CHP 13 cognitive perceptual approaches

perception

• integration/interpretation of sensory impressions received from environment into psychologically meaningful information

impaired alertness or arousal

• incre environmental and sensory stim

• use gross motor ax

impaired awareness

• prediction method: goal to have person predict how well they will perform and then compare prediction to actual performance

• provide feedback on performance

• role reversal

• video tape performance and watch and discuss

• group tx and peer feedback

acalculia

inability to perform calculations

agraphia

inability to write

alexia

inability to read

anomia

loss of ability to name objects or retrieve names of people

anosognosia

unawareness of motor deficit

aphasia

• broca’s (expressive): loss of expressive language indicated by loss of speech production

  • interventions:

    • give time to speak, encourage participation in conversation and use of AAC, visual supports, concise sentences, body language

• wernicke’s (receptive): deficit in auditory comprehension that affects semantic speech performance, manifested in paraphasia or nonsensical syllables

  • interventions:

    • stop strategy: use cues to stop flow of incomprehensible speech

    • during incr flow of speech > refocus to change topic, simplify written material, speak slowly and clearly, simplify spoken word, give time

• global: severe loss of ability to comprehend and express

ideational apraxia

• breakdown in knowledge of what is to be done or how to perform

  • loss of concept or idea required to perform task

  • lack of knowledge regarding object use

• results in daily life errors such as tool misuse, poor initiation, poor organization and sequencing, perseveration, and performance latency

  • EX: using comb to brush teeth, placing butter into cup of juice, brushing teeth with finger

• interventions:

  • provide step by step instructions

  • use hand over hand guiding

  • provide opportunities for motor planning and motor execution

  • tactile exploration of tools and functional objects

  • grade # tools during task

ideomotor apraxia

• motor apraxia

• loss of access to kinesthetic memory so purposeful movement cannot be achieved because ineffective motor planning or sequencing, even though idea or concept of task is intact

  • must rule out other deficits

• results in daily life errors such as clumsiness, slowness, poor hand shaping, timing errors, poor gesture production

  • EX: awkward grasp patterns, difficulty manipulating coins from hand into vending machine

• interventions

  • strategy training: teach person to compensate for apraxia by instruction, assistance, or feedback

  • decr manipulation demands, degrees of freedom to perform task (less actions)

  • provide hand over hand tactile-kinesthetic input

  • educate on moving arm along supported surface for tactile input

  • demonstrate!!

astereognosis

• tactile agnosia

• inability to recognize objects, forms, shapes, and sizes by touch alone

• failure of tactile recognition although sensations are intact

• EX: cannot recognize object in hand is a coin without looking at it; cannot locate phone on nightstand in dark and must turn light on; looking in purse or pockets

body scheme disorders

• loss of awareness of body parts and relationship of body parts to each other and objects

• types

  • right left indiscrimination: inability to discriminate btw R and L side of body or apply concepts of R and L to environment

    • EX: “raise your left hand. which one is that?”; “bathroom is on right. where?”; place shoe on wrong foot

  • somatoagnosia: diminished awareness of body structure and failure to recognize body parts as one’s own

    • EX: deny ownership of body part; attempts dress therapists arm as own; put shaving cream on mirror thinking it was face

  • unilateral body neglect: failure to respond to or report unilateral stimulus presented to body side contralateral to lesion

    • interventions: awareness training!!!! (discuss, feedback + video), bilateral ax, PROM through ax, sensory stim, mental imagery

figure/ground dysfunction

• iSpy

• inability to distinguish foreground from background

  • difficulty locating white bar of soap on white sink

perseveration

• continuation or repetition of motor act (premotor) or task (prefrontal)

  • premotor: person continues to pull up sock even though it is already on foot; washing same part of face; combing same part of hair

  • prefrontal: person washes face again and again

• interventions:

  • bring to conscious level and train person to inhibit behavior (bring awareness to behavior)

