11830 Westline Industrial Drive

St. Louis, Missouri 63146

COGNITIVE AND PERCEPTUAL REHABILITATION: ISBN: 978-0-323-04621-3

OPTIMIZING FUNCTION

Copyright © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights
Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333;
e-mail: ­healthpermissions@elsevier.com. You may also ­complete your request on-line via the Elsevier website at
http://www.elsevier.com/permissions.

Notice

Neither the Publisher nor the Editors/Author assume any responsibility for any loss or injury and/or ­damage
to persons or property arising out of or related to any use of the ­material ­contained in this book. It is the
responsibility of the treating practitioner, relying on ­independent expertise and ­knowledge of the patient, to
determine the best treatment and method of application for the patient.
The Publisher

Library of Congress Control Number: 2007938781

Publishing Director: Linda Duncan

Senior Editor: Kathy Falk
Senior Developmental Editor: Melissa Kuster Deutsch
Editorial Assistant: Lindsay Westbrook
Publishing Services Manager: Julie Eddy
Senior Project Manager: Celeste Clingan
Design Direction: Julia Dummitt

Printed in United States

Last digit is the print number: 9  8  7  6  5  4  3  2  1

For M.P.L.
 Preface
Opening and Background
Cognitive and Perceptual Rehabilitation: Optimizing
Function aims to provide an up-to-date and com-
prehensive overview of the process that has tra-
ditionally been called cognitive and perceptual
rehabilitation but may be better described as the
process of improving function in those who are liv­
ing with cognitive and perceptual impairments. Until
the recent past, this area of practice has been domi-
nated by assessments, interventions, and outcomes
that were far removed from everyday function. This
limitation is steadily being overcome as current cli-
nicians, researchers, and scientists are once again
placing a renewed focus on function-based assess-
ments, evidence-based interventions that promote
improved performance of necessary and meaning-
ful activities, decreasing participation restrictions,
and ultimately improving quality of life.
Cognitive and Perceptual Rehabilitation: Optimi­
zing Function aims to be a clinical and educational
resource that summarizes, highlights, and con-
structively critiques the state of the art of this area
of practice. The overall goal of writing this textbook
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.
Who will benefit from this book?
A variety of neurologists, neuropsychologists,
occupational therapists, psychologists, psychiatrist,
and speech and language pathologists from across
the world are working in and contributing to the
knowledge base of this area of practice. The pri-
mary audiences for this textbook are students and
clinicians who are learning about or directly work-
ing with clients who are living with functional lim-
itations secondary to cognitive and/or perceptual
impairments. Other professionals who may find
this textbook helpful in the evaluation and inter-
vention processes include vocational counselors,
nurses, physical therapists, and therapeutic recre-
ation specialists. Case managers and those making
referrals to rehabilitation services may also find the
information contained in this textbook helpful.
vii
Conceptual Approach
Cognitive and Perceptual Rehabilitation: Optimiz­
ing Function was written with three overarching
and interrelated approaches in mind: evidence-
based, function-based, and client-centered. Given
this, the textbook focuses on being a comprehen-
sive resource of valid and reliable tools that use
functional activities as the basis of assessment.
A particular emphasis has been placed on tools that
have ecological validity (i.e., reflective of behaviors
observed in everyday function). This focus limits
the inclusion of assessments that are not perfor-
mance based and that use contrived tasks as the
basis for assessment. This textbook also embraces
the inclusion of standardized client and significant
others reports of daily function. Similarly, this text-
book highlights and focuses on interventions that
have been empirically tested and that document a
positive change related to decreasing activity limi-
tations and participation restrictions. An emphasis
has been placed on interventions that use meaning-
ful activities as the primary change agent to improve
function.
Organization
Chapters 1 and 2 (Overview of Cognitive and
Perceptual Rehabilitation and General Considerations:
Evaluations and Interventions for Those Living with
Functional Limitations Secondary to Cognitive and
Perceptual Impairments) provide the necessary foun-
dations to using an evidence-based and function-
based approach to work with this population and
are therefore considered prerequisites to all of the
other chapters. Chapter 3 (Managing Visuospatial
Impairments to Optimize Function) provides neces-
sary foundation information related to visual impair-
ments that must be considered before assessing and
developing intervention plans for other problem
areas. Similarly, Chapter 4 (Self-Awareness and Insight:
Foundations for Intervention) focuses on the problem
of poor awareness and developing awareness as the
starting point for all interventions. These chapters are
also then considered foundations for the ­subsequent
chapters.
viii pREFACE
Chapters 5 through 10 emphasize functional
limitations caused by various impairments and
patterns of impairments including apraxia, neglect,
agnosia, impaired attention, impaired memory,
and impairments of the executive functions. Theses
chapters are all written as a user-friendly clini-
cal guide that primarily focus on assessment and
interventions.
Finally, Chapter 11 (Application of Concepts:
Case Studies) provides further clinical applica-
tions and integration based on case studies that
take place in various treatment environments from
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
impairments.
Distinctive Features
Key features of this book include the following:
• Inclusion of evidence-based intervention protocols.
• Evidence-based intervention tables focused on
improving daily function follow each chap-
ter. These include a summary of research and
summary of outcomes. These tables were built
based on published methodologies of critically
­analyzing the existing research literature.
• Samples of function-based assessments.
• Summary tables of assessments highlighting
their clinical utility and focus as well as their
­psychometric properties.
Learning Aids
Learn ing aids include the following:
• Key terms
• Learning objectives
• Review questions
• Case studies
Note
Note to reader: This book compiles informa-
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-
ticipating in research. These terms include patient,
client, person, subject, participant, etc. The terms
originally used in the reviewed literature have
been maintained. This in no way undermines the
importance of a client-centered approach, which
I consider a best practice standard. Adopting a cli-
ent- and significant other-centered approach is
a thread and consistent message throughout this
textbook.
 Acknowledgments
T he author would first and foremost like to
acknowledge the clinicians and scientists who
have directly or indirectly shaped the way he con-
ceptualizes function based rehabilitation. These
include (but are not limited to) Guðrún Árnadóttir,
M. Carolyn Baum, Anne G. Fisher, Gordon Muir
Giles, and Joan P. Toglia.
I must also acknowledge my colleagues on the
faculty of the Programs in Occupational Therapy,
Columbia University College of Physicians &
Surgeons for consistent support, ideas, and for
ix
creating a stimulating albeit fun environment.
Particularly I need to thank Janet Falk-Kessler for
encouragement and guidance. I look forward to
working with her for many more years.
For more than a decade, the editorial team at
Elsevier has been supportive of my work. The guid-
ance I always receive from both Kathy Falk and
Melissa Kuster has been invaluable. Thank you
(again!).
Finally, I would like to acknowledge the editorial
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
Perceptual Rehabilitation
The practice area of cognitive and perceptual
­rehabilitation has and continues to shift in focus.
In the recent past, interventions were focused on
cognitive and perceptual stimulation activities
aimed at the remediation of a particular impair­
ment. It was assumed that the remediation of an
identified impairment or impairments would
generalize into the ability to perform meaningful,

has not been supported by empirical research.
An early example is the elegant work of Neistadt.47
The researcher had previously identified a relation­
ship between construction tasks as measured by the
Wechsler Adult Intelligence Scale-Revised (WAIS-R)
Block Design Test and a standardized assessment of
meal preparation, the Rabideau Kitchen Evaluation-
Revised, concluding that constructional abilities may
contribute to meal preparation performance. Based
on these findings a randomized controlled trial was
 cognitive and perceptual rehabilitation: Optimizing function
conducted to examine the effects of interventions
focused on retraining meal preparation skills ver­
sus the remediation of constructional deficits in
adult men with head injuries. Outcomes were meal
preparation competence and objective measures of
const­ructional abilities. Forty-five subjects, ages 18
to 52, in long-term rehabilitation programs, were
randomly assigned to one of two treatment groups:
remediation of construction abilities (n = 22) via
training with parquetry block assembly, and a meal
preparation training group (n = 23). Both groups
received training for three 30-minute sessions per
week for 6 weeks, in addition to their regular reha­
bilitation programs. Results showed task-specific
learning in both groups and suggested that train­
ing in functional activities may be the better way to
improve performance in such activities in this popu­
lation. In other words, those trained in construction
tasks performed better on novel tabletop construc­
tion tasks but did not improve on meal preparation
measures, whereas those trained in the meal prepa­
ration group demonstrated significantly improved
abilities related to the ability to make a meal at the
end of the intervention despite not improving on
measures of construction ability. Although the results
of this study are not unexpected based on a current
understanding of recovery, the study challenged the
typical interventions that were being taught in aca­
demic settings and those that were commonly used
in the clinic at the time it was published.
In general, interventions at that time were pro­
vided in controlled environments consisting of
tabletop activities that were novel and not focused
on function. Examples include engaging individuals
in block design activities, sequencing picture cards,
puzzle making, design copying, canceling a tar­
get stimulus on paper, pegboard designs, memory
drills, and so on. As technology became more read­
ily available, specialized cognitive-retraining com­
puterized programs were developed, marketed, and
quickly adopted into the clinical setting. In terms
of outcomes, interventions were deemed successful
when improvements were documented on specific
cognitive and perceptual impairment tests.
Similar to the interventions that were being used
at this time, measurement instruments attempted to
isolate a particular impairment via novel and non­
functional test items such as copying words and
designs, picture matching, block building, sequenc­
ing pictures, free recall of words, memorizing and
attending to a number string, and so on. It has and
continues to become clear that interventions such as
these need to be reconsidered if we as clinicians expect
to influence function in the real world. In addition, it
is becoming clear that how we measure the success
of an intervention must be reconsidered. Significant
improvement in a letter cancellation test for a person
living with unilateral spatial neglect can no longer be
interpreted as a positive outcome if more meaning­
ful functional changes (e.g., improved ability to read,
manage medications, play board games, ­ manage
money, etc.) cannot be documented.
As rehabilitation professions began to under­
stand the importance of evidence-based practice
and have refocused on “real-world” functional out­
comes, the rehabilitation process has begun to shift
accordingly. Interventions that focus on strategies
for living independently, with a purpose, and
with improved quality of life despite the presence
perhaps of cognitive and perceptual impairments are
slowly becoming the clinical standard. Likewise, out­
come measures that focus on documenting improved
functioning outside of a clinic environment and
those that include test items focused on performing
functional activities are being embraced.
These positive changes should be welcomed by
clinicians and the individuals to whom they provide
services because making a positive change in the life
of an individual living with cognitive and percep­
tual impairments has been notoriously difficult. It
is expected that as the research literature focused on
testing interventions continues to emerge, further
shifts in practice patterns will occur. Philosophically,
the clinical focus of what is called cognitive and per-
ceptual rehabilitation may be better described as the
process of improving function and quality of life in
those individuals living with ­cognitive and perceptual
impairments.
World Health Organization’s
International Classification of
Function as a Framework for
Choosing Assessments, Interventions,
and Documenting Outcomes
The World Health Organization’s (WHO) Inter­
national Classification of Functioning, Disability,
and Health (ICF)68 is a classification system that
describes body functions and structures, activities,
and participation. The various domains are inclu­
sive and consider the body itself as well as the indi­
vidual and societal perspectives. The ICF embraces
the relationship between the person and the context
in which daily living occurs and therefore includes
environmental factors as part of the classification
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
and perceptual impairments.6,49 Elements of the clas­
sification system (Table 1-1) include the following68:
• Body structures: Anatomic parts of the body
(organs, limbs, and their components)
• Body functions: Physiologic functions of the body
systems inclusive of psychological functions
• Impairments: A negative aspect related to prob­
lems in body function or structure such as sig­
nificant deviation or loss
• Activities: Execution of a task or action by an
individual
• Activity limitation: A negative aspect mani­
fested as an individual’s difficulty in executing
activities
• Participation restrictions: A negative aspect man­
ifested as an individual experiencing problems
in life situations
• Environmental factors: Physical, social, and atti­
tudinal environment in which people live and
conduct their lives; includes environmental as
well as personal factors
From an evaluation, intervention, and reha­
bilitation outcomes perspective, it is important to
consider the relationships between the classifica­
tion categories of the ICF rather than focusing on
one category at a time (Figure 1-1). For example,
“Mark” may survive a right frontoparietal stroke
resulting in visuospatial impairments and unilat­
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

