Begin to differentiate between a lack of awareness ment and quantify decreased awareness.
and denial. 5. Implement at least five intervention strategies
2. Understand how rehabilitation outcomes are focused on decreasing activity limitations, and par-
affected if a lack of awareness is present. ticipation restrictions for those presenting with
3. Describe at least two conceptual models used to decreased awareness.
describe decreased awareness.

“Patients cannot maintain a productive lifestyle unless they have come to face with the realities of their
life and this means improving self-awareness and self-acceptance.”60

D   ifferent terminology and definitions related to 

 limited self-awareness are used in the literature.
These include lack of insight, lack of/impaired self-
to the clinician and other reasonably attentive individu-
als. The lack of awareness appears specific to individual
deficits and cannot be accounted for by hyperarousal or
awareness or unawareness, anosognosia, and denial. widespread cognitive impairment.” 61
Whereas nonimpaired self-awareness has been Other authors3,9 reserve the term anosognosia
defined as “the capacity to perceive the self in rela- for describing unawareness of physical deficits only
tively objective terms, while maintaining a sense of (i.e., not including cognitive impairments) such as
subjectivity,” 66 Prigatano62,65 uses the terms impaired “anosognosia for hemiplegia” or “anosognosia for
self-awareness and anosognosia interchangeably and hemianopsia.”
uses the following definition: Although impaired self-awareness and anosog-
“the clinical phenomena in which a brain dysfunctional nosia clearly have been used as overlapping terms
patient does not appear to be aware of impaired neuro- in the literature, the term denial must be considered
logical or neuropsychological function, which is obvious separately. Psychological denial has been defined as

68 cognitive and perceptual rehabilitation: Optimizing function

“a subconscious process that spares the patient the all metacognitive skills (see Chapters 9 and 10). 
psychological pain of accepting the serious conse- The impaired self-awareness does not affect all
quences of a brain injury and its unwanted effects areas of function equally. For example, it has been
on his or her life.”18 Complicating the matter is found that people with brain injury report greater
that impaired self-awareness and denial may occur physical as opposed to nonphysical impairments
together. Differentiation between denial (a psy- such as cognitive or behavioral involvement. 72 The
chological method of coping) and lack of aware- common link is that those living with brain injury
ness that is neurologically based is difficult because underestimate difficulties in their everyday life.23,72
some individuals present with both types of clinical Fleming and Strong29 found that self-awareness was
presentations (Table 4-1).43 most impaired for activities with a large cognitive
To aid clinicians in this process, Prigatano (work activities, scheduling daily activities, under-
and Klonoff 65 developed the Clinician’s Ratings standing new instructions, meeting daily responsi-
Scale for Evaluating Impaired Self-Awareness and bilities) and socioemotional (handling arguments,
Denial of Disability After Brain Injury. The tool showing affection, recognizing if actions upset
consists of two subscales: the Denial of Disability someone else, not letting emotions affect daily
(DD) subscale and the Impaired Self-Awareness activities) component, and least impaired for basic
(ISA) subscale, designed to measure denial and  activities of daily living, memory activities, and
anosognosia, respectively. Interrater reliability for both overt emotional responses. Toglia and Kirk91 sum-
subscales is .77. The authors suggest a cutoff of 40 on marized the multiple problems that can contribute
the DD subscale to identify participants in denial ver- to a lack of self-awareness (Table 4-2).
sus those who are not in denial (Figure 4-1).
Self-awareness is clearly related to and is one
Neurologic Considerations
component of metacognition or conscious knowl-
edge of cognitive processes inclusive of the ability In general a lack of awareness has been attributed to
to monitor and regulate ongoing activities or pro- damage to frontal regions and connecting pathways,
cesses during task performance.35 It is a complex particularly right hemisphere involvement.83 Those
issue and may be mediated by other factors such as with persistent (lasting months or years) impaired
executive functions,10,37 memory deficits, and over- self-awareness show evidence of brain damage that is

Table 4-1 Characteristics of Denial and Self-Awareness

DenIal Lack of Self-Awareness

Appears to be a psychological reaction Appears to be rooted in neurologic dysfunction

Clients demonstrate partial or implicit knowledge about Clients lack information about themselves
impaired function
Demonstrate resistance or anger when given feedback Are perplexed and surprised or confused when given
regarding their limitations feedback regarding limitations
Demonstrate an active struggle to work with new information Exhibit a cautious willingness or indifference when asked
about themselves and may make rationalizations or to work with new information about themselves
May be accompanied by reactions of depression or anger Can co-occur with denial
and can co-occur with impaired self-awareness
Higher levels of denial are associated with greater use of Is associated with other impairments such as decreased
avoidant coping strategies, and greater use of these coping initiation, planning, self-monitoring/regulation
strategies is related to higher levels of depression
For those with high levels of denial, ongoing psychological For those with high levels of neurologic-based
support and monitoring may be needed unawareness, challenging occupations structured to
highlight problems may be used

Data from Katz N, Fleming J, Keren N, et al: Unawareness and/or denial of disability: implications for occupational therapy intervention, Can J Occup Ther
69(5):281-292, 2002; Kortte KB, Wegener ST, Chwalisz K: Anosognosia and denial: their relationship to coping and depression in acquired brain injury,.
Rehabil Psychol 48(3):131-136, 2003; and Prigatano GP, Klonoff PS: A clinician’s rating scale for evaluating impaired self-awareness and denial of disability
after brain injury,. Clin Neuropsychol 12(1):56-67, 1998.
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 69

often bilateral and asymmetric throughout the brain Parkinson’s disease (PD), and multiple sclerosis
and including the cerebellum and brainstem.63 (MS) and others.
Pia and colleagues57 specifically examined the lit-
erature on anosognosia for hemiplegia (denial of
contralesional motor deficits) from 1938 to 2001.
Their review revealed that anosognosia for hemiple- Anderson and Tranel2 found that in those liv-
gia most frequently occurs in association with uni- ing with stroke, unawareness is associated with
lateral right-sided or bilateral lesions of different cognitive impairment and varies based on hemi-
brain areas (cortical and/or subcortical). In addition, spheric involvement and impairment investigated.
it seems to be equally frequent when the damage is Specifically, unawareness of motor deficit was doc-
confined to frontal, parietal, or temporal cortical umented in 28% of those with stroke (all with right
structures, and may also emerge as a consequence of brain damage [RBD]), whereas unawareness of
subcortical lesions. They also found that the prob- cognitive deficits was documented in 72% of those
ability of occurrence of anosognosia is highest when with stroke. Overall those with RBD had higher
the lesion involves parietal and frontal structures in mean levels of unawareness when other demo-
combination, if compared with other combinations graphics were controlled for statistically.
of lesioned areas. The authors hypothesized that this Other studies have also documented a high inci-
pattern of lesions suggests the existence of a complex dence of poststroke unawareness including 74%
cortical-subcortical circuit underlying awareness of (50% with mild impairment; 22% with moder-
motor acts that if damaged can result in anosogno- ate impairment; 2% with severe impairment),40
sia. Other researchers have concluded that impaired 50% to 64%,41 and approximately 40%.93 Lack of  
self-awareness is associated with the number but not awareness can be selective in that a person with
with the location or volume of focal lesions early multiple impairments may seem unaware of only
after traumatic brain injury.75 one particular impairment while appearing to be
fully aware of any others.9 Overall, it appears that
unawareness of cognitive deficits is much more
Clinical Presentation
prevalent than unawareness of motor deficits in
Decreased self-awareness had been documented in this population.2,40
multiple populations with acquired brain injury In their recent review of the literature related to
including stroke, traumatic brain injury (TBI), anosognosia and stroke, Jehkonen and associates42

Figure 4-1  Clinician’s rating scale for evaluating impaired self-awareness and denial of disability. (From Prigatano GP, Klonoff PS: A clinician’s
rating scale for evaluating impaired self-awareness and denial of disability after brain injury, Clin Neuropsychol 12[1]:56-67, 1998.)
70 cognitive and perceptual rehabilitation: Optimizing function

Figure 4-1—Cont’d

concluded that lack of awareness was more often charge. They found that discharge unawareness in
associated with right hemisphere damage, neglect the right hemisphere group was significantly asso-
(see Chapter 6) and anosognosia co-occurred, and ciated with lesions in the frontal and temporal lobes
anosognosia had predictive value on poor func- and with lesion size, whereas unawareness in the
tional outcome. left hemisphere–damaged group was not associated
Hartman-Maeir and coworkers39 documented with any neuroanatomic variables. In another study,
the frequency of unawareness of disabilities after Hartman-Maeir and colleagues38 documented
stroke as 73.3% at admission and 42.1% at dis- anosognosia for hemiplegia in 28% of those with
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 71

Figure 4-1—Cont’d

right hemispheric damage and 24% of those with Those with anosognosia for hemiplegia second-
left hemispheric damage in a sample of 46 stroke ary to left hemispheric damage had predominantly
survivors. The majority of those with anosognosia small subcortical lesions and no sensory or atten-
for hemiplegia secondary to the right hemispheric– tional deficits. The authors concluded that underly-
damaged group had large lesions involving the ing mechanisms of this deficit may be different for
frontal, parietal, or temporal lobes and had coex- left and right hemisphere clients, therefore requir-
isting sensory deficits and unilateral spatial neglect. ing different intervention approaches.
72 cognitive and perceptual rehabilitation: Optimizing function

Table 4-2 Problems That Contribute to Deficits in Self-Awareness

Area Problems

Self-knowledge—outside the context of a task Loss of the ability to access knowledge about task characteristics
and strategies
False judgments and beliefs about one’s capabilities
Lack of acceptance of deficits
Online awareness prior to performing a task: Task demands are unfamiliar or ambiguous
overestimation of task performance Failure to recognize, integrate, or perceive all aspects of the task or
task demands
Inaccurate assessment because of false beliefs about one’s skills
Tendency to judge task based on prior experiences, beliefs, and
knowledge, without regard to current level of abilities
Jumps into task without planning or assessing, or selecting goals
Bases judgments on what one likes to do rather than what one is
capable of
Failure to access previous task and strategic knowledge
Task performance Does not recognize errors
Failure to perceive and integrate all aspects of ongoing performance
Unable to simultaneously attend to the task and one’s own
Overfocuses on irrelevant information
Does not initiate self-checking
Does not adjust speed when errors are made
Receives inaccurate feedback
Lack of interest; unconcern—lack of motivation to monitor
False beliefs about task difficulty level and one’s capabilities
Loses track of the goal, expected level of performance
Does not compare ongoing performance with expectations based
on previous experience
Lack of knowledge about what the correct response should be
Failure to recognize need to use task strategies
Able to recognize problems but cannot adjust Unable to use feedback—involves initiation
performance Unable to access strategy knowledge when needed within the
context of a situation (unable to choose the correct solution or
response; inappropriate response to acknowledged error)
Lack of recognition trigger to apply strategy
Lack of flexibility in changing strategy
Lack of ability to initiate use of strategies
Self-evaluation Does not initiate self-checking of work
Does not compare results with previous experiences or with goals
Unable to grasp implications; recognize reasons; abstract—see
beyond the here and now
False beliefs about capabilities
Lack of knowledge regarding the correct outcome or unable to
access a representation of desired performance
Difficulty reflecting back and connecting one’s actions or
performance to the outcome
Failure to integrate Does not retain the new experience over time

From Toglia JP, Kirk U: Understanding awareness deficits following brain injury, Neurorehabil 15(1):57-70, 2000.
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 73

Traumatic Brain Injury c­ ontributions to prediction of subjective well-

being in those living with traumatic brain injury.21
The incidence of lack of self-awareness after TBI is
• Unawareness at discharge from stroke rehabili-
consistently high. Various samples have reported
tation is a negative predictor of activity level as
incidences of 52% 50 and 68%.2 Approximately 30%
measured by the Activity Card Sort at 1 year fol-
of those with severe TBI show residual impairment
low-up, after controlling for the severity of ini-
of self-awareness months or years after injury.63
tial disability level.39
• In a study76 of well-being among significant
others of people with multiple sclerosis, lack of
Parkinson’s Disease
awareness of functional deficit as measured by
Leritz and colleagues47 found that those living with the discrepancy between the clients’ and signifi-
PD rate themselves as less impaired than caregiv- cant others’ reports of the clients’ functional abil-
ers on measures of ADL functioning. They con- ities is associated with poor well-being outcomes
cluded that regardless of the side of the lesion, PD and increases significant others’ supervisory bur-
may impair the ability to recognize and accurately den as clients attempt activities independently.
report physical deficits providing support to the The presence of executive dysfunction and neu-
author’s hypothesis that reduced awareness is due robehavioral disturbances in loved ones is also
to frontal-subcortical dysfunction. related to poor well-being among significant
others. Level of relatives’ distress levels is also
correlated with levels of impaired self-awareness
Multiple Sclerosis
in those living with traumatic brain injury.64
Goverover and colleagues34 found that level of self- • Those with various brain etiologies who show
awareness of neurobehavioral symptoms in MS greater improvement in awareness are more
is related to level of cognitive impairment. The likely to obtain their rehabilitation goals.67
authors also noted that the symptoms of depression • Accuracy of self-awareness as measured by dis-
and anxiety reduced the accuracy of self-reporting crepancy between client self-rating and clinician
in this population. rating is predictive of employability at dis-
charge from rehabilitation.74 Similarly, accurate
self-awareness is related to favorable employ-
Impaired Self-Awareness
ment outcome.71 Work status is significantly
and Outcomes
correlated with scores on standardized mea-
The following paragraphs summarize the empiri- sures of assessment (i.e., the Self-Awareness of
cal research that has examined the relationship Deficits Interview and the Self-Regulation Skills
between self-awareness and outcomes. Interview).97
• Unawareness at admission to inpatient reha- • Impaired awareness is significantly associated
bilitation is a predictor of discharge Functional with lower vocational and independent living
Independence Measure (motor) scores for those status, maladaptive behavior, greater distract-
with right hemisphere damage. Unawareness at ibility, and increased perseveration in those with
admission is a detrimental factor to achieving traumatic brain injury.92
adequate safety levels and independence in basic • A study by Fleming and associates31 used a clus-
ADL functions at the time of discharge from a ter analysis to investigate the relationship among
rehabilitation hospital.40 Sherer and coworkers74 self-awareness, emotional distress, motivation,
also documented that admission Functional and outcome in adults with severe traumatic
Independence Measure scores are strongly asso- brain injury. Groups were labeled as high self-
ciated with degree of impaired self-awareness awareness, low self-awareness, and good recovery.
after traumatic brain injury. That is, clients with The high self-awareness cluster had significantly
higher levels of functional independence have higher levels of self-awareness, motivation, and
more accurate self-awareness. In addition, level emotional distress than the low self-awareness
of self-awareness is a good predictor of instru- cluster but did not differ significantly in outcome.
mental activities of daily living performance in The authors concluded that self-awareness after
those living with brain injury.33 brain injury is associated with greater motiva-
• Impaired self-awareness and functional status tion to change behavior and higher levels of
at rehabilitation admission make independent depression and anxiety. It was not clear from
74 cognitive and perceptual rehabilitation: Optimizing function

this study that this increased motivation actu-

ally led to any improvement in outcome. Of note
is that the relationship between higher levels of
self-awareness after brain injury and associated Anticipatory
higher levels of depression has been documented awareness
by others as well.32,94
• Impaired awareness is associated with executive awareness
dysfunction and interpersonal difficulties51; con-
versely a higher level of intellectual awareness Intellectual awareness
is associated with greater performance on mea-
sures of executive function.53 Others6 argue that Figure 4-2  Awareness represented as a pyramid. Intellectual
the association between reduced behavioral and awareness is the foundation for emergent and anticipatory awareness.
social self-awareness and deficits in executive Some degree of emergent awareness is necessary for anticipatory
function is not as consistent as once thought. awareness. (From Crosson B, Barco PP, Velozo CA, et al: Awareness
• Degree of error awareness is strongly correlated and compensation in postacute head injury rehabilitation, J Head
with sustained attention capacity, even for when Trauma Rehabil 4[3]:46-54, 1989.)
severity of injury is controlled.48
• Those with behavioral disturbances after
a brain injury show significantly less self- 
awareness compared with those without behav- This model includes three interdependent types of
ioral disturbances.6 awareness.
• Lower levels of awareness (particularly online 1. Intellectual awareness: The ability to understand
awareness as described later) and strategy behav- at some level that a function is impaired. At the
ior are associated with increased hopelessness.53 lowest level, one must be aware that one is ­having
• People who lack an awareness of their limita- difficulty performing certain activities. A more
tions in everyday functioning may be less moti- sophisticated level of awareness is to recognize
vated to change their performance.85 commonalities between difficult activities and
• The level of self-awareness after acquired brain the implications of the deficits. Crosson and
injury is a useful prognostic index of the neuro- associates18 hypothesize that factors that may
psychological, psychopathologic, and functional contribute to impaired intellectual awareness
status.50 include decreased knowledge of the manifesta-
• Anosognosia for hemiplegia is related to an tions of brain injury, deficits in abstract reason-
inability to retain safety measures at discharge ing, and severe memory loss. Refers to knowing
from rehabilitation and presents a significant you have a problem.
risk for negative functional outcome in stroke 2. Emergent awareness: The ability to recognize a
rehabilitation.38 problem when it is actually happening. Intellectual
• Although many authors find that lack of aware- awareness is considered a prerequisite to emer-
ness is persistent over time, there is some evi- gent awareness in this model because one must
dence that improvements can be documented first recognize that a problem exists (knowing
during the first year of recovery after a neuro- you are experiencing a problem when it occurs).
logic insult.29 Emergent awareness is included in the concept of
• After a brain injury, those with less awareness online awareness or monitoring of performance
of their limitations tend to set less realistic goals during the actual task.
and have lower rehabilitation outcomes com- 3. Anticipatory awareness: The ability to antici-
pared with those with a more realistic view of pate that a problem will occur as the result of
their limitations.22 a particular impairment in advance of actions.
• Awareness is linked to the ability to use compensa- Intellectual awareness and emergent aware-
tory cognitive strategies to support daily living.20 ness are considered prerequisites to anticipatory
awareness in this model because one must first
recognize that a problem exists and be aware that
Models of Self-Awareness
a problem is occurring to successfully anticipate
The pyramid model of self-awareness was devel- a potential problem (knowing in advance you
oped by Crosson and associates18 (Figure 4-2). have a problem that will affect future ­function).
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 75

are taught to be consistently used every time a

Table 4-3 Awareness and Compensations particular event occurs. An example is a student
Substantial Compensations who, secondary to memory impairments after a
Awareness Deficit Available
traumatic brain injury, tape records all lectures
Intellectual awareness External compensation in class. Although there are times when this may
deficit not be necessary (e.g., a particularly slow-mov-
Emergent awareness External compensation ing and limited-content lecture), the strategy
deficit Situation compensation is used anyway because this type of compensa-
Anticipatory awareness External compensation tion does not rely on the judgment of the cli-
deficit Situation compensation ent. Intellectual awareness is necessary to use
Recognition compensation this strategy because one must be aware that a
No substantial awareness External compensation
deficit exists in order to integrate a strategy to
deficit Situation compensation
Recognition compensation
overcome it.
Anticipatory compensation • External compensation: This type of compensa-
tion is triggered via an external agent or involves
From Crosson B, Barco PP, Velozo CA, et al: Awareness and compensa- an environmental modification. Examples include
tion in postacute head injury rehabilitation, J Head Trauma Rehabil 4(3): alarm watches, posted lists of steps related to meal
46-54, 1989.
preparation, and so on.
Abreu and colleagues1 empirically tested the hier-
archy proposed by Crosson and associates18 in a study
Anticipatory awareness is included in the con- of self-awareness after acute brain injury. They exam-
cept of online awareness. ined awareness related to performance of three func-
Those with brain injuries may be impaired across tional tasks (dressing, meal planning, and money
all three awareness domains51 or may present with management). A series of questions rated on a Likert
better skills in one or more domains of awareness. scale were used to ascertain awareness: “Are you aware
Crosson and associates18 further applied this model of any changes in your ability to perform the follow-
to the selection of compensatory strategies and cat- ing task since your injury?” (intellectual awareness),
egorized compensations appropriate to each type “How well do you predict you will do on the follow-
of awareness (Table 4-3). They classified compen- ing task?” (intellectual awareness), “How well do you
satory strategies according to the way their imple- think you did on the task?” (emergent awareness),
mentation is triggered: and “How do you think your performance on the
• Anticipatory compensation: Applied only when task might affect your ability to live independently,
needed, this term refers to implementation of work, and have fun?” (anticipatory awareness). Their
a compensatory technique by anticipating that analysis revealed significant differences for all levels of
a problem will occur (i.e., requires anticipatory self-awareness across the three tasks. Although their
awareness). An example is a person who needs findings did not support the proposed hierarchy, the
groceries for the week and is aware that because authors caution that the questions used in their study
busy environments result in increased memory may not have been sensitive to the levels described in
and attention deficits decides to defer shopping the model and other means of operationalizing the
until 7 pm when the local store is not as busy. levels of awareness are necessary. A recent study doc-
• Recognition compensation: Also applied only umented a strong association between emergent and
when needed, this term refers to strategies that anticipatory awareness.51
are triggered and implemented because a per- This model was constructively criticized and
son recognizes that a problem is occurring (i.e., expanded on by Toglia and Kirk.91 Their model, the
requires emergent awareness). An example is Dynamic Comprehensive Model of Awareness, sug-
asking a person to speak slower because you gests a dynamic rather than a hierarchic relation-
realize that you are not processing information ship. The model proposes a dynamic relationship
quickly enough and are having difficulty follow- among knowledge, beliefs, task demands, and the
ing the conversation. context of a situation based on the concept of meta-
• Situational compensation: This term applies to cognition. This model differentiates between meta-
compensatory strategies that can be triggered cognitive knowledge or declarative knowledge and
by a specific type of circumstance in which an beliefs about your abilities prior to the task (incor-
impairment may affect function. The strategies porating aspects of intellectual awareness) and
76 cognitive and perceptual rehabilitation: Optimizing function

Metacognitive Knowledge Online Awareness

“Knowing That” “Situational”
Exists prior to a task or situation Activated within tasks and situations

Domain of Knowledge Conceptualization and

concern • Knowledge about task characteristics appraisal of the task
• Physical • Knowledge of strategies or situation Influences
• Cognitive and • Knowledge of specific aspects within (Anticipatory awareness) • Cognitive
perceptual the domain of functioning perceptual deficits
• Interpersonal • Procedural knowledge of tasks • Emotional state
• Emotional Task experience • Fatigue
• Functional • Motivation
• Task difficulty and
Self monitoring of characteristics
current cognitive state • Meaningfulness
Self knowledge and beliefs (Emergent awareness) • Value
Depth of (Intellectual awareness) • Recognition of errors • Culture
awareness • Perceptions of one’s own mental • Adjusting performance • Context
Implicit functioning (self-regulatory skills)
Explicit: • Identification and understanding of
• Global strengths and limitations
• Task specific • Self efficacy beliefs Self evaluation
• Recognition • Beliefs regarding “why” one is having • Beliefs/perception of
across difficulty; Beliefs regarding tasks, performance
situations future and ability to function.
• Implications • Affective states concerning
across knowledge and abilities

Responses to feedback

Agrees (Confirms self-observations) Perplexity Surprise Confusion Indifference Resistance Hostility Anger

Figure 4-3  A proposed model of awareness. (From Toglia JP, Kirk U: Understanding awareness deficits following brain injury,
Neurorehabil 1[1]:57-70, 2000.)

online monitoring and regulation of performance clearly guide intervention choices. For example, a
of tasks (i.e., during task performance), which inte- person who exhibits insight into an everyday mem-
grates aspects of emergent and anticipatory aware- ory deficit may be a candidate for teaching compen-
ness (Figure 4-3). A study that incorporated Toglia satory strategies such as using a diary or notebook
and Kirk’s91 model into a comprehensive, multi- (see Chapter 9). However, a person who does not
dimensional approach to assessment of impaired realize he or she is presenting with a severe unilat-
self-awareness supported the authors’ categoriza- eral neglect may not be able to learn compensatory
tion of awareness into metacognitive knowledge strategies but may require environmental modifica-
versus online awareness.57 tions (e.g., all clothing hung on the right side of the
Finally, Fleming and Strong27 discuss a three- closet) to improve everyday function (see Chapter
level model of self-awareness: 6). In addition, ascertaining the level of insight to a
1. Self-awareness of the injury-related deficits them- disability is one factor that may determine how moti-
selves such as cognitive, emotional, and physical vated one is to participate in the rehabilitation pro-
impairments (i.e., knowledge of deficits). cess. In the most simplistic interpretation, one must
2. Awareness of the functional implications of be aware and concerned about a deficit in everyday
­deficits for independent living. function to be motivated to participate in what may
3. The ability to set realistic goals; the ability to be a long and difficult rehabilitation process.
­predict one’s future state and prognosis. A variety of assessment measures are typically
recommended to ascertain a person’s level of self-
awareness, including questionnaires (self or clinician
Measuring Awareness
rated); interviews; rating scales; functional observa-
Most authors recommend that self-awareness should tions; comparisons of self-ratings and ratings made
be evaluated before initiating an intervention pro- by others such as significant others, caretakers, or
gram focused on retraining living skills. Findings rehabilitation staff; and comparisons of self-ratings
from standardized evaluations of self-awareness will and ratings based on objective measures of function
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 77

or cognitive constructs. All these methods have pros Similar to the previous question, Sohlberg80
and cons58,81 and there is no universally accepted ­recommends collecting data from multiple
method to assess the construct of awareness or sources including a review of medical history,
lack thereof. In addition, naturalistic observations cognitive assessment, standardized question-
can provide further information related to how naires and rating scales, interviews with the client
decreased awareness interferes with performance and significant others, and observations (strat-
of everyday tasks. Tools such as the Assessment of egy use, use of prediction, self-evaluation, error
Motor and Process Skills,24,25 the Naturalistic Action response, and response to feedback).
Test,36 and the Árnadóttir OT-ADL Neurobehavioral 4. Does the individual consciously or unconsciously
Evaluation (A-ONE)3,4 are recommend (see Chapter accommodate changes in functioning? This ques-
1) for further information regarding these outcome tion may be answered via interviews with the
measures. client and significant others, observations (strat-
Simmond and Fleming77 summarize that a egy use, use of prediction, self-evaluation, error
comprehensive and clinically relevant assessment response, and response to feedback).
should: 5. What are the consequences of awareness? Similar
• Be preceded by an assessment of intellectual to question four, this may be answered via inter-
awareness (e.g., the Self-Awareness of Deficits views with the client and significant others, and
Interview as discussed following) as intellectual through observations (strategy use, use of predic-
awareness seems to be a prerequisite to online tion, self-evaluation, error response, and response
awareness. to feedback).
• Allow a client to rate his or her own performance The following paragraphs review a variety of
before, during, and after the assessment. standardized assessments that provide clinicians
• Use meaningful activities. with objective data regarding impairments related
• Use activities that allow enough flexibility to to awareness.
challenge clients. The Self-Awareness of Deficits Interview (SADI)30,78
• Be goal focused. The assessment findings should is an interviewer-rated structured interview used to
be used to work toward acceptance of a disability obtain quantitative and qualitative data on the sta-
followed by interventions to improve function. tus of self-awareness after brain injury. Specifically it
Sohlberg further suggests that five assessment assesses a client’s level of intellectual awareness (the
questions should be answered to comprehensively ability to understand that a function is decreased from
manage a lack of awareness. Sohlberg’s sugges- the premorbid level and to recognize implications of
tions for resources to answer each question follow deficits). It includes three areas for questioning.
as well80: 1. Self-awareness of deficits
1. What is an individual’s knowledge or understand- 2. Self-awareness of functional implications of
ing of strengths and deficits? Sohlberg80 suggests deficits
gleaning information from standardized ques- 3. Ability to set realistic goals
tionnaires and rating scales as well as from inter- Responses are rated on a 4-point scale (0 indicat-
views with the client and significant others. ing no disorder of self-awareness, whereas 3 indicates
2. How much of the problem is denial versus organi- a severe disorder of self-awareness). More recently,
cally based unawareness? This complicated ques- checklists that are filled out by significant others and
tion may be answered via a review of medical staff have been added to the SADI to assist in an over-
history, cognitive assessment, standardized all understanding of the client’s awareness and to assist
questionnaires and rating scales, interviews with with assigning scores (Figure 4-4 and Table 4-4).
the client and significant others, observations The Self-Regulation Skills Interview (SRSI)55 is a
(strategy use, use of prediction, self-evaluation, semistructured clinician-rated interview. Based on
and error response), and response to feedback. the model by Crosson and associates18 discussed ear-
As described earlier, Prigatano and Klonoff ’s65 lier, the tool includes six questions that assess meta-
Clinician’s Ratings Scale for Evaluating Impaired cognitive or self-regulation skills. The six questions
Self-Awareness and Denial of Disability After are applied to a main area of difficulty related to
Brain Injury may be a useful tool to assist in everyday living (e.g., memory loss, poor attention
answering this question (see Figure 4-1). or concentration, etc.) as identified by the client.
3. Is unawareness generalized or modality specific and The tool provides three indices: an awareness index,
does it accompany other cognitive impairments? readiness to change index, and a strategy behavior
78 cognitive and perceptual rehabilitation: Optimizing function

Self-Awareness of Deficits Interview

1. Self-awareness of deficits
Are you any different now compared to what you were like before your accident? In
what way? Do you feel that anything about you, or your abilities has changed? Do
people who know you well notice that anything is different about you since the
accident? What might they notice?
What do you see as your problems, if any, resulting from your injury? What is the
main thing you need to work on/would like to get better?