  • redirect attention

  • engage in task requiring repetitive action with concrete outcome to promote task completion and termination

spatial relations impairment

• difficulty relating objects to each other or to self

  • secondary to loss of spatial concepts

• EX: difficulty orienting clothing to body correctly; difficulty aligning fitted sheet to bed

• interventions:

  • utilize ax that challenge underlying spatial skills (orienting clothes during dressing, wrapping a gift, making bed)

  • utilize tasks that require discrimination of R/L

topographical disorientation

• difficulty finding one’s way in space

  • secondary to memory dysfunction or inability to interpret sensory stimuli

unilateral spatial neglect

• inattention to stimuli presented in extra-personal space contralateral to lesion

  • near extra: ask for fork when fork is on table on neglected side

  • far extra: bump into objects on neglected side while walking

• interventions:

  • awareness training

  • provide graded scanning ax

  • grade ax from simple to complex

  • anchoring techniques (strip of red tape on left side of sink to draw attention to left neglected field)

  • utilize manipulative tasks in conjunction with scanning ax

  • external cues and environmental mod

visual acuity

• clarity of vision on both near and far with glasses

  • 20/20

• fxnal implications: blurred vision

  • near acuity problem: trouble with reading book, typing

  • far acuity problem: traffic signs, whiteboard

• tx: corrective lenses (NBCOT > referral to dr)

• test:

  • Snellen chart 20ft or 16in away

visual fields

• available vision to right, left, superior, and inferior when eyes are positioned straight ahead

  • 65deg up, 75deg down, 95deg out, 60deg in

• fxnal implications: inability to see objects in affected visual field

  • right homonymous hemianopsia > cannot see objects on right side

• testing: confrontation

  • occlude one eye; fixed stare in front; start wide of field “tell me when you can see my finger”

oculomotor mobility

• control of eye movements

  • pursuits: ability to accurately follow moving object with eyes in smooth fashion

    • fxnal implications: difficulty driving, playing sports, and completing writing tasks

  • saccades: ability to look from one object quickly and accurately to the other (read, write, drive)

    • fxnal implications: poor concentration and attention when reading, writing, driving

• testing:

  • pursuit: occlude one eye; ask to follow pen with eye; move pen in H, X, O

  • saccades: occlude one eye; present 2 colored tapes at different distances; ask to look btw red and green when asked

scanning

• ability to systematically observe and locate items in environment

• fxnal implications: difficulty finding items in kitchen cabinets and fridge, difficulty reading and writing

• test: letter cancellation

strabismus

• deviation of one eye or one eye at a time while looking at target

  • lazy eye

• fxnal implications: double vision near or far

• test: look in their eyes and observe

convergence and divergence

• convergence: ability for both eyes to work as team and turn in (close vision)

  • sit in front and have eyes fixed on pen; move pen slowly towards nose and observe

• divergence: ability for both eyes to work as team and move out (far vision)

  • at convergence > move pen slowly back and observe

• fxnal implications: double vision

Arnadottir occupational therapy neurobehavioral evaluation (A-ONE)

• utilized in adult population presenting with cognitive/perceptual deficits

  • training required

• observation of ADL and mobility skills and uses error analysis to ID underlying performance components

behavioral inattention test

• utilized with adults post acquired brain injury with suspected unilateral spatial neglect to examine presence of neglect and its impact on fxnal task performance

• nine activity based subtests: picture scanning, menu reading, map navigation, sentence copying, etc.

Catherine Bergego scale (CBS)

• standardized checklist to detect presence and degrees of unilateral neglect during observation of everyday life situations

• functional scale with ten items related to neglect in everyday life

  • gaze orientation, limb awareness, auditor attention, dressing, grooming, etc.