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

Participation

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
process becomes more focused and defined, ­clients
become immediately empowered, the goals of ther­
apy are understood and agreed on, and an individ­
ually tailored intervention plan may be ­established.
The Canadian Occupational Performance Measure36
is a standardized tool that embraces a client-centered
approach and is discussed later.
van den Broek56 specifically recommends using
a client-centered approach as a way to enhance
neurorehabilitation outcomes and states that
treatment failure may be secondary to clinicians
focusing interventions on what they believe the
client needs rather than what the client actually
wants. van den Broek56 affirms that client-centered
goal setting is a key to successful ­ rehabilitation
­outcomes, stating:
“Goal setting is of central concern as without goals,
rehabilitation has no direction and the ­ intervention
­cannot be judged to be effective or ineffective. Moreover,
the quality and type of goal setting sets the tone of the
interaction between the clinician or treating team and
the patient. Goals that are proposed, suggested, or iden­
tified by the clinician tend to be those based on what
the clinician believes the patient needs. Of equal, if not
more importance, however, is what the patient wants to
achieve. Patients tend to be motivated toward achieving
or satisfying their wants, and may not be so motivated
or quite unmotivated toward achieving other goals. The
process of goal setting therefore involves arriving at an
overlap between needs and wants, or where this is not
possible agreeing to work toward wants that represent
a reasonable compromise. Goal setting that ends with
treatment goals that consist of needs that the patient does
not want or is indifferent toward is not client centered
but prescriptive, and runs the risk of concluding in an
­ineffective outcome.”
Another argument for using a client-centered
approach to guide the intervention focus with this
 cognitive and perceptual rehabilitation: Optimizing function
population is that interventions typically used for
those living with cognitive-perceptual dysfunction
are notoriously difficult to generalize to other real-
world settings and situations. For example, visual
scanning training via tabletop activities for those liv­
ing with unilateral spatial neglect most often will not
automatically generalize to the client’s being able to
use the scanning strategy to find items in the refrig­
erator unless the strategy is specifically taught in the
context of the activity. In addition, strategies that are
taught to accomplish a specific task (e.g., using an
alarm watch to maintain a medication schedule for
those living with memory loss) will not necessar­
ily generalize or “carry over” to another task such as
remembering therapy appointments. Finally, there
are a large number of clients whose level of brain
damage preclude them from generalizing learned
tasks.48 This issue of task-specificity related to treat­
ment interventions must always be considered by
clinicians working with this population. A client-
centered approach will help ensure that outcomes,
goals, and tasks used as the focus of therapy are at
least relevant, meaningful, and specific to each client
as well as the caretaker or significant others despite the
potential lack of being generalizable for a segment
of the population living with various cognitive and
­perceptual impairments.
What Are Appropriate Outcomes
When Designing Interventions
for People Living with Cognitive
and Perceptual Impairments?
Although not as a problematic as the recent past, the
practice area of cognitive and perceptual rehabili­
tation has been plagued by a lack of well-designed
clinical trials demonstrating positive outcomes.
A starting point is to decide what is considered
an appropriate, meaningful, and ideal outcome to
measure. This decision will help guide interventions
as well. The preceding paragraphs have already dis­
cussed the importance of keeping a client-centered
focus during the rehabilitation process. A client-
centered focus is paramount when considering out­
comes as well. The following case illustrates various
possible outcomes:
Mary is a 32-year-old woman who survived an
anoxic event that has resulted in moderate/severe
short term memory impairments. Mary is a sin­
gle mother of a 5-year-old boy. She works from
home (desktop publishing). Mary’s days were quite
­structured before her brain injury. Mornings were
characterized by basic self-care followed by tasks
related to getting her son to school (choosing his
clothing, making lunch, etc.). As the sole financial
provider, Mary spent the greater part of the rest of
the day in her home office working on the com­
puter, fielding phone calls, and organizing pres­
ent or upcoming jobs. Lunch was usually a quick
cold sandwich. Mary stopped working at 3:30 when
her son arrived home from school. Depending on
the day she would drive her son to Little League or
drum lessons. Mary always cooked a full dinner and
spent the rest of the evening helping with home­
work and watching television. Mary’s memory
impairments are preventing her from continuing
to work. For safety reasons, her mother has moved
in to help with childcare, household organization,
and financial matters. Mary has recently expressed
feelings of low self-esteem, saying that “she can’t
do anything by herself anymore.” Mary has stated
that she is most concerned about starting to work
(finances are limited) and she would like to take a
more active parenting role again. Prior to initiating
interventions, Mary participated in three assess­
ments including standardized measures of memory
impairment, instrumental activities of daily living
(IADL) (e.g., homemaking and child care), and
quality of life (QOL).
Possible (noninclusive) outcomes for Mary
based on the ICF68 may include the following:
• Outcome 1: Following cognitive reha­
bilitation, Mary has improved her scores
on a standardized memory scale (decreased
impairment) but changes are not detected on
measures of IADL and QOL (stable activity
limitations/participation restrictions).
• Outcome 2: Following cognitive rehabili­
tation, Mary has no detectable changes on the
standardized memory scale (stable impair­
ment) but changes are detected on mea­
sures of IADL and QOL (decreased activity
­limitations/participation restrictions).
• Outcome 3: Following cognitive rehabili­
tation, Mary has detectable changes on
the standardized memory scale (decreased
impairment) as well as changes that are
detected on measures of IADL and QOL
(decreased ­ activity limitations/­participation
restrictions).
Out of the three outcome scenarios, outcome 1 is
the least desirable. In the past this type of outcome
may have been considered successful (i.e., “Mary’s
memory has improved”). This outcome may be
indicative of an intervention plan that is over­
focused on attempts to remediate memory skills
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 
(e.g., memory drills, computerized ­ memory pro­
grams) without consideration of generalization
to real-life scenarios. If a change at the impair­
ment level of function does translate or general­
ize to improved ability to engage in meaningful
activities, participate successfully in life roles, or
enhance quality of life, the importance of the
intervention needs to be reconsidered. Outcomes
2 and 3 are more clinically relevant, arguably more
meaningful to Mary and her family, and repre­
sent more optimal results of structured rehabilita­
tion services. Outcome 2 may have been achieved
by focusing interventions on Mary’s chosen tasks.
Interventions such as teaching compensatory strat­
egies including the use of assistive technology may
have been responsible for this outcome. Mary is
able to engage in chosen tasks despite the presence
of stable memory impairments.
Finally, outcome 3 represents improvement
(decreased impairment, improved activity perfor­
mance, and improved quality of life) across mul­
tiple health domains. Although this outcome may
be considered the most optimal, the relationships
among the three measures are not clear. Clinicians
may assume that the improved status detected by
the standardized measure of memory was also
responsible for Mary’s improved ability to per­
form household chores and childcare. This reason­
ing is not necessarily accurate. The changes within
the health domains may in fact be independent of
each other. In other words, Mary’s improved abil­
ity to manage her household after participating in
treatment may be related to the fact that interven­
tions included specifically teaching Mary strate­
gies to manage her household. Similar to outcome
2, this positive change may have occurred with or
without a documented improvement in memory
skills.
Traditionally clinicians and researchers involved
in working with those living with cognitive and per­
ceptual impairments use standardized measures of
cognitive-perceptual impairment (i.e., standardized
tests of attention, memory, apraxia, neglect) as the
primary outcome measure to document effective­
ness of interventions. Although this is one impor­
tant level of measurement and following chapters
will review specific cognitive-perceptual measures
in detail, it is not sufficient to use these measures
as the sole or important indicator of successful
interventions. It is critical that clinical programs
and research protocols not only include but also
focus on measures of activity, participation, and
quality of life as a key outcome. As stated, positive
changes in these measures are more relevant than
an isolated change on an impairment measure—
the impairment change must be associated with a
change in other health domains. Individuals receiv­
ing ­services, family members, and third-party pay­
ers alike are likely to be more satisfied with changes
at these arguably more meaningful levels of func­
tion. The following standardized, valid, and reli­
able measurement instruments are suggested to
document successful clinical and research out­
comes related to improving function in those with
functional limitations secondary to the presence of
cognitive and perceptual impairments.
For a thorough review of performance-based
measures, refer to Law and associates.39 Unless oth­
erwise indicated, they are not impairment-specific
evaluations; therefore, they have high use when
working with this population.
Quality of Life Measures
The construct of quality of life is broad and com­
plicated. In her paper “What Is Quality of Life?”
Donald17 summarizes several issues related to qual­
ity of life:
• “Quality of life is a descriptive term that refers
to people’s emotional, social and physical well-
being, and their ability to function in the ordi­
nary tasks of living.
• Health-related quality of life analyses measure
the impact of treatments and disease processes
on these holistic aspects of a person’s life.
• Quality of life is measured using specially
designed and tested instruments, which measure
people’s ability to function in the ordinary tasks
of living.
• Quality of life analyses are particularly helpful
for investigating the social, emotional, and physi­
cal effects of treatments and disease processes on
people’s daily lives; analyzing the effects of treat­
ment or disease from the client’s perspective;
and determining the need for social, ­emotional,
and physical support during illness.
• Quality of life measures can therefore help to
decide between different treatments, to inform
clients about the likely effects of treatments, to
monitor the success of treatments from the cli­
ent’s perspective, and to plan and coordinate
care packages.”
Clinicians and researchers should consider
improving quality of life as an overarching theme
related to rehabilitation in general. Specific assess­
ments are reviewed below.
 cognitive and perceptual rehabilitation: Optimizing function
Medical Outcomes Study Short Form-36
The Medical Outcomes Study Short Form-36 (SF-
36)59 is a widely used survey instrument for assess­
ing a client’s health-related quality of life. The SF-36
measures eight domains: physical functioning, role
physical, bodily pain, general health, vitality, social
functioning, role emotional, and mental health,
and has two summary scores (physical and men­
tal). The SF-36 has demonstrated its reliability and
validity in multiple populations and can be admin­
istered in various ways. The SF-1258 and SF-2060 are
abbreviated versions of the SF-36 health profile.
Sickness Impact Profile
The Sickness Impact Profile (SIP)11 is used to evalu­
ate the effect of disease on physical and emotional
functioning. The measure includes two overall
domains: physical and psychosocial. The measure
has 12 categories including sleep and rest, eating,
work, home management, recreation and pastimes,
ambulation, mobility, body care and movement,
social interaction, alertness behavior, emotional
behavior, and communication. The instrument
yields an overall score, 2 domain scores, and 12
category scores; items are weighted according to a
standardized weighting scheme. A stroke-specific
version (Stroke Adapted Sickness Impact Profile) is
available.57
Nottingham Health Profile
The Nottingham Health Profile (NHP)27,28 was
developed to be used in epidemiologic studies of
health and disease and consists of two parts. Part
1 contains 38 yes/no items in six dimensions: pain,
physical mobility, emotional reactions, energy,
social isolation, and sleep. Part 2 contains 7 gen­
eral yes/no questions concerning daily living prob­
lems including paid employment, jobs around the
house, personal relationships, social life, sex life,
hobbies, and holidays. The two parts may be used
independently.
Stroke Impact Scale
The Stroke Impact Scale (SIS)19,33 is a stroke-specific
measure that provides information on function and
quality of life. This self report measure including 59
items that form eight subgroups including strength,
hand function, basic and instrumental activities of
daily living, mobility, communication, emotion,
memory and thinking, and participation. The SIS
is valid, reliable, and sensitive to change in stroke
populations and is reliable when responses are
­provided by proxy.
Reintegration to Normal Living
The Reintegration to Normal Living (RNL)66,67
assessment is used to document reentry into every­
day life following a sudden illness or event. This
functional status measure quantitatively assesses the
degree of reintegration to normal living achieved
by clients after illness or trauma and is useful. This
tool assesses global function and the individual’s
satisfaction with basic self-care, in-home mobility,
leisure activities, travel, and productive pursuits.
Clients are provided with 11 statements to which
they respond. The test can be completed using a
pen-and-paper format or an interview format.
Satisfaction with Life Scale
The Satisfaction with Life Scale (SWLS)16 is a 5-
item scale that uses a 7-point Likert scale response
format. Individual scores are added to create a total
score ranging from 5 to 35. A score of 20 represents
a neutral point at which the respondent is equally
satisfied and dissatisfied. The items in the SWLS are
limited to general life satisfaction.
Activity and Participation Measures
Outcomes related to cognitive perceptual rehabilita­
tion must be detectable and evidenced by decreasing
activity limitations and participation restrictions. Out­
comes are individualized and based on the activities
(basic activities of daily living [ADL], IADL, paid
and unpaid work, and play and leisure) that clients
want to be able to do or need to do to live a safe and
productive life. Measurement instruments that focus
on the activity and participation levels are critical to
document the effectiveness of cognitive-perceptual
rehabilitation interventions. Examples follow.
Community Integration Questionnaire
The Community Integration Questionnaire (CIQ)62-64
consists of 15 items relevant to home integration, social
integration, and productive activities. It is scored to
provide subtotals for each of these, as well as for com­
munity integration overall. Scoring is primarily based
on frequency of performing activities or roles, with
secondary weight given to whether activities are done
jointly with others, and the nature of these other per­
sons. The CIQ can be completed, by either the client or
a proxy, in about 15 minutes.
Craig Handicap Assessment and
Reporting Technique
The Craig Handicap Assessment and Reporting
Technique (CHART)61 measures the degree to
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 
which impairments and activity limitations result in
decreased participation. The original CHART had
27 questions and included the following domains:
(1) physical independence: ability to sustain a
customarily effective independent existence; (2)
mobility: ability to move about effectively in one’s
surroundings; (3) occupation: ability to occupy
time in the manner customary to that person’s sex,
age, and culture; (4) social integration: ability to
participate in and maintain customary social rela­
tionships; and (5) economic self-sufficiency: ability
to sustain customary socioeconomic activity and
independence.
The revised CHART46 (32 questions) contains a
sixth domain designed to assess orientation: cog­
nitive independence. Each of the domains or sub­
scales of the CHART has a maximum score of 100
points. High subscale scores indicate less handicap,
or higher social and community participation. The
CHART can be administered by interview, either in
person or by telephone, and takes approximately
15 minutes to administer. Participant-proxy agree­
ment across disability groups on the CHART has
provided evidence in support of the use of proxy
data for people with various types of disabilities.
A shorter version of the instrument, the CHART
Short Form, has 19 items that yield the same
­subscales as the original CHART.
Activity Card Sort
The Activity Card Sort (ACS)9,30 uses a Q-sort
methodology to assess participation in 80 instru­
mental, social, and high and low physical demand
leisure activities. Clients sort the cards into different
piles to identify activities that were done prior to
insult or injury, those activities they are doing less,
and those they have given up since their injury. The
ACS uses cards with pictures of tasks that people do
every day. There are different versions of the card
sort based on where interventions are taking place.
An institutional version sorts the cards into cate­
gories of done prior to illness and not done. The
recovering version identifies activities not done in
the past 5 years, those given up because of illness,
those beginning to do again, and those activities the
client is doing now.25
In all versions, a current activity level is deter­
mined. This assessment takes approximately 30
minutes to administer and results in a score of
percent of activities retained. The ACS has been
found to be a reliable and valid measure with indi­
viduals with cognitive loss9 as well as stroke30 and
is available in several culture-specific formats.
In ­addition, an adolescent as well as child version is
in development.25
Canadian Occupational Performance Measure
The Canadian Occupational Performance Measure
(COPM)12,36 is a self-report measure used to assess
a client’s perception of recovery and goals. This
client-centered assessment allows the recipient of
treatment (or a caretaker) to identify activities that
are difficult, rate the importance of each activity,
rate own level of performance for each identified
activity, and rate satisfaction with current perfor­
mance. Overall areas of assessment include self-care,
leisure, and productivity. The tool is not diagnosis
specific and can be used with children, adolescents,
and adults. To be used with success, the client must
be able to understand a 10-point Likert scale scor­
ing format. If this is not possible, a caregiver may be
involved in the assessment process (Figure 1-3).
Barthel Index
The Barthel Index (BI)44 is a measure of basic activ­
ities of daily living and mobility. It is scored from
0 to 100, with higher scores indicative of increased
function. The specific items measured include feed­
ing, bathing, grooming, dressing, bowel control,
bladder control, toilet use, transfers, mobility on
even surfaces, and stairs.
Functional Independence Measure
The Functional Independence Measure (FIM)31
is a widely accepted functional assessment mea­
sure used during inpatient rehabilitation. The FIM
is an 18-item ordinal scale, used with all diagno­
ses within a rehabilitation population. FIM scores
range from 1 to 7 (1 = total assist and 7 = com­
plete independence). Scores falling below 6 require
another person for supervision or assistance. The
FIM measures independent performance in self-
care, sphincter control, transfers, locomotion, com­
munication, and social cognition. By adding the
points for each item, the possible total score ranges
from 18 (lowest) to 126 (highest) level of inde­
pendence. During rehabilitation, admission and
discharge scores are rated by a multidisciplinary
team while observing client function. Functioning
postdischarge can be accurately assessed using a
telephone version of FIM when administered by
qualified interviewers.
Revised Observed Tasks of Daily Living
The Revised Observed Tasks of Daily Living
(OTDL-R)15 is a performance-based test of ­everyday
10 cognitive and perceptual rehabilitation: Optimizing function