Physical abilities (e.g., movement of arms and legs, balance, vision, endurance)?
Problem-solving, decision-making, organizing and planning things?
Controlling behavior?
Getting along with other people?
Has your personality changed?
Are there any other problems that I haven’t mentioned?

2. Self-awareness of functional implications of deficits

Does your head injury have any effect on your everyday life? In what way?

Ability to live independently?
Managing finances?
Look after family/manage home?
Leisure/social life?
Are there any other areas of life which you feel have changed/may change?

3. Ability to set realistic goals

What do you hope to achieve in the next 6 months? Do you have any goals? What are
In 6 months time, what do you think you will be doing? Where do you think you will
Do you think your head injury will still be having an effect on your life in 6 months
time? If yes, how? If no, are you sure?

Figure 4-4  Self-awareness of deficits interview. (From Fleming JM, Strong J, Ashton R: Self-awareness of deficits in adults with traumatic
brain injury: how best to measure? Brain Inj 10[1]:1-15, 1996.)

index. Scores range from 0 (very high) to 5 (moder- the number of items rated as more competent by
ate) to 10 (very low) (Figure 4-5). the client as compared with the informant, the same
The Patient Competency Rating Scale (PCRS)59 by the client as compared with the informant, or
evaluates self-awareness following TBI. It is a 30- more competent by the informant than the client.
item self-report instrument that uses a 5-point Clients with more items self-rated as more compe-
Likert scale (1 = can’t do and 5 = can do with tent as compared with informant ratings are con-
ease) to self-rate the degree of difficulty in a vari- sidered to have poor self-awareness. A third scoring
ety of tasks and functions. Three forms are avail- method involves considering the actual magnitude
able including client rating, relative’s rating, and difference between the client and informant rat-
clinician’s rating. The tool has been used with those ings on specific items. Awareness of deficit also may
presenting with various levels of severity of injury.46 be examined separately for the various domains
The client’s responses are compared with those of sampled by PCRS items (activities of daily living,
another such as a relative or therapist. Impaired behavioral and emotional function, cognitive abili-
self-awareness is ascertained from discrepancies ties, and physical function) (Figure 4-6).
between the two ratings (subtracting family or cli- More recently Borgaro and Prigatano11 devel-
nicians ratings from client ratings) or from tallying oped a modified yet still psychometrically sound
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 79


1. Self-awareness of deficits
0 Cognitive/psychological problems (where relevant) reported by the patient/client
in response to general question, or readily acknowledged in response to specific
1 Some cognitive/psychological problems reported, but others denied or minimized/
Patient/client may have a tendency to focus on relatively minor physical changes
(e.g., scars) and acknowledge cognitive/psychological problems only on specific
questioning about deficits.
2 Physical deficits only acknowledged; denies, minimizes or is unsure of
cognitive/psychological changes. Patient/client may recognize problems that
occurred at an earlier stage but denies existence of persisting deficits, or may state
that other people think there are deficits but he/she does not think so.
3 No acknowledgment of deficits (other than obvious physical deficits) can be
obtained, or patient/client will only acknowledge problems that have been
imposed on him/her, e.g., not allowed to drive, not allowed to drink alcohol.

2. Self-awareness of functional implications of deficits

0 Patient/client accurately describes current functional status (in independent living,
work/study, leisure, home management, driving), and specifies how his/her head
injury problems limit function where relevant, and/or any compensatory measures
adopted to overcome problems.
1 Some functional implications reported following questions or examples of
problems in independent living, work, driving, leisure, etc. Patient/client may not
be sure of other likely functional problems, e.g., is unable to say because he/she
has not tried an activity yet.
2 Patient/client may acknowledge some functional implications of deficits but
minimizes the importance of identified problems. Other likely functional
implications may be actively denied by the patient/client.
3 Little acknowledgment of functional consequences can be obtained; the
patient/client will not acknowledge problems: except that he/she is not allowed to
perform certain tasks. He/she may actively ignore medical advice and may not
engage in risk-taking behaviors, e.g., drinking, driving.

3. Ability to set realistic goals

0 Patient/client sets reasonably realistic goals, and (where relevant) identifies that
the head injury will probably continue to have an impact on some areas of
functioning, i.e., goals for the future have been modified in some way since the
1 Patient/client sets goals which are somewhat unrealistic, or is unable to specify a
goal, but recognizes that he/she may still have problems in some areas of function
in the future, i.e., sees that goals for the future may need some modification, even
if he/she has not yet done so.
2 Patient/client sets unrealistic goals, or is unable to specify a goal, and does not
know how he/she will be functioning in 6 months time, but hopes he/she will
return to pre-trauma, i.e., no modification of goals has occurred.
3 Patient/client expects without uncertainty that in 6 months time he/she will be
functioning at pre-trauma level (or at a higher level).

Figure 4-4—Cont’d

version of the PCRS for use on an acute, inpatient completed by the client, one by a significant other,
neurorehabilitation unit. This version retains 13 and one by a clinician). The self-rated and fam-
items from the original PCRS based on their appli- ily/significant others forms contain 17 items and
cability to an inpatient neurorehabilitation unit. the clinician form contains 18 items. The client’s
This modified version has been called the Patient abilities to perform various tasks after the injury
Competency Rating Scale for Neurorehabilitation as compared with before the injury are rated on a
(PCRS-NR) (Figure 4-7). 5-point scale ranging from 1 (“much worse”) to 5
The Awareness Questionnaire (AQ)70,73 is also a (“much better”). Scores range from 17 to 85, and
measure of impaired self-awareness after TBI. The a score of 51 indicates the level of functioning is
instrument consists of three forms (one form is about the same as the preinjury level. Impaired
Table 4-4 Self-Awareness of Deficits Interview
Section Interview Questions Checklist Questions

Section 1: Are you any different now compared Please indicate whether your relative/friend/client
Self-awareness of deficits with what you were like before experiences any difficulties in the following areas
your accident? (i.e., are they any different now compared with
what he or she was like before the injury),
e.g., movement and balance, memory, concentra­
tion, controlling behavior, personality changes, etc.
What do you see as your relative/friend/client’s
main problem(s), if any, resulting from the
Section 2: Does your brain injury have any Does your relative/friend/client experience any
Self-awareness of functional effect on your everyday life? difficulties in the following areas: driving, work,
implications of deficits In what way? risk-taking behaviors?
What type of support/assistance do you feel that
your relative/friend/client needs?
Section 3: What do you hope to achieve in the What does your relative/friend/client hope to
Ability to set realistic goals next 6 months? achieve in the next 6 months?
Do you think your brain injury will Do you believe that such goals are realistic? Why or
have any effect on your life in 6 why not?
months’ time? Have you encountered any difficulty setting realistic
rehabilitation goals in collaboration with your
client? If so, please describe (therapist version

From Simmond M, Fleming J: Reliability of the self-awareness of deficits interview for adults with traumatic brain injury, Brain Inj 17(4):325-337, 2003.

The Format and Questions for the Self-Regulation Skills Interview

Screening question: “Think about the various ways that you may have changed since
your injury. Can you tell me one aspect of yourself that has changed which causes you
the most distress and holds you back in everyday living?”
Main area of difficulty.
1. Emergent awareness: “Can you tell me how you know that you experience (main
difficulty); that is, what do you notice about yourself?”
Prompt: “What else might you notice?”; “So far you’ve told me ______, is there
anything else?
2. Anticipatory awareness: “When are you most likely to experience (main difficulty),
or, in which situations does it mainly occur?”
Prompt: “In what other situations would you expect more or greater (main difficulty)?”;
“So far you’ve told me ______, can you think of anything else?”
3. Motivation to change:* “How motivated are you to learn some different strategies
to help overcome (main difficulty)?”
0 1 2 3 4 5 6 7 8 9 10
“Not at all” “Very motivated”
4. Strategy awareness: “Have you thought of any strategies that you could use to
help cope with your (main difficulty)?” and “What are they?”
Prompt: “What else could you try that might help?”; “So far you’ve told me ______, can
you think of any other strategies?”
5. Strategy use: “What strategies are you currently using to cope with your (main
Prompt: “Can you think of anything else that you are currently using or have tried
recently?”; “So far you have said ______, are there any other strategies you are using?”
6. Strategy effectiveness: “How weel do the strategies that you are using for (main
difficulty) work for you?”
Prompt: “How do you know that they are helpful/unhelpful?”; “Would you notice any
difference if you stopped using the strategies?”
*It is suggested that the phrasing of this question changes after a rehabilitation program
has been completed (e.g., “How motivated are you to keep using the strategies you have

Figure 4-5  Self-regulation skills interview. (From O w nsworth TL, McFarland KM, Young RM: Development and standardization of the
Self-regulation Skills Interview (SRSI): a new clinical assessment tool for acquired brain injury, Clin Neuropsychol 14(1):76-92, 2000.)
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 81

self-awareness is determined by a discrepancy score solution: emotional/physical, emotional/dysphoria,

(subtracting family/significant others or clinicians and emotional/restlessness.
ratings from self-ratings). The instrument is effi- Anderson and Tranel2 developed the Awareness
cient because it only takes about 10 minutes to Interview to evaluate awareness of cognitive and
administer. A factor analysis indicates three factors: motor defects after cerebral infarction, dementia, or
cognitive, behavioral/affective, and motor/sensory. head trauma. Operationally, they defined unaware-
Although clients’ self-ratings on the AQ tend not to ness as a discrepancy between the client’s opinion
correlate with family/significant others’ ratings or of his or her abilities in the interview and his or her
clinician’s ratings, family and clinician’s ratings do  abilities as measured in neuropsychological and
correlate (Table 4-5).74 While all investigations of neurologic examinations. The Awareness Interview
the AQ up to this point have studied people with comprises eight questions, each of which is evalu-
TBI, the tool may be appropriate for use with peo- ated on a 3-point scale (3 = the patient reports
ple with other types of acquired brain injury such that he/she is unimpaired in a particular area, 2 =
as stroke, tumor, and so on. Further investigation is the patient indicates minimal impairment, 1 = the
warranted for use with other diagnoses. patient indicates a significant impairment). The
The Patient Distress Scale12 is an 11-item self- scores can have various interpretations based on
report questionnaire specifically designed to the clinical scenario. For example, a score of 3 may
assess awareness of emotional disturbances dur- indicate that thre is no impairment and the patient
ing acute recovery from brain injury. Clients are is reporting accurately or an impairment exists and
asked to rate their level of distress since injury on the patient is not reporting it accurately. Only the
a 4-point Likert scale (0 = no problem; 4 = severe later situation influences the ratings.2 The follow-
problem). A relative version of the scale allows for ing domains are included: reasons for hospitaliza-
comparison. A factor analysis yielded a three-factor ­  tion, awareness of motor impairments, awareness

Figure 4-6  Patient competency rating scale. A, Clinician’s form. (From Prigatano GP: Neuropsychological rehabilitation after brain
injury, Baltimore, 1986, Johns Hopkins University Press.)
(Continued )
82 cognitive and perceptual rehabilitation: Optimizing function

Figure 4-6—Cont’d
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 83

Figure 4-6—Cont’d  Patient competency rating scale. B, Client’s form.

(Continued )
Figure 4-6—Cont’d  Patient competency rating scale. C, Relative’s form.
Figure 4-6—Cont’d 
86 cognitive and perceptual rehabilitation: Optimizing function

Figure 4-7  Patient Competency Rating Scale for Neurorehabilitation (PCRS-NR). (From Borgaro SR, Prigatano GP: Modification of the
Patient Competency Rating Scale for use on an acute neurorehabilitation unit: the PCRS-NR, Brain Inj 17[10]:847-853, 2003.)

of cognitive defects in the areas of general think- standardized neurologic and neuropsychological
ing and intellect, orientation, memory, speech and instruments (Box 4-1).
language, and visual perception, and the client’s The Assessment of Awareness of Disability
opinion of his or her performance in the tests and (AAD)44,84 is an assessment based on a semistruc-
ability to return to normal activities. Unawareness tured interview, which is used in conjunction
is determined by the discrepancy between the cli- with the Assessment of Motor and Process Skills
ent’s description of his or her abilities and mea- (AMPS)24,25 (see Chapter 1). It consists of general
surement of those abilities based on findings from and specific questions related to activities of daily
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 87

Table 4-5 Awareness Questionnaire

Item Load

Factor 1 (Cognitive)
How good is your memory for recent events now compared with before your injury 0.77
How good are you at keeping up with the time and date and where you are now compared with before 0.70
your injury
How well can you concentrate now compared with before your injury? 0.69
How well can you express your thoughts to others now compared with before your injury? 0.58
How well can you do on tests that measure thinking and memory skills now compared with before your injury? 0.54
How well organized are you now compared with before your injury? 0.48
How good is your ability to live independently now compared with before your injury? 0.44

Factor 2 (Behavioral/Affective)
How well adjusted emotionally are you now compared with before your injury? 0.67
How good are you at planning things now compared with before your injury? 0.64
How well can you keep your feelings in control now compared with before your injury? 0.64
How well do you get along with people now compared with before your injury? 0.64
How good is your ability to manage money now compared with before your injury? 0.62
How well can you do the things you want to do in life now compared with before your injury? 0.51

Factor 3 (Motor/Sensory)
How well can you move your arms and legs now compared with before your injury? 0.68
How well are you able to see now compared with before your injury? 0.66
How good is your coordination now compared with before your injury? 0.64
How well can you hear now compared with before your injury? 0.54

From Sherer M, Bergloff P, Boake C, et al: The Awareness Questionnaire: factor structure and internal consistency, Brain Inj 12(1):63-68, 1998.

Box 4-1 Awareness Interview

I. Awareness of the reason for the hospitalization 2. Patient describes a minimal impairment or motor
Ask, “Why are you in the hospital? What is wrong with function.
you?” If the patient does not explicitly describe the primary 1. Patient complains of a significant motor impairment.
reason for hospitalization, ask (for CVA patients) “Did you
 wareness of impairments of intellect or “thinking
have a stroke?”; (for HT patients) “Did you have an accident
or hit your head?”; (for DEM patients) “Did anything hap-
Ask, “How is your thinking? Are you thinking as clearly as
pen to you, or are you having any difficulties that may have
you normally do?”
brought you in?”
3. Patient describes clear thinking without any notable
3. Patient explicitly denies the primary reason for
changes from the normal state.
2. Patient notes a mild change in one or several aspects
2. Patient admits to, but does not initially state the primary
of thinking (e.g., decreased ability to concentrate, solve
reason for hospitalization.
problems, or respond to situations).
1. Patient describes the primary reason for hospitalization.
1. Patient complains of major difficulty or changes in
II. Awareness of motor impairments thinking.
Question the patient regarding movement of his or her
IV. Awareness of orientation problems
arms and legs, paying particular attention to deficits noted
Ask, “Are you ever confused about where you are or what
in the neurologic evaluation. For example, “How do your
month or year it is?”
arms work? Can you move them normally? Both of them?”
3. Patient indicates no problems with disorientation.
3. Patient denies any motor impairments.
2. Patient indicates disorientation to time or place.

(Continued )
88 cognitive and perceptual rehabilitation: Optimizing function

Box 4-1 Awareness Interview—Cont’d

1. Patient indicates disorientation to the time and place. SCORING
3. Patient denies any problems with visual perception.
V. Awareness of memory impairment
2. Patient describes mild problems with visual perception.
Ask, “Are you having any trouble with your memory?”
1. Patient complains of significant visual perception impairment.
3. Patient denies any problems or changes in memory. VIII. Posttest questions: Awareness of quality of test perfor-
2. Patient describes mild problems with memory, but denies mance and ability to return to normal activities
any significant problems with disorientation of memory. Ask (1) “How do you think you did on these tests today?”
1. Patient describes significant problems with memory. (2) “Based on how you are doing now, do you think you
will be able to return to your normal activities in the next
VI. Awareness of speech or language problems several weeks?” (Specify activities based on the patient’s
Ask, “How is your speech? Has it been affected at all? Do current circumstances, i.e., employment, hobbies, activities
you have any difficulty understanding what other people or daily living.)
SCORING 3. Patient indicates that test performances were normal
3. Patient denies any speech or language problems. and that there will be no problem returning to normal
2. Patient describes mild speech or language problems activities.
(e.g., word finding problems, slurring). 2. Patient indicates that either (a) test performance was
1. Patient complains of impaired comprehension, aphasic defective, or (b) that there will be difficulty returning to
speech, or severe dysarthria. normal activities, but not both.
VII. Awareness of visual perceptual problems 1. Patient indicates that test performance was defective and
Ask, “Are you having any trouble with your vision?” that there will be difficulty returning to normal activities
in the next several weeks.

From Anderson SW, Tranel D: Awareness of disease states following cerebral infarction, dementia, and head trauma: standardized assessment,
Clin Neuropsychol 3:327-39, 1989.

living (ADL) tasks and the interview is conducted For example, O’Keeffe and coworkers51 measured
after performance of each AMPS task (Box 4-2). online emergent awareness via asking participants
Similar to the AMPS, the AAD was developed to be to indicate each time they made a mistake by say-
used with a client-centered and top-down approach ing the word “hit” to demonstrate awareness of the
in intervention planning (see Chapter 1). The AAD, error during a cognitive task. The same researchers
in conjunction with the AMPS, is used to identify assessed anticipatory awareness by having partici-
areas in occupational performance of which the cli- pants being tested predict their performance and
ent is more or less aware. It measures awareness of then compared the discrepancy between predicted
disability by assessing the discrepancy between the performance and actual performance using the
observed level of skill and the experience reported formula [(Prediction – performance)/prediction
by the person being tested. It provides information × 100].
for selecting, planning, and implementing different Hart and colleagues36 examined those with
intervention strategies. The AAD is also used for brain injury as they completed everyday activities.
measuring improvements in awareness of disabil- Errors on these tasks was scored as to whether
ity over time. Preliminary testing of the instrument the subject corrected it and whether the subject
was conducted with those living with a stroke. otherwise demonstrated awareness of the error.
Although most assessments that use question- Error scores were also compared with subjects’
naires or interviews only measure intellectual responses to a questionnaire in which they rated
awareness, there are fewer standardized measures their own performance. The authors found that
that incorporate measures of online (anticipatory those with TBI corrected and showed awareness of
and/or emergent) awareness).77 An exception is the proportionally fewer of their errors as compared
Self-Regulation Skills Interview described earlier.  with controls. In addition, despite making more
It is typically recommended that online awareness errors than control subjects, those with TBI did
be assessed via observations of task performance not rate themselves as performing more poorly
coupled with questions from the clinician.77 with respect to its cognitive demands. The authors
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 89

Box 4-2 Assessment of Awareness of Disability

Scoring 2. Can you describe whether you experienced any specific
4 p = The client has a completely realistic opinion about his difficulties during the performance (in specific steps of
or her disabilities (can describe exactly his or her difficulties in the task)?
the Assessment of Motor and Process Skills [AMPS] task). 3. Can you describe how you needed to do the task in a new
3 p = The client has a realistic opinion about his or her way compared with how you used to do it at home?
disabilities in general, but cannot describe the difficulties 4. Can you describe how you managed to use your left and
in detail. right hand in this task? Did you have any difficulties?
2 p = The client has a somewhat unrealistic opinion 5. Can you describe how you managed to move or trans-
about his or her abilities (overvalues his or her abilities or fer your body during the task performance (stand, walk,
underestimates his or her disabilities). or use the wheelchair)? Did you have any difficulties? (If
1 p = The client has a very unrealistic opinion about his transferring is not included in the AMPS task, the occupa-
or her abilities (greatly overvalues his or her abilities or tional therapist (OT) should ask how the client managed
greatly underestimates his or her disabilities). to transfer when he or she came into the room before
0 p = The client completely denies his or her disabilities. the AMPS task).
6. Did you have any difficulties in remembering what you
Test Items (Questions) should do or how you should organize the task, or to do
1. How do you think you managed to perform the task if the steps in the right order?
you compare it with how you used to manage at home, 7. Did you have any problems in seeing, finding, or locating
before you had your stroke? the objects you needed to use in the task?

From Tham KB, Bernsprang B, Fisher AG: Development of the assessment of awareness of disability, Scand J Occup Ther 6(4):184-190, 1999.

concluded that error detection and correction can • Why are you here?
be reliably measured during naturalistic action. • What is the matter with you?
Jehkonen and associates42 recently reviewed the • Is there anything wrong with your arm or leg?
methods used to assess anosognosia for noncognitive • Is it weak, paralyzed, or numb?
impairments after stroke. Their review highlighted • How does it feel?
many inconsistencies related to assessment. The most • What is this? (arm picked up)
commonly used assessments are discussed in the fol- • Can you lift it?
lowing paragraphs. The Anosognosia Scale suggested • You clearly have some problem with this?
by Bisiach and colleagues9 is frequently used to objec- • Can’t you see that the two arms are not at the
tify lack of awareness related to motor involvement same level? (asked to lift arms)
(hemiplegia) and visual field deficits after stroke. The • Do you ever feel that it belongs to someone else?
rating scale is as follows: • Do you ever call it names?
• Grade 0 (no anosognosia): The disorder is sponta- • Do you ever feel a strange arm lying beside you,
neously reported or mentioned by clients follow- separate from the real arm?
ing a general question about their complaints. Starkstein and colleagues’82 Anosognosia Ques­
• Grade 1: The disorder is reported only follow- tion­naire was developed to objectify anosognosia
ing a specific question about the strength of the for motor and visual deficits. The tool consists of
client’s limbs six general questions about the client’s motor and
• Grade 2: The disorder is acknowledged only after visual deficits: Why are you here? What is the mat-
demonstrations through routine techniques of ter with you? Is there anything wrong with your
neurologic examination arm or leg? Is there anything wrong with your eye-
• Grade 3: No acknowledgment of the disorder sight? Is your limb weak, paralyzed, or numb? and
can be obtained How does your limb feel? In addition, it includes
Cutting’s Anosognosia Questionnaire19 was five questions that are used when denial is elicited:
developed for the purposes of studying anosog- What is this? (arm picked up) Can you lift it? You
nosia in clients with hemiplegia after stroke. The clearly have some problem with this? Can’t you see
instrument consists of general questions concern- that the two arms are not at the same level? (asked
ing the disease and specific questions concerning to lift both arms), and Can’t you see that you have
the affected limb. a problem with your eyesight? (asked to ­ identify
90 cognitive and perceptual rehabilitation: Optimizing function

f­ inger movements in and out of the abnormal • Encouraging the participants to describe their
visual field). Responses are rated as 1, no anosog- anticipated difficulties.
nosia (current disorder spontaneously reported or • Linking their earlier experiences of disability to
mentioned after a general question about the cli- new tasks.
ent’s complaint); 2, mild anosognosia (current dis- • Planning how they would handle new situations.
order reported only after a specific question about • Asking the participants to evaluate and describe
the strength of the client’s limb or the presence their performance.
of visual field deficits); 3, moderate anosognosia • Asking participants to think about whether they
(current disorder acknowledged only after its dem- could improve their performance by performing
onstration through the routine techniques of neu- the task in another way.
rologic examination); and 4, severe anosognosia • Providing feedback about the observed difficul-
(no acknowledgment of the disorder after asking ties including verbal feedback, discussion and use
the client about specific impairments and demon- of compensatory techniques that could improve
strating the existence of either motor or visual field task performance.
deficits). • Providing opportunities for further task practice
Subsequent chapters will highlight assessments using newly learned compensatory techniques.
that are used to ascertain awareness for specific • Utilizing video feedback to improve awareness
impairments such as the Catherine Bergego Scale5,7 (see below).
to assess the awareness of the effect of neglect on • Utilizing interviews to reflect on and heighten
daily activities, the Dysexecutive Questionnaire14,95,96 awareness.
to ascertain awareness related to dysexecutive symp­ Using this approach, awareness of disabilities and
toms, and the Cognitive Failures Questionnaire (see ADL ability improved in all four participants, unilat-
Chapters 6, 8 and 10).13 Table 4-6 gives a summary eral neglect decreased in three participants, and sus-
of assessments. tained attention improved in two participants. The
authors concluded that training to improve aware-
ness of disabilities might improve the ability to learn
the use of compensatory techniques in the perfor-
Although most researchers and scholars agree that mance of ADL in clients with unilateral neglect.
interventions focused on improving awareness are Fleming and coworkers26 completed a pilot study
critical to maximize rehabilitations and that greater examining the effect of an occupation-based inter-
awareness of deficits is associated with better treat- vention program on the self-awareness and emo-
ment outcomes,52 others have documented func- tional status of four men after acquired brain injury.
tional changes via task-specific treatment without Each participant received an individualized program
concurrent improvements in awareness. The fol- that focused on the performance of three client-
lowing paragraphs expand on these points. Overall, chosen occupations (e.g., writing a job application,
there is a lack of empirical studies that have exam- budgeting, meal preparation, playing lawn bowl-
ined the effectiveness of various interventions ing, cooking with one hand, etc.) for which they had
aimed at improving awareness. In addition, many decreased awareness according to significant oth-
of the published studies have not included func- ers. The intervention was based on Toglia’s multi-
tional outcomes. contextual approach88,90 (see Chapter 1). Techniques
included providing a nonthreatening environment to
build positive therapeutic alliances, having the par-
Improving Awareness Using Occupation
ticipants analyze underlying skills, self-predict, self-
Tham and associates86 developed an interven- evaluate preoccupation and postoccupation, setting
tion to improve awareness related to the effect of “just the right challenge,” supported and structured
neglect (see Chapter 6) on functional performance. ­occupational performance, brain injury education,
Purposeful and meaningful (for the participant) timely and nonconfrontive verbal feedback in a sand-
daily occupations were used as therapeutic change wich format (negative comments are preceded and
agents to improve awareness of disabilities. Specific followed by positive feedback), and video feedback.
interventions included encouraging the ­participants Repeated measures of participants’ self-awareness
to choose motivating tasks as the modality of inter- and emotional status were taken preintervention and
vention and discussions around task performance. postintervention, and analyzed descriptively. The
Examples include: authors found that their results indicated preliminary
Chapter 4 Self-Awareness and Insight: Foundations for Intervention 91
Table 4-6 Recommended Outcome Measures of Awareness
Dimension Based
on International
Classification of
Author Instrument Population Validity Reliability Function (ICF) Comments

Fleming et al, Self-Awareness of Deficits Adults with traumatic Correlated with the Inter-rater: Intra-class Impairment Measures intellectual
199630,78 Interview brain injury Self-Regulation Skills correlation coefficient awareness via a rating
Interview and the (ICC) = 0.85 scale
Awareness Questionnaire Test-re-test: ICC = 0.94 Rated by clinicians
Correlated with work status
Discriminates between
those with brain injury
and spinal injury
Ownsworth et al, Self-Regulation Skills Interview Adults with acquired Discriminates between brain Inter-rater: items range Impairment Rated by clinicians
200055 brain injuries injured and non–brain from 0.81 to 0.92 As area of difficulty is
injured subjects Test-retest: items range determined by the
Correlated with the Self- from 0.69 to 0.91 client, it requires a
Awareness of Deficits level of intellectual
Interview and Health and awareness and
Safety Scale includes items related
Correlated with work status to emergent and
anticipatory awareness
Prigatano, Patient Competency Rating Scale Adults with traumatic Factor analysis reveals Test-retest: = 0.85-0.97 Impairment Measures intellectual
198659 brain injury 6 discrete factors Internal consistency: awareness via a
supporting content Cronbach’s alpha ranges discrepancy score as
validity from 0.91-0.95 compared with others’
Moderately correlated Inter-rater reliability = 0.92 ratings
with the Awareness for staff version Includes 3 forms (client,
Questionnaire relative, clinician)
Differentiates between those Used for those with variety
with and without brain of cultural backgrounds
damage Brief version (13 items) is

92 cognitive and perceptual rehabilitation: Optimizing function
Table 4-6 Recommended Outcome Measures of Awareness—Cont’d
Dimension Based
on International
Classification of
Author Instrument Population Validity Reliability Function (ICF) Comments