Cognistat Cognitive Assessment/Neurobehavioral cognitive status examination

• screening and assessment tool for rapid testing people with cognitive dysfunction

  • CVA, TBI, dementia, delirium, major psych disorders, SUD, neurocognitive disorders

  • adolescents+

• three general areas: consciousness, orientation, simple attention

• five major domains: language, constructional ability, memory, calculation skills, executive skills

executive function performance test (EFPT)

• standardized objective performance test that assesses executive function deficits during performance of real world tasks

  • cooking oatmeal, making phone call, managing meds, etc.

• structured cueing and scoring based on initiation, organization, sequencing, judgement, safety, and task completion

  • higher scores = greater cueing and assistance needed

kettle test (KT)

• adults post CVA, mild dementia, or healthy older adults

• performance based test, person assembles electric kettle and prepares 2 diff hot beverages

lowenstein occupational therapy cognitive assessment (LOTCA)

• CVA, TBI, brain tumor

• measures basic cognitive fxn that are prerequisite for managing everyday tasks

montreal cognitive assessment (MoCA)

• screening instrument for mild cognitive dysfunction administered by trained evaluators

• eight cognitive domains: attention and concentration, executive fxn, memory, language, visuoconstruction, conceptual thinking, calculations, orientation

multiple errands test (MET)

• adults with ABI

• measures impact of EF deficits on performance of everyday tasks in real environment

• several versions

• tasks are divided into errands

  • errands: purchase item, mail letter,

  • obtaining info: closing time of library, price of candy

  • meeting assessor at particular place and time

  • informing assessor when tasks are completed

Rivermead Behavioral Memory test-3 (RBMT-3)

• identify memory deficits through everyday ax

• assesses visual and auditory memory, immediate and delayed recall and recognition

• 14 subtests

Rivermead Perceptual assessment battery

• 16+yr with visual perceptual deficits post ABI or CVA

• 16 performance tests that assess form and color constancy, object completion, figure-ground, body image, etc.

• utilizes deficit-specific tasks in isolation from ADL tasks

weekly calendar planning activity (WCPA)

• adolescents to older adults with EF deficits

• examine how subtle EF difficulties affect performance in multi-step activities

  • organize 10-18 appointments or errands into weekly schedule while adhering to rules

remedial/restorative/transfer of training approach

• focuses on remediation of impairments to increase function

  • improvements in client factors and performance skills = increased occupational performance

• uses deficit specific cognitive and perceptual retraining activities to address identified impairments

  • targets cause of sx and emphasizes client factors and performance skills

• uses non-occupation based ax (memory drills, block designs, pegboard, picture matching)

compensatory/adaptive/functional approach

• focuses on decreasing activity and participation restrictions

  • treats sx not their cause

• interventions focus on..

  • repetitive practice of functional tasks

  • modifications, strategies, and adaptive techniques

    • visual memory aids, class notes for ADHD, etc.

  • activity choices driven by task person needs or wants to perform

    • task specific and functional

information processing approach

• provides information on how individual approaches task through standardized cues and feedback to draw attention to relevant features of task

  • investigates how performance changes with cueing

  • use investigative questions to provide insight

dynamic interactional approach

• emphasizes transfer of information from one situation to next by developing a metacognition of problem solving strategies to be used in varying environments

  • practice targeted strategy in variety environments

  • utilizes self-monitoring and therapist awareness questioning

• transfer of learning

  • does not immediately happen

  • occurs through a graded series of task that decrease similarity

Quadraphonic approach

• based on…

  • biomechanical: AROM, endurance, strength, coordination are assessed

  • information processing theory: sensory responsiveness after head injury

  • teaching/learning theory: learning environment and cues

  • neurodevelopmental: postural control, symmetry of movement, mobility, stability

• Micro-perspective: evaluation and management of client factors and performance skills (attention, memory, perception, higher level cognition, etc.)

• macro-perspective: evaluation includes use of narratives, interview, real-life occupations

neurofunctional approach

• based on learning theory and used for CVA and TBI pts

• focuses on retraining real world skills rather than cognitive-perceptual processes

  • overall adaptive approach with some remediation components

  • tx focused on training specific fxnal skills in true context