STEP 1A: Self-Care IMPORTANCE

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)

Play/School
(e.g., play skills,
homework)

STEP 1C: Leisure

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

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

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

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

Table 1-3 Instrumental Activities of Daily Living Standardized Assessments

Rivermead
Activities
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
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

(Continued)
12 cognitive and perceptual rehabilitation: Optimizing function

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

Rivermead
Activities
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
home
Hobby
Telephone calls to
family/friends
Attend religious
events
Outdoor
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
ground
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
hands
Put on makeup or
shave
Eat
Undress/dress
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
were “excellent” and “excellent” or “good” for the
test retest reliability study. They suggested that the
tool has potential for clinical use. More recently the
Nottingham Leisure Questionnaire has been short­
ened (37 to 30 items) and the response categories
collapsed (five to three categories) in order to make
it suitable for mail use.
Leisure Competence Measure
The Leisure Competence Measure32 provides infor­
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
includes nine areas: social contact, community par­
ticipation, leisure awareness, leisure attitude, social
behaviors, cultural behaviors, leisure skills, inter­
personal kills, and community integration skills.
Items are rated on a seven-point Likert scale.
Leisure Diagnostic Battery
The original version of the Leisure Diagnostic
Battery65 includes 95 items, whereas the newer
shorter version includes 25 items.13 Items are scaled
on three-point scale. Assessment areas include play­
fulness, competence, barriers, knowledge, and so on.
Measures That Simultaneously Assess
Activity/Participation and Underlying
Impairments or Subskills
There is a short list of available assessments that are
highly recommended because they are unique in
their ability to simultaneously assess more than one
level of function such as activity limitations and the
impairments responsible for the limitations. These
assessments provide clinicians with critical and
substantial information via skilled observation of
functional tasks.
Árnadóttir OT-ADL Neurobehavioral Evaluation
The Árnadóttir OT-ADL Neurobehavioral Evalua­
tion (A-ONE)3–5,22 is an instrument that allows the
Box 1-1 Items Included on the Árnadóttir OT-ADL Neurobehavioral Evaluation (A-ONE)
The A-ONE uses standardized and structured observations
as the method of assessment during the following daily
­living skills:
• Feeding
• Grooming and hygiene (upper body washing, oral/hair
care, shaving, etc.)
• Dressing (upper and lower body)
• Transfers and mobility (bed mobility, transfers,
maneuvering in a wheelchair or during ambulation)
• Functional communication (comprehension and
expression)
Using standardized procedures and uniform conceptual
and operational definitions as guidelines the following spe-
cific impairments are evaluated in the context of functional
skills:
• Ideational apraxia
• Motor apraxia
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).
therapist to detect impairments that interfere with
task performance to understand factors underlying
activity limitations. It is used with clients who are
16 years and older and are living with functional
limitations secondary to central nervous system
dysfunction such as stroke, traumatic brain injury,
dementia, and multiple sclerosis.
The A-ONE aids the therapist in analyzing the
nature or cause of a functional problem requiring
intervention. Subsequently, therapists can speculate
about the best intervention for activity limitation
and impairments. The A-ONE is a performance-
based tool that uses structured observations of
upper and lower body dressing, grooming, hygiene,
feeding, transfers, mobility and communication to
detect the underlying impairments that interfere
with function (Box 1-1).
Impairments detected during the observation
of these tasks include motor apraxia, ideational
apraxia, unilateral body neglect, somatoagnosia,
spatial relations, unilateral spatial neglect, impaired
motor control, perseveration, and organization and
sequencing. In addition pervasive impairments such
as agnosias, memory loss, disorientation, confabu­
lation, and affective disturbances can be detected
throughout the observations. Figure 1-4 shows an
example of the dressing domain of the A-ONE. Note
that the instrument includes two scales; the Indepen­
dence Score ­ measures each activity in terms of
functional independence, and the Neurobehavioral
• Unilateral body neglect
• Somatoagnosia
• Spatial relations dysfunction
• Unilateral spatial neglect
• Perseveration
• Organization and sequencing dysfunction
• Topographic disorientation
• Motor control impairments
In addition, the following pervasive impairments can be
detected and objectified:
• Agnosias (visual object, associative visual object,
visuospatial)
• Anosognosia
• Body scheme disturbances
• Emotional/affective disturbances
• Impaired attention and alertness
• Memory loss
14 cognitive and perceptual rehabilitation: Optimizing function

Functional Independence Scale and

Neurobehavioral Specific Impairment Subscale

Ms. Wilson 6/13/03

Name______________________________________________________________________
Date _________________________

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

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

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

PRIMARY ADL ACTIVITY SCORING COMMENTS AND REASONING

DRESSING IP SCORE

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
Other

NB IMPAIRMENT NB SCORE

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
Other

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

Árnadóttir OT-ADL
Neurobehavioral Evaluation
(A-ONE)
Ms. Wilson
Name _____________________________________________ 6–13–03
Date ________________________________________
4–15–1943
Birthdate __________________________________________ 60
Age _________________________________________
Female
Gender ____________________________________________ Caucasian
Ethnicity _____________________________________
Right
Dominance ________________________________________ Dressmaker
Profession ___________________________________

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

Medications:

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.

FUNCTIONAL INDEPENDENCE SCORE (optional)

FUNCTION TOTAL SCORE % SCORE
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
(Continued)
16 cognitive and perceptual rehabilitation: Optimizing function

LIST OF NEUROBEHAVIORAL IMPAIRMENTS OBSERVED:

SPECIFIC IMPAIRMENT D G T F C PERVASIVE IMPAIRMENT ADL PERVASIVE IMPAIRMENT ADL

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-
tions.
Treatment Considerations:

Occupational Therapist:

A-ONE Certification Number:

Figure 1-4—Cont’d

a person uses to (1) select, interact with, and use
tools and materials, (2) carry out ­individual actions
and steps, and (3) modify performance when prob­
lems are encountered. Process skills should not be
confused with cognitive or ­perceptual skills.
For example, one process skill included on the
AMPS is the ability “search and locate.” Searching for
and locating necessary items to perform a task relies
on multiple underlying skills such as visual ­attention,
figure-ground skills, problem solving, intact visual
fields, and so on. The AMPS detects the behavioral
output of these subskills. Following the skilled obser­
vation of each ADL task, the client is rated on 16
motor and 20 process skill items for each task per­
formed using a four-point Likert scale. Once the
items are scored for each task, the results are entered
in the AMPS computer scoring program. The pro­
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
process skill scores results in ADL motor ability and
ADL process ability measures. The measures repre­
sent the placement of the person on a continuum of
motor or process ability (Figure 1-5, B).
The AMPS requires no specialized equipment
and can be conducted in any ADL-relevant setting
within 60 minutes. A study42 found that the AMPS
may give a better indication of the client’s ability
to resume independent living than neuropsycho­
logical testing alone. The occupational therapy
practitioner who uses the AMPS must attend a
5-day AMPS training course to become certified
in its use.

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

PERFORMANCE SKILL SUMMARY
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
intervention

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.

(Continued)
18 cognitive and perceptual rehabilitation: Optimizing function

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

PERFORMANCE SKILL SUMMARY
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
intervention

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

OCCUPATIONAL THERAPY EVALUATION OF ADL ABILITY

(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
AMPS EVALUATION
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.
OVERALL QUALITY OF PERFORMANCE
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.

SPECIFIC SKILLS THAT MOST IMPACTED PERFORMANCE

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
(Transports)
• 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)
OVERALL ADL MOTOR ABILITY
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.
OVERALL ADL PROCESS ABILITY
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.
SUMMARY OF MAIN FINDINGS
• 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
A
Figure 1-5—Cont’d
20 cognitive and perceptual rehabilitation: Optimizing function

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

GRAPHIC REPORT

Client: John S Date MOTOR PROCESS

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

ADL MOTOR ADL PROCESS

4 3

Less physical More likely to be safe and ADL performance

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

ADL ADL
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
ADL

0 −1

−1 −2

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

effort independent living in the less efficient
performing community
ADL
−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.
B
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,
Elsevier/Mosby.)