Sherer et al, Awareness Questionnaire Adults with traumatic Predictive of eventual Internal consistency: Impairment Measures intellectual
199870 brain injury productivity outcome for Cronbach’s alpha = 0.93 awareness via a
and others with traumatic brain injury (self-rated) and 0.87 discrepancy score as
acquired brain (TBI) (relative ratings) compared with others’
damage Sensitive to differences in ratings
client, family/significant Includes 3 forms (client,
other, and clinician significant other/family,
ratings clinician)
Discrepancy scores are
correlated with injury
severity and scores on
the Self-Awareness of
Deficits Interview
Borgaro et al, Patient Distress Scale Adults with acute Not reported Internal consistency: Impairment Measures intellectual
200311 head injuries Cronbach’s alpha for awareness via a
total scale = 0.82 (client) discrepancy score as
and 0.86 (relatives) compared with others’
Test-retest: r = 0.97 (client) ratings
and 0.93 (relatives) Emphasis is on awareness
of emotional
Anderson and Awareness Interview Those living with Correlated in the expected Inter-rater = 0.92 Impairment Measures intellectual
Tranel, 19892 stroke, dementia, direction with the awareness via a
and head trauma Wechsler Adult discrepancy score
Intelligence Scale and compared with
measures of temporal performance on
disorientation standardized neurologic
Kottorp and Assessment of Awareness of Those living with a A Rasch analysis suggested A Rasch analysis suggested Impairment as it relates Used in conjunction with
Tham, 200544 Disability lack of awareness acceptable scale validity, acceptable rater to activity limitations the Assessment of
Tham et al, 199984 related to construct validity, and reliability Motor and Process
occupational person response validity Skills (AMPS)
Chapter 4  Self-Awareness and Insight: Foundations for Intervention
B ergeg o, 19957 Catherine Bergego Scale (CBS) Adults with unilateralBoth conventional statistics Interrater: 0.59-0.99 Activity limitations Has been used as a
Azouvi, 20035 Examines the presence of neglect neglect and Rasch analysis self-assessment with
related to direct observation suggest that the CBS results compared with
of functional activities such is valid, and that the therapist ratings to
as grooming, dressing, 10 items define a objectify anosognosia
feeding, walking, wheelchair homogeneous construct (lack of awareness)
navigation, finding belongings, Concurrent validity:
positioning self in a chair, etc. correlates well with pen-
and-paper tests; more
sensitive than pen-and
-paper tests
Wilson et al, Dysexecutive Questionnaire Those presenting Scores by independent Test-retest: 0.7 using a Impairments assessed DEX-C is available to use
199695 (DEX) with executive raters correlated Huntington’s disease during reflection of with children
Burgess, et al, 20-item questionnaire sampling dysfunction significantly with both sample everyday functioning Self-rating and ratings by
199614 everyday symptoms secondary to subtests and overall Cronbach’s alpha = >0.8 significant others are
associated with executive neurologic scores on the Behavioral using a sample of those compared to ascertain
function impairments; disorders such Assessment of the with Parkinson’s disease level of awareness
self-rating and ratings by as head injury, Dysexecutive Syndrome
significant others versions are stroke, Parkinson’s (BADS)
available disease, No associations between
Huntington’s self-report on the DEX
disease, etc. and the BADS, most
Has been used probably secondary to
with those living problems with insight
schizophrenia as
Broadbent et al, Cognitive Failures Questionnaire Used with multiple Predicts car accidents, Stable test-retest reliability Activity limitations Includes items related to
198213 Self-report measure of the populations workplace safety, memory, attention, and
frequency of lapses of including those falls, etc. executive dysfunction
attention and cognition in with brain injuries Self-rating and ratings by
daily life significant others are
compared to ascertain
level of awareness


cognitive and perceptual rehabilitation: Optimizing function
Table 4-6 Recommended Outcome Measures of Awareness—Cont’d
Dimension Based
on International
Classification of
Author Instrument Population Validity Reliability Function (ICF) Comments

Árnadóttir, 19903; A-ONE: 16 years and older Content: via expert review Inter-rater: 0.84 Impairments and Includes item related to
20044 Árnadóttir Occupational Therapy- with central and literature review Test-retest: 0.86 activity limitations insight
ADL Neurobehavioral Evaluation nervous system Concurrent: Barthel Index, Use behavioral
Structured observation of involvement Katz Index, Mini Mental observations
basic activities of daily living Status Examination Scoring criteria captures
(ADL) including feeding, Valid for multiple diagnoses ability to self-correct
grooming and hygiene, including: stroke, brain or not.
dressing, transfers and tumor, dementia, etc. Requires training.
mobility to determine the
effect of multiple underlying
impairments, neglect on these
Fisher, 200324,25 Assessment of Motor and 3 years old and up Strong validity and Cronbach’s alpha range Activity limitations Provides information
Process Skills (AMPS), and difficulties appropriate to use with from 0.74 to 0.93 related to how
An observational assessment that related to multiple diagnoses and Test-retest range from 0.7 impairments of motor
is used to measure the quality occupational cultures to 0.91 and process skills affect
of a person’s ADL assessed performance everyday living
by rating the effort, efficiency, Requires training
safety, and independence of
16 ADL motor and 20 ADL
process skill items
Includes choices from 85 tasks
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 95

s­ upport for the effectiveness of the program in using tactile discrimination with the right hand to
facilitating participants’ self-awareness, although find the left edge of the tray and systematically place
baseline and follow-up data indicated a complex and the “buns” from left to right. Both groups were pro-
inconsistent picture. Of note is that slight increased vided with the same compensatory strategy. Short
anxiety was found to accompany improvements in term follow-up three hours later revealed that the
participants’ self-awareness in all four cases and slight video feedback group improved significantly on the
increases in depressive symptoms were noted for three baking tray test without generalization to other mea-
participants. These findings are consistent with the sures, whereas conventional training had no effect
literature discussed earlier focused on the relationships on the task or on other neglect measures.
between emotional status and awareness as well as the Soderback and colleagues79 had similar results
interconnections of denial and self-awareness. in an earlier study that focused on functional tasks.
Landa-Gonzalez45 describes a multicontextual88,90 Using a single-case research experimental pretest,
(see Chapter 1), community reentry occupational posttest, and follow-up design, three household
therapy program focused on awareness training tasks were assessed, and the clients’ neglect behav-
and compensation for cognitive impairments in a  ior while performing these tasks was video recorded.
34-year-old man 8 years after a traumatic brain During the intervention, the subjects watched the
injury. His impairments consisted of decreased film, which was stopped by the occupational ther-
insight, planning, mental flexibility, problem solving, apist where the neglect behavior was significant.
and memory. The client showed some level of intel- Through dialogue, the subjects were led to perceive
lectual awareness but his emergent and anticipatory and interpret their neglect behavior, and strategies
awareness were severely impaired. Interventions for relearning and remediation were recommended.
were carried out in the home and community The program was deemed to be effective for relearn-
and consisted of metacognitive training, explora- ing functional tasks.
tion and use of effective processing strategies, task
gradations, and practice of functional activities in
Use of a Game Format
multiple environmental contexts. Awareness train-
ing was carried out in conjunction with daily activ- Zhou and coworkers99 tested the feasibility of using
ities such as self-care, cooking, household chores, a game format to teach information about acquired
banking, shopping, planning vacations, and so on. brain injury. The authors examined three adult males
Specific strategies such as self-prediction using a with brain injuries as they were trained in knowl-
rating scale, self-monitoring for error detection, role edge of brain injury residuals, using a trivia game
reversal, and the use of checklists to facilitate orga- format to present training information. Questions
nization were used. Feedback was given related to were divided into categories that represented typi-
planning and monitoring skills, and discrepancies cal impairments and residuals after brain injury
between predicted scores and actual performance (e.g., “What difficulty might you have if you can-
were used. Results showed improvements in the cli- not remember information presented a few seconds
ent’s awareness level, enhancement of occupational ago?” and “What does decreased frustration toler-
function, increased satisfaction with performance, ance mean?”). Using a multiple baseline experimen-
and a decrease in the level of attendant care. tal design, the study found that all three participants
increased their percentage of correct responses in
the study areas of: behavior emotion, cognition,
Video Feedback to Improve Awareness
communication, and physical and sensory residuals.
Video feedback has been used to increase awareness Further analyses revealed that subjective data related
of errors made secondary to unilateral neglect (see to the effect of these improvements on participant
Chapter 6). Tham and Tegner87 compared the effects functioning were not consistent.
of a video procedure and a conventional verbal pro- Chittum and associates16 also used a board game
cedure in giving subjects feedback on their neglect format to teach awareness to adults with acquired
behavior during a contrived task, the baking tray brain injury who exhibited serious unwanted behav-
task. After watching the video of their performance, iors. It used an individualized training package based
subjects were asked to comment on their own per- on specific needs of each participant in conjunc-
formance and results, as was the therapist. In addi- tion with a game format in order to more specifi-
tion, they were asked to develop strategies to improve cally target individual client awareness of personal
performance, and the therapist gave ­suggestions on cognitive and behavioral deficits. The authors felt
96 cognitive and perceptual rehabilitation: Optimizing function

that a focus on individual needs would not only be a­ wareness deficits. The intervention involved a meta-
more effective than focusing on general brain injury cognitive contextual intervention based on a con-
behaviors but would reduce the time of the inter- ceptualization of neurocognitive, psychological, and
vention and therefore the frustration of participants. socioenvironmental factors that may contribute to
Training focused on knowledge (e.g., “True or false: awareness deficits. The intervention focused on improv-
Immediate memory includes recalling things that ing error awareness and self-correction during cli-
happened hours ago”), comprehension (e.g., “How ent-selected goals of cooking at home and performing
does having decreased problem-solving skills affect volunteer work. Interventions included the following:
your life, and give an example from your life that • A systematic feedback approach was used to
occurred recently”), and application using role-play target error behavior (self-monitoring and
exercises (e.g., “Pretend I am your employer and I ­correction). Feedback was based on the “pause/
just gave you a warning about not following through prompt/praise” technique.49 Specifically this
with the task I had asked you to do several days included delayed responses to errors detected by
ago. How would you explain your failure to follow the observer to provide an opportunity for the
through given your deficits?”). The game was pre- participant to self-correct or attempt to correct,
ceded by a short group information and discussion using nonspecific prompts (e.g., “Can you stop
period teaching the members the behavioral or cog- and tell me what you are doing?”) if error cor-
nitive deficit areas that affected the group. Correct rection did not occur after the pause, and the
answers were reinforced in an individualized fash- use of a specific prompt (e.g., “Can you check
ion. Generalization was probed by asking questions the recipe and see what goes in the mixing bowl
regarding behaviors that had not yet been taught. All first?”) if correction did not occur after the non-
three participants responded favorably to training, specific cue. Of note is that Toglia89 also recom-
as evidenced by increases in percentage of questions mend the use of systematic cues that were graded
answered correctly during the game sessions and in from general to more specific as a method to cue
pregeneralization and postgeneralization probes in for insight, error detection, and strategy devel-
both cognitive and behavioral categories. opment (Table 4-7).
• The therapists provided opportunities for the
client to identify and correct his errors or receive
Promoting Error Awareness and Self-Correction
systematic external prompts for correction as
During Functional Tasks
Ownsworth and colleagues54 used a single-case experi- • Education was provided for the client’s social
mental design to test an intervention to improve daily supports.
function of a 36-year-old man 4 years after a severe • Opportunities for task-specific cooking practice
traumatic brain injury who demonstrated ­ long-term with family supervision was provided.

Table 4-7 Prompting Procedures to Promote Awareness of Errors During Functional Activities
Prompts Rationale

“How do you know this is the right answer/procedure?” Refocuses client’s attention to task performance and error
or “Tell me why you chose this answer/procedure.” detection. Can client self-correct with a general cue?
“That is not correct. Can you see why?” Provides general feedback about error but is not specific.
Can client find error and initiate correction?
“It is not correct because…” Provides specific feedback about error. Can client correct error
when it is pointed out?
“Try this [strategy]” (e.g., going slower, saying each step Provides client with a specific, alternate approach. Can client use
out loud, verbalizing a plan before starting, or using a strategy given?
Task is altered. “Try it another way.” Modifies task by one parameter. Can client perform task?
Begin again with grading of prompting described previously.

From Brockmann-Rubio K, Gillen G: Treatment of cognitive-perceptual impairments: a function-based approach. In Gillen G, Burkhardt A, editors: Stroke
rehabilitation: a function-based approach, ed 2, pp. 427-446, St Louis, 2004, Elsevier/Mosby. Modified from Toglia JP: Attention and memory. In Royen CB,
editor: AOTA self-study series: cognitive rehabilitation, Rockville, Md, 1993, American Occupational Therapy Association; Toglia JP: Generalization of treat-
ment: a multicontext approach to cognitive perceptual impairment in adults with brain injury, Am J Occup Ther 45:505, 1991.
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 97

• Role reversal techniques were used. The client ­ erformance on a functional task before per-
observed his mother cooking as she made similar forming it. During task performance, the par-
errors. The client was encouraged to describe his ticipants were reminded to monitor their
mother’s errors and corrective actions. This was performance. Feedback was given on comple-
followed by the client making the same meal. tion of the task and participants were asked to
• An electronic timer was used to alert the client set short-term goals based on their performance
to periodically check his recipe. The timer was of the task.
eventually withdrawn. 3. Practicing the processes related to self-awareness
• Videotape feedback was used to allow the client such as self-prediction, self-monitoring, judgment,
to observe his performance, identify his errors, and practice of goal setting as described earlier.
and describe corrective actions. Preintervention and postintervention outcome
• Similar techniques were used to provide feed- measures taken from the two groups were com-
back on volunteer work activities. pared. The participants in the experimental group
The authors’ chosen outcome measures included demonstrated significant improvement in their
behavioral observation of error behavior and stan- level of awareness as compared with the control
dardized awareness measures. The client demon- group. However, the functional outcomes of the
strated a 44% reduction in error frequency and participants in experimental group did not show
increased self-correction. Although no spontane- significant differences. The authors concluded that
ous generalization was evident in the volunteer their program promoted improvement in the level
work setting, specific training in this environment of self-awareness of people with traumatic brain
led to a 39% decrease in errors. The client later injury and that new programs can be further devel-
gained paid employment and received brief meta- oped to extend carryover treatment effects to func-
cognitive training in his work environment. Also tional improvement in daily activities.
of note is that the client’s global self-knowledge of
deficits assessed by self-report was unchanged after
Managing a Lack of Awareness of
the program. The authors concluded that the study
Memory Deficits
provides preliminary support for a metacognitive
contextual approach to improve error awareness Rebmann and Hannon68 examined the use of an
and functional outcome in real-life settings. intervention for reducing unawareness of memory
deficits in adults with brain injury. The authors
defined unawareness as high predicted test scores
An Awareness Intervention Program
on a brief multiparametric memory test, relative
Cheng and Man15 developed and evaluated a sys- to actual test scores. The intervention consisted
tematic intervention program for the management of an estimation technique, feedback, and explicit
of impaired self-awareness in people with trau- positive reinforcement for decreases in discrep-
matic brain injury. The authors randomly assigned ancies between predicted and actual scores to
subjects to an experimental group (an Awareness reduce unawareness. During the intervention
Intervention Program) and a control group (con- phase, participants were shown what they pre-
ventional rehabilitation program) according to their dicted related to test performance as compared
admission sequence. The Awareness Intervention with actual performance on the subtests (e.g.,
Program was delivered individually and focused on number of words recalled). Positive reinforce-
the following: ment consisted of verbal praise and lottery tickets
1. Awareness of knowledge of personal deficits via contingent on decrease in the difference between
education and concrete and extensive feedback. predicted scores and actual scores compared with
Specific topics included knowledge of disease previous sessions. Verbal feedback using a prob-
and resultant physical, cognitive, and functional lem-­solving approach and encouraging clients to
conditions. Participants were asked to report on figure out why their predictions did not match
their conditions, and feedback was given to rein- performance was used when differences between
force the true clinical presentation. scores were found. At the end of the intervention,
2. Application of knowledge of deficits related differences between participants’ predicted and
to real-world function via experiential exer- actual scores decreased over time, indicating that
cises to enhance awareness of changes in abil- participants were able to match their predictions
ity. The participants were asked to predict their and their performance.
98 cognitive and perceptual rehabilitation: Optimizing function

Schlund69 examined an intervention for self- ­ erseverative phone calls (which were documented
awareness related to memory impairment, spe- as up to 90 per day), a time-based strategy was used
cifically, the effects of practice and feedback on in which the person was provided two half-hour
self-report and remembering. Several prospective periods for placing phone calls and was encouraged
and retrospective self-reports were obtained by the to generate reasons acceptable as to why these limits
author, to allow an examination of reporting about were appropriate (e.g., polite to others). To limit sex-
past or future recall. A memory questionnaire was ually explicit and suggestive behaviors, daily oppor-
presented and the subject estimated the percentage tunities for feedback about the person’s behavior
of correct answers attained or percent correct that were instituted focused on how others may perceive
would be attained on the recall task. Each session specific instances. The staff did not link these behav-
began with a 24-hour retrospective report (“What iors to the brain injury but instead focused on that
percent correct did you get on the recall task yes- these behaviors might be tolerated in a large city but
terday?”). Next, a prospective report was obtained would not be appropriate or polite for a small town
(“What percent correct will you get on the recall such as where the rehabilitation facility was located.
task today?”). The recall test was then completed The staff did not confront the client about her brain
without feedback and followed by a retrospective injury and they did not collude with her confabula-
report (“Now that we have finished, what percent tions that she was not brain injured or that she had
correct did you get on the recall task?”). The thera- no problems. The phrase “We’ll have to agree to dis-
pist then reviewed the subject’s performance, pro- agree on this point” was used frequently during the
vided correct answers, and reviewed the accuracy of intervention. Marked reductions in inappropriate
reporting. Finally, after the feedback and review, a behaviors were achieved along with a return to sup-
prospective 24-hour report was obtained (“When portive community living. Of note is that despite
we do the recall task again tomorrow, what percent that positive behavior changes, there was no change
correct will you get?”). Results showed that recall in level of awareness.
improved and the magnitude of report-recall dif- The authors concluded that a nonconfrontive
ferences was reduced with practice and feedback. behavioral approach could be successful and is con-
These studies related to awareness and memory sistent with the view that poor awareness is based
used contrived laboratory-type tasks. It is recom- in altered neural systems. They feel that when con-
mended to instead use similar intervention proce- frontation is removed, clients do not have to defend
dures but in the context of meaningful tasks such their position and they realize that support makes
as remembering a grocery list or a series of errands them more effective in their day-to-day life, which
that must completed in a day. becomes further reinforcing. They further state that
“one can no more alleviate anosognosia by having
a person rehearsing their limitations than one can
Behavioral Interventions
alleviate amnesia by having clients rehearse word
Bieman-Copland and Dywan8 argue that ­traditional lists.”
awareness rehabilitation approaches that make use
of direct feedback and education are often ineffective
Use of Feedback
because “they elicit more elaborated and entrenched
confabulatory beliefs as individuals are forced to Coetzer and Corney17 examined those with trau-
defend their position.” They tested an approach for matic brain and stroke to determine the effect
treating people with ­ anosognosia that combines of providing feedback related to the individu-
implementation of behavioral therapy techniques al’s understanding of the injury (self-­awareness)
with the development of a supportive and collabor- on subsequent levels of grief and awareness.
ative therapeutic alliance. They presented case data Participants and family members completed stan-
from a woman with profound anosognosia follow- dardized measures of depression, awareness, and
ing a TBI with right frontal involvement. grief, and reported difficulties after brain injury.
Targeted behaviors (reducing perseverative phone Participants were then given feedback regarding
calls and reducing sexually explicit and sugges- to what extent their ratings differed from family 
tive behaviors) were decreased through behavioral members. The main finding of the study was
interventions, but the emphasis of treatment was on that feedback of self-awareness assessment data
the formation of trusting, nonconfrontational ther- resulted in a decrease of subjective reports of grief
apeutic relationships. To decrease the number of among participants.
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 99

Group Interventions
both within and across treatment sessions, suggest-
Youngjohn and Altman98 developed and tested a per- ing improved awareness of cognitive impairments
formance-based group (self-awareness group) treat- and strengths. The authors also provided some anec-
ment to manage anosognosia and defensive denial dotal evidence that these effects generalized into
manifested in those with various types of brain everyday life such as ability to predict driving ability
pathologies. The group focused on having each or return to work although the effects were not as
of the participants predict their own performance extensive as they were on the specific tasks that were
prior to attempting various cognitive tasks such as a  tested. The authors reported that the team found it
12-word free-recall task and written arithmetic task. helpful to refer back to the performance in the self-
Predictions were written on a blackboard for the awareness group in situations when unrealistic pre-
group to see. The participants then performed the dictions were being made. They also suggested using
task and their responses were scored. The predic- a variety of tasks in the group to facilitate generaliza-
tions were compared with their actual performance tion. Finally, similar to other studies28 that have doc-
in a group format and discrepancies were noted umented interventions to improve awareness, some
and discussed. The findings demonstrated signifi- participants developed a mild reactive depression as
cantly improved self-predictions for performance the treatment progressed.

Box 4-3 Other Suggestions for Improving Awareness

Have clients perform tasks of interest and then provide The development of a strong therapeutic alliance is criti-
them with feedback about their performance. The goal is cal in managing both denial and lack of self-awareness. This
to have clients monitor and observe their behavior more alliance should be open and based on trust. Coaching cli-
accurately so that they can make more realistic predictions ents to make better choices and understand how defensive
about future performance as well as gain insight into their strategies affect daily function.
strengths and weaknesses. Use familiar tasks that are graded to match the person’s
Encourage self-questioning during a task and self-evalu- cognitive level (“just the right challenge”) to develop self-
ation after a task (e.g., “Have I completed all of the steps monitoring skills and error recognition.
needed?”). Provide education related to deficit areas for clients as
Provide methods of comparing functioning preinjury and well as families.
postinjury to improve awareness. Integrate experiential feedback experiences. This method
Use prediction methods. Have the client estimate various has been called “supported risk taking” and “planned fail-
task parameters such as difficulty, time needed for comple- ures” and is used during daily activities to gently demon-
tion, number of errors, and/or amount assistance needed strate impairments. High levels of therapist support are
before, during, or after a task and compare with actual mandatory during this intervention.
results. Monitor for increased signs of depression and anxiety as
Help clients develop and appropriately set their personal awareness increases.
goals. Increase mastery and control during performance of
Allow clients to observe their own performance during daily tasks to increase awareness.
specific tasks (i.e., via videotape) and compare actual per- Use emotionally neutral tasks to increase error
formance to what they state they can do. recognition.
Group treatments and peer feedback may used because Use tasks that offer “just the right challenge” to increase
one person can receive feedback on performance from error recognition/correction.
multiple individuals. Provide feedback in a sandwich format (negative com-
Use role reversals. Have the therapist perform the task, ments are preceded and followed by positive feedback).
make errors, and have the client detect the errors.

Data from Fleming JM, Strong J, Ashton R: Cluster analysis of self-awareness levels in adults with traumatic brain injury and relationship to outcome, J Head
Trauma Rehabil 13(5):39-51, 1998; Klonoff PS, O’Brien KP, Prigatano GP et al: Cognitive retraining after traumatic brain injury and its role in facilitating
awareness, J Head Trauma Rehabil 4(3):37-45, 1989; Lucas SE, Fleming JM: Interventions for improving self-awareness following acquired brain injury,
Austr Occup Ther J 52(2):160-170, 2005; Prigatano GP: Disturbances of self-awareness and rehabilitation of patients with traumatic brain injury: a 20-year
perspective, J Head Trauma Rehabil 20(1):19-29, 2005; Sherer M, Oden K, Bergloff P, et al: Assessment and treatment of impaired awareness after brain
injury: implications for community re-integration, Neurorehabil 10:25-37, 1998; Tham K, Tegner R: Video feedback in the rehabilitation of patients with uni-
lateral neglect, Arch Phys Med Rehabil 78(4)410-413, 1997; Toglia J: A dynamic interactional approach to cognitive rehabilitation. In Katz N, editor: Cognition
and occupation across the life span, Bethesda, Md, 2005, AOTA Press; Toglia JP: Generalization of treatment: a multicontext approach to cognitive percep-
tual impairment in adults with brain injury, Am J Occup Ther 45(6):505-516, 1991; and Toglia J, Kirk U: Understanding awareness deficits following brain
injury, Neurorehabil 15(1):57-70, 2000.
Table 4-8 A Summary of Awareness Intervention Approaches Based on an Integrated Biopsychosocial Approach
Bases for Unawareness Specific Factor Contributing to Awareness Deficits Corresponding Treatment Guidelines and Intervention Components

Neurocognitive factors Damage to the right hemisphere or parietal regions Select key tasks and environments in which awareness behaviors are most
(domain-specific awareness deficits), frontal systems important within everyday activities and roles

cognitive and perceptual rehabilitation: Optimizing function

or diffuse brain injury (global awareness deficits and Provide clear feedback and structured opportunities to help people evaluate their
difficulty self-monitoring and assimilating experiences into performance, discover errors, and compensate for deficits
self-knowledge) Focus on habit formation through repetition and procedural or implicit learning
Impaired executive functioning or significant cognitive Specifically train for application outside the learning environment. Be realistic: some
impairment contributing to the onset or maintenance of people might be taught to recognize a mismatch but not retain this experience or
awareness deficits generalize learning
Group therapy, family education and environmental supports to provide external
Psychological factors Information about self is partially or fully recognized but Building the therapeutic alliance to initially get a “foot in the door” with an
may not be disclosed because of premorbid personality individual and validate any frustration or distress
characteristics or coping methods Commence with nonconfrontational approaches such as teaching individuals
a range of adaptive coping strategies (e.g., relaxation techniques) before
attempting to change any maladaptive strategies that may be protecting them
from emotional distress
Enhance perceived control over the therapy process by presenting a lot of choices
and allowing the individual to direct sessions
Psychotherapy and adjustment counseling techniques can help reestablish sense
of self and self-mastery by exploring the subjective meaning of loss and to
acknowledge grief. Techniques for working through grief include reading books
or watching videos, writing a personal story or a poem, artwork, compiling a
photo album or scrapbook, keeping a journal on thoughts and feelings, and
joining a support group
Promote and reinforce acceptance of change and gradually develop modified goals
for the future
Socioenvironmental context Information about self is not disclosed because of concerns Clarify the rationale for the assessment or rehabilitation program and help
about how such information will be used in the referral the person to identify any concerns (e.g., discuss the pros and cons of the
context individual’s being involved in an assessment or rehabilitation program)
Individuals have not had relevant information or meaningful Consider the timing of the intervention and need for safe and supportive
opportunities to observe postinjury changes opportunities to observe postinjury changes. Educate significant others to
Cultural values affect individual’s understanding of the provide appropriate feedback and support. Link people to support or educational
assessment or rehabilitation process groups to provide a positive social context and normalize people’s experiences
Seek advice from a cultural liaison officer and speak to the family and friends of the
individual to develop a shared understanding

From Fleming JM, Ownsworth T: A review of awareness interventions in brain injury rehabilitation, Neuropsychol Rehabil 16(4):474-500, 2006.
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 101

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89. Toglia JP: Attention and memory. In Royeen CB, group approach to the treatment of anosognosia and
editor: AOTA self-studies series: cognitive rehabilita- denial, Rehabil Psychol 34(3):217-222, 1989.
tion, Rockville, Md, 1993, American Occupational 99. Zhou J, Chittum R, Johnson K, et al: The utilization
Therapy Association. of a game format to increase knowledge of residu-
90. Toglia JP: A dynamic interactional approach to cog- als among people with acquired brain injury, J Head
nitive rehabilitation. In Katz N, editor: Cognition and Trauma Rehabil 11(1):51-61, 1996.
occupation across the life span, Bethesda, Md, 2005,
AOTA Press.
Appendix 4-1
Evidence-Based Practice for Awareness Interventions

Table 1 Summary of Research

Study Intervention Description Characteristics n Age

Tham et al, 200184 Awareness training focused on Adults with right-sided  4 Range: 58-76
performance of activities of daily stroke
living (ADL)
Fleming, Lucas, and Using meaningful occupations Adults with chronic  4 23, 32, 37, and 40
Lightbody, 200626 with experiential feedback and acquired brain injury
Landa-Gonzalez, Multicontextual occupational therapy Adult with chronic brain  1 34
200145 injury
Tham and Tegner, Using video feedback to increase Adults with right brain 14 M = 67.9 (SD = 11)
199787 awareness of unilateral neglect damage
Soderback et al, Using video feedback to increase Adults with right  4 50, 65, 69, and 75
199279 awareness of unilateral neglect hemispheric stroke
behaviors during instrumental
activities of daily living (IADL)
Zhou et al, 199699 Using a game format to teach Adults with acquired brain  3 30, 31, and 32
knowledge of residuals after brain injury ranging from
injury 18 months to 10 years
Chittum et al, 199616 A combination of a discussion Adults with acquired  3 19, 23, and 56
and a game format to improve postacute brain injury
Ownsworth et al, Enhancing error awareness during An adult with severe brain  1 36
200654 functional tasks injury
Cheng and Man, Awareness Intervention Program Adults with traumatic brain 21 M = 54.9
200615 injury (TBI)
Rebmann and Techniques (estimation, feedback, Adults with acquired brain  3 20, 21, and 25
Hannon, 199568 and reinforcement) to improve injury (traumatic brain
awareness of memory deficits injury and arteriovenous
malformation rupture)
ranging from 15 months
to 36 months postinjury
Schlund, 199969 Using feedback and review to An adult male 5 years  1 21
improve awareness related to post TBI
memory impairment
Bieman-Copland and Nonconfrontive behavioral approach An adult female with a  1 28
Dywan, 20008 postacute TBI
Coetzer and Corney, Feedback based on discrepancies Adults with various brain 22 M = 41.4, SD = 11.9
200117 between self and caregiver ratings pathologies such as
stroke, trauma, and
brain infection