Executive Function Performance Test and Kitchen
Task Assessment
The Executive Function Performance Test
(EFPT)10 was developed subsequently to the
Kitchen Task Assessment (KTA).8 Both measures
are standardized performance-based assessments
that examine cognitive functioning through the
observation of cues needed for a person to carry
out a functional task. Specifically observed is the
ability to initiate the task when asked, organize
the task, perform the necessary steps of the task,
sequence the steps in a logical order, develop
awareness related to safety and judgment, and
recognize completion of the task. Cueing is sys­
tematic and includes visual, ­gestural, and ­physical
cues that are provided in a hierarchic fashion.
These cues provide support to the client when
task execution begins to fail.
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 21
The original KTA was completed by observ­
ing one task, making store-bought pudding on a
stovetop. The KTA was validated on those living
with dementia. More recently the EFPT was devel­
oped using the same cueing system from the KTA.
The tasks have been expanded to include preparing
or heating up a light meal (cooked oatmeal), man­
aging medications, using the telephone, and paying
bills. The tool has been used for those with stroke
and was recently found to be sensitive to the cogni­
tive difficulties experienced in everyday life for those
living with multiple sclerosis (see Chapter 10).
Performance Assessment of Self-Care Skills
The Performance Assessment of Self-Care Skills
(PASS)20,26,51 is also a performance-based observa­
tional test with a home and clinic version. The PASS
is composed of 26 core tasks within four functional
domains:
• Functional mobility (5 tasks)
• Personal self-care (3 tasks)
• IADL with a cognitive emphasis (14 tasks: shop­
ping, bill paying, check writing, balancing a
checkbook, mailing, telephone use, medication
management, 2 tasks related to obtaining infor­
mation from the media, small home repairs,
home safety, playing bingo, oven use, stove use,
and use of sharp utensils)
• IADL with a physical emphasis
Performance is rated for independence, safety, and
adequacy. If an individual requires assistance to com­
plete a task, the PASS provides a hierarchy of prompts.
The types of prompts, beginning with the least assis­
tive and progressing to the most assistive are (1) ver­
bal supportive, (2) verbal nondirective, (3) verbal
directive, (4) gestures, (5) task object or environmen­
tal rearrangement, (6) demonstration, (7) physical
guidance, (8) physical support, and (9) total assist.
The PASS is criterion referenced and may be
given in total, or selected tasks may be used alone
or in combination. The PASS can be used with ado­
lescents and adults with various diagnoses includ­
ing stroke, head injury, and multiple sclerosis. The
interactive assessment used when administering the
PASS allows clinicians to identify the point of task
breakdown and the types of assistance that enable
improvement in task performance. Self-report,
proxy-report, and clinical judgment versions of the
PASS are available.
Naturalistic Action Test
The Naturalistic Action Test (NAT)53 is a measure­
ment of naturalistic action production across a
wide range of client impairment that was devel­
oped subsequently to the Multi-level Action Test. It
is based on research demonstrating that ­recovering
stroke and brain injury clients and those with pro­
gressive dementia are highly prone to errors of
action when performing routine ADL. The NAT
is a ­ performance-based test of naturalistic action
in which the tasks are associated with disorders
of higher cortical function. The materials, layout,
and cueing procedures are standardized. Scoring
is simple and objective and can be performed
reliably with little formal training. Tasks that are
observed include making toast with butter and jelly
and instant coffee with cream and sugar, wrapping
a gift, and preparing and packing a child’s lunch­
box and schoolbag. Instructions are spoken and
­reinforced with ­ drawings. Items are scored for
accomplishment of necessary steps, and this score
is combined with an error score that tracks 12 com­
mission errors. The test has been validated on those
with right and left strokes and those with traumatic
brain injury.
Structured Observational Test of Function
The Structured Observational Test of Function
(SOTOF)34,35 is a valid and reliable tool that assesses
the following:
• Occupational performance (deficits in simple
ADL)
• Performance components (perceptual, cogni­
tive, motor, and sensory impairment)
• Behavioral skill components (reaching, scan­
ning, grasp, sequence)
• Neuropsychological deficits (spatial relations
apraxia, agnosia, aphasia, spasticity, memory loss)
Impairments are detected by the structured
observation of simple ADL (e.g., eating from a
bowl, pouring a drink and drinking, upper body
dressing, washing and drying hands).
This relative quick tool aims to answer the fol­
lowing questions:
1. How does the subject perform ADL tasks?
2. What behavioral skill components are intact?
Which have been affected by neurologic damage?
3. Which perceptual, cognitive, motor, and sensory
impairments are present?
4. Why is function impaired?
Overview of Models That
Guide Practice
Various models that guide this practice area have
been described in the literature. The reader is
22 cognitive and perceptual rehabilitation: Optimizing function
referred to Katz29 for comprehensive descriptions of
these models. The following paragraphs are sum­
maries of commonly used approaches.
Dynamic Interactional Approach
The Dynamic Interactional Approach55 views cog­
nition as a product of the interaction among the
person, activity, and environment. Therefore, per­
formance of a skill can be promoted by changing
either the demands of the activity, the environ­
ment in which the activity is carried out, or the
person’s use of particular strategies to facilitate
skill performance. To illustrate the interaction
among the three factors (person, activity, and
environment), the reader is encouraged to think
about how the efficiency and effectiveness of skill
performance vary based on the following task
descriptions:
• Driving your own automatic transmission mid­
size car versus renting and driving a standard
transmission pickup truck
• Performing a morning self-care routine in your
own home versus the same routine carried out
in a hotel room
• Cooking a meal versus cooking a meal while
simultaneously babysitting twin 2-year-old boys
Toglia55 describes several constructs associated
with this model including the following:
• Structural capacity or the physical limits in the
ability to process and interpret information
• Personal context or characteristics of the person
such as coping style, beliefs, values, and lifestyle
• Self-awareness or understanding your own
strengths and limitations, as well as metacog­
nitive skills such as the ability to judge task
demands, evaluate performance, and anticipate
the likelihood of problems (see Chapter 4)
• Processing strategies or underlying components
that improve task performance such as atten­
tion, visual processing, memory, organization,
and problem solving
• The activity itself considering the demands,
meaningfulness, and how familiar the activity is
• Environmental factors such as the social, physi­
cal, and cultural aspects.
Toglia55 summarizes that “to understand cog­
nitive function and occupational performance,
one needs to analyze the interaction among per­
son, activity, and environment. If the activity and
environmental demands change, the type of cog­
nitive strategies needed for efficient performance
changes as well. Optimal performance is observed
when there is a match between all three variables.
Assessment and treatment reflect this dynamic
view of cognition.” This approach may be used with
adults, children, and adolescents.
Toglia used the Dynamic Interactional Model to
develop the Multicontext Treatment Approach.54,55
Combining both remedial and compensatory strat­
egies, this approach focuses on teaching a par­
ticular strategy to perform a task and practicing
this strategy across different activities, situations,
and environments over time. Toglia summarizes
the components of this approach to include the
following:
• Awareness training or using structured expe­
riences in conjunction with self-monitoring
techniques so that clients may redefine their
knowledge of their strengths and weaknesses
(see Chapter 4).
• Personal context. Treatment activities are chosen
based on client’s interest and goals. A particular
emphasis is placed on the relevance and purpose
of the activities. Managing monthly bills may be
an appropriate activity for a single person living
alone, whereas crossword puzzles may be used as
an activity for a retiree who previously enjoyed
this activity.
• Processing strategies are practiced during a vari­
ety of functional activities and situations. Toglia
defines processing strategies as strategies that
help a client to control cognitive and percep­
tual symptoms such as distractibility, impulsiv­
ity, inability to shift attention, disorganization,
attention to only one side of the environment,
or a tendency to over focus on one part of an
activity.
• Activity analysis is used to choose tasks that
systematically place increased demands on the
ability to generalize strategies that enhance
performance.
• Transfer of learning occurs gradually and sys­
tematically as the client practices the same strat­
egy during activities that gradually differ in
physical appearance and complexity.
• Interventions occur in multiple environments to
promote generalization of learning.
Quadraphonic Approach
The Quadraphonic Approach was developed by
Abreu and colleagues1 for use with those living
with cognitive impairments after brain injury. This
approach is described as including both a “micro”
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
“macro” perspective (i.e., a focus on functional skills
such as ADL, leisure, etc.). The approach supports the
use of remediation as well as compensatory strategies.
The micro perspective incorporates four
theories:
1. Teaching-learning theory is used to describe
how clients use cues to increase cognitive aware­
ness and control.
2. Information-processing theory describes how
an individual perceives and reacts to the envi­
ronment. Three successive processing strategies
are described including detection of a stimulus,
discrimination and analysis of the stimulus, and
selection and determination of a response.
3. Biomechanical theory is used to explain the
client’s movement, with an emphasis on the
integration of the central nervous system, mus­
culoskeletal system, and perceptual-motor skills.
4. Neurodevelopmental theory is concerned with
quality of movement.
The macro perspective is based on narrative and
functional analysis to explain behavior based on the
following four characteristics:
1. Lifestyle status or personal characteristics related
to performing everyday activities
2. Life-stage status such as childhood, adolescence,
adulthood, and married
3. Health status such as the presence of premorbid
conditions
4. Disadvantage status or the degree of functional
restrictions resulting from impairment
Cognitive-Retraining Model
The Cognitive-Retraining Model7 is used for ado­
lescents and adults living with neurologic and
neuropsychological dysfunction. Based on neuropsy­
chological, cognitive, and neurobiologic rationales,
this model focuses on cognitive training by enhanc­
ing remaining skills, and by teaching cognitive strate­
gies, learning strategies, or procedural strategies.
Neurofunctional Approach
The neurofunctional approach23 is applied to those
living with severe cognitive impairments secondary
to brain injuries. The approach focuses on train­
ing clients in highly specific compensatory strate­
gies (not expecting generalization) and specific task
training. Contextual and metacognitive factors are
specifically considered during intervention plan­
ning. The approach does not target the underly­
ing cause of the functional limitation but focuses
directly on retraining the skill itself.
Patterns of Cognitive-Perceptual
Impairments Based on Diagnoses
and Area(s) of Brain Pathology
A critical aspect of the evaluation process involves
determining the impairment(s) that are interfering
with an individual’s ability to participate in mean­
ingful activities. Several clients may have similar
activity level scores, but the impairments causing
the limitations may be quite different (Table 1-4).
Identifying the correct impairment(s) will help cli­
nicians determine which interventions are required
including necessary adaptations, which strategy
choices are appropriate, and to begin to determine
the focus of rehabilitation. Depending on the diag­
noses, clinicians can begin to expect usual pre­
sentations of patterns of cognitive and perceptual
impairments although variations from these typical
patterns may occur.
Stroke
If neuroimaging data are available they may provide
information related to which structures are compro­
mised. Using knowledge of neuroanatomy and neuro­
logic processing, the clinician may begin to hypothesize
which impairments will be present and how they
interfere with function (Tables 1-5 and 1-6).
Even a basic understanding of cortical func­
tion related to understanding the various functions
associated with different areas of the brain can help
clinicians in the clinical reasoning process associ­
ated to identifying impairments that affect daily
functioning (Tables 1-7 and 1-8).3,4
Multiple Sclerosis
Those living with multiple sclerosis may experience
slowed information processing, decreased atten­
tion, decreased concentration, difficulty shifting
attention, difficulty dividing attention, decreased
explicit memory, decreased episodic memory,
loss of executive functioning (concept forma­
tion, reasoning, problem solving, planning, and
sequencing.14,52
Parkinson’s Disease
In general, individuals living with Parkinson’s dis­
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
B Left frontoparietal stroke
Unilateral neglect, figure-ground
impairment, spatial relations
dysfunction, distractibility
Motor planning deficits, ideational
apraxia, impaired organization and
sequencing
Inability to “find” grooming items
on the left side of the sink,
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
Uses grooming objects incorrectly
(eats soap), brushes teeth
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
functions more prominently affected. More specifi­
cally, attention functions are commonly decreased.
In addition free recall (immediate and delayed)
is impaired as is visuospatial processing, motor
­planning, shifting attention, alternating tasks, and
­verbal fluency.45
Huntington’s Disease
In this disease, selective cognitive abilities are pro­
gressively impaired, whereas others remain intact.
Abilities affected include executive function (plan­
ning, cognitive flexibility, abstract thinking, rule
acquisition, initiating appropriate actions, and
inhibiting inappropriate actions), psychomotor
function (slowing of thought processes to con­
trol muscles), perceptual and spatial skills of self
and surrounding environment, selection of cor­
rect methods of remembering information (but
not actual memory itself), and ability to learn new
skills. Problems in attention, working memory,
verbal learning, verbal long-term memory, and
learning of random associations are the earliest
cognitive manifestations.41
Severe cognitive and perceptual deficits are
common after traumatic brain injury (TBI)
including deficits of attention, memory, infor­
mation-­processing speed, and problems in self-
perception. In addition posttrauma for anxiety,
expressive deficit, emotional withdrawal, depres­
sive mood, hostility, suspiciousness, fatigabil­
ity, hallucinatory behavior, motor retardation,
unusual thought content, lability of mood, and
comprehension deficits have been documented.
A recent longitudinal study43 of those with severe
TBI documented a tendency of improvement
for inattention, somatic concern, ­disorientation,
guilt feelings, excitement, poor planning, and
articulation deficits. In addition, for the impair­
ments of conceptual disorganization, disinhi­
bition, memory deficit, agitation, inaccurate
self-appraisal, decreased initiative, blunted affect,
and tension the authors noted a tendency for fur­
ther deterioration in the posttraumatic follow-
up. Changes between 6 and 12 months post-TBI
were statistically significant for disorientation
(improvement), inattention or reduced alertness
­(improvement), and ­ excitement (deterioration).
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
Perseveration
Field dependency
Impaired organization of behavior
Depression
Lability
Apathy

Right hemisphere dysfunction

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

Left hemisphere dysfunction

Bilateral motor apraxia
Broca’s aphasia
Frustration
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
trunks