106 cognitive and perceptual rehabilitation: Optimizing function

Table 1 Summary of Research—Cont’d

Study Intervention Description Characteristics n Age

Youngjohn and Performance-Based Group Approach Adults with various brain  6 Not indicated
Altman, 198998 pathologies such as
stroke, trauma, and
Ownsworth, Group support program Adults with chronic brain 21 M = 33.5, range =
McFarland, and injury (ranging from 22-49
Young, 200056 1-36 years postinjury)

Table 2 Summary of Outcomes

Dimension Based
on International
Study Statistically Classification of
Study Design Outcome Measure Results Valid Function (ICF)*

Tham et al, Single-case Assessment of + for 4/4 N/A Impairment

200184 experimental Awareness of subjects
ABA design Disability
Assessment of Motor + for 4/4 N/A Activity limitations
and Process Skills subjects
Cancellation Task + for 3/4 N/A Impairment
Baking Tray Task + for 3/4 N/A Impairment
Sustained Attention + for 2/4 N/A Impairment
Fleming, Case series Self-Awareness of Inconsistent N/A Impairment
Lucas, and Deficits Interview findings
Lightbody, Patient Competency Inconsistent N/A Impairment
200626 Rating Scale findings
Center for – for 3/4 N/A Impairment
Epidemiological participants
Studies Depression
Hospital Anxiety and − N/A Impairment
Depression Scale
Landa- Case study Canadian + N/A Activity limitations
Gonzalez, Occupational
200145 Performance
Canadian + N/A Activity limitations
Kohlman Evaluation + N/A Activity limitations
of Living Skills
Self-Awareness + N/A Impairment
Chapter 4  Self-Awareness and Insight: Foundations for Intervention 107

Table 2 Summary of Outcomes—Cont’d

Dimension Based
on International
Study Statistically Classification of
Study Design Outcome Measure Results Valid Function (ICF)*

Tham and Quasi- Baking Tray Task + p < 0.02 Impairment

Tegner, experimental Line Cancellation − − Impairment
199787 comparison Figure Copy Task − − Impairment
study Line Bisection − − Impairment
Soderback Single case Performance of + N/A Activity limitations
et al, 199279 research household tasks
experimental Albert’s Test (line + N/A Impairment
design cancellation)
Zhou et al, Multiple Knowledge of + N/A Impairment
199699 baseline acquired brain
design injury
Subjective measure of Inconsistent N/A Activity limitations
daily function results
Chittum et al, Multiple Percentage of + N/A Impairment
199616 baseline questions
design regarding cognitive
and behavioral
deficits answered
Percentage of + N/A Impairment
correctly during
Ownsworth Single subject Decreased error + N/A Activity limitations
et al, 200654 design frequency during
Decreased error + N/A Activity limitations
frequency during
volunteer work
Proportion of self- + N/A Activity limitations
corrected errors
during cooking
Self-Awareness of − N/A Impairment
Deficits Interview
Cheng and Randomized Self-Awareness of + p < 0.01 Impairment
Man, 200615 controlled Deficits Interview
trial Functional − NS Activity limitations
Lawton Instrumental − NS Activity limitations
Activities of Daily
Rebmann and Single subject Decreased differences + N/A Impairment
Hannon, design between predicted
199568 and actual
performance on
memory test

108 cognitive and perceptual rehabilitation: Optimizing function

Table 2 Summary of Outcomes—Cont’d

Dimension Based
on International
Study Statistically Classification of
Study Design Outcome Measure Results Valid Function (ICF)*

Schlund, Case study Recall ability + N/A Impairment

199969 Increased accuracy of + N/A Impairment
self-report related
to recall
Bieman- Case study Reduction in + N/A Activity limitations
Copland perseverative
and phone use
Dywan, Reduction in + N/A Activity limitations
20008 sexually explicit
and suggestive
Coetzer and Pretest-posttest Beck Depression + p < 0.05 Impairment
Corney, Inventory
200117 Clinician’s Rating + p < 0.05 Impairment
Scale for
Youngjohn Pretest-posttest Accurate predictions + p < 0.05 Impairment
and of performance on
Altman, various cognitive
198998 tasks
Ownsworth, Pretest-posttest Head Injury Behavior + p < 0.001 Impairment
McFarland, Scale (relative
and Young, report)
200056 Head Injury Behavior − NS Impairment
Scale (client
Self-Regulation Skills + p < 0.01 Impairment
Sickness Impact + p < 0.05 Quality of life

*Dimension based on World Health Organization’s (WHO) International Classification of Function (ICF). Impairments are problems in body function (physi-
ologic functions of body systems) or structure (anatomic parts of the body such as organs, limbs, and their components) such as a significant deviation or
loss. Activity limitations are difficulties an individual may have in executing activities. Participation restrictions are problems an individual may experience
in involvement in life situations.
+, Improvement in the outcome measure that was beneficial to the participants; −, worsening or no change in status based on the outcome measure.
Chapter 5
Managing Apraxia to Optimize Function

Key Terms
Errorless learning Motor Planning Sequencing
Ideational apraxia Organization Strategy training
Ideomotor apraxia Praxicons
Motor apraxia Praxis

Learning Objectives
At the end of this chapter, readers will be able to: 4. Implement at least five intervention strategies
1. Differentiate between various types of apraxia. focused on decreasing activity limitations and par-
2. Understand how everyday living is affected if apraxia ticipation restrictions for those living with apraxia.
is present.
3. Be aware of evaluation and assessment procedures
related to apraxia.

“Praxis is a uniquely human skill that enables us to interact effectively with the physical world.”5

A   praxia is defined as a disorder of purposeful 

  skilled movement that cannot be attributed to
sensorimotor dysfunction (i.e., weakness, tremor,
5. It can be described by a two-step process that
results in execution of a purposeful activity2,4,5,42:
(1) Conceptual/ideation: provides ­ information
spasticity, loss of joint position sense) or comprehen- related to the overall concept and purpose of
sion deficits.34 While apraxia is the impairment, it refers the task, information related to what to do, an
to a loss of the skill known as praxis. Characteristics overall plan to engage in the task, sequence of
of the praxis system include the following42: actions, and knowledge related to tool use. If an 
1. It is most often lateralized to the left hemi­sphere. adult person without neurologic ­ impairment
2. It serves to store skilled motor information for is placed in front of a meal tray that ­ person
future use. has an understanding of the purpose and goal
3. It facilitates interaction with environment. of the task, understands which utensils to
4. It provides a processing advantage so that new choose, understands how to use them, and can
planning is not required each time an activity is sequence the steps of the task to completion.
started. (2) Production/planning: refers to knowing how

110 cognitive and perceptual rehabilitation: Optimizing function

to perform the task, the implementation of a

Ideational Apraxia
movement sequence including timing and spa-
tial components of movement. A typical per- Apraxia that is related to errors in content dur-
son can plan and program movements to open ing performance is termed ideational apraxia and
containers, cut with a knife, scoop or stir with a is defined as a breakdown of knowledge of what
spoon, manipulate a fork in the hand, and place is to be done to perform—results from loss of a
food in the mouth. neuronal model or a mental representation about
Execution of the task is the output of praxis and the concept required for performance; lack of
relies on sufficient sensory and motor skills to exe- knowledge regarding object/tool us. It also refers
cute the task—enough strength to lift the hand to to sequencing of activity steps or use of objects in
the mouth, no influence of tremor while drinking, relation to each other.3,4 Some authors prefer the
sensory feedback for a piece of bread in your hand. term conceptual apraxia as opposed to ideational
A breakdown of the praxis skills (conceptual or pro- apraxia57 particularly to focus on the problems
duction errors) results in apraxia, whereas a break- related to tool use.35 During functional obser-
down in execution is attributed to a primary motor vations in naturalistic settings, impaired use of
or sensory deficit.3,4 Where the breakdown in func- objects and problems related to the sequence of the
tion occurs (conceptual and/or production and/or task are often observed together,2,4 so for this chap-
execution) dictates the use of different ­intervention ter ideational and ­conceptual apraxia will be used
techniques. synonymously.
Árnadóttir,4 gives the following clinical examples
of ideational apraxia: The person does not know
what to do with toothbrush, toothpaste, or shav-
One of the frustrations of reviewing the literature ing cream; uses tools inappropriately (e.g., smears
related to apraxia is the various definitions and the toothpaste on face); and sequences activity steps
terminology used to describe apraxia.65 These dif- incorrectly so that there are errors in end result of
ferences further emerge based on the country and tasks (e.g., puts socks on top of shoes) (Figure 5-1).
discipline of the authors. Even a cursory review The person does not know what to do related to
reveals the use of multiple terms related to apraxia, the task at hand and has an overall loss of the concept.
such as ideational, motor, constructional, dressing, Clinical observations related to errors during task
ideomotor, kinetic, conduction, limb-kinetic, swal- performance may include the following2,4,14,34,48,51,55:
lowing, oral, bucco-facial, respiratory, conceptual, • Uses familiar objects/tools incorrectly: eats
frontal, axial, and oculomotor. Many of these terms soap, toothbrush is used as hairbrush, attempts
are describing the same impairment; some are used to place sock on head, attempts to maneuver
to specify the body part affected by the impairment, wheelchair by pulling on the arm rest, chews
whereas several are subcomponents of others. Two on a washcloth, brings knife to mouth, does not
of the terms, dressing and constructional apraxia, understand what to do with a cane or walker.
may be misleading and confusing. Although com- Difficulty relating objects to each other such as
monly described in the past, recent analysis of those the relationship between a toothbrush and paste.
living with these particular subtypes of apraxia has This may occur in the presence of a person being
revealed the deficits may be better described as a able to name the objects correctly.
visuospatial deficits secondary to right hemispheric • Tasks requiring use of multiple objects and that
lesions as opposed to a praxis deficit.23 For, example, are multistep are particularly difficult, for exam-
to dress efficiently and independently requires one ple, a morning grooming routine, self-feeding,
to be able to interpret spatial relations so that cloth- or meal preparation
ing is oriented to the body correctly.2,4 The contin- • Does not use object when it is culturally appro-
ued use of these terms as a descriptor of apraxia priate and available: uses finger to brush teeth,
must be questioned. The decision as to which terms eats with fingers when it is inappropriate, stirs
to use in this chapter was based on a review of the coffee with finger
literature and an attempt to be consistent with the • Performance latency (continues the task very
rehabilitation literature that focuses the discussion slowly)
of apraxia on how the different types are related to • Does not initiate the task or does not perform
functional performance.2,4 at all
Chapter 5  Managing Apraxia to Optimize Function 111

Figure 5-1  Manifestations of ideational apraxia during performance of activities of daily living (grooming, mobility, feeding) based on
Árnadóttir’s analysis of errors. A, A client with ideational problems may use a washcloth to wash the sink instead of the face. B, The client
who lacks ideas regarding correct object use uses a toothbrush to comb the hair instead of a brush. C, The client, not having an idea of
what the toothpaste is intended for, attempts to smear it over the face. D, The client’s plan of action is completely disrupted by grasping
an incorrect object, a cup, instead of a toothbrush when reaching for a toothbrush. As a result, the client tries to pour the toothpaste into
the cup, again without having an idea of how to go about it.

• Organization and sequencing deficits such as • Perseveration: making the same mistakes over
misordering or missing steps of the task result- and over and perseverating on components of a
ing in an incorrect end product: washing with- task that was just completed
out water, attempting to drink milk without The conceptual errors and resulting clinical
opening the container, underwear is placed over behaviors described here are observed at the task
pants, disorganized workspace level as opposed to the movement level. Clinicians
112 cognitive and perceptual rehabilitation: Optimizing function

Figure 5-1—Cont’d  E, The client simplifies the activity of washing the face by wetting the hand and using it as an object, in this case, as
a washcloth. F, Organization problem manifested by a client who leaves out one step: removing the toothpaste tube from the box. (From
Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby.)

must differentiate between ideational apraxia and hand-over-hand guidance, may result in the person
other deficits during the clinical reasoning pro- “taking over” and completing the task without dif-
cess. Comprehension must be considered and ficulty. This would not be consistent with ideational
­controlled because apraxia and aphasia may coex- apraxia because problems most often would persist
ist. Using the person’s own tools or objects and throughout the task. The areas of the cortex that, if
performing a purposeful task in the appropriate damaged, may result in conceptual errors include
naturalistic ­ environment and at the appropriate the prefrontal and premotor cortex and the left
time of day decrease the need for substantial ver- inferior parietal lobe.
bal directions. Apraxia/aphasia relationships are
further described later. In addition, primary visual
Ideomotor Apraxia
deficits (such as acuity) and higher order visual
functions (such as visual agnosia or the inability While ideational apraxia is a result of a breakdown
to recognize visual input) must also be considered in the conceptual praxis system, ideomotor apraxia,
(see Chapters 3 and 7). synonymous with motor apraxia,2,4 is a disorder of
Allowing the person to attempt to recognize and the production praxis system and may be defined
use objects appropriately through touch will help as the loss of access to kinesthetic memory patterns
determine the cause of the error. For example, dur- so that purposeful movement cannot be produced
ing a grooming evaluation at the sink, a man with or achieved because of defective planning and
visual agnosia will not be able to recognize objects sequencing of movements, even though idea and
through the visual system leading to him reaching the purpose of task is understood.2,4
out for a comb when in fact the goal of the task is The person knows what to do related to the task
to shave. He will be able to recognize the mistake at hand and has the overall concept of what to do.
as he identifies the object via the tactile system. If language is intact and the person is questioned, he
If praxis is intact, he will either use the comb as a or she can explain the purpose of the task at hand.
comb or put the comb down and continue to search Instead, he or she cannot program, plan, or produce
for the razor. If ideational apraxia is the problem, the movements necessary to accomplish the task
he may use the comb as a razor. Processing sites are despite having the sensory and motor skills to execute
also different for apraxia (frontal and parietal lobe the task. Clinical observations related to errors dur-
dysfunction) and visual agnosia (occipital lobe dys- ing task performance may include the following*:
function) and this information, if available, can be • Difficulties related to motor planning in general,
used for clinical reasoning. Finally, a person with resulting in awkward or clumsy movements
severe ideational apraxia may not perform at all • Difficulties when planning movements to cross
(i.e., sit at the sink without doing anything). This the body’s midline. For example, difficulty
also may be a problem related to initiation or moti-
vation. Verbally or physically cueing the person to
start the task, for example, initiating the task by *From references 2, 3, 4, 31, 34, 36, 43, and 54.
Chapter 5  Managing Apraxia to Optimize Function 113

in adjusting the grasp on a hairbrush when ­  also have sensory or motor impairments on the
moving it from one side of head to other to turn right side of the body (making it difficult to assess
the bristles toward the hair.3,4 for motor planning deficits), with a left-sided brain
• Difficulty orienting the upper extremity or hand injury, the left side of the body should be sensory
to conform to objects such as picking up a juice and motor spared. Testing the left side of the body
bottle with the radial side of the hand down or in these cases will control for superimposed sensory
via picking the bottle up with a pinch grip on the and motor deficits.
lip of the bottle instead of a typical cylindrical Neurologic processing models have been pro-
grip on the base posed to explain the production aspects of praxis.2,4,34
• Inflexible and static hand patterns such as not Under­standing the areas of the cortex responsible to
being able to manipulate coins out of the palm of support motor planning will aid ­ clinicians in the
the hand to insert them into a vending machine clinical reasoning process. Key areas include the
or difficulty holding objects appropriately following:
• Difficulty sequencing movements such as the • Left inferior parietal lobe (supramarginal gyrus
sequence to get out of bed or off the floor, or and angular gyrus): appears to be a storage area
sequencing complex upper limb movements related to knowledge of motor skills or storage of
such as picking up the phone and lifting it to motor plans. These “formulas for movement” or
the ear learned time-space movement representations
• Spatial orientation and spatial movement errors or motor plans have been termed praxicons.34
such as moving scissors laterally instead of for- When a skilled movement that has been previ-
ward or not spatially moving feeding utensils ously learned such as shaving in an adult male is
correctly34 to be carried out, the representation for the act
• Difficulty coordinating two or more joints, such of shaving is retrieved and used to program the
as coupling the shoulder and elbow movements premotor cortex.
for cutting.54 In general, the more joints involved • The arcuate fasciculus serves to connect the stor-
in the tasks the more degraded the motor plan- age area in the left parietal lobe to the premotor
ning. In other words, an increase in degrees area in the frontal lobe.
of freedom worsens the clinical presentation • Using the formulas for movement, the premo-
(Figure 5-2). tor areas serve to selectively activate the motor
• Difficulty timing movement such as a delay in cortex because this area of the cortex uses infor-
initiation of movement, pauses, or difficulty mation from other cortical regions to select
related to the speed of movement. movements appropriate to the context of the
• Poor gesture production ability, particularly action.
when gesturing the use of an object (transitive • The anterior fibers of the corpus callosum serve
gestures) to bring the shaving plans to the right hemi-
• Using a body part as an object when asked to sphere if the left side of the body will be used in
pantomime use of an object. Usually, used as a the activity.
diagnostic screen for ideomotor apraxia • The primary motor cortex then innervates the
• Movements are imprecise. muscle groups necessary to shave (Figures 5-4
The production errors and resulting clinical and 5-5).
behaviors described are observed at the movement Clinically this is important because ideomotor
level (Figure 5-3). Clinicians must differentiate apraxia can occur if the formulas for movement in
between ideomotor apraxia and other deficits dur- the left parietal lobe are destroyed by a brain injury
ing the clinical reasoning process. As discussed, or if lesions occur anterior to this area in the frontal
comprehension must be considered and controlled areas or the connecting pathways (i.e., disconnect-
for. In addition, the presence of sensory and motor ing the critical cortical areas). If neuroimaging data
impairments must be considered. For example, loss are available, documented lesions in this area should
of joint position sense may result in awkward or serve as a “red flag” as to the possible presence of
clumsy movements. Unlike those with ideomotor this impairment and the potential loss of function. 
apraxia, visual guidance markedly improves func- In addition, the location of the lesion dictates the
tion in a person with sensory loss. As described distribution of the motor planning difficulties.
later, left hemispheric lesions usually result in bilat- Lesions in the left hemisphere usually result in
eral ideomotor apraxia. Although it is typical to bilateral motor planning problems, whereas lesions
114 cognitive and perceptual rehabilitation: Optimizing function

Command Both
150 150 140 140
Elbow Flexion/Extension (�)

Elbow Flexion/Extension (�)

Elbow Flexion/Extension (�)

Elbow Flexion/Extension (�)

130 130 ion
Fle 130 130

110 110

120 120

io n
90 90

n te
nsio Ex
70 70 110 110
30 40 50 60 70 0 0.5 1 1.5 20 30 40 50 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
Upper Arm Elevation (�) Wrist Velocity (m/s) Upper Arm Elevation (�) Wrist Velocity (m/s)

150 1.5 140 0.7

Elbow Flexion/Extension (�)

Elbow Flexion/Extension (�)

Wrist Velocity (m/s)


Wrist velocity (m/s)

1 130
0.5 120
90 0.2

70 0 110 0
−90 −80 −70 −60 −50 −40 −30 −20 0 0.5 1 1.5 −30 −25 −20 −15 −10 −5 0 0.2 0.4 0.6 0.8
Upper Arm Yaw (�) Elbow velocity (m/s) Upper Arm Yaw (�) Elbow Velocity (m/s)

Apraxic M.R.
Command Both
160 160
140 140
Elbow Flexion/Extension (�)

Elbow Flexion/Extension (�)

Elbow Flexion/Extension (�)

Elbow Flexion/Extension (�)

150 150
130 130
140 140

130 130
120 120
120 120 Flexion

110 110 110 Flexion

sio n
Exten Extension
100 100
70 75 80 85 90 95 0.1 0.3 0.5 0.7 0.9 100 100
30 40 50 60 70 0.2 0.4 0.6 0.8 1
Upper Arm Elevation (�) Wrist Velocity (m/s) Upper Arm Elevation (�) Wrist Velocity (m/s)

160 0.9
140 1
Elbow Flexion/Extension (�)

Elbow Flexion/Extension (�)

Wrist Velocity (m/s)

130 0.8
Wrist Velocity (m/s)


130 0.5 120 0.6

0.3 110 0.4

100 0.1 100

40 −30 −20 −10 0 10 20 0 0.1 0.2 0.3 0.4 0.5 0.6 0.2
−60 −50 −40 −30 −20 0.1 0.2 0.3 0.4 0.5 0.6
Upper Arm Yaw (�) Elbow Velocity (m/s) Upper Arm Yaw (�) Elbow Velocity (m/s)

Figure 5-2  Comparing the relationships between multiple joints while gesturing “slicing bread.” A, Smooth joint coordination in typical
controls versus B, distorted joint relationships in those with apraxia. In daily life this is noted as clumsy and awkward movements. (From
Poizner H, Clark MA, Merians AS, et al: Joint coordination deficits in limb apraxia, Brain 118:227-242, 1995.)

in the corpus collosum or right premotor area although this association is not as consistent in the
usually result in unilateral motor planning prob- published literature.34,60
lems on the left side of the body only (see Figure It is important to differentiate the type of
5-4).2,30 Finally, damage to the basal ganglia or tha- apraxia that is interfering with function because
lamic lesions also may result in ideomotor apraxia, it will dictate cueing and environmental strategies
Chapter 5  Managing Apraxia to Optimize Function 115

Figure 5-3  Manifestations of ideomotor apraxia during performance of activities of daily living (grooming and feeding) based on
Árnadóttir’s analysis of errors. A, The left apraxic hand may hold a brush and have no observable problem with brushing the hair 
on the left side of the scalp. B, Under normal circumstances, when the hand is moved to brush the right side, adjustments of hand position
are automatically made by sequences of organized hand movements directed toward the goal of changing the position of the brush. 
C, The client with motor apraxia is unable to perform and sequence the required movements when the hand is moved over to the
right side, resulting in an awkward grasp when considering the task requirements. D, During normal performance the client adjusts the
movements of the wrist and forearm when approaching the mouth with the spoon. E, A client with motor apraxia may be able to hold 
the spoon correctly but is unable to adjust the movements when approaching the mouth, resulting in spilling from the spoon. F, The client
holds the spoon with a very “clumsy” and inflexible grasp. She is totally unable to adjust her grasp when approaching the mouth, again
resulting in spilling of the soup from the spoon.
116 cognitive and perceptual rehabilitation: Optimizing function

Figure 5-3—Cont’d  G, The client with a flaccid right arm grasps the washcloth and is unable to plan and sequence the hand movements of
the left hand to straighten out the cloth. H, The client has to let go of the washcloth and straighten it out on the sink before grasping one corner
so that the cloth will fall straight over the hand. I, The client who is unable to use the right “dominant” hand because of a severe motor apraxia
uses the left hand to comb. However, the right hand moves simultaneously, automatically, as if it were participating in the combing activity.
(From Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby.)

necessary to improve performance. Ideational and formance to differentiate the effect of the different
ideomotor apraxia can occur together or sepa- types of apraxia (Box 5-1 and Figure 5-6).
rately.52 In a classic study of apraxia, 21% of those
with left brain damage had both types of apraxia,
Prevalence and Recovery
whereas 14% had one form or the other. The corre-
lation coefficient documented to test the strength Several studies have examined the prevalence of
of the association of the two types of apraxia has apraxia. In general, approximately one third of
been reported as 0.41 (p < 0.001).16 Árnadóttir those with left brain damage present with apraxia.
encourages analyzing errors made during task per- Recent findings include the following:
Chapter 5  Managing Apraxia to Optimize Function 117

Left hemisphere Right hemisphere

Primary Sensory-motor Primary motor area

motor area feedback Supplementary
Supplementary Tactile and proprioceptive motor area
motor area information Premotor
Premotor area Praxicons

prefrontal Visual
cortex information
Auditory Sensory-motor prefrontal
Superior feedback Superior
temporal area Arcuate information area
fasciculus temporal area

Corpus callosum

Premotor cortex
Primary motor Primary motor
cortex cortex
Arcuate fasciculus

Angular and
supramarginal gyri

Left hemisphere Right hemisphere

Figure 5-4  Processing of motor praxis. Apraxia will manifest if praxicons usually “stored” in the left inferior parietal lobe (angular and
supramarginal gyri) are destroyed by acquired brain injury or via disconnections between the processing areas (i.e., along the arcuate
fasciculus or corpus callosum). Lesions in the left hemisphere may result in bilateral ideomotor apraxia, whereas lesions of the corpus
callosum or right premotor area may result in unilateral ideomotor apraxia on the left side. (From Árnadóttir G: Impact of neurobehavioral
deficits on activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach, ed 2, St Louis, 2004,

• An examination of 100 stroke survivors revealed disease40 (errors related to planning), progressive
that for the group, 25.3% presented with apraxia; supranuclear palsy40 (content and planning errors),
specifically apraxia was present in 51.3% of those and Huntington’s disease61 (planning errors).
with left-sided stroke and in 6% of those with Recovery patterns from apraxia also have been
right-sided stroke.73 examined. Findings related to recovery include the
• Reviews of the literature consistently find that following:
this impairment occurs after left-sided brain • Improvement from ideomotor apraxia may be
damage as opposed to right-sided damage.19 related to the site of the lesion, anterior lesions
• The prevalence of apraxia among 492 first left may fare better.8
hemisphere stroke survivors in rehabilitation • An examination of recovery of 26 clients with
centers was 28% (96/338) and was higher in apraxia revealed that 13 remained apraxic 5 months
long-term care facilities at 37% (57/154).19 later.8
Apraxia has been documented in a variety of • Age, gender, aphasia, education level, and lesion
­populations including left hemisphere–acquired size do not seem to influence recovery from
brain injury19 (errors related to content and apraxia.8
­planning), corticobasal degeneration37,45 (errors • In long-term limb apraxia recovery, the more
related to planning), Alzheimer’s disease25,38,41 severe the initial impairment, the less complete
(errors related to content and planning), Parkinson’s the long-term outcome.46
118 cognitive and perceptual rehabilitation: Optimizing function

Left Inferior Parietal LobeA

(angular and supramarginal gyri):
Box 5-1 Clinical Reasoning
Storage for formulas of movement (praxicons) to Differentiate Between
Two Types of Apraxia

Apraxias Locations of Dysfunction

Left premotor areaA Left premotor areaA Ideomotor/Motor Left inferior parietal lobule
apraxia Left premotor frontal cortex
Left supplementary motor cortex
Anterior corpus callosum
Left primary motor areaC Corpus collosumB Right supplementary motor area
Right premotor frontal area
Ideational apraxia Left inferior parietal lobe
Left premotor frontal cortex
Control right side of body Right premotor areaB Left prefrontal cortex
Corpus callosum
Right premotor frontal cortex
Right prefrontal cortex
Right primary motor areaC
Evaluative Considerations for
Differentiation of Apraxia Types
Does the client have an idea of what to do (ideation)?
Control left side of body
Does the client know which objects to use (ideation)?
Figure 5-5  Flow of information while planning movements of Does the client know how to perform or how to use the
either side of the body. A, Lesions in this area result in bilateral objects (ideation)?
ideomotor apraxia. B, Lesions in this area result in unilateral (left) Do the movements appear to be clumsy (motoric)?
ideomotor apraxia. C, Lesions in this area result in unilateral motor Can the client adjust grasp according to altered
impairments such as weakness or spasticity. ­requirements during object use (motoric)?
Are there problems with sequencing and organization
of activity steps (ideation)?
Are there problems with sequencing of movements
• Limb apraxia recovery showed no significant (motoric)?
correlation with recovery of language deficits.46
• Aphasia and apraxia seem to have related but From Árnadóttir G: The brain and behavior: assessing cortical dysfunction
through activities of daily living, St Louis, 1990, Mosby.
distinguishable recovery processes.46
• In a long-term follow-up study of a group
of 44 clients with ideomotor apraxia, the cli- to the specificity of training and/or the ­inability
ents’ apraxia status was evaluated three times to generalize. This issue may be addressed by
(1.6 months, 9.4 months, and 27.9 months’ mean home visits by the team and client during the
time postonset). All but one client demonstrated rehabilitation process.9 A focus on home reha-
some recovery from apraxia between the first and bilitation seems to be warranted based on this
second examinations. After that point, very few finding.
of the clients showed further recovery and 6 cli-
ents worsened. At all three examinations, clients
with anterior lesions had more severe apraxia,
Apraxia’s Relationship to
but unlike previous studies, the degree of recov-
Other Impairments
ery was not significantly different in the two Although apraxia may occur in isolation, it is typ-
groups.7 ical to see patterns of impairments in those living
• Limb apraxia and oral apraxia appears to follow with apraxia. These include motor impairments,
the same trajectory of recovery.7 “cognitive dementia-like impairments,” memory
• After the first few months of recovery, clients will difficulties, and comprehension difficulties.69 In
plateau.7 addition, it is typical to identify organization and
• Clients with apraxia who improve during the sequencing deficits.2,4 Most commonly, aphasia and
rehabilitation stay on functional measures may apraxia may occur together. Both impairments are
worsen when discharged home.9 This may be due commonly seen in those living with left ­hemispheric
Chapter 5  Managing Apraxia to Optimize Function 119