(Continued )
26 cognitive and perceptual rehabilitation: Optimizing function
Table 1-5 Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment—Cont’d
Artery Location
Anterior cerebral artery Medial and superior aspects of
frontal and parietal lobes
Internal carotid artery Combination of middle cerebral
artery distribution and anterior
cerebral artery
Anterior choroidal artery, Globus pallidus, lateral geniculate
a branch of the internal body, posterior limb of the
carotid artery internal capsule, medial
temporal lobe
Posterior cerebral artery Medial and inferior aspects of
right temporal and occipital
lobes, posterior corpus
callosum and penetrating
arteries to midbrain and
thalamus
Basilar artery proximal Pons
Possible Impairments
Contralateral hemiparesis, greatest in foot
Contralateral hemisensory loss, greatest in foot
Left unilateral apraxia
Inertia of speech or mutism
Behavioral disturbances
Impairments related to dysfunction of middle and
anterior cerebral arteries as listed above
Hemiparesis of face, arm, and leg
Hemisensory loss
Hemianopsia
Dysfunction of either side
Homonymous hemianopsia
Visual agnosia (visual object agnosia, prosopagnosia,
color agnosia)
Memory impairment
Occasional contralateral numbness
Right side dysfunction
Cortical blindness
Visuospatial impairment
Impaired left-right discrimination
Left side dysfunction
Finger agnosia
Anomia
Agraphia
Acalculia
Alexia
Quadriparesis
Bilateral asymmetric weakness
Bulbar or pseudobulbar paralysis (bilateral paralysis of
face, palate, pharynx, neck, or tongue)
Paralysis of eye abductors
Nystagmus
Ptosis
Cranial nerve abnormalities
Diplopia
Dizziness
Occipital headache
Coma
 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
Coma
Memory loss
Agitation
Hallucination
Vertebral artery Lateral medulla and cerebellum Dizziness
Vomiting
Nystagmus
Pain in ipsilateral eye and face
Numbness in face
Clumsiness of ipsilateral limbs
Hypotonia of ipsilateral limbs
Tachycardia
Gait ataxia
Systemic hypoperfusion Watershed region on lateral side Coma
of hemisphere, hippocampus Dizziness
and surrounding structures in Confusion
medial temporal lobe Decreased eoncentration
Agitation
Memory impairment
Visual abnormalities caused by disconnection from
frontal eye fields
Simultanognosia
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
Slowness
Right side
Visual neglect
Left side
Aphasia
Lateral thalamus Contralateral hemisensory symptoms
Contralateral limb ataxia
Bilateral thalamus Memory impairment
Behavioral abnormalities
Hypersomnolence
Internal capsule or basis pontis Pure motor stroke
Posterior thalamus Numbness or decreased sensibility of face and arm
Choreic movements
Impaired eye movements
Hypersomnolence

(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
Anosognosia
Visuospatial abnormalities
Left side
Aphasia
Jargon aphasia
Good comprehension of speech
Paraphasia
Anomia
Caudate Dysarthria
Apathy
Restlessness
Agitation
Confusion
Delirium
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
Aphasia
Pons Quadriplegia
Coma
Impaired eye movement
Cerebellum Ipsilateral limb ataxia
Gait ataxia
Vomiting
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
disappear over time and that some aspects related
to self-appraisal, conceptual ­disorganization and
affect may even deteriorate.
Review Questions
1. Name and describe three assessments that may
be used to document improvements in quality
of life and participation.
2. What are the expected patterns of cognitive or
perceptual impairments if a person presents
with a right middle cerebral artery stroke? Left
middle cerebral artery stroke?
3. How can the principles of client-centered prac­
tice be integrated into the development of an
intervention plan for a person with attention
deficits after a brain injury?
4. Give two examples of how the ICF levels of func­
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:

References
1. Abreu BC, Peloquin SM: The quadraphonic
approach: a holistic rehabilitation model for brain
injury. In Katz N, editors: Cognition and occupation
across the life span, Bethesda, Md, 2005, AOTA Press.
2. American Occupational Therapy Association:
Occupational therapy practice framework: domain
and process, Am J Occup Ther 56:609-639, 2002.
3. Árnadóttir G: The brain and behavior: assessing cor-
tical dysfunction through activities of daily living,
St Louis, 1990, Mosby.
4. 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.
5. Árnadóttir G: Rasch analysis of the ADL scale of the
A-ONE, Am J Occup Ther (in press).
6. Arthanat S, Nochajski SM, Stone J: The international
classification of functioning, disability and health
and its application to cognitive disorders, Disabil
Rehabil 26(4):235-245, 2004.
a retraining model for clients with neurologi­
cal ­ disabilities. In Katz N, editor: Cognition and
­occupation across the life span, Bethesda, Md, 2005,
AOTA Press.
8. Baum C, Edwards DF: Cognitive performance in senile
dementia of the Alzheimer’s type: the kitchen task
assessment, Am J Occup Ther 47(5):431-436, 1993.
9. Baum C, Edwards D: The activity card sort, St Louis,
2001, Washington University at St. Louis.
10. Baum CM, Edwards DF, Morrison T, et al: The reli­
ability, validity, and clinical utility of the Executive
Function Performance Test: a measure of executive
function in a sample of persons with stroke, Am J
Occup Ther (in press).
11. Bergner M, Bobbitt RA, Carter WB, et al: The sick­
ness impact profile: development and final revision of
a health status measure, Med Care 19:787-805, 1981.
12. Carswell A, McColl MA, Baptiste S, et al: The Canadian
occupational performance measure: a research and
clinical literature review, Can J Occup Ther 71(4):
210-222, 2004.
30 cognitive and perceptual rehabilitation: Optimizing function
13. Chang Y, Card JA: The reliability of the leisure diag­
nostic battery short form version B in assessing
healthy, older individuals: a preliminary study, Ther
Recreation J 28:163, 1994.
14. Christodoulou C, Melville P, Scherl WF, et al:
Perceived cognitive dysfunction and observed neuro­
psychological performance: longitudinal relation in
persons with multiple sclerosis, J Clin Exp Neuropsych
11(5):614-619, 2005.
15. Diehl M, Marsiske M, Horgas AL, et al: The Revised
Observed Tasks of Daily Living: a performance-based
assessment of everyday problem solving in older
adults, J Appl Gerontol 24(3):211-230, 2005.
16. Diener E: Subjective well-being, Psychol Bull 95:
542-575, 1984.
17. Donald A: What is quality of life? What is…? 1:9,
2003.
18. Drummond AE, Parker CJ, Gladman JR, et al:
Development and validation of the Nottingham lei­
sure questionnaire (NLQ), Clin Rehabil 15(6):647,
2001.
19. Duncan PW, Wallace D, Lai SM, et al: The stroke
impact scale version 2.0: evaluation of reliability,
validity, and sensitivity to change, Stroke 30(10):
2131-2140, 1999.
20. Finlayson M, Havens B, Holm MB, et al: Integrating
a performance-based observation measure of func­
tional status into a population-based longitudinal
study of aging, Can J Aging 22:185-195, 2003.
21. Fisher AG: Assessment of motor and process skills, ed 4,
Fort Collins, Colo, 2001, Three Star Press.
22. Gardarsdottir S, Kaplan S: Validity of the Árnadóttir
OT-ADL Neurobehavioral Evaluation (A-ONE): per­
formance in activities of daily living and neurobe­
havioral impairments of persons with left and right
hemisphere damage, Am J Occup Ther 56(5):499-508,
2002.
23. Giles GM: A neurofunctional approach to reha­
bilitation following severe brain injury. In Katz N,
­editor: Cognition and occupation across the life span,
Bethesda, Md, 2005, AOTA Press.
24. Goverover Y, Josman N: Everyday problem solving
among four groups of individuals with cognitive
impairments: examination of the discriminant valid­
ity of the Observed Tasks of Daily Living-Revised.
Occup Ther J Res 24(3):103-112, 2004.
25. Hahn MG, Baum CM: Improving participation
and quality of life through occupation. In Gillen G,
Burkhardt A, editors: Stroke rehabilitation: a function-
based approach, ed 2, St Louis, 2004, Elsevier/Mosby.
26. Holm MB, Rogers JC: Functional assessment: The
performance assessment of self-care skills (PASS). In
Hemphill BJ, editor: Assessments in occupational ther-
apy mental health: an integrative approach, Thorofare,
NJ, 1999, Slack.
27. Hunt SM, McEwan T: The development of a subjec­
tive health indicator, Soc Health Illness 2:231-246,
1980.
28. Hunt SM, McEwen J, McKenna SP: Measuring health
stats: a new tool for clinicians and epidemiologists,
J Royal Coll Gen Pract 35:185-188, 1985.
29. Katz N: Cognition and occupation across the life span,
Bethesda, Md, 2005, AOTA Press.
30. Katz N, Karpin H, Lak A, et al: Participation and
occupational performance: reliability and validity of
the activity card sort, Occup Ther J Res 23(1):10-17,
2003.
31. Keith RA, Granger CV, Hamilton BB, et al: The func­
tional independence measure: a new tool for reha­
bilitation. In Eisenberg MG, Grzesiak RC, editors:
Advances in clinical rehabilitation, vol 1, New York,
1987, Springer-Verlag.
32. Kloseck M, Crilly RG, Hutchinson-Troyer L:
Measuring therapeutic recreation outcomes in
rehabilitation: further testing of the leisure com­
petence measure, Ther Recreation J 35(1):31-42,
2001.
33. Lai S, Studenski S, Duncan P, et al: Persisting con­
sequences of stroke measured by the stroke impact
scale, Stroke 33(7):1840-1850, 2002.
34. Laver AJ: The Structured Observational Test of
Function, Gerontology Special Interest Section
Newsletter 17(1), 1994.
35. Laver AJ: Clinical reasoning with simple perceptual
impairment. In Unsworth C, editor: Cognitive and
perceptual dysfunction: a clinical reasoning approach
to evaluation and intervention, Philadelphia, 1999,
F.A. Davis.
36. Law M: The Canadian occupational performance
­measure, ed 2, Ottawa, 1994, CAOT Publications ACE.
37. Law M, Baptiste S, Mills J: Client-centered practice:
what does it mean and does it make a difference? Can
J Occup Ther 62(5):250-257, 1995.
38. Law M, Baum C: Measurement in occupational ther­
apy. In Law M, Baum C, Dunn W, editors: Measuring
occupational performance: supporting best practice in
occupational therapy, Thorofare, NJ, 2005, Slack.
39. Law M, Baum C, Dunn W: Measuring occupational
performance: supporting best practice in occupational
therapy, Thorofare, NJ, 2005, Slack.
40. Lawton MP: Instrumental activities of daily liv­
ing scale: self-rated version, Psychopharmacol Bull
24(4):785-787, 1988.
41. Lemiere J, Decruyenaere M, Evers-Kiebooms G, et al:
Cognitive changes in patients with Huntington’s dis­
ease (HD) and asymptomatic carriers of the HD
mutation—a longitudinal follow-up study, J Neurol
251(8):935-942, 2004.
42. Linden A, Boschian K, Eker C, et al: Assessment
of motor and process skills reflects brain-injured
patients’ ability to resume independent living bet­
ter than neuropsychological tests, Acta Neurol Scand
111(1):48-53, 2005
43. Lippert-Gruner M, Kuchta J, Hellmich M, et al:
Neurobehavioural deficits after severe traumatic
brain injury (TBI), Brain Inj 20(6):569-574, 2006.
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 31
44. Mahoney FI, Barthel DW: Functional evaluation: the
Barthel index, Maryland State Med J 14:61-65, 1965.
45. Marinus J, Visser M, Verwey NA, et al: Assessment
of cognition in Parkinson’s disease, Neurology 61(9):
1222-1228, 2003.
46. Mellick D, Walker N, Brooks CA, et al: Incorporating
the cognitive independence domain into CHART,
J Rehabil Outcomes Meas 3(3):12-21, 1999.
47. Neistadt ME: Occupational therapy treatments for con­
structional deficits, Am J Occup Ther 46(2):141-148,
1992.
48. Neistadt ME: Perceptual retraining for adults with
diffuse brain injury, Am J Occup Ther 48(3):225-233,
1994.
49. Peterson DB: International classification of func­
tioning, disability and health: an introduction for
rehabilitation psychologists, Rehabil Psychology
50(2):105-112, 2005.
50. Pollock N: Client-centered assessment, Am J Occup
Ther 47(4):298-301, 1993.
51. Rogers JC, Holm MB: Evaluation of activities of daily
living (ADL) and instrumental activities of daily liv­
ing (IADL). In Crepeau EB, Cohn ES, Schell BAB,
editors: Willard and Spackman’s occupational ther-
apy, ed 10, Philadelphia, 2003, Lippincott Williams &
Wilkins.
52. Schiffer, RB: Cognitive loss. In van den Noort S,
Holland N, editors: Multiple sclerosis in clinical prac-
tice, New York, 1999, Demos Medical Publishing.
53. Schwartz MF, Segal M, Veramonti T, et al: The
Naturalistic Action Test: A standardised assessment
for everyday action impairment, Neuropsychol Rehabil
12(4):311-339, 2002.
54. Toglia J: Generalization of treatment: a multi­
context approach to cognitive perceptual impair­
ment in adults with brain injury, Am J Occup Ther
45(6):505-516, 1991.
55. Toglia J: A dynamic interactional approach to cogni­
tive rehabilitation. In Katz N, editor: Cognition and
occupation across the life span, Bethesda, Md, 2005,
AOTA Press.
56. van den Broek MD: Why does neurorehabilitation
fail? J Head Trauma Rehabil 20(5):464-543, 2005.
57. van Straten A, de Haan RJ, Limburg M, et al:
A stroke-adapted 30-item version of the sickness
impact profile to assess quality of life (SAS-SIP30),
Stroke 28:2155-2161, 1997.
58. Ware JE, Kosinski M, Keller SD: SF-12: how to score
the SF-12 physical and mental health summary scales,
ed 2, Boston, 1995, The Health Institute New England
Medical Center.
59. Ware JE, Sherbourne CD: The MOS 36-item short-
form health survey (SF-36): I. Conceptual framework
and item selection, Med Care 30(6):473-483, 1992.
60. Ware JE, Sherbourne CD, Davies AR: Developing and
testing the MOS 20-item short-form health survey: a
general population application. In Stewart AL, Ware
JE, editors: Measuring functioning and well-being: the
medical outcomes study approach, Durham, NC, 1992,
Duke University Press.
61. Whiteneck GG, Charlifue SW, Gerhart KA, et al:
Quantifying handicap: a new measure of long-term
rehabilitation outcomes, Arch Phys Med Rehabil
73:519-526, 1992.
62. Willer B, Linn R, Allen K: Community integra­
tion and barriers to integration for individuals with
brain injury. In Finlayson MAJ, Garner SH, editors:
Brain injury rehabilitation: clinical considerations,
Baltimore, Md, 1994, Williams & Wilkins.
63. Willer B, Ottenbacher KJ, Coad ML: The community
integration questionnaire: a comparative examina­
tion, Am J Phys Med Rehabil 73:103-111, 1994.
64. Willer B, Rosenthal M, Kreutzer JS, et al: Assessment
of community integration following rehabilitation
for traumatic brain injury, J Head Trauma Rehabil
8:75-87, 1993.
65. Witt PA, Ellis G: Leisure Diagnostic Battery Users
Manual and Scales, 1989, State College, Pennsylvania:
Venture Publishing.
66. Wood-Dauphinee S, Opzoomer MA, Williams J,
et al: Assessment of global function: the reintegra­
tion to normal living index, Arch Phys Med Rehabil
69(8):583-590, 1988.
67. Wood-Dauphinee S, Williams J: Reintegration to
normal living as a proxy to quality of life, J Chronic
Disabil 40(6):491-502, 1987.
68. World Health Organization: International Classification
of Functioning, Disability and Health, Geneva, 2001,
World Health Organization.
 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:
1. Understand the differences between top-down and
bottom-up approaches to assessment and evaluation.
2. Constructively critique the use of pen-and-paper
(tabletop) assessment procedures.
3.  Be able to differentiate among various forms of reli-
ability and validity.
4. Discuss the issue of generalization of clinical inter-
vention strategies to everyday function.
5. Understand the interplay of the environmental con-
text and task performance as it relates to assessment
and interventions.

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

32
 Chapter 2  General Considerations: Evaluations and Interventions 33
standardized instruments (checklists, interviews,
etc.), the therapist obtains information regarding
role competency and meaningfulness as the start-
ing point for evaluation. Roles (e.g., student, vol-
unteer, homemaker, parent, boyfriend, baseball
team member, etc.) that comprised an individu-
al’s life before his or her neurologic event become
the starting point for assessment. Discrepancies
between past and present performance are deter-
mined, and this information is used to guide
treatment.
Once an individual’s roles are defined, the spe-
cific tasks that define a person’s life and those
required to engage in these roles are identified (e.g.,
making a shopping list, managing bills, keeping
score, taking notes, reading a newspaper, respond-
ing to e-mail on a computer) and evaluated by
standardized and nonstandardized direct observa-
tion and self-report methods. If a person cannot
perform a particular task, the level and type of sup-
port required to perform the task is determined.
The reasons that a task cannot be performed are
then determined (e.g., apraxia, memory loss, visuo-
spatial dysfunction). In other words, a connection
is determined between the components of function
and task performance.
In contrast, a bottom-up approach first focuses
on an evaluation of specific cognitive and percep-
tual impairments using standardized assessments
and nonstandardized observations. This is fol-
lowed by an assessment of functional limitations.
Using this approach exclusively makes it difficult to
determine the clinical and functional connection
between the underlying impairments and noted
performance deficits.39
A comprehensive evaluation dictates that a
­clinician must use both top-down and bottom-up
approaches. In general, it is recommended that
the starting point of the evaluation process should
focus on top-down procedures. This allows the
therapist to collect critical information related to the
functional areas that are targeted for change, allows
the individual who is receiving services to under-
stand the focus of interventions and outcomes, and
provides the clinician with ideas related to integrat-
ing functional activities into the intervention plan.
That being said, in many cases it is difficult to differ-
entiate among impairments, thus making treatment
planning difficult. For example, if an individual
is observed to have difficulty identifying or using
objects required to eat a meal independently, it is
necessary to determine if the problem is related to
decreased visual acuity, visual agnosia, ideational
apraxia, or other ­impairments. Determining which
impairment is affecting ­mealtime will further dic-
tate the treatment (e.g., illumination, providing
contrast, and magnification versus using tactile
information to recognize objects, etc.). In these
cases, a bottom-up approach may be used to glean
information related to the presence or absence
and effect of ­ various impairments. See Chapter 1
for infor­mation regarding recommended stan-
dardized assessments (e.g., Árnadóttir OT-ADL
Neurobehavioral Evaluation [A-ONE], Assessment
of Motor and Process Skills [AMPS], Executive
Functions Performance Test, etc.) that simultane-
ously assess functional activities in addition to the
underlying impairments or processing dysfunction
that affects functional performance.
Psychometric Properties of
Measurement Instruments
Although multiple standardized measurement
instruments are available to evaluate those living
with cognitive and perceptual impairments (see
Chapter 1 and all subsequent chapters), it is all too
common for clinicians to use only nonstandard-
ized observations, piecemeal assessments (choos-
ing one or two items from a variety of tests and
combining them for use based on a clinics needs),
nonstandardized procedures to administer a stan-
dardized assessment, or a valid and reliable assess-
ment for a population or diagnostic category for
which the instrument has not been formally tested.
Whereas nonstandardized observations are com-
monly used and may help clinicians determine an
individual’s needs, they must be used in conjunc-
tion with a standardized measure that is both valid
and reliable.
A valid test measures what it was intended to
measure. A reliable test yields consistent results.
A test may reliable and valid, valid or reliable, or
neither valid nor reliable. Box 2-1 reviews types of
validity and reliability.
A particular emphasis should be placed on the
ecologic validity of an instrument. This term refers
to the degree to which the cognitive demands
of the test theoretically resemble the cognitive
demands in the everyday environment, some-
times termed functional cognition. A test with high
ecologic validity identifies difficulty in perform-
ing real-world functional and meaningful tasks.
Ecologic validity also refers to the degree to which
existing tests are empirically related to measures of
everyday functioning via a statistical analysis.11
34 cognitive and perceptual rehabilitation: Optimizing function
Box 2-1 Quick Review of Validity and Reliability
Validity
Face validity: Does the instrument appear to measure
what it’s supposed to measure? Is the content appropri-
ate for the purpose of the instrument? Do the items look
like they test what they are supposed to? Is the test a good
translation of the construct being measured? Determining
face validity depends on intuitive judgment.
Content validity: Usually determined via expert review
and literature reviews, and refers to whether the full con-
tent of a construct’s definition is included or represented
in the measure.
Criterion validity: Is the measure consistent with what we
already know and what we expect? Is the instrument valid
against a known external criterion? Includes two subcatego-
ries of validity: predictive and concurrent.
Predictive validity: Predicts a known association
between the construct you’re measuring and something
else. Determines how someone will do in the future on the
basis of a particular instrument.
Concurrent validity: Associated with preexisting indica-
tors; something that already measures the same concept.
Construct validity: Refers to whether the measure relates
to a variety of other measures as specified in a theory.
Subcategories: discriminant and convergent validity
Discriminant validity: The measure does not associate
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.
Performance-Based Assessment
Compared with Pen-and-Paper or Tabletop
Assessment Procedures
Even after a cursory review of the items included on
assessments that evaluate cognitive and perceptual
impairments after a neurologic event, it becomes
clear that two approaches to assessment are used in
both clinical and research settings. Pen-and-paper
or tabletop assessments most typically include items
that attempt to detect the presence of a particular
impairment (i.e., they are deficit specific). Test items
are usually contrived and nonfunctional tasks such
as copying geometric forms, creating pegboard con-
structions, constructing block designs, matching
picture halves, performing drawing tasks, sequenc-
ing pictures, remembering number strings, per-
forming cancellation tasks, identifying overlapping
figures, completing body puzzles, and so on. It may
be argued that this type of test has low ­ ecologic
validity. Does the ability to sequence a series of
Convergent validity: The measure associates with related
constructs.
Ecologic validity: The degree to which the cognitive demands
of the test theoretically resemble the cognitive demands in
the everyday environment. “Functional cognition” identifies
difficulty in performing real world tasks or the degree to which
existing tests are empirically related to measures of everyday
functioning.
Reliability (Determined Quantitatively)
Interrater/interobserver: Refers to consistent results
between various testers.
Test-retest: Refers to the stability of the test over time. If a
test is administered at two different times without an inter-
vention in between, it should yield the same results.
Parallel forms: Used to assess the consistency of the
results of two forms or versions of a test constructed in the
same way from the same content domain. Parallel forms
are used to control for a testing effect or practice effect;
in other words controlling for participants gaining knowl-
edge from the testing procedure itself, which may influence
outcomes.
Internal consistency: Refers to the extent to which tests
assess the same construct, skill, or quality. Used to assess
the consistency of results across items within a test.
­ icture cards predict the ability to plan, cook, and
p
clean up a family meal? Does failure to accurately
create a three-dimensional block design from a two-
dimensional cue card mean that an individual won’t
be able to dress or bathe independently?
The use of this type of assessment procedure as
the basis for clinical assessment needs to be ques-
tioned if the goal of the cognitive and perceptual
assessment is to determine if or how impairment(s)
will affect functioning in the real world. This type
of assessment does not give enough detail to be able
to predict what kinds of daily life problems will
be encountered or provide information regarding
the nature and frequency of problems.43 Kingstone
and colleagues ask “to what extent does the sim-
ple, impoverished, and highly artificial experi-
mental task…have to do with the many complex,
rich, real life experiences that people share?”22
Particular concerns related to this type of assess-
ment are addressed in the following paragraphs. In
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-
Assessments
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
strings
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).
Transfers
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
those living with stroke, subarachnoid ­hemorrhages,
and head injuries to perform cognitive tasks (spo-
ken word generation, mental calculations, remem-
bering the order of paired words, and visuospatial
tasks) and motor tasks in isolation and then simul-
taneously. The authors documented decrements in
both cognitive and motor function in subjects with
CNS dysfunction during dual task conditions as
compared to performing a single cognitive or motor
task. In other words, evaluating cognitive and motor
function separately (which commonly occurs in the
clinical setting), yields different results as compared
to evaluating these skills simultaneously. When
performed simultaneously, ­ performance may be
degraded.
Lindenberger and colleagues examined the dual
task of memorizing while walking in healthy adults
classified as young (ages 20 to 30 years), middle-aged
(40 to 50 years), and older (60 to 70 years) adults.23
Dual-task costs increased with age in both ­cognitive
and motor function. Specifically, with advancing age,
participants showed greater reductions in memory
accuracy when they were walking.
Similarly Baddeley and associates examined
older adults with cognitive impairment performing
a visual search task and auditory processing task
separately and then simultaneously.5 The authors
documented a similar trend as the previously men-
tioned studies (i.e., older adults had a decreased abil-
ity to perform visual and auditory processing tasks
simultaneously as compared with performing the
tasks separately). This same paper examined single-
task performance of motor task and digit span task
followed by simultaneously dual-task performance.
During dual-task conditions, adults with cognitive
impairments demonstrated decreased performance
on both tasks.
Southwood and Dagenais examined the single-
task versus dual-task performance in adults with
apraxia.34 Single tasks consisted of a manual motor
reaction time task and a voice reaction time task,
followed by dual-task performance. The authors
documented an increase in apraxic errors during
dual-task conditions.
Holtzer and colleagues examined dual-task per-
formance in older adults with cognitive impair-
ments.21 Specifically, they used two sets of tasks that
challenged different perceptual processing skills.
The first set of tasks consisted of a visual cancel-
lation test and an auditory digit span examined
under single and dual task conditions. The sec-
ond set of tasks was composed of a parallel form
of the visual cancellation test and letter fluency.
The authors concluded that those with cognitive
impairment incurred significantly greater dual-task
costs (i.e., degraded performance while performing
both tasks) compared with control groups.
To summarize, in healthy older adults, peo-
ple living with a variety of neurologic diagnoses,
adults with cognitive impairments, and those living
with apraxia, levels of cognitive function decrease
when they are involved in tasks that place demands
on more than one underlying skill. One can argue
that typical daily living tasks such as cooking, driv-
ing, a morning self-care routine, childcare, and so
on are even more demanding than the dual-task
conditions that are examined in highly controlled
research protocols. Therefore clinicians need to
reconsider if the results from a highly controlled
deficit specific (single task) test can be general-
ized to a real-world setting. Holtzer and colleagues
summarized that dual-task measures were accurate
and better than the traditional neuropsychological
measures at discriminating cognitive impairments
from normal controls.21 They further concluded
that dual-task measures can provide additional and
important information regarding cognitive status
that is not available from routinely used standard-
ized neuropsychological measures. In further con-
trast, a performance-based measure that uses daily
living tasks as test items not only increases the eco-
logic validity of the test but also may provide even
more accurate information related to real-life func-
tional performance as compared with the exclusive
use of deficit-specific pen-and-paper tests.
The focus of a tabletop examination is on diag-
nosing the impairment as opposed to determining
the effect of a deficit on a particular living skill as
is the focus of a performance-based test. The diag-
nostic abilities of a pen-and-paper test also may be
questioned.3,4 For example, body puzzles have been
suggested to diagnose the presence of body scheme
disorders. Failure to accurately complete the puzzle
may be caused by a variety of reasons beyond the
loss of a body scheme. Visuospatial impairments,
loss of sustained attention, decreased visual acuity,
decreased arousal, or lack of motivation to engage
in a task that is not meaningful all may contribute to
poor performance. A similar problem involves tests
that detect impairments via two-dimensional test