Figure 5-6  Potential errors while attempting to demonstrate use of a toothbrush. A, Object wrongly held. B, correct choice. C, Object
wrongly oriented. D, Object used as another object (toothbrush as a comb). (From Cubelli R, Marchetti C, Boscolo G, et al: Cognition in
action: testing a model of limb apraxia, Brain Cogn 44[2]:144-165, 2000.)

dysfunction. Because the two impairments have con- and global aphasia) dictates the use of familiar
tiguous cortical structures they often occur concur- tasks, performed in logical environments, at the
rently but the two may be dissociated (i.e., a client appropriate time of day. Dressing practice during
may present with aphasia or apraxia, or both).44 an afternoon session in a therapy clinic or isolated
Alexander and associates1 examined the rela- practice of object use in a therapy office does not
tionship between aphasia and ideomotor apraxia provide the contextual cues necessary to elicit func-
and concluded that those presenting with conduc- tional performance. This factor makes it impossible
tion aphasia and anomic aphasia were not signifi- to differentiate between the effects of apraxia or dif-
cantly apraxic compared with controls, and those ficulties related to comprehension. Using a familiar
with global aphasia were significantly more apraxic task in the appropriate environment circumvents
than all other groups. The method used to elicit the the need to use excessive verbal cues and at least
apraxic behaviors influenced their findings as well. begins to control for the presence of aphasia.
There appears to be a stronger association between
Broca’s aphasia and ideomotor apraxia. There also
Effect of Apraxia on Daily Life
appears to be a stronger relationship with aphasia
and Rehabilitation Outcomes
and severe ideational apraxia.16 The combination
of apraxia and aphasia may compound the dif- Although the early literature discussed apraxia as
ficulties related to functional retraining. In addi- being an impairment observed only during specific
tion, a hallmark of ideomotor apraxia is impaired neurologic testing or during contrived clinical situ-
gesture production ability, a typical compensa- ations, it is now well recognized that apraxia does
tory technique used during the rehabilitation of have a substantial negative effect on an individual’s
those with language impairments. From an assess- ability to engage in meaningful activities and par-
ment and intervention perspective, the presence of   ticipate fully in the community. Specific findings
aphasia (particularly Wernicke’s/receptive ­ aphasia include the following:
120 cognitive and perceptual rehabilitation: Optimizing function

• Apraxia affects behavior during meals. Foundas impairment of apraxia, whereas the other is focused
and associates24 examined mealtime behaviors on how apraxia affects everyday living skills.
of neurologically intact people as compared Although both are important, philosophically from
with those with left brain damage (most with a rehabilitation perspective the latter should be
apraxia) via videotapes. Even though all neu- emphasized. The literature has typically focused on
rologically intact people were found to proceed diagnosing apraxia using nonfunctional tasks out
through three specific phases of a meal (prepa- of context. These tests typically include ­ selections
ratory, eating, and cleanup), only 20% of those from the following items34:
with left brain damage did. All intact controls • Gesturing to command. Focusing on pantomime
had a preparatory phase, whereas only 40% of of the use of tools, that is, transitive movements
those with apraxia did. In addition, those with (“Show me how you would use a hammer”)
apraxia from left brain damage used fewer uten- and nonverbal communications or intransi-
sils, were less organized, were less efficient, ate tive moments (“Show me how you would wave
haphazardly, placed too much or too little food goodbye”).
on the utensils, and demonstrated action deficits • Gesture to imitation.
(tool misuse, sequencing errors, etc.). A signif- • Gesture or pantomime in response to seeing a tool.
icant correlation was found between the sever- For example, showing the person a toothbrush
ity of apraxia and difficulties observed with the and asking him or her to pantomime its use.
meal. • Demonstrate tool use albeit not in the context of
• Six months after discharge from hospitalization, a functional task.
apraxia and the need for assistance with daily • Imitation of the examiner using a tool.
activities are highly correlated. Those with apraxia • Discriminating correct and incorrect move-
require more assistance than those with other ments of the examiner.
­neurologic impairments.64 • Performing serial acts (putting batteries in a
• The absence of apraxia is a significant predictor flashlight and turning it on, making a sandwich,
of the ability to return to work.59 etc.).
• Apraxia severity is strongly related to meal prep- Many of the tests used to diagnose the presence
aration competency.33 of apraxia were developed as research tools and
• Apraxia severity is moderately predictive of some that are commonly used in clinical settings
caregiver and client reports of functional are not standardized. The following are examples
independence.33 of standardized impairment tests used to make the
• People with ideomotor apraxia have increased diagnosis of apraxia:
dependency in grooming, bathing, and toileting • Florida Apraxia Screening Test-Revised58: a
relative to age-matched control subjects.32 short screening of apraxia and part of the larger
• The number of errors made during basic ADL is Florida Apraxia Battery. It includes 30 items that
correlated with the severity of apraxia.29 must be gestured to command. The test includes
• The number of errors made during complex 20 transitive (requiring pantomime of a tool)
ADL is correlated with the severity of apraxia.28 and 10 intransitive (not requiring a tool) items.
• The relationship of severity of apraxia to long- All are related to arm and hand movements and
term dependency after rehabilitation is strong.9 can be done with one hand. Examples include
• Learning of old and new skills is compromised showing how to salute, go away, how to use a
in those with apraxia and requires increased scoop to serve ice cream, wave goodbye, stop, use
repetitions.47,56 a salt shaker to salt food, and hitchhike. Scoring
Clearly the presence of apraxia warrants special is based on error type: content, temporal, spatial,
attention from a rehabilitation perspective. Specific and others.
assessment and intervention strategies are neces- • Cambridge Apraxia Battery26: includes 11 items 
sary to improve functional performance in this such as imitation of posture, imitation of seq­
population. uence, bilateral motor coordination, functional
object description, finger maze, and ­ manual
form perception.
Evaluation and Assessments
• Kaufman Hand Movement Test6,39,49: a standard-
Two schools of thought exist related to the assess- ized test that requires subjects to imitate 75 hand
ment of apraxia. One is focused on diagnosing the positions.
Chapter 5  Managing Apraxia to Optimize Function 121

• Limb Apraxia Test20: an objective, quantifi- ­performance-based measures of activity limitations,

able, valid, and reliable measure of the ability to ­ articipation restrictions, and quality of life.
­imitate 252 movements. Instead, from a rehabilitation perspective, the
• Ideomotor Apraxia Test17: developed for older focus of assessment should be on determining
adults, the test consists of demonstrating 10 if/how the presence of apraxia interferes with a
gestures (3 one-handed symbolic gestures and  person’s ability to perform basic self-care, instru-
7 two-handed meaningless gestures). mental activities of daily living, work, and play/
• Movement Imitation Test15: includes 24 gestures leisure abilities. Árnadóttir,2-4 van Heugten and
classified according to type of movement (finger colleagues,71 and Goldenberg and Hagmann29
versus hand, symbolic vs. nonsymbolic gestures, have concluded that structured observation of the
etc.). errors that people make during functional activi-
• Diagnostic Test for Apraxia67,73: a test to diagnose ties is a valid method of assessing apraxia. Success
the presence of ideational and ideomotor apraxia using this method of assessment is based on the
via demonstration of object use (ideational) and assumption that apraxia results in an observable
imitation of gestures (ideomotor). problem related to function, allowing people with
Impairment tests aimed at diagnosing the apraxia to make safe errors during task perfor-
impairment of apraxia must be interpreted with mance, analyzing the errors to classify them based
caution from a rehabilitation perspective as they on type of apraxia and error type, and using con-
are performed out of context and one cannot gen- sistent descriptive terminology and operational
eralize poor test performance to real-world perfor- definitions.2,4
mance (see Chapter 1). Therefore, from a clinical van Heugten and colleagues68,70 and others have
rehabilitative practice perspective, they are recom- documented at least three types of errors that can be
mended as a screening only if they are to be used at observed during structured observations of func-
all. Those engaged in clinical research such as test- tional tasks including content, temporal, and spatial
ing the effectiveness of interventions for those living (Table 5-1). Identifying the error type enables clini-
with apraxia should consider using an impair- cians to develop the appropriate intervention plan
ment test of apraxia in conjunction with objective (discussed later). van Heugten and colleagues68,70

Table 5-1 Potential Apraxic Errors Made During Functional Task Performance
Error Observable Behavior

Difficulties initiating the task Difficulty choosing the proper plan of action
Difficulty choosing the correct objects
Difficulty executing the task Difficulty performing the plan
Difficulty controlling the task Inability to evaluate the results of the task
Inability to make corrections for mistakes
Content/object errors Related errors: uses knife instead of fork
Nonrelated errors: eats soap
Perseverative errors: integrates a component of the previous task into a new task (e.g.,
after eating soup from a bowl with a spoon, brings spoon toward the glass of milk)
Temporal errors Difficulty sequencing movements
Increased, decreased, or irregular speed of movements
Spatial errors Increased or decreased amplitude of movement
Difficulty configuring the hand to hold an object
Difficulty orienting the limbs and trunk to an object
Sits too far away from workspace or body is improperly aligned

Data from Goldenberg G, Hagmann S: Therapy of activities of daily living in patients with apraxia, Neuropsychol Rehabil 8(2):123-141, 1998; Heilman KM,
Gonzalez Rothi LJ: Apraxia. In Heilman KM, Valenstein E, editors: Clinical neuropsychology, ed 4, New York, 2003, Oxford University Press; Raymer M,
Ochipa C: Conceptual praxis. In Gonzalez Rothi LJ, Heilman KM, editors: Apraxia: the neuropsychology of action, pp. 75-91, Hove, United Kingdom, 1997,
Psychology Press; Rothi L, Raymer A, Heilman K: Limb praxis assessment. In Gonzalez Rothi L, Heilman K, editors: Apraxia: the neuropsychology of action,
pp. 61-73, Hove, United Kingdom, 1997, Psychology Press; and van Heugten C, Dekker J, Deelman B, et al: Outcome of strategy training in stroke patients
with apraxia: a phase II study, Clin Rehabil 12:294-303, 1998.
122 cognitive and perceptual rehabilitation: Optimizing function

developed a standardized assessment to document

Review of Evidence-Based
the presence of disabilities resulting from apraxia.
Interventions to Improve
Scoring is based on structured observation of ADL
Activity and Participation for
and a client-chosen activity (Box 5-2).
Those Living with Apraxia
Árnadóttir proposed a relationship between
the presence of impairments such as apraxia and Empirical research focused on interventions for
observable errors during a variety of daily living those living with apraxia falls into two categories:
tasks. Although these observations are typically interventions focused on attempting to decrease
made in a nonstandardized manner (Table 5-2), the apraxic impairment itself and those focused on
they also have been standardized (Table 5-3). improving activity performance despite apraxia.

Box 5-2 Observation and Scoring of Activities of Daily Living

Purpose: 1—The verbal instruction has to be adapted or extended.
• To assess the presence of disabilities resulting from —The therapist has to demonstrate the activity.
apraxia —It is necessary to show pictures or write down the
• To gain an insight in the style of action of the patient instructions.
and the sort of errors made —The objects needed to perform the task have to be
• To prepare treatment goals for specific training given to the patient.
2—The therapist has to initiate the activity together with
Method: the patient.
The therapist observes the following activities and scores —The activity has to be modified in order to be
the findings for each activity and each aspect. performed adequately.
1. Personal hygiene: washing the face and upper body 3—The therapist has to take over.
2. Dressing: putting on a shirt or blouse
3. Feeding: preparing and eating a sandwich B. Execution
4. The therapist chooses an activity that is relevant for the 0—There are no observable problems: the activity is
patient or standard at the department performed correctly.
1—The patient needs verbal guidance.
I. Score of independence —Verbal guidance has to be combined with gestures,
0—The patient is totally independent, can function without pantomime, and intonation.
any help in any situation. —Pictures of the proper sequence of action have to be
1—The patient is able to perform the activity but needs shown.
some supervision. 2—The patient needs physical guidance.
—The patient needs minimal verbal assistance to perform 3—The therapist has to take over.
—The patient needs maximal verbal assistance to perform C. Control
adequately. 0—There are no observable problems: the patient does not
2—The patient needs minimal physical assistance to need feedback.
perform adequately. 1—The patient needs verbal feedback about the result of
—The patient needs maximal physical assistance to the performance.
perform adequately. —The patient needs physical feedback about the result of
3—The patient cannot perform the task despite full the performance.
assistance. 2—The patient needs verbal feedback about the execution.
—The patient needs physical feedback about the
II. The course of an activity execution.
In every aspect the patient can encounter problems; how- —It is necessary to use mirrors or video recordings.
ever, for each aspect only one score can be entered. 3—The therapist has to take over.

A. Initiation
0—There are no observable problems: the patient under-
stands the instruction and initiates the activity.

From van Heugten C, Dekker J, Deelman B, et al: Assessment of disabilities in stroke patients with apraxia: internal consistency and inter-observer ­reliability,
Occup Ther J Res 19(1):55-73, 1999.
Chapter 5  Managing Apraxia to Optimize Function 123

Table 5-2 Sample Observable Apraxic Errors Made During Functional Task Performance
Activity Domain Observable Error

Feeding Uses a spoon as a straw (IA)

Unable to adjust movements to guide spoon to mouth smoothly without spilling (MA)
Puts butter in coffee (IA)
Awkward grip on knife interferes with cutting skills (MA)
Grooming and hygiene Smears toothpaste on sink (IA)
Can’t maintain razor in contact with face when crossing midline (MA)
Doesn’t “know how” to turn on water faucet (IA)
Can’t plan squeezing toothpaste out of tube (MA)
Dressing Attempts to put socks on hands (IA)
Not able to plan movement sequence for donning a shirt (MA)
Socks are put on over shoes (IA)
Not able to readjust sock within the hand after picking it up (MA)
Mobility Attempts to propel wheelchair by pushing on the brakes repetitively (IA)
Cannot plan movements to roll and sit up over the edge of the bed (MA)
Attempts to lock wheelchair brakes by pulling on the armrest (IA)
More than expected difficulty in learning the motor sequence of propelling the wheelchair with
one side of the body (MA)

Data from Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby.
IA, Ideational apraxia; MA, ideomotor apraxia

The available research does not support the some- focused on decreasing activity limitations and par-
times assumed relationship that decreasing the ticipation restrictions for those living with apraxia.
severity of apraxia will automatically result in
improved daily function. Examples of interven-
Strategy Training
tions that have focused on treating the impairment
of apraxia include the following: van Heugten and colleagues70 described an inter-
• Using tactile and kinesthetic stimulation in addi- vention study designed for use by occupational
tion to visual and verbal mediation input, such therapists based on teaching clients strategies to
as deep pressure, sharp touch input, soft touch, compensate for the presence of apraxia. The treat-
self-touch, and proprioceptive input10,11 ment was focused on training activities that were
• Practice of gestures42,50 relevant to the individual client. The therapist and
• Practice of object use via conductive education53 client decided on which activities to focus. Interest
These interventions have been tested by case stud- checklists were also used to choose activities in addi-
ies that have concluded that in general the interven- tion to focusing on activities that were important
tions demonstrated only immediate changes in motor to carry out in the future. Every two weeks other
performance without any carryover related to sen- ­activities were chosen.
sory stimulation. The major limitation is that either The focus of the intervention was error specific
functional outcomes were not considered or changes and determined by the specific problems observed
in functional performance were not observed for during standardized ADL observations. Specifically,
these interventions. In addition, no generalizations interventions were focused on errors related to the
to untrained actions were noted. At this point they following:
cannot be recommended for use in clinical practice. • Initiation: inclusive of developing a plan of action
van Heugten66 states that “recovery from apraxia and selection of necessary and correct objects
is not a realistic goal for therapy. Instead, the aim of • Execution: performance of the plan
rehabilitation should be to help the client develop • Control: inclusive of controlling and correcting
new patterns of cognitive activity through internal the activity to ensure an adequate end result
or external compensatory mechanisms, or through Difficulties related to initiation were treated via
adaptation of tasks or environments.” The follow- specific instructions. Instructions were hierarchi-
ing paragraphs review tested interventions that have cal in nature and could include verbal instructions,
Table 5-3 Recommended Outcome Measures and Function-Based Apraxia Assessments
Dimension Based

cognitive and perceptual rehabilitation: Optimizing function

on International
Instrument and Validity and Classification
Author Instrument Description Population Reliability Reliability of Function* Comments

Standardized assessments of basic Activity limitations See Chapter 1

activities of daily living (ADL)
Standardized assessments of Activity limitations See Chapter 1
instrumental ADL (IADL)
Standardized assessments of leisure Activity limitations See Chapter 1
Standardized assessments of Participation restrictions
Standardized assessments of quality Quality of life See Chapter 1
of life
ADL Observations to Structured observation of four Adults living with Discriminative: able Interrater based Activity limitations Provides information
Measure Disabilities activities: washing face and apraxia to differentiate on intraclass related to how
in those with apraxia, upper body, putting on a shirt or between those correlation for apraxia affects
van Heugten et al, 199968; blouse, preparing food, and an with and without the total score is everyday living
200071 individualized task chosen by the apraxia 0.98 Warrants further
occupational therapist (OT) Construct: highly Cronbach’s alpha investigation
Scored based on initiation, associated with = 0.94
execution, and control impairment tests
of apraxia and
the Barthel Index
Valid for stroke
The ADL Test for those Observation of spreading margarine Adults with apraxia Significant Interrater: 0.83 for Activity limitations Provides information
with apraxia, on bread, putting on a T-shirt, correlations with reparable errors related to how
Goldenberg and brushing teeth, or putting cream five impairment and 0.96 for fatal apraxia affects
Hagmann, 199829 on hands tests of apraxia errors everyday living
Scores based on reparable or Warrants further
fatal errors related to selection investigation
of objects, movements, or Initial data are available
sequencing related to complex
ADL as well
Chapter 5  Managing Apraxia to Optimize Function
Árnadóttir Occupational Structured observation of basic ADL Those 16 years and Content: via expert Interrater: 0.84 Impairments Provides information
Therapy-ADL including feeding, grooming and older with central review and Test-retest: 0.86 Activity limitations related to how
Neurobehavioral hygiene, dressing, transfers and nervous system literature review apraxia affects
Evaluation (A-ONE), mobility to detect the impact of involvement Concurrent: Barthel everyday living
Árnadóttir, 19902; 20044 multiple underlying impairments Index, Katz Includes items related
including ideational and motor Index, Mini to both ideational
apraxia on these tasks Mental Status and motor apraxia
Examination Requires training
Valid for multiple
including: stroke,
brain tumor,
dementia, etc.
Assessment of Motor and An observational assessment that is Those 3 years old Strong validity and Cronbach’s alpha Activity limitations Provides information
Process Skills (AMPS), used to measure the quality of a and up and appropriate to range from 0.74 related to everyday
Fisher, 200321,22 person’s ADL assessed by rating difficulties related use with multiple to 0.93 function
the effort, efficiency, safety, and to occupational diagnoses and Test-retest range Requires training
independence of 16 ADL motor performance cultures from 0.7 to 0.91
and 20 ADL process skill items
Includes choices from 85 tasks

126 cognitive and perceptual rehabilitation: Optimizing function

alerting the client with tactile or auditory cues, of the task and controlling for errors. The specific
­gesturing, pointing, handing objects, or starting the strategy training ­intervention protocol is included
activity together. Assistance was the intervention in Box 5-3.
provided when problems related to execution of This strategy training approach for apraxia has
the activity occurred. Also hierarchical, assistance been tested with promising results.70 A pretest-post-
could range from various types of verbal assist, test study design demonstrated significant improve-
stimulating verbalization of steps, naming the ments and large effects for three different ADL
steps of the activity, to physical assistance such as measures (Barthel Index, a standardized evaluation
guiding movements. When having difficulty with of personal hygiene, dressing, preparing food and
control (i.e., clients do not detect or correct the a client-chosen activity, and an ADL questionnaire
errors they make during the activity), feedback was that was filled out by therapists as well as clients).
provided. Feedback ranged from verbal feedback In addition, significant improvements were docu-
related to knowledge of results to taking control mented on tests of apraxia (small-medium effects)

Box 5-3 Protocol for Strategy Training for Those Living with Functional Deficits
Secondary to Apraxia
The specific interventions are built up in a hierarchic order, • Use gestures, mimics, and vary intonation in your speech.
depending on the patient’s level of functioning. The thera- • Show pictures of the proper sequence of steps in the
pist can use instructions, assistance, and feedback. activity.
• Physical assistance is needed:
Instructions • By guiding the limbs.
The occupational therapist can give the following • In positioning the limbs.
instructions: • To use the neurodevelopmental treatment method
• Start with a verbal instruction. (NDT).
• Shift to a relevant environment for the task at hand. • To use aids to support the activity.
• Alert the patient by: • To take over until the patient starts performing.
• Touching • To provoke movements.
• Using the patient’s name • Finally, take over the task.
• Asking questions about the instruction
• Use gestures, point to the objects. Feedback
• Demonstrate (part of) the task. Feedback can be offered in the following ways:
• Show pictures of the activity. • No feedback is necessary because the result is adequate.
• Write down the instruction. • Verbal feedback is needed in terms of the result
• Place the objects near the patient, point to the objects, (knowledge of results).
put the objects in the proper sequence. • Verbal feedback by telling the patient to consciously use
• Hand the objects one at a time to the patient. the senses to evaluate the result (tell the patient see,
• Start the activity together with the patient one or more hear, feel, smell, or taste).
times. • Physical feedback is needed in terms of the result
• Adjust the task to make it easier for the patient. (knowledge of results):
• Finally, take over the task because all efforts did not • To evaluate the posture of the patient.
lead to the desired result. • To evaluate the position of the limbs.
• To support the limbs.
Assistance • Physical feedback is given by pointing or handing the
The following forms of assistance can be given by the objects to the patient.
therapist: • Verbal feedback is needed in terms of performance
• There is no need to assist the patient during the (knowledge of performance).
execution of the activity. • Physical feedback is needed in terms of performance
• Verbal assistance is needed: (knowledge of performance).
• By offering rhythm and not interrupting performance. • Place the patient in front of a mirror.
• To stimulate verbalization of the steps in the activity. • Make video recordings of the patient’s performance and
• To name the steps in the activity or name the objects. show the recordings.
• To direct the attention to the task at hand. • Take over the control of the task and correct possible errors.

From van Heugten C, Dekker J, Deelman B, et al: Outcome of strategy training in stroke patients with apraxia: a phase II study, Clin Rehabil 12:294-303, 1998.
Chapter 5  Managing Apraxia to Optimize Function 127

and motor function (small effects). Improved tasks but on teaching clients new ways to cope with
ADL function was still significant after correct- and manage the impairments during performance
ing for the improvement on the apraxia measures, of tasks in general. The analyses revealed that both
motor measure, and time poststroke. Of the cli- intervention groups (traditional occupational ther-
ents in this study, 84% perceived complete recovery apy [OT] and traditional OT combined with strat-
or ­ substantial improvement because of the inter- egy training) demonstrated significantly improved
vention. The authors concluded that the “therapy scores on tasks that were not trained. Change scores
programme succeeded in teaching clients com- of the nontrained activities were significantly larger
pensatory strategies, which enable them to func- in the strategy training group as compared with
tion more independently.” Further analysis of these usual occupational therapy. The authors hypothe-
data revealed that older age, the presence of addi- sized that this success was secondary to the design of
tional cognitive impairments, and/or severe motor the intervention (i.e., strategies are selected based on
impairment did not diminish the effects of the the specific type of error each client makes during
strategy training intervention. In fact, the initially engagement in ADL). Strategy training for apraxia
more severely impaired clients showed the most is considered a practice standard by the American
marked improvement.69 Of note is that although Congress of Rehabilitation Medicine.13
the intervention did not explicitly focus on decreas-
ing the apraxic impairment, the strategy training
Errorless Completion and Training of Details
approach during participation in functional activi-
ties decreased activity limitations as well as severity Goldenberg and Hagmann29 tested a method of spe-
of impairment. cifically training ADL for those living with apraxia.
Donkervoort and coworkers18 also tested this They specifically examined spreading margarine on
intervention via a randomized clinical trial compar- a slice of bread, putting on a T-shirt, and brushing
ing usual occupational therapy to strategy training teeth or applying hand cream. Each of the activi-
integrated into usual occupational therapy. Blind ties was trained for 1 week by an occupational ther-
evaluators administered measures of ADL, apraxia, apist. Those not being trained were carried out
and motor function pre- and postintervention. with maximal support and without specific train-
Postintervention, those receiving strategy training ing. When an activity was being trained, the focus
improved significantly on ADL observations (small was on errorless completion of the whole activ-
to medium effect size) as well as the Barthel Index ity. As opposed to trial-and-error learning, error-
(medium effect size) as compared with those who less learning or completion is a technique in which
received usual care. Although a 5-month follow- the person learns the activity by doing it. The ther-
up did not demonstrate beneficial effects (i.e., the apist intervenes to prevent errors from occurring
groups were similar), it was noted that those in the during the learning process. This technique also
usual care group required continued ­occupational has been used for those with memory impairments 
therapy to obtain a corresponding level of improve- (see Chapter 9). Support from the therapist was pro-
ment. It is possible that this finding may reveal that vided at various stages of the activity until the client
the strategy training approach improved the effi- could move through the area of difficulty on his or her
ciency of the rehabilitation process, but further own. Specific interventions included the following:
examination of this hypothesis is required. The • Guiding the hand through a difficult aspect of
authors concluded that the trial “showed benefi- the activity
cial effects of strategy training on ADL functioning • Sitting beside the client (parallel position) and
in left hemisphere stroke clients with apraxia. The doing the same action simultaneously with the
results suggest that the therapy programme is suc- client
cessful in teaching clients compensatory strategies, • Demonstrating the required action and ask the
which enable them to function more ­independently, client to copy it afterwards
despite the lasting effects of apraxia.” In addition, the intervention focused on train-
A posthoc analysis of Donkervoort and cowork- ing of details. This was aimed at directing the
ers’18 data (Geusgens and associates27) focused on ­client’s attention to “the functional significance
whether the strategy training approach results in of single perceptual details and to critical fea-
transfer of training to untrained tasks. The hypoth- tures of the actions associated with them.” Specific
esis is that in strategy training, transfer is expected as ­difficult steps of the activity were trained using this
the intervention is not focused on learning specific approach. To promote knowledge of object use, key
128 cognitive and perceptual rehabilitation: Optimizing function

details of ADL objects were explored and examined to functionally significant details of the object (e.g.,
such as the bristles on a toothbrush and the teeth prongs on a fork, serrations on a butter knife, bris-
on a comb. Actions connected to the details were tles on a toothbrush, etc.). The therapist explained
then practiced (e.g., searching for and positioning the functional significance via verbal, gestural, and
a shirtsleeve for a person with dressing difficulties) pointing cues. The clients did not practice use of
outside of therapy. Specific necessary motor actions the tools. Specific interventions related to explora-
also were practiced in other activities and contexts tion training included explanation, ­ touching, and
(e.g., squeezing paint from tubes as a similar action ­comparing objects with photographs.
as squeezing toothpaste). The direct training focused on the client’s car-
Goldenberg and Hagmann29 tested this inter- rying out the whole activity with a minimum of
vention by examining 15 clients with apraxia with errors. The technique is similar to errorless comple-
repeated measures of ADL function. Success of therapy tion as reviewed above and included guided move-
was based on the reduction of errors of specific tasks. ments and the therapist sitting beside the client to
The authors differentiated between reparable errors perform the task simultaneously. Particularly diffi-
(the client succeeds in continuing the task) or fatal cult components of the activity were practiced, but
errors (the client is unable to proceed without help or the whole activity was always completed. Specific
the task is completed but did not fulfill its purpose). interventions for direct training included guided
Across the whole group, the number of fatal errors performance of the whole activity, passive ­guidance,
decreased significantly, whereas the number of repa- guidance by example, and rehearsal of steps.
rable errors did not significantly change. The authors Goldenberg and colleagues28 tested these inter-
also noted several clinically relevant observations: ventions related to the training of four complex
• Even though therapy led to significant improve- ADL: preparing coffee from an automatic coffee
ments in trained ADL, there was no improve- maker, fixing a carpet knife to cut out cardboard,
ment in ADL if left to spontaneous recovery. changing batteries on a tape recorder and playing
• Long-term success of the intervention was based a cassette, and slicing bread followed by spreading
on continued practice and ADL participation margarine and jam. Necessary objects were avail-
after completion of the intervention. able as well as distracters (nonsensical objects not
• The success of the intervention seemed to be related to the task at hand such as a toothbrush for
based on teaching clients “instructions of use” meal preparation). The authors found that explora-
related to specific objects. tion training had no effect on performance, whereas
• Specific training can restore independence for direct training resulted in a significant reduction of
trained activities. errors and the amount of assist required to com-
• There was no generalization from trained to plete the task. Follow-up 3 months later revealed
untrained tasks. that gains were maintained. Although exploration
In terms of the lack of generalization to untrained training was not found to be successful in this study,
tasks, by definition the errorless component of the it should be pointed out that the protocol did not
intervention is in fact task specific and training of allow the clients to practice actual use of the objects
details is aimed only at object use errors seen in or the actions associated with them. Future stud-
those living with apraxia and not other difficulties ies should examine whether combining exploration
encountered by this population.27 This may repre- training with practice is more beneficial.
sent a limitation of the intervention, but ­ further Of note was that the authors again documented
research is necessary. that there was no generalization from trained to
untrained tasks. This lack of generalization was at
times evident even when the same task was tested
Direct Training of the Whole Activity versus
with different objects. They concluded that therapy
Exploration Training
“should be tailored to the specific needs and desires
Goldenberg and colleagues28 developed and com- of the clients and their relatives, and it should be
pared two therapy interventions aimed at restoring tied as closely as possible to the normal environ-
the ability to engage in complex ADL for those living ment of the client’s daily life. Otherwise, it runs
with apraxia. Exploration training was aimed at hav- the danger of remaining a pure exercise of thera-
ing clients infer function from structure and solve peutic efficiency which does not help the client to
mechanical problems embedded in tasks. During master the challenges of daily life.” Similar to the
treatment, the therapist directs the client’s attention preceding critique, direct training is in and of itself
Chapter 5  Managing Apraxia to Optimize Function 129