items, particularly tests of visual perception, and
attempt to provide information related to ­living in
a three-dimensional world.
The previous paragraphs question the assumed
relationship between findings on deficit-specific
 Chapter 2  General Considerations: Evaluations and Interventions 37
novel pen-and-paper tasks and real-world function.
Findings from published empirical research continue
to question this relationship as well. These studies
have attempted to clarify the relationships between
impairments and activity limitations and impair-
ments and participation restrictions. Reviews of the
literature10,24,42 have determined that these relation-
ships are small to moderate, ranging from Pearson
correlations of 0.2 to 0.5, at best. Other specific rela-
tionships that have been examined and determined to
have a limited relationship include impaired execu-
tive functions as tested by deficit-­specific impairment
measures and activity limitations or participation
restrictions,27 as well as poor attention span as assessed
via digit span and tests of everyday attention.19 Finally,
impairment based measures of neuropsychological
function have been found to be generally poor pre-
dictors of vocational functioning in those living with
traumatic brain injury.18
Overall, the ecologic validity of deficit specific test
results has not been well examined. Findings from
this type of assessment may underestimate7 or overes-
timate36 the degree of impairment. Generalizing test
findings to compromised real-world function should
be done with restraint.36 In other words, predicting
real-world function based on a pen-and-paper assess-
ment, if done at all, should be done with extreme
­caution if the particular functional skill in ques-
tion has not been observed by the clinician. Bennett
summarizes that “the ecological validity…can be
extended by observing the patient’s approach to tasks
in the assessment environment and by ­observing the
patient in his or her normal activities.”7
The Influence of the Environment on Functional
Performance and Assessment Outcomes
There is a dynamic interplay between a person, his
or her impairments, task(s) being evaluated, and the
environment in which the evaluation takes place.13
For example, the severity of left spatial neglect and
the presence of extinction (see Chapter 6) is increased
in a situation in which distracters in the right visual
field must be processed.16 Those living with right
brain damage and concurrent attention deficits typi-
cally present with degraded functional performance
in environments that provide increased ­sensory stim-
ulation (e.g., a quiet reading room ­versus a cafeteria).
The relationship between task performance, under-
lying skills, and the environment in which the task
has been ­performed has been empirically tested.
Park and colleagues examined the effect of home
versus clinical settings on the instrumental activi-
ties of daily living (IADL) performance of older
adults.28 Twenty older adults living in the commu-
nity were evaluated in their homes and in an occu-
pational therapy clinic with the Assessment of Motor
and Process Skills (AMPS) (see Chapter 1). The
motor and process ability measures were compared
between the two settings. The authors found that the
subjects’ motor ability measures tended to remain
stable from clinic to home settings, but the process
ability measures tended not to remain stable from
clinic to home settings. The authors concluded that
process skill abilities are affected by the environment
to a greater degree than are motor skill abilities. In
this particular study the familiar home environment
tended to support IADL performance (i.e., improved
performance was noted in familiar home settings).
Gillen and Wasserman examined the effect of
the environment on functional mobility (specifi-
cally the ability to transfer) in individuals with a
central nervous system (CNS) disorder within two
varying environments.17 The two environmental
conditions were a traditional clinic setting, and a
more naturalistic simulated apartment. Overall,
100 transfer observations were objectively mea-
sured using the Functional Independence Measure
(FIM) method. Forty-four percent (44%) of the
participants performed better in the clinic setting;
20% performed better in the simulated apartment.
Analysis of FIM data revealed that 36% of the par-
ticipants transferred consistently in both environ-
ments. However, overall 64% of the participants
were inconsistent in the same transfer task across
the two environments. This research further sup-
ports the concept that the environment affects
functional performance. Performance of activi-
ties of daily living (ADL) and functional mobility
tasks such as transfers may differ across various
environmental contexts.
Brown and coworkers examined 20 people with
severe mental illness on two tasks (making a pur-
chase in a store and using the bus).9 The partici-
pants were evaluated on each task with two methods
of assessment: interview or simulation (using the
Kohlman Evaluation of Living Skills) and observa-
tion in the natural environment. Results demon-
strated inconsistent performance across assessment
approaches and task performance. The research-
ers highlighted the importance of considering the
influence of the environment when evaluating the
complexity of real-world performance. Of particu-
lar concern was a trend toward false positives that
was found when participants were judged indepen-
dent on the standardized assessment but could not
38 cognitive and perceptual rehabilitation: Optimizing function
perform the same tasks in the natural environment.
The authors concluded that clinicians “should be
cautious when making judgments of independence
on the basis of interview and observation of simu-
lated tasks. Evaluating IADL performance in the
persons’ natural environment may provide more
accurate information.”
Sbordone emphasized that the typical assess-
ment environment (a quiet room without environ-
mental distracters) is not the real world. Specific
concerns with a typical testing environment include
the following31:
• The conditions of testing are set up in such a way
as to optimize performance.
• The environment in which testing occurs tends
to be distraction-free.
• The tasks used are highly structured.
• The person administering the test provides clear
and immediate feedback.
• Time demands are minimized.
• Repeated and clarified instructions are used to
optimize performance.
• Problems with task initiation, organization,
and follow-through are minimized as the cli-
Table 2-2 Traditional Classifications of Interventions
Remediation
Also known as a restorative or transfer of training approach
Focused on decreasing the severity of impairment(s)
Focused on the cause of the functional limitation. Assumes
cortical reorganization takes place.
Typically uses deficit specific cognitive and perceptual
retraining activities chosen based on the pattern of
impairment
Examples of interventions: cognitive and perceptual tabletop
“exercises,” parquetry blocks, specialized computer
software programs, cancellation tasks, block designs,
pegboard design copying, puzzles, sequencing cards,
gesture imitation, picture matching, design copying, etc.
Requires the ability to learn and generalize the intervention
strategies to a real-world situation
Assumes that improvement in a particular cognitive-
perceptual activity will “carry over” to functional activities
nician provides multiple cues for task progres-
sion and the tests tend to include discrete items
that are performed one at a time as opposed to a
sequence of events7.
Intervention Overview
General Approaches to Intervention:
Remediation and Compensation or Adaptation
Common interventions for those living with cog-
nitive and perceptual impairments are grossly
classified as those focused on remediation of an
underlying impairment or compensatory or adap-
tive strategies used to function despite the effect of
cognitive perceptual deficits (Table 2-2).
Although describing and critiquing specific
interventions is the focus of the rest of this book, in
general, there is little research in the published lit-
erature that supports the sole use of a remediation
program. Traditionally, the remediation and adap-
tive approaches have been viewed as completely
separate approaches, and clinicians had to make a
decision as to which one to choose when develop-
Adaptation
Also known as a functional approach
Focused on decreasing activity limitations and participation
restrictions
Focused on the symptoms of the problem
Typically uses functional activities chosen based what the
clients receiving services want to do, need to do, or have to
do in their own environment
Examples of interventions: meal preparation, dressing,
generating a shopping list, balancing a checkbook, finding
a number in the phonebook. Environmental adaptations
(e.g., placing all necessary grooming items on the right
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).
A compensatory strategy requires insight to the functional
deficits and accepting that the impairment is relatively
permanent. Environmental modifications do not require
insight or learning on the part of the person receiving
services.
Does not assume that the underlying impairment is even
affected by the intervention
 Chapter 2  General Considerations: Evaluations and Interventions 39
ing an intervention plan. More recently this dichot-
omy has been challenged, with newer approaches
embracing the use of both approaches.1,2 In a study
comparing remedial and compensatory interven-
tions for those living with brain injury, it was found
that 80% of the participants used compensatory
strategies regardless of intervention (remediation
or compensatory). In this study, those who used
these strategies demonstrated better performance
than those who did not.12 Clinicians must also con-
sider that focusing interventions on adaptations or
strategy training does not necessarily mean reme-
diation will not occur.15 Although the remedia-
tion approach assumes that perceptual retraining
activities may affect functional performance (even
though as stated above empirical support for this
relationship is quite weak), engagement in func-
tional activities most likely affects cognitive and
perceptual processing as well.14 An intervention
study for apraxia40 illustrates this point. The focus
of the intervention was a strategy-training approach
to improve functional performance despite the
­presence of apraxia (see Chapter 5). The emphasis
of the intervention was on task performance and
not explicitly focused on improving praxis. The
outcome demonstrated a large effect size related to
improving the performance of functional skills in
addition to a small to moderate effect size related to
measures of apraxia and motor function. Note: the
improvement in functional skills should be consid-
ered the more clinically relevant outcome.
Choosing the appropriate intervention approach
relies on the results of the assessment. Brockmann-
Rubio and Gillen suggest that the following questions
should be answered prior to choosing an approach8:
• Does the person receiving services have the
potential to learn?
• Is he or she aware of errors during task
performance?
• If so, does he or she have the potential to seek
solutions to those errors?
If poor learning potential is exhibited, insight
to deficits do not respond to metacognitive train-
ing (see Chapter 4), and the use of cues and task
performance strategies is not effective or ­consistent,
a strictly functional approach involving task-­specific
training may be recommended. This approach
requires little or no transfer of learning and involves
repetitive performance of a specific functional task
using a system of vanishing cues or cues that are
provided at every step of task performance but then
gradually removed.8 The goal is to maximize task
performance with a minimum number of cues.
A limitation of this approach is that the success of
performing a skill is dependent on approaching the
task exactly the same way in the same environment
each time.
Abreu and colleagues proposed an integrated
functional approach to treatment in which princi-
ples from both remediation and adaptive approaches
are used simultaneously.2 In this approach, mean-
ingful and functional activities challenge underly-
ing cognitive and perceptual impairments. With this
integrated functional approach, interventions may
be focused on a specific impairment such as sus-
tained attention, but relevant tasks are used as the
modality to affect change. Brockmann-Rubio and
Gillen use the example of self-feeding as a task that
may improve sustained attention to task.8 Mealtime
is often distracting. Eating can be a difficult task if
attention deficits are present. A system of vanish-
ing cues and a gradual increase in the amount of
environmental distraction can address inattention
to task and activity participation. Most functional
tasks can address multiple impairments. A detailed
task analysis is required when evaluating an activity
for its effectiveness in addressing particular cogni-
tive or perceptual deficits (Box 2-2 and Figure 2-1).
Issues Regarding Generalization of Task
Performance and Strategy Training
One of the biggest challenges to providing interven-
tions to this population is the issue of generalizing
or transfer of what is learned in therapy sessions to
other real-world situations. Examples include gen-
eralizing the skills learned on an inpatient rehabili-
tation unit related to meal preparation to making a
meal at home upon discharge, ­generalizing a scan-
ning strategy used to read a newspaper article to
­locating an item of clothing in a closet, and gen-
eralizing tactile feedback to identify objects on a
meal tray to using this strategy when shopping for
grooming items. The consistent perspective on the
idea of generalization is that it will not occur spon-
taneously but instead needs to be addressed explic-
itly in an intervention plan.26,33,37,38
Suggestions have been made in the literature to
enhance generalization of cognitive and perceptual
rehabilitation techniques.
• Avoid repetitively teaching the same activity in
the same environment.37,38 Consistently practic-
ing bed mobility and wheelchair transfers in a
person’s hospital room does not guarantee that
the skill will generalize to the ability to transfer
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
Positioning of toothbrush and toothpaste while applying
paste to toothbrush
Placement of toothbrush in mouth
Positioning of bristles in mouth
Placement of toothbrush under faucet
Spatial Neglect
Visual search for and use of toothbrush, toothpaste, and
cup in affected hemisphere
Visual search and use of faucet handle in affected
hemisphere
Body Neglect