a task-specific training method (i.e., transfer is not a ­ common tool (i.e., a spoon), and then was
expected to occur).27 Nonetheless, the idea of trans- required to pantomime the use of that object.
fer of training remains controversial and should • Intransitive-symbolic gesture training in which
be considered when developing an individualized the client was shown two pictures, one of which
treatment program. At this point, only the strategy illustrated a given context (i.e., a man eating a
training approach as discussed has been found to sandwich), and the other showing a symbolic
result in generalization. gesture related to that context (i.e., the gesture
of eating). After the presentation, the client was
asked to reproduce the symbolic gesture shown
Task-Specific Training
in the picture. Following this intervention, the
Poole56 examined the ability of those living with task was to produce the correct gesture (i.e.,
apraxia to master the technique of one-handed the gesture of eating) after the presentation of 
shoe tying (commonly a necessary skill to be mas- the context picture alone (i.e., a man eating a
tered after brain injury). She compared those liv- sandwich), followed by the task of producing the
ing with a stroke without apraxia, those living correct gesture (i.e., gesture of eating) after the
stroke with apraxia, and healthy adults. The task presentation of a picture showing a new, though
was taught using published standardized pro- similar, contextual situation (i.e., a man eating
cedures via demonstration and simultaneously canned food with a fork).
verbalizing instructions. Repetition of demonstra- • Intransitive-nonsymbolic gesture training in
tions and instructions was used until the task was which the client was asked to imitate meaning-
achieved. The mean number of trials to learn the less intransitive gestures previously shown by
task was higher for those with apraxia (M = 6.4) the examiner.
as compared with those stroke survivors without Multiple neuropsychological tests were used as
apraxia (M = 3.2) versus healthy controls (M = 1.2). outcome measures including aphasia, verbal com-
Although the number of trial required to learn the prehension, intelligence, oral apraxia, constructional
task was greater, the majority of those with apraxia apraxia, ideational apraxia, ideomotor apraxia, and
were able to learn and retain the task. gesture recognition. The clients in the study group
Wilson72 documented a task-specific training achieved a significant improvement of performance
program for a young woman after an anoxic brain in both ideational and ideomotor apraxia tests. 
injury. Two tasks focused on were drinking from In addition, they showed a significant reduction of
a cup and sitting on a chair followed by position- errors committed during the apraxia tests. No sig-
ing it correctly at the table. Functional performance nificant changes occurred in the control group. The
was improved for this woman via the techniques of authors concluded that “the results show the pos-
breaking down the steps of the tasks followed by sible effectiveness of a specific training ­programme
practice of the steps, chaining procedures, and ver- for the treatment of limb apraxia.” A follow-up to
bal mediation. The author noted that ­generalization this study62 involved further investigation of nine
to untrained tasks was not evident. clients in the study group and eight clients in the
Smania and coworkers63 examined the effec- control group 2 months after the end of the treat-
tiveness of a behavioral training program consist- ment. The outcome measures used in the follow-
ing of gesture-production exercises for those living up evaluation were impairment-based apraxia tests
with apraxia via a randomized controlled trial. and an ADL questionnaire. The authors found that
Subjects with left-sided strokes averaging 5 months those who received specific apraxia training not only
post onset were included. The study compared improved the ability to produce a wide range of ges-
the experimental group with a control group who tures but also required less assistance from caregiv-
received conventional treatment for aphasia. The ers during ADL. In other words they ­concluded that
interventions consisted of the following: training generalized to untrained tasks.
• Transitive gesture training in which the client In summary, based on the available research
was required to show the use of common tools related to apraxia and consistent with the above
(i.e., a spoon) followed by the client being shown findings, Cappa and associates12 concluded that
a picture illustrating a transitive gesture (i.e., “there is grade A evidence for the effectiveness of
using a spoon), and then required to produce the apraxia treatment with compensatory strategies.
corresponding gestural pantomime, followed Treatment should focus on functional activities,
by the client being presented a picture showing which are structured and practised using errorless
130 cognitive and perceptual rehabilitation: Optimizing function

learning approaches. As transfer of training is dif- also address if the treatment effects generalize to ­ 
ficult to achieve, training should focus on specific non-trained activities and situations.”
activities in a specific context close to the normal Appendix 5-1 lists a summary of interventions.
routines of the clients. Recovery of apraxia should These referenced studies provide clinicians
not be the goal for rehabilitation. Further stud- with guidance regarding how to design an ineffec-
ies of treatment interventions are needed, which tive intervention plan for those who are living with

Box 5-4 Potential Interventions for Those Living with Functional Limitations
Secondary to Apraxia
• Use functional tasks (previously learned and new tasks • Object affordances (the functional utility of particular
that are necessary to perform secondary to neurologic objects within a context) support motor performance.
impairments) as the basis of the interventions (i.e., an Using meaningful objects and tasks will yield better
individualized task-specific approach). results than movements performed in isolation.
• “Tap into” an individual’s routines and habits. • Because those with apraxia have compromised learning
• Collaborate with the client and significant others/ of old and new tasks, increased repetitions and practice
caregivers in order to choose the tasks that will be will be necessary. Goals should be scaled accordingly.
focused on and that will become the goals of therapy • Encourage practice of learned skills outside of therapy
(i.e., a client-centered approach). and throughout the day.
• Practice these activities in the appropriate environments • For those with ideomotor apraxia, experiment with
and at the appropriate time of day (i.e., context specific decreasing the degrees of freedom (i.e., number of
with full contextual cues). joints) used to perform the task. For example, encourage
• Use strategy-training interventions to develop internal a woman who is attempting to apply makeup to keep
or external compensations during the performance of her elbow on the table. Grade required functional
functional activities. See Box 5-3. movements from simple to complex such as grading
• Focus interventions based on the errors that are made from smoothing out a bedspread, to removing a pillow
during the task: initiation, execution, and or control from a pillowcase, to placing a pillow into a pillowcase,
(i.e., error-specific interventions). to folding a large sheet, to making a bed, etc.
• Practice functional activities with vanishing cues. • Grade the number of tools and distracters used in a
• Provide graded assistance via graded instructions, task. For example, finger feeding (no tools), followed
assistance, or feedback during task performance. by eating applesauce with only a spoon available,
• Practice functional activities using errorless learning followed by eating applesauce with the choice of one
(preempting the error via assistance) approaches. to three utensils, followed by eating a meal requiring
• If physical guiding of the limbs is used during a task, the choice of various tools for different aspects of the
incorporate the suggested principles of guiding: task (spoon to stir coffee, knife to cut and spread butter,
• The therapist should place his/her hands over the etc.), followed by a meal with the necessary and usual
client’s whole hand, down to the fingertips. utensils in addition to distracter tools such as comb,
• Keep talking to a minimum. toothbrush, etc.
• Guide both sides of the body when possible. • Grade the number of steps of an activity via chaining
• Move along a supported surface to give the client procedures. The whole task should be completed for
maximum tactile feedback. each trial.
• Involve the whole body in the task to challenge • Grade the number of tasks that will be performed in
posture. succession such as during a morning routine.
• Provide changes in resistance during the activity. • Use clear and short directions.
• Allow the client to make mistakes to give • Use multiple cues to elicit functions: visual
opportunities to solve problems. demonstration, verbal explanation, and tactile guiding.
• Encourage tactile exploration of functional objects • Demonstrate the task while sitting parallel to the person
and tools to enhance performance as somatosensory with apraxia to help develop a visual model of the task
feedback from the tool may play a role in organizing at hand.
movements. • Encourage verbalization of what is to be done.

Data from Brockmann-Rubio K, Gillen G: Treatment of cognitive-perceptual impairments: a function-based approach. In Gillen G, Burkhardt A, editors:
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formance through occupational embedded exercise: a meta-analytic review, Occup Ther J Res 17(1):25-47, 1997; Wada Y, Nakagawa Y, Nishikawa T, et al:
Role of somatosensory feedback from tools in realizing movements by patients with ideomotor apraxia, Eur Neurol 41:73-78, 1999; and Wu C, Trombly C,
Tickle-Degnen L: Effects of object affordances on movement performances: a meta-analysis, Scand J Occup Ther 5(2):83-92, 1998.
Chapter 5  Managing Apraxia to Optimize Function 131

Box 5-5 Interventions for Caregivers of Those Living with Functional Limitations
Secondary to Apraxia
• Be mindful that cognitive and perceptual deficits in • Emphasize that more time will be needed to complete
general are not commonly understood by the lay daily activities and rushing should be avoided.
community. In particular, it is difficult to watch a person • Based on evaluation findings, teach caregivers
with apraxia function (e.g., using tools incorrectly), appropriate cueing strategies (gestures, tactile, visual,
and education as to the nature of the deficit for family and/or auditory) that enhance function.
members is warranted early on. • Emphasize the need to allow for independent
• Make sure that caregivers understand that the behaviors performance of at least part if not the whole
observed are not caused by a lack of motivation. activity—educating as to the importance of not
• Emphasize the importance of maintaining habits and overassisting.
routines and keeping a consistent sequence of daily

functional limitations secondary to apraxia. Other 4. Árnadóttir G: Impact of neurobehavioral deficits

authors have made useful treatment suggestions on activities of daily living. In Gillen G, Burkhardt
that warrant further empirical testing. Box 5-4 lists A, editors: Stroke rehabilitation: a function-based
further potential interventions based on these stud- approach, ed 2, St Louis, 2004, Elsevier/Mosby.
5. Ayres AJ: Developmental dyspraxia and adult onset
ies and the available literature. In addition, inter-
apraxia, Torrance, Calif, 1985, Sensory Integration
ventions and education for caregivers are crucial
and are included in Box 5-5. 6. Barry P, Riley JM: Adult norms for the Kaufman Hand
Movements Test and a single-subject design for acute
brain injury rehabilitation, J Clin Exp Neuropsychol
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grooming session?
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12. Cappa SF, Benke T, Clarke S, et al: Task force on
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61. Shelton P, Knopman D: Ideomotor apraxia in Wright.
Huntington’s disease, Arch Neurol 48:35-41, 1991. 73. Zwinkels A, Geusgens C, van de Sande P, et al:
62. Smania N, Aglioti SM, Girardi F, et al: Rehabilitation Assessment of apraxia: inter-rater reliability of a new
of limb apraxia improves daily life activities in apraxia test, association between apraxia and other
patients with stroke, Neurology 67(11):2050-2052, cognitive deficits and prevalence of apraxia in a reha-
2006. bilitation setting, Clin Rehabil 18(7):819-827, 2004.
Appendix 5-1
Evidence-Based Interventions for Apraxia Focused on Improving
Daily Function

Table 1 Summary of Research

Study Intervention Description Characteristics n Age

van Heugten et al, 1998 70

Strategy training to Stroke survivors ranging 33 M = 70.1 (SD = 11);
compensate for the from 1.6 to 21.4 weeks range = 39 to 91
presence of apraxia poststroke (M = 9
weeks poststroke)
Donkervoort et al, 200118 Strategy training to Left hemisphere stroke 113 M = 67.6 (SD = 11.7)
compensate for the survivors
presence of apraxia Average number of days
poststroke is equal to
100.2 (SD = 63.3)
Goldenberg and Specific training of activities of Stroke survivors with right 15 M = 55.7;
Hagmann, 199829 daily living (ADL) focusing hemiplegia range 36 to 72
on errorless completion Average number of weeks
of the whole activity and poststroke is equal to
training of details 6.1; range = 4 to 12
Goldenberg et al, 200128 Specific training of complex Left middle cerebral 6 M = 54.4;
ADL focusing on exploration artery stroke survivors range 31 to 81
training and direct training at least 6 months
Poole, 199856 Specific training of one-handed Ten left hemispheric 15 M = 70
shoe tying chronic stroke survivors
(5 with apraxia) and
5 controls
Wilson, 198872 Step-by-step practice, An adolescent with an 1 Adolescent
chaining procedures, verbal anoxic brain injury
Smania et al, 200662 Behavioral training of gesture Those with apraxia 9 M = 65.67 (SD = 9.83)
production secondary to a stroke

M, Mean; SD, standard deviation.

Chapter 5  Managing Apraxia to Optimize Function 135

Table 2 Summary of Outcomes

Dimension Based
on International
Statistically Classification
Study Study Design Outcome Measure Results Valid of Function*

van Heugten Pretest/posttest Apraxia: gesture imitation and + p < 0.01 Impairment
et al, 199870 object use demonstration
Motor function: balance, + p < 0.05 Impairment
motor control of the upper
extremity, and sensation
ADL: standardized + p < 0.001 Activity limitations
ADL: Barthel Index + p < 0.01 Activity limitations
ADL: questionnaires + p < 0.01 Activity limitations
Donkervoort Randomized Apraxia: gesture imitation and No difference p < 0.25 Impairment
et al, 200118 controlled trial object use demonstration
Motor Function: Motricity No difference p < 0.39 Impairment
Functional motor test No difference p < 0.13 Impairment
ADL: standardized + p < 0.03 Activity limitations
ADL: Barthel Index + p < 0.00 Activity limitations
ADL: questionnaires No difference p < 0.48 Activity limitations
Goldenberg Pretest/posttest ADL: spreading margarine Activity limitations
and on bread; brushing teeth,
Hagmann, and putting on a T-shirt.
199829 Measures of decrease in
number of:
Fatal errors + p < 0.01
Reparable errors No difference p > 0.5
Goldenberg Pretest/posttest Complex ADL: spreading Activity limitations
et al, 200128 margarine and jam after
cutting bread; making
coffee, fixing a carpet knife
and cutting, managing a
tape recorder. Measures
of error reduction and
decrease in assistance
needed based on:
Direct training + p = 0.027
Exploration training No difference p = 0.17
Poole, 199856 Description ADL: comared to controls, Activity limitations
of learning the number of trials to:
one handed Learn to tie a shoe — p < 0.0001
techniques Retain the skill — p < 0.001
Wilson, 198872 Case study Drinking from a cup + No statistics Activity limitations
Positioning a chair at the table + No statistics Activity limitations
Smania Randomized ADL questionnaire + p < 0.001 Activity limitations
et al, 200662 controlled Ideational apraxia + p < 0.01 Impairment
trial Ideomotor apraxia + p < 0.01 Impairment
Gesture comprehension + p < 0.01 Impairment

* Dimension based on World Health Organization’s (WHO) International Classification of Function (ICF). Impairments are problems in body function (phys-
iologic functions of body systems) or structure (anatomic parts of the body such as organs, limbs, and their components) such as a significant deviation or
loss. Activity limitations are difficulties an individual may have in executing activities. Participation restrictions are problems an individual may experience
in involvement in life situations.
+, Improvement in the outcome measure that was beneficial to the participants; —, worsening or no change in status based on the outcome measure.
Chapter 6
Managing Unilateral Neglect to Optimize Function

Key Terms
Anosognosia Extinction Prism
Awareness Hemianopsia Scanning
Body/Personal Neglect Left-limb Activation Spatial Neglect
Environmental Modification Partial Visual Occlusion Spatio-motor Cueing

Learning Objectives
At the end of this chapter, readers will be able to: 4. Be aware of evaluation/assessment procedures related
1. Differentiate among various types of neglect and to neglect.
neglect and coexisting impairments. 5. Implement at least five intervention strategies
2. Understand recovery patterns related to neglect. focused on decreasing activity limitations and par-
3.  Understand how everyday living is affected by neglect. ticipation restrictions for those living with neglect.

“Compounding the women’s confusion and anxiety about the external world was the sense of
estrangement from the left half of their own bodies. These women all felt as though the left half of
their bodies did not belong to them. In the same way the left-world was no longer part of their
life-world, the left half of the body also seemed not to be part of the self.”89

U nilateral neglect has been defined as “the fail-

ure to report, respond, or orient to novel or
meaningful stimuli presented to the side opposite
observed during everyday activities lend support to
the attentional hypothesis, including the following:
• Not being aware of incoming stimuli on the side
a brain lesion, when this failure cannot be attrib- opposite the brain lesion (e.g., hypoattentive to
uted to either sensory or motor defects.”43 Unilateral the left side).
neglect is most often seen when right-side brain • A bias in attention to information presented on
damage occurs; therefore the most frequent clini- same side of the lesion (e.g., hyperattentive to the
cal presentation is that of left unilateral neglect. right side).
Although the mechanisms underlying neglect are • Not being able to disengage from right-side
still debated, a common hypothesis is that neglect is stimuli.
related to attention-based impairments and has been The fact that those living with neglect most often
described as a lateralized attention deficit. Behaviors present with left neglect also supports the ­attentional

Chapter 6  Managing Unilateral Neglect to Optimize Function 137

hypothesis because the right hemisphere is thought of detail of the description may change based on
to be dominant for attention (Figure 6-1). That imagined vantage point. If the person imagines sit-
being said, right unilateral neglect is possible.83 ting behind the desk, the description may be overly
Beis and associates16 documented right neglect in focused on details of the right side of the office with
10% to 13.2% of those they examined. They con- only a gross description (if any) of the left side of
cluded that right neglect caused by left hemispheric the office. If the person then imagines a change in
involvement is an elusive phenomenon and is less viewed vantage point (e.g., imagine yourself fac-
consistent than right hemispheric neglect. In addi- ing the desk), the previously neglected descrip-
tion, the frequency of occurrence of right neglect tion of the left side of the room will now be on the
was, as expected, much lower than that reported in right side and the person my able to describe it in
a study using the same assessment battery in right more detail than before. In addition, a person with
brain damage stroke ­clients. Árnadóttir8,9 cautions neglect may misplace the midpoint of an imagined
that behaviors observed during everyday activities number line when asked to bisect it (e.g., stating
that appear to be indicative of right neglect may in that five is halfway between two and six), with an
fact be caused by other impairments such as ide- error ­pattern that closely resembles the bisection of
ational apraxia (see Chapter 5) or comprehension physical lines.102
deficits. Heilman and colleagues43 reviewed the litera-
In addition to the attentional hypothesis, those ture related to anatomic areas related to neglect and
presenting with unilateral neglect also may have summarized that lesions in the following areas may
lost the representation of left space that is stored cause neglect (Figure 6-2):
in the right hemisphere because the brain injury • Inferior parietal lobe (temporoparietal-occiptal
may lead to a destruction of this representation. junction) (most frequent)
In other words, attention may not be directed to • Dorsolateral frontal lobe
the left side of space because the person no longer • Cingulate gyrus
has the knowledge that it exists.43,60 For example, if • Neostriatum
a person with neglect is asked to describe a room • Thalamus
from memory, such as a familiar office, the level • Posterior limb of the internal capsule

Right Hemisphere Left Hemisphere

Able to attend to right and left stimuli Able to attend to right stimuli
Right Hemisphere Left Hemisphere

Not attending Able to attend to right stimuli only

Right Hemisphere Left Hemisphere

Able to attend to right and left stimuli Not attending

Figure 6-1  Right hemispheric dominance related to attention or neglect. A, Typical (intact central nervous system) presentation 
(i.e., right and left hemispheres intact). Typically the right hemisphere is dominant for attention (i.e., it is able to attend to both right and
left stimuli). Inaddition, the left hemisphere can also support attention processes but only attends to the right. Therefore, right-sided stimuli
can be attended to by both the right and left hemispheres. B, Right hemispheric damage. When the right hemisphere is damaged, the
left hemisphere is attending only to right-sided stimuli and is not able to attend to the left (i.e., left unilateral neglect). C, Left hemispheric
damage. When the left hemisphere is damaged, the right hemisphere is still able to attend to stimuli from both the right and left 
(i.e., neglect is less probable).
138 cognitive and perceptual rehabilitation: Optimizing function

deficits such as hemianopsia. Includes neglect of

near (peripersonal) and far space (Table 6-1).
• Unilateral body/personal neglect8,9: Failure to
report respond, or orient to body side (personal
space) contralateral to a cerebral lesion.
The term inattention is not used in this chapter.
In many clinical settings the term is used to qualify
the severity of neglect. Inattention is discussed as a
milder form of neglect in terms of daily effect. This
differentiation should be used with caution because
functional manifestations of neglect vary based on
the task and the environment. For example, in a
quiet hospital room without distractions and with
Figure 6-2  Lateral view of the right hemisphere. Lesions (as controlled and relatively limited incoming stimuli,
determined by computed tomography [CT] scan) of 10 clients a person with neglect may perform well and attend
with the neglect syndrome are superimposed. (From Heilman to both the right and the left fields. The same person
KM, Watson RT, Valenstein E: Neglect and related disorders. In may present completely differently (i.e., an increased
Heilman KM, Valenstein E, editors: Clinical neuropsychology, ed 4, 
impact of the underlying neglect) during a commu-
New York, 2003, Oxford University Press.)
nity reintegration session focused on walking in a
crowded environment.
Conceptual and Operational
Neglect Presentations
The following definitions are used throughout the
rest of this chapter: As mentioned, neglect can be perceptual (i.e., not
• Unilateral spatial or extrapersonal neglect8,9: responding to contralateral sensory stimuli) or in
Inattention to or neglect of visual stimuli pre- the absence of such sensory input, representational
sented in extrapersonal space of side contralateral (by imagining familiar scenes). Although it is most
to a cerebral lesion as a result of visual-percep- common for these phenomena to occur together,
tual deficits or impaired attention. It may occur there is recent evidence that one may occur with-
independently or in conjunction with visual out the other. In other words, there appears to be a

Table 6-1 Spatial Aspects of Neglect During Functional Activities*

Type of Neglect Functional Activity Difficulties

Personal or body neglect Does not shave left side of face

Does not comb left side of head
Does not apply makeup to left side of face
Does not wash or dry left side of body
Does not integrate left side of body during bed mobility and transfers
Does not use left side of body when able
Near extrapersonal (peripersonal [within Cannot find objects on left side of sink
arms’ reach]) neglect Cannot find objects on left side of desk
Inability to read
Inability to locate numbers on the left side of the phone
Does not eat food on left side of the plate
Cannot find wheelchair brakes on left side of the chair
Far extrapersonal neglect Cannot locate clock on left side of wall
Gets lost easily during ambulation or wheelchair mobility
Cannot navigate doorways
Difficulty watching TV
Cannot locate source of voices when being addressed from the left side

*Spatial neglect includes both near and far extrapersonal space.

Chapter 6  Managing Unilateral Neglect to Optimize Function 139

dissociation between the two presentations.59,60 One

may present with perceptual neglect or representa-
Box 6-1 Functional Manifestations of
tional neglect or both.
Motor Neglect or Extinction
From a clinical perspective, neglect may occur Degraded performance of the left (usually) upper
within personal space (body neglect) or in extra- extremity during bilateral activities such as cutting,
personal space (spatial neglect). In addition, spa- aspects of oral care (placing toothpaste on brush),
tial neglect can affect both near (peripersonal) or folding a sheet, opening a container, typing,
far stimuli (see Table 6-1). Personal and extraper- buttoning, chopping vegetables.
sonal can occur together or separately (i.e., they are Loss of spontaneous use of the limb opposite the lesion
also dissociated).12,20,39,51 A person may fully attend Dropping or “forgetting” about items in the left hand
to his or her body during self-care (brushing both as the right hand is engaged in activity. For example,
sides of the mouth, dressing both sides of the body) dropping the shopping bag that the left hand was
but not be able to “find” the soap located on the left carrying as the right hand is engaged in retrieving keys
and opening a door or spilling a glass of water that
side of the sink. In this case the person is presenting
was in the left hand as the right hand is used to eat
with extrapersonal/spatial neglect but not personal/ Dragging of foot during gait activities and upright
body neglect. Beschin and Robertson19 documented function
a high incidence (59%) of personal neglect among
those with extrapersonal neglect and again con-
firmed a dissociation between personal and extra-
personal neglect. Seven subjects with extrapersonal damage and is sitting at the dinner table. Mary takes
neglect showed no personal neglect, whereas five the seat across from John and to his left (contra-
subjects exhibiting no extrapersonal neglect did lateral to John’s brain lesion). For a while they are
show personal neglect. having dinner alone and John can attend to Mary
The term motor neglect refers to the underuse and socialize with her. In the middle of the meal,
of a contralesional limb that cannot be explained Peter sits across from John to his right (ipsilesional
by primary sensorimotor deficits.68 Documented to John’s brain injury). At this point, the extinc-
behaviors include the following (Box 6-1)48,68: tion behaviors are observed. John will begin to not
• When a task may be performed by the ipsile- attend to Mary and will focus attention on Peter.
sional side, there will be underuse of the contral- This hyperattention to ipsilesional stimuli has been
esional side. described as a “magnetic” attraction that can’t be
• No or little involvement of the contralesional overcome by cueing (Figure 6-3).36
limb in bimanual tasks. Another manifestation of extinction is motor
• No or little involvement of the contralesional extinction,67,68 which refers to reduced performance
limb in gesture. of the contralesional limb during bilateral activ-
• Relatively intact movement when encouraged ity. Motor extinction is strongly related to motor
specifically to use the contralesional limb. neglect as described earlier. When a person pres-
• When walking, the contralesional limb may ents with motor extinction, the deficit is observed
lag behind the ipsilesional limb, although as degraded performance of the contralesional limb
when attention is drawn to it, performance is that either becomes apparent or worsens dispropor-
improved. tionately when a simultaneous ipsilesional move-
Another behavior commonly seen in those with ment is made (Figure 6-4).68 Examples of activities
neglect is extinction. In extinction, a person fails to that may be impeded secondary to motor extinction
detect contralesional stimulation that is accompa- including folding laundry, pulling up pants, etc.
nied by ipsilesional stimulation (i.e. bilateral simul- Neglect and extinction often coexist but, albeit
taneous stimulation), despite being able to detect rarely, they can also dissociate, suggesting that
contralesional stimuli in isolation.54 In other words, they may have separate neural underpinnings.46,54
ipsilesional stimuli interfere with the processing of A recent lesion overlap study concluded that the
contralesional stimuli.36 Extinction occurs because temporoparietal junction is the neural substrate
the hemispheres are unbalanced in the way they of visual extinction.46 It is important to screen for
allocate attention as described above. The left, intact extinction because its presence will affect the reha-
hemisphere competes with and “wins over” the bilitation process. It may be particularly noted
damaged right hemisphere.For example, John pre­ during the performance of functional activities in
sents with extinction after right hemispheric brain stimulating environments such as a lobby or store
140 cognitive and perceptual rehabilitation: Optimizing function

Mary Peter as information is “bombarding” both hemispheres.

In these cases, a person with extinction may worsen
and be hyperattentive to the right (Box 6-2).
A Frequency and Recovery Patterns
Mary Several published studies have attempted to docu-
ment the frequency of neglect with various findings
including the following:
John • Kalra and colleagues45 documented that 32%
B of those receiving stroke rehabilitation present
with neglect.
Mary Peter
• Halligan and coworkers41 reported that 48% of
right hemisphere stroke clients in rehabilitation
presented with neglect.
John • Zoccolotti and associates101 found that estimates
C of the disorder in rehabilitation clients varied
Figure 6-3  An example of potential functional manifestation of with the test used from 26.7% to 52.0%, but
extinction during mealtime. A, Typical behavior when extinction only 20% of clients had very severe neglect on
is not present. John is able to attend to Mary, who is seated to the basis of overall clinical judgment.
the left of John, as well as to Peter seated to his right. B, When • Stone and colleagues83 reported a neglect inci-
extinction is present, John (who has right hemispheric brain dence of 75% in right hemisphere stroke survi-
damage) is able to attend to Mary who is seated to John’s left side vors 3 months after stroke.
when they are dining alone. C, When extinction is present, John • Azouvi and associates12 found that sensitivity
will have difficulty attending to Mary to the left side of the table but
greatly varied depending on which test of neglect
may be hyperattentive to Peter, who is seated to the right of John
was used ranging from 19% to 50.5%. More
as in this situation. Mary and Peter serve as double simultaneous
visual stimulation. than 85% of clients presented with some degree
of neglect on at least one test. According to the
behavioral/functional assessment (Catherine
Bergego Scale11,18 as discussed later), neglect was

Figure 6-4  The person was previously using his left limb to pour out aftershave lotion. Now that he is applying the lotion with his right
hand, he loses attention to the left side and begins to spill the lotion. Screen for joint position sense deficits as well. (From Árnadóttir G:
The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby.)
Chapter 6  Managing Unilateral Neglect to Optimize Function 141

Box 6-2 Screening Techniques for Extinction

A person with an intact central nervous system should be the left, or both.” A normal response is that the person
able to attend to and identify tactile, visual, and/or audi- can detect unilateral and bilateral stimulation. If the client
tory stimuli that are presented to both sides of the body at neglects one side during double simultaneous visual stimu-
the same time. Note that prior to testing it must be ascer- lation, visual extinction is present. For example, the person
tained that the person being tested is able to detect incom- can detect the moving finger on only the right side and only
ing sensory information on both sides. In other words, first on the left side. When the examiner moves both fingers, the
screen for homonymous hemianopsia, unilateral deafness, person being tested only reports right-sided stimulation.
or hemisensory loss.
Tactile Double simultaneous auditory stimulation is tested by giving
Double simultaneous tactile stimulation is tested by touch- auditory stimulation (a snapping sound) to one side of the
ing homologous parts (e.g., hands or shins) of the body on body, the other side, or both sides at once, with the person
one side, the other side, or both sides at once with the per- identifying where the sound is heard. The examiner stands
son identifying which side or if both sides are touched with behind the person being tested with the hands positioned
their eyes closed. The examiner requests that the person next to each ear. “Tell where you hear the snap sound—
close the eyes and states, “Tell where I am touching you—on on the right side, the left side, or on both sides.” A normal
the right side, the left side, or on both sides.” A normal response is that the person can detect unilateral and bilat-
response is that the person can detect unilateral and bilat- eral stimulation. If the client neglects one side during dou-
eral stimulation. If the client neglects one side during dou- ble simultaneous auditory stimulation, auditory extinction
ble simultaneous tactile stimulation, tactile extinction is is present. For example, the person can detect the snapping
present. For example, the person can detect being touched only on the right side and only on the left side. When the
only on the right side and only on the left side. When the examiner snaps next to both ears, the ­person being tested
examiner touches both sides, the person being tested only only reports right-sided stimulation.
reports right-sided stimulation.
Visual Reduced performance of the contralesional limb during
Double simultaneous visual stimulation is tested by provid- bilateral activity is termed motor extinction. For testing,
ing visual input such as wiggling fingers in one visual field, the person is asked to make as many tapping movements
the other visual field, or both visual fields at once, with the as possible under both unimanual and bimanual testing
person identifying where movement is detected while the conditions in 15 seconds. A person who shows a dispro-
eyes are focused forward on the examiner. The examiner portionately lower number of taps with the contralesional
requests that the person being tested look at the examin- limb under bimanual conditions is thought to demonstrate
er’s nose and states, “Tell which finger is moving—the right, motor extinction.

Data from Gutman SA, Schonfeld AB: Screening adult neurologic populations, Bethesda, Md, 2003, AOTA Press; Punt TD, Riddoch MJ: Motor neglect:
implications for movement and rehabilitation, Disabil Rehabil 28(13-14):857-864, 2006; and Tucker DM, Bigler ED: Clinical assessment of tactile extinction:
traditional double simultaneous stimulation versus Quality Extinction Test, Arch Clin Neuropsychol 4(3):283-296, 1989.

considered as clinically significant (moderate to neglect varies with the tool used. Similarly, assess-
severe) in 36.2% of cases. ments were performed at different times, and there is
• Buxbaum and coworkers24 found that neglect was some evidence that frequency varies according to the
present in 48% of right hemisphere stroke clients. timing of the assessment. Finally, neglect is variable
• In a community-based study of 602 consecutive or inconsistent and not an “all or none” impairment.
stroke clients, neglect was found in 23% of the It is commonly influenced by extraneous factors such
sample.64 as fatigue, distractions, motivation, external cues,
Bowen and associates22 also reviewed the litera- task difficulty, density of stimuli, and so on.12,22
ture and found that the frequency of occurrence of Recovery from neglect was recently examined by
neglect in clients with right brain damage ranged Farne and colleagues,29 who examined a consecu-
from 13% to 82%. The assessment method used tive series of right brain-damaged clients with and
was one of the main factors explaining the discrep- without neglect via weekly tests in the acute phase
ancies between the different studies.22 As differing of recovery. They found that spatial attention def-
methods of assessment are used, the frequency of icits partially improved during the acute phase of
142 cognitive and perceptual rehabilitation: Optimizing function

the disease in less than half the clients investigated. Kalra and coworkers45 examined 150 subjects
There was an improvement in left visuospatial undergoing rehabilitation. They found that people
neglect at the chronic stage of the ­disease, but the with visual neglect have greater activity limitations
recovery was not complete. than those without neglect. In addition, those with
Appelros and coworkers6 examined the ­recovery neglect took longer to recover despite comparable
process for different forms of unilateral neglect stroke pathology and severity of motor impair-
­(personal neglect and neglect of far space). Subjects ment. Although other studies have documented
were tested at 2 to 4 weeks, at 6 months, and at 1 greater institutionalization for those with neglect,
year using the Behavioral Inattention Test (discussed Kalra and coworkers45 found that discharge des-
later) and a test for personal neglect. They found that tination in those with neglect is comparable with
peripersonal neglect diminishes within 6 months, that of others of equal stroke severity managed on
but complete recovery occurred in only 13% of those a stroke unit.
examined. Also the prognosis for personal neglect Chen-Sea25 documented that those with concur-
and neglect of far space is better, with a recovery rent personal and extrapersonal neglect were sig-
ratio at 6 months of 52% and 46%, respectively. They nificantly more impaired in activities of daily living
also found that a few of the subjects’ neglect status (ADL) performance as compared with those with
deteriorated in the absence of recurrent stroke. The extrapersonal neglect and those with test results
authors concluded that it is practical to postpone within normal range on standardized neglect
a neglect evaluation until a couple of weeks after a testing.
stroke. At that point, many of the clients who ­present Buxbaum and colleagues24 assessed 166 rehabili-
with neglect are likely to retain it, although many will tation in patients and outpatients with right hemi-
also improve. sphere stroke with measures of neglect and neglect
subtypes, attention, motor and sensory function,
functional disability, and family burden. Those with
Effect of Unilateral Neglect on Daily
neglect had more motor impairment, sensory dys-
Life and Rehabilitation Outcomes
function, visual extinction, basic (nonlateralized)
The presence of neglect has the potential to affect a attention deficit, and anosognosia than did those
person’s ability to participate in many daily ­activities. without neglect. Neglect severity predicted scores
Basic as well as instrumental activities of daily living on the FIM and Family Burden Questionnaire more
may be adversely affected as well as work and leisure accurately than did the number of lesioned regions.
pursuits. They concluded that the neglect syndrome, rather
Cherney and associates26 investigated the func- than overall stroke severity, predicts poor outcome
tional aspects of those with neglect and found the in right hemisphere stroke.
following: Katz and colleagues47 evaluated the effect of uni-
• Clients made significant functional gains between lateral spatial neglect on the rehabilitation outcome
admission and discharge, as well as between dis- and long-term functioning in ADL and instru-
charge and follow-up on the Functional mental ADL (IADL) of right hemisphere–dam-
Independence Measure (FIM). aged stroke survivors. The authors administered
• Severity of neglect was correlated with total, assessments of sensorimotor, cognitive impair-
motor, and cognitive FIM scores at admission, ment, functional disability at admission to reha-
discharge, and follow-up. bilitation, discharge, and 6 months after discharge.
• Those living with neglect had significantly more Based on their score on the Behavioral Inattention
days from onset to admission to rehabilitation Test (BIT), subjects were divided into two groups:
and a longer length of rehabilitation stay than 19 with neglect and 21 without neglect. They found
subjects without neglect. that both impairment and activity measures of
• FIM outcomes were significantly different for those with and without neglect were differentiated.
subject groups with more severe neglect. Neglect was associated with lower performance on
• Both the presence of neglect and its severity were measures of sensorimotor and cognitive impair-
significantly related to functional outcomes for ment as well as on measures of basic and instru-
reading and writing. mental ADL. Differences were significant in all
• Clients with neglect show reduced overall and testing periods. In addition, the recovery pattern of
cognitive-communicative functional ­ performance those with neglect was slower. In both groups, the
and outcome than clients without neglect. most improvement occurred in the first 5 months
Chapter 6  Managing Unilateral Neglect to Optimize Function 143

after onset of stroke. They concluded that neglect As discussed related to representational neglect,
is a major predictor of rehabilitation outcome from those with neglect have difficulty describing a
admission to follow-up and that neglect is a major familiar route from memory, particularly when
source of stroke-related long-term disability. left-sided turns are involved. Guariglia and
Gialanella and associates37 examined whether the Antonucci39 documented a specific navigational
presence of anosognosia or denial or lack of aware- impairment in right brain–­damaged subjects pre-
ness of deficits affects the rehabilitative prognosis senting with representational neglect. Specifically
of hemiplegic subjects with neglect (see Chapter 4). those with neglect had difficulty reorienting to
They examined 30 clients with left hemiplegia: 15 the room, and the target location was reached
clients had neglect (N) and 15 had neglect and only after getting lost and long and imprecise
anosognosia (N+A). Before rehabilitation, cog- wandering. The authors concluded that those
nitive FIM scores of group N were significantly with neglect were unable to manipulate that men-
higher than those of group N+A, whereas motor tal representation in order to reorient themselves
FIM scores and total FIM scores did not differ into the environment.
between the two groups. After rehabilitation, cog- • General nonlateralized attention deficits. Those
nitive FIM scores, motor FIM, and total FIM scores with neglect are more likely to present with gen-
were statistically higher in group N than in group eralized attention disorders as well.24,75,101 See
N+A. Overall disability was lower in group N. The Chapter 8.
authors concluded that the presence of anosognosia • Anosognosia or a denial or lack of awareness of
worsens the rehabilitation prognosis in hemiplegic deficits can occur in conjunction with neglect. In
subjects who also have neglect. addition, anosognosia and neglect usually present
In terms of long-term outcome, it has been found together, but in some cases may be dissociated.11
that neglect in the acute phase negatively affects dis- Those with neglect have less awareness of their
ability after 1 year.3 Finally, those with a right-sided deficits than those without neglect24 and anosog-
bias are at risk for increased falls and wheelchair col- nosia is correlated with neglect severity.10,11 Both
lisions.94 Clinicians should consider the consistent neglect and anosognosia are predictors of func-
findings of these studies when planning rehabilitation tional independence.3 When they occur together,
interventions including deciding on appropriate the prognosis worsens.37 A recent review revealed
length of stay for inpatients and “scaled-down” that anosognosia or a lack of awareness is present
short-term goals. in 20% to 58% of those with neglect.65 If a lack
of awareness of the deficit is present, it will influ-
ence intervention choices. Several of the interven-
Patterns of Impairments
tions discussed here are based on strategy training
It is typical for those presenting with neglect to also approaches; therefore, a certain level of awareness
exhibit other impairments that will further impede is a prerequisite to using these strategies. Awareness
function. These include the following: training is the starting point of intervention, if
• Unilateral sensory loss. Tactile sensory loss is not successful, environmental modifications are
more likely to occur in clients with neglect than ­necessary to improve function (see Chapter 4).
in those without neglect.24 • Visual field deficits. Visual sensory loss is more
• Unilateral loss of motor control. Those with likely to occur in those with neglect than in
more severe neglect are more likely to have more those without neglect.24 Visual field deficits such
severe motor impairment.24 as hemianopsia can occur in conjunction with
• Loss of postural control and postural alignment.87 neglect or the impairments can present indepen-
Neglect has been implicated in the phenomenon dently.12 It is sometimes difficult to differentiate
known as the “pusher syndrome.”67 between visual field deficits and neglect. Muller-
• Topographical disorientation or difficulty finding Oehring and associates55 investigated 11 subjects
one’s way in space. Ambulation and wheelchair with combined neglect/hemianopsia and 11 sub-
mobility will be affected and is usually charac- jects with pure hemianopsia via behaviors on a
terized by a bias toward right-hand turns. Those visual search task with single or double stimula-
with neglect typically cannot find their rooms on tion conditions. The second stimulus was either
a unit and even within the room have difficulty the fixation point itself or a distracter appearing
finding closets and bathrooms because they can- in the hemifield opposite the target. The ­fixation
not make use of left-sided environmental cues. point did not worsen left-sided perception, but
144 cognitive and perceptual rehabilitation: Optimizing function

its disappearance led to a bias of exploration • Design copying tasks

toward the right side in those with neglect but • Drawing tasks such as a drawing a clock, house,
not in those with pure hemianopsia. A distracter or flower
in the intact hemifield worsened the perfor- Using these types of tests exclusively is of concern.
mance to left-sided stimuli—those with neglect Specifically, they focus only on peripersonal neglect
behaved as if they were completely hemianopsic, and their relationship to real-world performance is
even in intact parts of the visual field. Further questionable. People with normal performance on
suggestions to differentiate between impair- pen and paper tests may demonstrate clinically sig-
ments are included in Table 6-2 (see Chapter 3). nificant neglect in everyday life.5,82 Performance of
daily activities involves multiple motor, postural,
visual, and cognitive-perceptual skills (see discus-
Evaluation and Assessments
sion on dual task performance in Chapter 2). It may
Similar to other cognitive and perceptual impair- be that a test that attempts to single out an impair-
ments, instruments designed to test neglect are ment may not be sensitive enough to detect neglect
focused either on documenting the presence of that would interfere during function. In addition,
neglect (i.e., diagnostic in nature) or on how the it has been hypothesized that a person may be able
presence of neglect affects daily functioning. The to compensate for neglect during a relatively short
latter issue is more relevant from a rehabilitation and simple test but not have the same ability during
perspective. Typical pen-and-paper tests that are complex everyday function.
used to document the presence of neglect include Azouvi and colleagues12 assessed the sensitivity of
the following44: different tests of neglect after right hemisphere stroke
• Star cancellations (N = 206). Subjects were given a test battery includ-
• Letter cancellations ing an assessment of anosognosia, visual extinction,
• Line bisection tests assessment of gaze orientation, personal neglect, and

Table 6-2 Suggestions to Differentiate Between Neglect and Visual Field Loss Based
on Analysis of Behaviors
Visual Field Loss Neglect

Objectively tested via confrontation testing (screening) or via Objectively tested using a battery of assessments to
formalized perimetry testing (see Chapter 3) identify body/personal, extrapersonal (near and far),
and motor neglect
Awareness of deficits emerge early in the recovery process Lack of awareness is more severe and persistent
Compensatory strategies such as head turning and wide Compensatory interventions are difficult, may require
saccades are observed early and relatively easily taught multiple sessions, or may not be effective
Postural alignment is usually not affected Postural alignment of the head, neck, and trunk may bias
toward the right side
Sensory-based deficit Attention-based deficit
Visual deficit only Multiple sensory systems may be involved (visual, auditory,
Effective compensatory strategies result in positive functional Functional outcomes tend to be poor as compared to those
outcomes without neglect
Cortical representation of the “whole real world” is intact Decreased representation of the left side of space while
describing a room from memory
Movement into both hemifields is not affected Resistance to moving actively (akinesia) or passively into the
left field
Long delays related to moving into the affected field
Extinction is not present Extinction may be present
Early leftward eye movements noted Rightward-biased eye movements
Not fully effective but consistent scanning patterns Haphazard scanning patterns biased to the right
Comparatively, not as severe a deficit A severe deficit related to functional outcome, rehabilitation
needs, and caregiver burden
Chapter 6  Managing Unilateral Neglect to Optimize Function 145

paper-and-pencil tests of spatial neglect in the peri­ s­ ingle measure of neglect and comparable to the
personal space. The subjects were compared with a complete pen-and-paper battery.
previously reported control group. A subgroup of • Functional neglect was considered as moderate
subjects received a functional assessment of neglect to severe in 36% of cases.
in daily life situations (Catherine Bergego Scale) • Dissociations were found between extraper-
(Figure 6-5). The authors found the following: sonal neglect, personal neglect, anosognosia,
• The most sensitive pen and paper measure and extinction (i.e., they can exist together or in
was the starting point in the cancellation task isolation).
(i.e., a rightward orientation). • Anatomic analyses showed that neglect was more
• The complete test battery was more sensitive common and severe when the posterior associa-
than any single test alone. tion cortex was damaged.
• Approximately 76% of clients presented some • The presence of neglect was task dependent.
degree of neglect on at least one measure. • Tasks including a strong visual component were
• A critical finding from a rehabilitation perspec- the most sensitive.
tive was that the functional assessment of neglect • The automatic rightward orientation bias seemed
in daily life was more sensitive than any other to be the best indicator of unilateral neglect.

Figure 6-5  Catherine Bergego Scale. A test of functional neglect including personal, peripersonal, and extrapersonal aspects of neglect.
Score of 0 is given if no spatial bias is noted. Score of 1 is given when the patient is always first exploring the right hemispace then going
slowly and hestitatingly toward the left space and shows occasional left-sided omissions. Score of 2 is given if the patient shows clear and
constant left-sided omissions and collisions. Score of 3 is given when the patient is totally unable to explore the left hemispace. (Bergego
C, Azouvi P, Samuel C, et al: Validation d’une échelle d’évaluation fonctionnelle de l’héminégligence dans la vie quotidienne: l’échelle CB,
Ann Readapt Med Phys 38:183-189, 1995.)
146 cognitive and perceptual rehabilitation: Optimizing function

Tests of neglect that are more ecologically valid the proportion of the total activity that is directed
have been developed. As discussed in Chapter 1, to the left side of the body. The test is highly reli-
the Árnadóttir Occupational Therapy-ADL Neuro­ able, and more sensitive than previous diagnostic
behavioral Evaluation (A-ONE)8,9 uses structured techniques.19 The person is asked to comb his or
naturalistic observations of basic ADL and mobil- her hair and, during a 30-second period, the rater
ity tasks to assess the effect of both body and spa- categorizes each stroke according to whether it was
tial neglect. Although not an impairment-based applied to the left or the right side of the head, or
test, the Assessment of Motor and Process Skills was ambiguous. Similar 30-second observations are
(AMPS)31,32 objectively documents problematic documented for simulated shaving (men) or facial
motor and process skills during the performance of compact use (women). For each person, a “left over
IADL and some basic ADL. total” percent score is calculated for each of the
The Catherine Bergego Scale11,18 is a standard- activities performed, according to the formula:
ized behavioral assessment of unilateral neglect. It is
% Left = left strokes ÷ left + ambiguous + right strokes
based on a direct observation of the client’s behavior
in 10 everyday situations such as grooming, dress- A recent update of the test characterizes personal
ing, eating, or wheelchair mobility. For each item, a neglect as a lateral bias of behavior rather than as a lat-
4-point scale is used, ranging from 0 (no neglect) to eralized deficit.53 These authors suggest an alternative
3 (severe neglect). The total score ranges from 0 to formula that indexes the magnitude and direction of
30 (see Figure 6-5). This functional assessment of lateral bias as a proportion of the total activity:
neglect in daily life has been found to be more sen-
% Bias = right − left strokes ÷ left + ambiguous
sitive than any other single measure of neglect and
 + right strokes × 100
comparable to a complete pen-and-paper battery12.
A self-assessment version of the scale can be used to A rightward bias yields a positive percentage
objectify anosognosia/awareness (see Chapter 4). score, whereas a leftward bias yields a negative per-
The Behavioral Inattention Test (BIT)97 consists centage score. A score of zero indicates symmetric
of six conventional subtests—figure and shape copy- performance.
ing, line crossing, star cancellation, letter cancellation, The Comb and Razor/Compact Test is test of
line bisection, and representational drawing—as well personal neglect as is the Fluff Test,28 which objec-
as nine behavioral subtests—telephone dialing, map tifies body exploration as 24 stickers are applied to
navigation, address and sentence copying, menu the right and left sides of the body (9 on the right
reading, coin sorting, telling and setting the time, and 15 on the left) (Figure 6-7). The stickers are
picture scanning, card sorting, and ­ article reading. applied while the person is blindfolded and the per-
The test has strong psychometric properties. Further son is asked to search for them while blindfolded
investigation42 of the behavioral subtests revealed without a time limit. Normative data have been col-
that seven of the nine subtests differentiated signifi- lected and published.28
cantly among subjects with visual neglect and those Bowen and associates21 have published preliminary
without neglect (article reading and telling time did data on a functional test of neglect that is under devel-
not discriminate), whereas six of the nine subtests opment. During this test participants must remove keys
correlated significantly with parallel performance from a rack, identify grocery items, wash their face, and
tasks or ADL checklist items. Picture scanning, map clean a tray as method to test for neglect in various spa-
navigation, and card sorting did not correlate with tial domains. The authors report that further testing is
similar tasks based on an ADL checklist. under way. Table 6-3 reviews various instruments used
The BIT uses simulated functional tasks performed for those with unilateral neglect summarized earlier as
out of context to evaluate neglect. In addition the test well as the Wheelchair Collision Test69 used to screen
is only administered in the peripersonal space. The for behavioral manifestations of neglect.
Baking Tray Task4,14, 90 is similar in terms of testing for
neglect of peripersonal space using a simulated task.
Evidence-Based Interventions
The person being examined is required to spread out
cubes evenly across a board as if they were buns on a Although the body of literature focused on testing inter-
baking tray. The Baking Tray Task seems to be a quick ventions related to improving neglect continues to grow,
and yet sensitive test, suitable for screening purposes there continues to be a lack of well-designed and high-
and longitudinal studies (Figure 6-6). quality studies.50 There is a particular lack of studies that
The Comb and Razor/Compact Test19 objectively have tested the effect of intervention at the activity and
evaluates personal grooming behavior according to ­participation levels of function. The following para-
Chapter 6  Managing Unilateral Neglect to Optimize Function 147



Figure 6-6  A, A client performing the Baking Tray Task. B, Normal/typical result. C, Rightward bias (unilateral neglect). D, Rightward
bias (more severe unilateral neglect). E-G, Figure formation (cognitive impairment). Note: The grid shown in these examples is not visible
to the client. It is applied after the cubes have been applied for scoring purposes only. (From Appelros P, Karlsson GM, Thorwalls A, et al:
Unilateral neglect: further validation of the baking tray task, J Rehabil Med 36[6]:258-261, 2004.)

graphs review tested interventions that have included functional performance. Purposeful and meaningful
outcomes related to function, as well as various ­levels (for the participant) daily occupations were used as
of evidence. therapeutic change agents to improve awareness of dis-
abilities. Specific interventions include the following:
• Encouraging the participants to choose motivat-
Awareness Training
ing tasks as the modality of intervention.
Tham and coworkers88 developed an intervention to • Discussions around task performance. Examples
improve awareness related to the effect of neglect on include encouraging the participants to describe
148 cognitive and perceptual rehabilitation: Optimizing function

• The home environment was used to confront

difficulties in familiar settings.
Right Left • Video feedback was used (see later).
• Interviews were used to reflect on and heighten
Using this approach awareness of disabilities
and ADL ability improved in all four participants,
unilateral neglect decreased in three participants,
and sustained attention improved in two partic-
H ipants. The authors concluded that training to
B E I improve awareness of disabilities might improve
the ability to learn the use of compensatory tech-
C F niques in the performance of ADL in clients with
unilateral neglect. Despite the well-documented
L relationship between a lack of awareness and
M S neglect, there is a clear lack of empirical evidence
to support the use of a particular strategy focused
N T on improving awareness. Video feedback (dis-
cussed later) has been used as an intervention to
assist in developing awareness related to neglect
P V behaviors that interfere with task performance
(see Chapter 4).

R Y Scanning Training
Scanning training has long been considered a criti-
cal aspect of intervention programs for those with
neglect. In an early study of scanning training via a
Figure 6-7  The Fluff Test. Placement of targets. (From Cocchini G, randomized trial, Weinberg and colleagues95 studied
Beschin N, Jehkonen M: The fluff test: a simple task to assess body the effects of an intervention consisting of 20 hours
representation neglect, Neuropsychol Rehabil 11[1]:17-31, 2001.) of visual training (1 hour each day for 4 weeks in
reading, writing, and calculation) to promote left-
side scanning. The intervention group significantly
their anticipated difficulties and to link their ear- improved on impairment-based scanning mea-
lier experiences of disability to new tasks and to sures as well as on academic reading tests. Similarly,
plan how they would handle new situations, and Gordon and associates38 examined the effects of
asking the participants to evaluate and describe a perceptual remediation program that included
their performance and to think about whether basic visual scanning, somatosensory awareness
they could improve performance by doing the and size estimation training, and complex visual-
task in another way. perceptual organization. By discharge from reha-
• Provide feedback about the observed difficul- bilitation, the experimental group showed greater
ties including verbal feedback (describe to the gains in all three types of perceptual functioning.
participant difficulties with reading and under- Positive functional effects of these types of interven-
standing the text in the left half of the page of the tions have not been well documented.
newspaper), visual feedback (give visual guid- Wiart and coworkers96 examined the effectiveness
ance to show the “neglected” text in the left half of combined scanning and trunk rotation using a
of the page), and physical guidance. specially designed device (Bon Saint Come’s device)
• When participants could describe their difficul- via a randomized controlled trial. The device uses a
ties, the therapists and participants discussed pointer that comes into contact with specific targets
compensatory techniques that could improve via voluntary trunk rotation. The intervention sig-
task performance. nificantly improved recent and chronic neglect as
• The participant performed the task again, using objectified by standardized impairment measures,
the newly learned compensatory techniques. as well as ADL function as measured by the FIM.

Table 6-3 Recommended Outcome Measures and Function-Based Neglect Assessments
Dimension Based
Instrument and on International
Author Instrument Description Population Validity Reliability Classification of Function Comments

Standardized Activity limitations See Chapter 1

assessments of basic
activities of daily living
Standardized Activity limitations See Chapter 1
assessments of
instrumental ADL
Standardized Activity limitations See Chapter 1

Chapter 6  Managing Unilateral Neglect to Optimize Function

assessments of leisure
Standardized Participation restrictions See Chapter 1
assessments of
Standardized Quality of life See Chapter 1
assessments of quality
of life
Behavioral Inattention Assessment for unilateral Adults with Strong concurrent Interrater = 0.99 Impairment Behavioral tests consist
Test (BIT), neglect using 6 pen- unilateral validity between Test-retest = 0.99 Simulated activity of simulated tasks
Wilson, Cockburn, and-paper tests and 9 neglect the pen-and-paper limitations An eight-item version83
and Halligan, behavioral tests secondary to test and behavioral and a three-item
198797; acquired brain tests and between version44 has been
Halligan, Cockburn, damage test results and ADL used clinically
and Wilson, 199140 observations and Measures peripersonal
performance neglect
Baking Tray Task, Clients are asked to Adults with Initial validity studies Test-retest = 0.87 Impairment measured via Sensitivity can be
Tham and Tegner, spread out 16 cubes unilateral conducted using simulated activity further enhanced
199690; on a 75 × 50-cm neglect modified versions of when it is used in
Appelros et al, 20044 board or A4 paper secondary to the BIT and a test of combination with
(8.27 × 11.69 inches) acquired brain personal neglect other tests
“as if they were buns damage Measures peripersonal
on a baking tray” neglect


150 cognitive and perceptual rehabilitation: Optimizing function
Table 6-3 Recommended Outcome Measures and Function-Based Neglect Assessments—Cont’d
Dimension Based
Instrument and on International
Author Instrument Description Population Validity Reliability Classification of Function Comments

Fluff Test, 24 white cardboard Adults with Appears to have Test-retest = 0.79 Impairment Measures personal/
Cocchini et al, 200128 circles are adhered unilateral content and face to 0.89 body neglect
to various areas on body neglect validity
a person’s clothing secondary to Further validation is
(15 on the left side of acquired brain warranted
the body and 9 on the damage
The person must find
and remove the
targets from the
Comb and Razor/ Analyzes attention to Adults with High reliability Clearly Impairment measured Rapid measure of
Compact Test, both sides of the unilateral differentiates via real and simulated personal neglect
Beschin and body during hair body neglect those with activity
Robertson, 199719; combing followed by secondary to neglect from all
McIntosh et al, 200053 simulating shaving or acquired brain other groups
applying makeup damage
Each task is 30 seconds
Catherine Bergego Examines the presence Adults with Both conventional Interrater: 0.59 to Impairment Has been used as a
Scale (CBS), of neglect related to unilateral statistics and Rasch 0.99 Activity limitations self-assessment with
Bergego et al, 199518 direct observation of neglect analysis suggest results compared
Azouvi et al, 200311 functional activities that the CBS is with therapist’s
such as grooming, valid, and that the ratings to objectify
dressing, feeding, 10 items define anosognosia
walking, wheelchair a homogeneous (awareness)
navigation, finding construct Measures personal and
belongings, Concurrent validity: extrapersonal neglect
positioning self in a correlate well with
chair pen-and-paper tests;
more sensitive than
pen-and-paper tests

Wheelchair collision The person is asked to Adults with Concurrent validity: Test-retest Activity limitations Screening tool only
test, propel a wheelchair unilateral correlated well reliability
Qiang et al, 200569 to pass four chairs neglect with CBS and ranged from
arranged in two rows the Functional 0.68 to 0.97
A-ONE: Structured observation 16 years and older Content: via expert Interrater: 0.84 Impairments Provides information
Árnadóttir of basic ADL including with central review and literature Test-retest: 0.86 Activity limitations related to how
Occupational feeding, grooming nervous system review neglect affects
Therapy-ADL and hygiene, dressing, involvement Concurrent: Barthel everyday living
Neurobehavioral transfers and mobility Index, Katz Index, Requires training
Evaluation, to detect the presence Mini Mental Status Measures personal,
Árnadóttir, 19908; of multiple underlying Examination extrapersonal neglect
20049 impairments including Valid for multiple

Chapter 6  Managing Unilateral Neglect to Optimize Function

spatial (extrapersonal) diagnoses including
and body (personal) stroke, brain tumor,
neglect on these tasks dementia
Assessment of Motor An observational 3 years old and up Strong validity and Cronbach’s alpha Activity limitations Provides information
and Process Skills assessment that and difficulties appropriate to range from related to how
(AMPS), measures the related to use with multiple 0.74 to 0.93 neglect affects
Fisher, 200331,32 quality of a person’s occupational diagnoses and Test-retest range everyday living
occupational performance cultures from 0.7 to 0.91 Requires training
performance assessed
by rating the effort,
efficiency, safety, and
independence of 16
motor and 20 process
skill items Includes
choices from 85 tasks

152 cognitive and perceptual rehabilitation: Optimizing function

Using an A-B-A (A refers to the nontreatment or months of rehabilitation the types of training were
control phase of the experiment whereas B refers to switched in the two groups. At the time of admission,
the treatment phase of the experiment) treatment- the two neglect groups performed at the same level
withdrawal, single-subject experimental design, but after 2 months of rehabilitation, the group with
Bailey and associates13 examined the effects of scan- neglect training showed higher functional recovery
ning training on five older subjects with neglect. than the group with only general cognitive interven-
Active scanning to the left was encouraged by a tion. When the latter group received neglect train-
therapist, using visual and verbal cues and mental ing, there was no longer any difference between the
imagery techniques during reading, copying tasks, two neglect groups. The recovery was documented
and simple board games. Neglect was examined by for both of the functional scales used but not for the
a blinded examiner using a star cancellation test, neurologic scale.
line bisection test , and the Baking Tray Task. Three Antonucci and coworkers2 examined the effec-
of the five subjects who received scanning and cue- tiveness of neglect rehabilitation training focused on
ing showed a reduction in neglect in one or more scanning training (the same protocol as described
tests. This improvement was maintained during the by Pizzamiglio and associates66) for those with per-
withdrawal phase. sistent neglect via a randomized controlled trial. The
Pizzamiglio and associates66 tested an interven- experimental group received treatment immedi-
tion to reduce scanning impairments in 13 sub- ately after admission to a clinic, and the other group
jects with stable neglect symptoms. The training received only general cognitive stimulation for the
consisted of four procedures: visuospatial scan- same amount of time. Following the intervention, a
ning (computer-based), reading and copying train- comparison showed significant improvement in the
ing (sentences and newspapers), copying of line experimental group based on standardized tests of
drawings on a dot matrix, and figure description of impairment as well as on a functional scale. The sec-
simple and realistic scenes. The overall focus of the ond group was then given rehabilitation training for
intervention was to have the subjects actively and neglect for the same amount of time, and obtained
sequentially scan various parts of the visual field. similar improvement. The authors concluded that
After the intervention the group showed signifi- the rehabilitation program produced significant
cant improvements on several standardized neglect results that generalize to situations similar to those
impairment tests. In addition, the results on a func- of everyday life.
tional evaluation of neglect (including the items of Attempts at retraining functional scanning
serving tea, use common objects, describing a com- solely via computer assisted training have been
plex figure, and describing a room) pointed to the mostly unsuccessful thus far.17,70,76 Without a spe-
generalization of improvements to situations simi- cific focus on generalization, scanning training
lar to those of daily life. Seven subjects were exam- may be restricted to the task that was specifically
ined several months after the end of therapy and trained.92 Scanning training also has been inte-
appeared stable on both standard and functional grated into other interventions such as limb activa-
tests of neglect. The authors also noted that sub- tion approaches and is discussed later. In summary,
jects only improved very slightly on a variety of scanning training has been documented to include
standard visuospatial tests, indicating the training the following:
was ­specific to reducing the scanning impairment. • Rotation activities (trunk, head/neck)
Similarly, Paolucci and colleagues61 studied the • Scanning while static
effect of specific training for visual neglect on the • Scanning while mobile (ambulation or wheel-
recovery of motor and functional impairment in chair navigation)
those with neglect secondary to stroke. The inter- • Using perceptual anchors (the left arm on the
vention was consistent with Pizzamiglio and asso- table or a brightly colored strip of tape on the
ciates66 described earlier. The subjects were assessed left side of an activity)
by the Rivermead Mobility Index, Barthel Index, • Specific reading, writing and mathematical
and the Canadian Neurological Scale, completed ­calcualtions training
at 0, 2, and 4 months from the beginning of physi- It may be concluded that scanning training
cal rehabilitation. One of the two groups of those may not generalize automatically, empirical stud-
with neglect clients was randomly assigned to spe- ies that have tested scanning training usually com-
cific training for neglect, and the second group to bined training with other interventions making it
a general cognitive intervention; during the final 2 difficult to document the main therapeutic factor,
Chapter 6  Managing Unilateral Neglect to Optimize Function 153

and ­ scanning should be trained in the context of the right (or left) side of the ocean and horizon.
daily functional activities. It should be noted that The ­ therapist probes for consequences of the
scanning training is considered a practice stan- lighthouse ­illuminating only one side.
dard by the American Congress of Rehabilitation • The picture of the lighthouse is placed on the
Medicine.27 table to the right and in front of the person.
• The therapist then introduces a task requiring
full scanning of the left and right fields. The per-
Lighthouse Strategy
son is asked to close the eyes while the therapist
A specific scanning protocol combing scanning sets up objects across the table in front of the per-
training with visual imagery that has been published son. The person is asked to find these objects.
and tested is the Lighthouse Strategy (LHS). The • Each time an object is missed, the person is
specific intervention is outlined as follows56-58: asked to turn the head “like a lighthouse, left and
• A cancellation test is administered during the right, like this” while the therapist demonstrates
initial evaluation. the proper degree and pace of head turning. The
• The test is scored and the person is shown the person is shown how to line the tip of the chin
letters missed on the test. first with the top of the right and then the top of
• The therapist makes introductory statements the left shoulder.
such as, “I teach a strategy to help people pay • The person is then asked to find the objects
better attention to their left [or right]. See how again, this time using the LHS.
you missed these on this side? I can help you fix • A tactile cue such as a light tap on the left shoul-
this problem.” der may be given in addition to the verbal cue.
• The LHS is introduced as a strategy for help- • The person is asked to notice how many more
ing people pay better attention to their left and objects can be seen when the LHS is used.
right, and explained fully. The person is shown • A copy of the lighthouse poster is placed on the
a simple line drawing of the Cape Hatteras light- wall of the person’s room, to the right of the bed.
house (Figure 6-8), with the light beams and • All therapists are given copies of the poster and
top lights highlighted with a yellow marker. The asked to use it to cue the person when task per-
­person is told to imagine that his or her eyes formance requires attention to both the right and
and head were like the light inside the top of the left fields (grooming, feeding, mobility, etc.).
lighthouse, sweeping to the left and to the right Initial testing56 of the LHS was done with 16 adults
of the horizon to guide ships to safety. The per- with stroke. The treatment group’s performance on
son is then asked to think about what would a cancellation test given at admission and discharge
­happen if the lighthouse only provided light to was significantly improved (p = 0.002) as compared

Figure 6-8  Visual cue for the Lighthouse Strategy. (From Niemeier JP: The Lighthouse Strategy: use of a visual imagery technique to treat
visual inattention in stroke patients, Brain Inj 12[5]:399-406, 1998.)
154 cognitive and perceptual rehabilitation: Optimizing function

with controls matched for diagnoses, race, and age. well as in peripersonal space. Another case study
In addition, significant improvement (p = 0.007) ­documented decreased neglect using this technique
for those taught the LHS was documented in over- as demonstrated by improved reading ability.
all attention as measured by a facility rating scale Robertson and associates74 documented three
and reports by family and caregivers. case studies using left limb activation interventions.
Further testing58 of the strategy was done on The first study used a combination of perceptual
10 people with unilateral neglect undergoing acute anchoring training (keeping the left arm at the left
rehabilitation for brain injury. The patients were margin of the activity engaged in and being encour-
cued by their interdisciplinary treatment team mem- aged to “find” the arm prior to the task) with left
bers to “be like horizon-illuminating lighthouses arm activation procedures and produced improve-
and turn their heads left and right during functional ments on impairment tests as well as reading and
and therapy training tasks.” Those who were taught telephone dialing ability. The second used the same
the LHS as compared with waiting list controls per- method, but stimulated left arm activation using
formed better and safer on route finding (p < 0.001), a buzzer reminder system to maintain limb acti-
walking or wheelchair use (p < 0.05), and problem- vation. Positive results were noted on impairment
solving (p < 0.05) tasks. tests and functional mobility skills. The third case
study focused on cueing for left arm activation with-
out explicit instructions for perceptual anchoring.
Limb Activation/Spatio-motor Cueing
Positive results were noted on impairment tests.
Limb activation is based on the idea that any move- Robertson and coworkers71 applied this interven-
ment of the contralesional side may function as a tion to a 22-year-old man with a severe traumatic
motor stimulus, activating the right hemisphere brain injury. He was assessed on three different mea-
and improving neglect. It has been shown across sures (hair-combing task, navigation task, and the
a series of studies that unilateral neglect can be Baking Tray Task as described earlier). The inter-
improved by encouraging clients to make even vention focused on moving the left hand in the left
small movements with some part of the left side of hemispace as cued by a buzzer system during tra-
their body, if these movements are performed in the ditional occupational therapy sessions involving
left hemispace. In general, the principle behind this self-care instruction, reading, and so on. All three
approach is to “find” the affected limb and encour- measures of three different types of neglect—naviga-
age movements of the affected limb in the neglected tion (far space), hair combing (personal/body space),
hemispace (i.e., spatio-motor cueing). It is hypoth- and baking tray (peripersonal or reaching space)—
esized that these movements lead to summation of showed significant improvements coinciding with
activation of affected receptive fields of two distinct the onset of limb activation training.
but linked spatial systems for personal and extra­ Wilson and coworkers99 examined the combined
personal space, resulting in improvements in atten- effect of contralesional limb activation (tapping in
tional skills and appreciation of spatial relationships the left hemispace with the residual movement in
on the affected side.45,72 A counter hypothesis is that the left hand for 5 minutes) and sustained atten-
the movements in the left hemispace serve as per- tion training (a loud noise to alert the subject dur-
ceptual cues such as an anchor. Studies have dem- ing task performance and encouraging the subject
onstrated a reduction in the severity of neglect to say the self-directed verbal cue “Attend!” aloud
when subjects actively engage their left hand in a followed by using the cue internally as training
task. One meta-analysis examining limb activation continued) on impaired ADL via two single cases,
approaches49 demonstrated large effect sizes for using time-series designs. The authors concluded
both group and single subject studies. that combining both limb activation and sustained
Robertson and North73 described a case of severe attention training may produce additive effects.
left visual neglect in which the client consistently They documented significant improvements in
showed a reduction in visual neglect as tested by both neuropsychological impairment measures
a cancellation task, with left hand movements and in the independent performance of ADL. The
in the neglected left hemispace. While reduction benefits were maintained during the post-training
did not occur when the left hand was moved pas- period (Figure 6-9).
sively, neglect was also reduced with left leg move- Samuel and colleagues80 assessed the efficacy of
ments. It was noted that hand movements in the left voluntary activation of the left upper limb in the left
hemispace reduced neglect for stimuli in far as hemispace focusing on its generalizability to ADL,
Chapter 6  Managing Unilateral Neglect to Optimize Function 155

Baseline Limb activation training Baseline Sustained attention training Baseline








1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

Figure 6-9  Functional improvements using combined contralesional limb activation training and sustained attention training. A reduction
in the number of verbal prompts (Y-axis) to complete self care is achieved. (From Wilson FC, Manly T, Coyle D, et al: The effect of
contralesional limb activation training and sustained attention training for self-care programmes in unilateral spatial neglect, Restor Neurol
Neurosci 16[1]:1-4, 2000.)

in reducing unilateral neglect in two male subjects back concerning improvements in the speed and
with chronic stroke who did not respond to previ- quality of movement; selecting tasks that are tailored
ous scanning activities. Both cases had significant to address the motor deficits of the individual; use
treatment-related improvements on an impair- of modeling, prompting, and cueing of task perfor-
ment test of neglect. More important, improvement mance; and systematically increasing the difficulty
was ­ documented on neglect behavior in daily life level of the task performed in small steps.85 In addi-
(Catherine Bergego Scale). The effect was main- tion, several techniques are used to achieve transfer
tained at 1-month follow-up. The authors concluded of improved motor function to the life situation.85,100
that left limb activation (i.e., visuo-spatio-motor Whereas the impairment that is being treated has
cueing) may be efficient in severe neglect and may been termed “learned nonuse,” or a failure to inte-
help in obtaining generalization to ADL. grate the effected limb into real-world activities
Kalra and associates45 conducted a randomized despite having the underlying potential, it is not clear
controlled study to compare the use of a limb acti- how or if “learned nonuse” and neglect are related.
vation approach and an early emphasis of func- The term motor neglect also is used to refer to the
tional training compared to treatment as usual underuse of a limb opposite a brain lesion that can-
group defined as neurodevelopmental treatment not be fully explained by primary sensory and motor
(NDT). Those in the experimental group showed deficits.67 CIMT has been recommend as a poten-
a trend toward higher Barthel scores at 12 weeks tial intervention for those living with neglect and is
(14 vs. 12.5) and a significant reduction in median ­consistent with limb activation approaches.35,65
length of hospital stay (42 vs. 66 days). An obvious limitation to this approach is for those
Constraint-induced movement therapy (CIMT)84,86 living with combined impairments of neglect and left
was first applied to those with neurologic diagno- hemiplegia. Although an earlier study73 did not find
ses more than 15 years ago. The intervention differs any effects from passive limb movements, a more
from conventional physical rehabilitation in its dura- recent study has. Frassinetti and colleagues34 exam-
tion and intensity. It involves training of the more ined whether a complex passive movement, such
affected upper extremity by mass practiced of func- as abduction and adduction of the arm, was able to
tional tasks and shaping for 5-6 hours per day over reduce neglect also when it was associated to simulta-
2-3 consecutive weeks. During therapy and for the neous active right arm movements. The authors had
majority of waking hours during this period the less subjects perform an object cancellation test and a line
affected extremity is constrained to induce increased bisection test by using the right hand while the left
use of the more affected limb. Shaping techniques arm was passively moved. Subjects performed tasks
consist of quantifying and frequent immediate feed- in near and far space. The authors found that when
156 cognitive and perceptual rehabilitation: Optimizing function

the left arm was passively moved, the results showed a stroke were more successful, the authors conclude
a significant reduction of neglect with respect to the that imagined activation of the left arm may signifi-
baseline condition, and the improvement equally cantly reduce the severity of left neglect.
affected the near and the far space. They concluded Smania and colleagues81 examined two subjects
that the improvement of visual neglect caused by a with acquired brain injury and severe and chronic
left passive movement is related to proprioceptive unilateral neglect secondary to right brain damage.
signals specifying left hand position. The intervention consisted of both visual and move-
ment imagery exercises. Specific visual imagery
tasks included describing a familiar room in their
Mental Imagery
home from a particular vantage point, describing
Although limb activation approaches as described a familiar route or path, describing a well-known
may be useful for some, a large number of peo- geographic area, and imaging a word and spelling
ple with right hemispheric damage live with both it backward. Cues were provided by the examiner
neglect and left hemiplegia, making use of the inter- to focus on missed details (e.g., “Are you sure you
vention as usually described difficult or impossible. named all of the objects in the room?”). Movement
Mental imagery is an emerging rehabilitation tech- imagery tasks included imagining postures and
nique that includes imagining the limb movements describing the position of the contralateral arm,
without actually moving or practicing movements and imagining movement sequences using both
in “the mind’s eye.” arms.
McCarthy and coworkers52 investigated whether Outcomes were assessed via six neuropsycho-
imagined limb movements would reduce the extent logical tests of unilateral neglect, seven functional
of neglect in clients with severe disabilities and tests (avoiding obstacles during mobility, describing
described application of this technique for two a room, reading a newspaper, serving coffee, playing
cases. One person was living with the effects of a cards, using self-care objects, and recognizing bank
stroke, the other with a traumatic brain injury. Both notes), assessing neglect behavior during daily life
were in the chronic stage and both presented with conditions, and a questionnaire (filled out by rela-
dense left hemiplegia and left neglect. tives) concerning the subject’s disability in the con-
The intervention consisted of the following exer- text of the family that was attributable to neglect.
cises performed first with the intact right arm, along The outcome measures were recorded before, after,
with the test administrator: and 6 months after the end of the experimental
• Bend arm at elbow. training. The authors found that imagery train-
• Clench fist (participant asked to “think about ing decreased the deficit in performance related to
how the exercise feels”). neglect in both subjects. All of the outcome mea-
• Unclench fist. sures were positively influenced by the treatment.
• Stretch out arm. In addition, the improvement was stable over a
• Stretch out fingers. 6-month period, suggesting that the treatment
• Wiggle fingers. had a long-term effect. The use of mental ­imagery
• Pinch fingers and thumb together (again partici- to improve function seems to be promising and
pant was asked to “think about how the exercise warrants further investigation.
The exercises were performed twice. The subjects
Partial Visual Occlusion
were then asked to imagine performing these same
movements, first with the right arm and then with Interventions aimed at partially occluding visual
the left arm. Subjects were asked to imagine making input via eye patching are also showing prom-
these movements four times (e.g., “try to imagine ise in the literature in terms of demonstrating
the fingers of your left arm wiggling” and “imagine improved functional skill in those with unilateral
pinching your left fingers and thumb together”). All spatial neglect. Early work in this area by Butter
therapists working with the subjects were encour- and Kirsch23 examined 13 stroke survivors with
aged to use this technique for all types of therapy left-sided neglect and documented improvement
and while performing ADL. Neglect was assessed in 11 of the 13 subjects from monocular patching
with the following tests: line bisection, star cancella- of the right eye in at least one (of five) impairment
tion, and a scanning task. Although outcomes of the tests of neglect. They also noted that the benefi-
intervention for the subject living with the effects of cial effect was mostly limited to the period when
Chapter 6  Managing Unilateral Neglect to Optimize Function 157

the patch was worn. In a second study of another

group of stroke survivors with left neglect (N =
18), performance on a line-bisection task with Prisms have been tested as intervention for those
monocular patching and/or lateralized visual living with unilateral neglect (and hemianopsia)
stimulation was examined. Although each inter- with mixed results. The prism is typically of the
vention had positive results, the two interventions plastic press-on type and is used to shift the visual
combined resulted in significantly larger benefits field. Specifically, the idea is to shift the peripheral
than either alone. The authors concluded that image toward the central retinal meridian.
monocular patching, in conjunction with lateral- Rossi and coworkers78 randomly assigned 39
ized visual stimulation, may significantly reduce clients with stroke and homonymous hemiano-
neglect in daily activities. pia or unilateral visual neglect to treatment with
A study by Arai and associates7 examined 10 15-diopter plastic press-on Fresnel prisms or to
subjects with left neglect and investigated whether serve as controls. In terms of visual perception and
using glasses shaded on the non-neglected side ADL, the groups were statistically comparable. The
would lead to a decrease in the severity of unilateral prisms were worn for all daytime activities. After
neglect during pen and paper activities. The authors 4 weeks, the prism-treated group performed signifi-
found that improvement was mixed for each of the cantly better than controls on the following tests of
three outcome measures (deviation from mark- visual perceptual impairment: Motor Free Visual
ing the middle of a 20-cm horizontal line, number Perception Test, line bisection test, line cancella-
of lines left unmarked on the left-hand portion of tion test, Harrington Flocks Visual Field Screener,
a page of 40 randomly oriented lines, and degree and tangent screen examination. In terms of mak-
of failure to copy a representation of a cube). One ing a change in activity limitations, there was no
subject was noted to have substantial and lasting significant difference in Barthel Index (ADL)
improvement in functional activities by wearing the scores. The authors concluded that treatment with
hemispatial sunglasses. Although somewhat prom- 15-diopter Fresnel prisms improves visual percep-
ising results were obtained, the aforementioned tion test scores but not ADL function in stroke
studies only used impairment tests of neglect. ­clients with homonymous hemianopia or unilateral
In a randomized study, Beis and colleagues15 visual neglect.
examined 22 subjects with left unilateral neglect. The term prism adaptation refers to the phenom-
Interventions included the use of right half-field enon in which the motor system adapts to shifted
patches (n = 7), a right monocular patch (n = 7), and a visuospatial information caused by prisms that
control group (n = 8). Patches were worn throughout displace the visual field. Rossetti and associates77
the day during inpatient rehabilitation (Figure 6-10). investigated the effect of prism adaptation (wear-
Results of paired comparison tests showed significant ing prisms in conjunction with pointing activities)
differences between the control group and the group on various neglect symptoms, including the com-
with the half-eye patches for the total FIM score and monly observed subjective midline shift to the right.
objective measures of displacements of the right eye All subjects exposed to the optical shift of the visual
in the left field. No significant differences were found field to the right were improved on their manual
between the control group and the group with the body-midline demonstration and on impairment
right monocular patch. The authors concluded that tests (cancellation tests, copying, and line bisec-
patching the right half-field helped subjects initially tion). The authors noted that this improvement
regain voluntary control over the neglect impair- lasted for at least 2 hours after prism removal and
ment, thereby improving daily function. The authors thus could be useful during rehabilitation.
hypothesized that their intervention was successful Further testing the effectiveness prism adapta-
because wearing a patch over the two right hemifields tion, Frassinetti and colleagues33 had seven subjects
causes a right homonymous hemianopsia and acti- perform a pointing task wearing base-left wedge
vation of the right hemisphere in isolation, therefore prisms inducing a shift of the visual field to the right
causing an increase in the level of attention. In addi- by 10 degrees. The presence of visual neglect was
tion, the authors hypothesized that covering the right assessed before the treatment and 2 days, 1 week,
half-field helped establish a balance between the acti- and 5 weeks after treatment by using a standardized
vation of the two hemispheres as well as improvement battery that included a series of tests including the
in the mechanisms that control voluntary ­redirection BIT, cancellation test, reading test, room descrip-
of the gaze. tion test, Fluff Test, and an object reaching test.
158 cognitive and perceptual rehabilitation: Optimizing function

Figure 6-10  Partial visual occlusion. Occluding the right hemifield was the most effective related to functional improvement. A, Glasses
and complete right patch. B, Glasses and right half-field patches (preferred). (From Beis JM, Andre JM, Baumgarten A, et al: Eye patching
in unilateral spatial neglect: efficacy of two methods, Arch Phys Med Rehabil 80[1]:71-76, 1999.)

Six matched controls, untreated subjects, underwent Although Farne and associates30 have concluded
the same tests at the same intervals as the experi- that the effects of prism adaptation are very long
mental clients. The results showed an improvement lasting and spread over a wide range of visuospatial
in the experimental subjects’ performance, which deficits, recent findings79 related to use the use of
was maintained during the 5-week period after prisms to manage neglect have not been consistent
treatment. The decrease in neglect was found in and are at times conflicting. The intervention war-
impairment as well as in behavioral tests and in all rants further investigation related to the long-term
spatial domains. Control subjects did not show any effects on function.
improvement in neglect. The authors concluded
that their findings show that prism adaptation is a
Video Feedback
productive way of achieving long-lasting improve-
ments in neglect treatment. Using videotaped feedback of task performance has
Angeli and coworkers1 studied the effects of prism been suggested as a strategy to decrease the effects of
adaptation and found that it resulted in an improve- unilateral neglect. When viewing your own perfor-
ment in reading ability, an increased left-sided mance on a TV screen during video playback, one
exploration of letter strings, and increased ampli- can see and attend to the neglected left side on the
tude of the first left-sided saccade. They concluded right side of the TV monitor (i.e., neglect behav-
that prism adaptation reduces the chronic oculomo- iors can be observed in the non-neglected space).
tor orienting bias to the ipsilesional side, and as a This may be a key therapeutic factor. In usual care,
consequence clients are able to compensate for their the therapist describes the neglect behavior but the
asymmetric distribution of spatial attention. person with neglect may not be able to “see” his or
Chapter 6  Managing Unilateral Neglect to Optimize Function 159

her mistakes. Visualizing the mistakes, followed by by time taken to complete the task and percentage of
processing them with the therapist may help insight accuracy for all three clients across the intervention
building and subsequent strategy formation. phase. Although performance declined in the follow-
Tham and Tegner91 compared the effects of a up phase, some long-term carryover effect was noted
video procedure and a conventional verbal procedure even after the video-assisted feedback was terminated.
in giving subjects feedback on their neglect behavior Further investigation is warranted for this interven-
during a contrived task, the Baking Tray Task. See tion because it may have a facilitatory effect on aware-
Figure 6-6. The task consists of symmetrically placing ness building and eventual strategy training.
16 wood blocks or “buns” on a wood board or baking
tray. Subjects in one group were trained with a video
Computerized Training
feedback procedure and subjects in the comparison
group were trained with a conventional verbal pro- Findings related to computerized assisted train-
cedure. After watching the video, subjects were asked ing for neglect have been mixed. Webster and
to comment on their own performance and results coworkers93 demonstrated positive results related
as did the therapist. In addition, they were asked to to improving wheelchair mobility skills. Twenty
develop strategies to improve performance, and the right-handed subjects with left unilateral neglect
therapist gave suggestions on using tactile discrimi- on screening measures were assigned to a com-
nation with the right hand to find the left edge of puter-assisted training (CAT) treatment group and
the tray and systematically place the buns from left 20 subjects who showed similar levels of unilateral
to right. Both groups were provided with the same neglect on the screening measures were assigned to
compensatory strategy. a control group. All subjects were inpatients on an
Three hours after the intervention, the subjects acute rehabilitation unit and received rehabilitation
were tested with four different neglect tests (line therapy. The treatment group received the experi-
cancellation task, figure copying task, line bisection, mental CAT program, 12 to 20 sessions of about 45
and the Baking Tray Task) pre- and postintervention minutes each. The program consisted of five mod-
to evaluate the effects of training. The video feed- ules, each of increasing complexity, to improve
back group improved significantly on the Baking attention to stimuli in the left hemisphere, and two
Tray Task, as tested 3 hours after training (p < 0.02). simulated wheelchair courses to propel a wheelchair
Conventional training had no effect on the task or while avoiding obstacles. Modules included scan-
on the other neglect measures. Of note is that no ning the full environment, coordinating scanning
generalization effects from the videotaped Baking with right upper extremity movements, detecting
Tray Task on other neglect tests were observed. stimuli in the hemispace, wheelchair simulation,
The authors suggest using the video feedback tech- and training on obstacle avoidance. The outcomes
nique during functional tasks to enhance generaliza- were computer tasks designed for the study, a real-
tion and to make the intervention more meaningful. world wheelchair obstacle course, and incident
Soderback and associates82 had similar results in reports indicating falls and accidents. Those in the
an earlier study that did focus on functional tasks. experimental group performed significantly better
Using a single-case research experimental pretest, (i.e., fewer left-sided collisions) on the wheelchair
posttest, and follow-up design, three household obstacles as compared with controls. They also had
tasks were assessed, and the clients’ neglect behavior fewer incident reports than controls during their
while performing these was video recorded. During hospitalization.
the intervention the subjects watched the film, which Robertson and colleagues70 conducted a ran-
was stopped by the occupational therapist when the domized controlled trial (n = 36) of computer-
neglect behavior was significant. Through dialog, based rehabilitation to treat left neglect with blind
the subjects were led to perceive and interpret their follow-up for 6 months. One group of 20 sub-
neglect behavior, and strategies for relearning and jects received a mean of 15.5 hours of computer-
remediation were recommended. ized scanning and attentional training, whereas the
Paul63 examined the effects of video feedback on other group of 16 subjects received a mean of 11.4
grocery-shelf scanning with three subjects with visual hours of recreational computing that were specifi-
neglect. Performance of the task was videotaped and cally selected to minimize scanning and timed atten-
played back as a means of visual and auditory feed- tional skills. Blind follow-up at the end of training
back focused on improving performance. Results and 6 months after the intervention revealed no
showed an improvement in performance measured statistically or clinically significant results between
160 cognitive and perceptual rehabilitation: Optimizing function

groups. The authors argued against routine clinical • The SAT was used in conjunction with the
use of computerized training until further studies Baking Tray Task to improve awareness.
are conducted. • She then used t