Brushing of affected side of mouth
Motor Apraxia
Manipulation of toothbrush during task performance
Manipulation of cap from toothpaste
Squeezing toothpaste onto toothbrush
Ideational Apraxia
Appropriate use of objects (toothbrush, toothpaste, cup)
during task
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
For example, if the “lighthouse strategy”(see
Chapter 6) is successful during the treatment of
an individual with spatial neglect to accurately
read an 8½ by 11–inch menu, the same strategy
should consistently and progressively ­ practiced
to read a newspaper, followed by ­ reading the
labels on spices in a spice rack, followed by
a street sign, and so on.
• Practice the same task and strategies in multiple
natural environments.37,38 Practice of organized
visual scanning for an inpatient should be done
in the therapy clinic, in the person’s hospital
room, in the facility’s lobby and gift shop, in the
therapist’s office, and so on.
• Include metacognitive training in the interven-
tion plan to improve awareness (see Chapter 4).
Toglia has identified a continuum related to the
transfer of learning and emphasizes that general-
ization is not an all-or-none phenomenon.37,38 She
­discusses grading tasks to promote generalization
Organization and Sequencing
Sequencing of task (removal of cap, application of tooth-
paste to toothbrush, turning on water, and putting tooth-
brush in mouth)
Continuing task to completion
Attention
Attention to task (for greater difficulty, distractions such as
conversation, flushing toilet, or running water may be
added)
Refocus on task after distraction
Figure-Ground
Distinguishing white toothbrush and toothpaste from sink
Initiation and Perseverance
Initiation of task on command
Cleaning parts of mouth for appropriate period of time and
then moving bristles to another part of mouth
Discontinuation of task when complete
Visual Agnosia
Use of touch to identify objects
Problem Solving
Search for alternatives if toothpaste or toothbrush is
missing
of learning from those that are very similar to those
that are very different. Toglia’s criteria for transfer
include the following37,38:
• Near transfer: Only one or two of the character-
istics are changed from the originally practiced
task. The tasks are similar. Toglia gives the exam-
ple of making coffee as compared with making
hot chocolate or lemonade.38
• Intermediate transfer: Three to six characteristics
are changed from the original task. The tasks are
somewhat similar, such as making coffee as com-
pared with making oatmeal.
• Far transfer: The tasks are conceptually ­ similar
but share only one similarity. The tasks are
­different, such as making coffee as compared
with making a sandwich.
• Very far transfer: The tasks are very different,
such as making coffee as compared with setting
a table.
Neistadt has suggested, based on her research and
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
transfers of learning are candidates for the reme-
dial approach to cognitive and perceptual reha-
bilitation.26 But she suggests that those who are
only capable of near and intermediate transfers of
learning are candidates for the adaptive approach
as described earlier. Similarly, near transfers seem
to be possible for all individuals regardless of sever-
ity of brain damage, whereas intermediate, far, and
very far transfers may be possible only for those
with localized brain lesions, preserved abstract
thinking, and with those who have been ­explicitly
taught to generalize.25 Although these statements
should continue to be tested empirically, they
give clinicians guidelines related to intervention
planning.
Evidence-Based Practice and Levels of Evidence
In the recent past, many of the interventions com-
monly used with this population were anecdotal
in nature only. For instance, the transfer of train-
ing approach (as described earlier) was consistently
recommended and applied in clinic settings despite
there being little evidence to support its use, par-
ticularly related to the effect it has on daily perfor-
mance. Fortunately, a recent focus on evidence-based
­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
the rest of this text). Evidence-based practice can be
defined as “the conscientious, explicit, and judicious
use of current best evidence in making decisions
about the care of individual patients. The practice of
evidence-based medicine means integrating individ-
ual clinical expertise with the best available ­external
clinical evidence from systematic research.”30
When interpreting research that has examined
various interventions, it important to understand
that there are different levels of evidence. Sackett
outlined the following levels of evidence to rank
research articles30:
• Level I: Large randomized controlled trials
(RCTs) with low false positives.
• Level II: Small RCTs with high false positives.
• Level III: Nonrandomized concurrent cohort
comparisons between subjects that did and did
not receive intervention.
• Level IV: Nonrandomized historical cohort
comparisons between current subjects who did
receive intervention with former subjects who
did not.
• Level V: Case series without controls.
Another consideration when reviewing the
­evidence related to cognitive and perceptual reha-
bilitation interventions is related to the type of
outcome measure. Three categories of assessments
with varying levels of ecological validity have been
utilized in the published empirical research:
• Impairment based measures composed of
contrived tabletop or pen and paper tasks.
Examples include cancellation tasks, draw-
ing tasks, block designs, memorizing number
strings, etc. (See Chapter 1.)
• Simulated activity performance measures such
as the Baking Tray Task and the Behavioral
Inattention Test. (See Chapter 6.)
• Sructured observations of tasks in con-
text such as the A-ONE and the AMPS (see
Chapter 1) and the Catherine Bergego Scale
(see Chapter 6).
The majority of studies that have been ­published
have only examined changes at the impairment
level (e.g., improved ability to perform a cancella-
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-
not be generalized to the activity or participation
and quality-of-life levels of function. Future clinical
trials related to this area of practice should consider
measures across the levels of function to confirm if
on outcomes that objectify a meaningful decrease in
activity limitations and participation restrictions as
well as document an improvement in quality of life.
Considerations Related to Aphasia
The presence of language impairments (particu-
larly receptive language deficits) results in consistent
problems related to both assessment and interven-
tions for this population. Problems particularly arise
when novel tasks are used to asses impairments and
when novel and contrived tasks are used for attempts
at remediation. Consistent with the previous para-
graphs, both assessment and interventions should
be consistent of meaningful and familiar tasks per-
formed in context. This approach will begin to con-
trol for aphasia by decreasing the need to verbally
explain the task at hand. For example, an attention
task that requires the person to cancel or cross out
the letter “R” on a sheet of paper requires a verbal or
written explanation because of its novelty. Another
approach is to use morning grooming tasks at the
sink followed by observation during breakfast to
ascertain levels of attention. If the tasks are provided
at the correct time of day and the person’s own
grooming items are used, the task “speaks for itself ”
and the need for verbal explanation is decreased.
Review Questions
1. What factors are examined to determine if an
assessment has high ecologic validity?
2. What are three interventions that promote gen-
eralization of a strategy used to improve basic
ADL for someone living with unilateral neglect
in the clinic to a home environment?
3. What is the sequence of evaluation when using a
top-down approach versus a bottom-up approach
to assessment?
4. How does the dual-task paradigm apply to
assessment of those living with cognitive and
perceptual impairments?
5. What are three concerns related to the exclusive
use of tabletop assessments to form functional
goals?
References
1. Abreu BC, Peloquin SM: The quadraphonic
approach: a holistic rehabilitation model for brain
injury. In Katz N, editor: Cognition and occupation
across the life span, Bethesda, Md, 2005, AOTA Press.
 Chapter 2  General Considerations: Evaluations and Interventions 43
2. Abreu B, et al: Occupational performance and the
functional approach. In Royeen CB, editor: AOTA self-
study series: cognitive rehabilitation, Rockville, Md,
1994, American Occupational Therapy Association.
3. Árnadóttir G: The brain and behavior: assessing cor-
tical dysfunction through activities of daily living,
St Louis, 1990, Mosby.
4. 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.
5. Baddeley AD, Baddeley HA, Bucks RS, et al:
Attentional control in Alzheimer’s disease, Brain Inj
24:1492-1508, 2001.
6. Beilock SL, Wierenga SA, Carr TH: Expertise, atten-
tion, and memory in sensorimotor skill execution:
impact of novel task constraints on dual task per-
formance and episodic memory, Q J Exp Psychol A
55(4):1211-1240, 2002.
7. Bennett TL: Neuropsychological evaluation in reha-
bilitation planning and evaluation of functional
skills, Arch Clin Neuropsychol 16:237-253, 2001.
8. 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, St Louis, 2004, Elsevier
Science/Mosby.
9. Brown C, Moore WP, Hemman D, Yunek A: Influence
of instrumental activities of daily living assessment
method on judgments of independence, Am J Occup
Ther 50(3):202-206, 1996.
10. Burgess PW, Alderman N, Evans J, et al: The ecologi-
cal validity of tests of executive function. J Clin Exp
Neuropsychol 4:547-558, 1998.
11. 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.
12. Dirette DK, Hinojosa J: The effects of a compensa-
tory intervention on processing deficits of adults
with acquired brain injuries. Occup Ther J Res 19(4):
223-240, 1999.
13. Dunn W, Brown C, McGuigan A: The ecology of
human performance: a framework for thought and
action, Am J Occup Ther 48(7):595-607, 1994.
14. Edmans JA, Webster J, Lincoln NB: A comparison
of two approaches in the treatment of perceptual
problems after stroke, Clin Rehabil 14(3):230-243,
2000.
15. Fisher AG: Assessment of motor and process skills, ed 4,
Fort Collins, Colo, 2001, Three Star Press.
16. Geeraerts S, Lafosse C, Vandenbussche E, et al: A psy-
chophysical study of visual extinction: ipsilesional
distractor interference with contralesional orien-
tation thresholds in visual hemineglect patients,
Neuropsychologia 43(4):530-541, 2005.
17. Gillen, G, Wasserman M: Mobility: examining the
impact of the environment on transfer performance,
Phys Occup Ther Ger 22:21, 2004.
18. Griffin SL: Ecological validity of neuropsychological
assessment in severe traumatic brain injury, Dissert
Abstr Intl 62:8-B, 2002.
19. Groth-Marnat G, Baker S: Digit span as a measure
of everyday attention: a study of ecological validity,
Percept Mot Skills 97(3 Pt 2):1209-1218, 2003.
20. Haggard P, Cockburn J, Cock J, et al: Interference
between gait and cognitive tasks in a rehabilitating
neurological population, J Neurol Neurosurg Psychol
69:479-486, 2000.
21. Holtzer R, Burright RG, Donovivk PJ: The sensitivity
of dual task performance to cognitive status in aging,
J Int Neuropsychol Soc 10:230-238, 2004.
22. Kingstone A, Smilek D, Birmingham E, et al:
Cognitive ethology: giving real life to attention
research. In Duncan J, Phillips L, McLeod P, edi-
tors: Measuring the mind: speed, control & age. 2005,
Oxford University Press.
23. Lindenberger U, Marsike M, Baltes PB: Memorizing
while walking: increase in dual task costs from young
adulthood to old age, Psych Aging 15:417-436, 2000.
24. Manchester D, Priestly N, Jackson H: The assessment
of executive functions: coming out of the office,
Brain Inj 18(11):1067-1081, 2004.
25. Neistadt ME: Perceptual retraining for adults with
diffuse brain injury, Am J Occup Ther 48:225, 1994.
26. Neistadt ME: The neurobiology of learning: implica-
tions for treatment of adults with brain injury, Am J
Occup Ther 48:421, 1994.
27. Odhuba RA, van den Broek MD, Johns LC: Ecological
validity of measures of executive functioning, Br J
Clin Psychol 44(2):269-278, 2005.
28. Park S, Fisher AG, & Velozo CA: Using the assessment
of motor and process skills to compare occupational
performance between clinic and home settings, Am J
Occup Ther 48:687-709, 1994.
29. Sabari J: Activity based intervention in stroke
­rehabilitation. In Gillen G, Burkhardt A, editors:
Stroke rehabilitation: a function-based approach,
ed 2, St Louis, 2004, Elsevier/Mosby.
30. Sackett DL: Clinical epidemiology: a basic science for
clinical medicine, ed 2, Boston, 1991, Little Brown.
31. Sbordone RJ: Limitations of neuropsychological
testing to predict the cognitive and behavioral func-
tioning of persons with brain injury in real world set-
tings, Neurorehabil 16:199-201, 2002.
32. Schwartz MF, Segal M, Veramonti T, et al: The
Naturalistic Action Test: A standardised assessment
for everyday action impairment. Neuropsychological
Rehabil 12(4):311-339, 2002.
33. Sohlberg MM, Mateer CA: Cognitive rehabilitation:
an integrative neuropsychological approach, New York,
2001, Guilford Press.
44 cognitive and perceptual rehabilitation: Optimizing function
34. Southwood MH, Dagenais P: The role of attention in
apraxic errors, Clin Ling Phonetics 15:113-116, 2001.
35. Sunderland A, Walker CM, Walker MF: Action errors
and dressing disability after stroke: an ecological
approach to neuropsychological assessment and inter­
vention. Neuropsychological Rehabil 16(6):666-683,
2006.
36. Therapeutics and Technology Assessment Sub­
committee. Assessment: neuropsychological testing
of adults: considerations for neurologists, Arch Clin
Neuropsychol 16(3):255-269, 2001.
37. Toglia J: Generalization of treatment: a multicontext
approach to cognitive perceptual impairment in adults
with brain injury, Am J Occup Ther 45(6):505-516,
1991.
38. Toglia J: A dynamic interactional approach to cogni-
tive rehabilitation. In Katz N, editor: Cognition and
occupation across the life span, Bethesda, Md, 2005,
AOTA Press.
39. Trombly CA: Anticipating the future: assessment of
occupational function, Am J Occup Ther 47(3):253-257,
1993.
40. 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.
41. van Heugten C, Dekker J, Deelman B, et al: Measuring
disabilities in stroke patients with apraxia: A validity
study of an observational method, Neuropsychological
Rehabil 10(4):401-414, 2000.
42. Williams JM: A practical model of everyday assess-
ment. In Sbordone R, Long CJ, editors: Ecological
validity of neuropsychological testing, Delray, Fla,
1997, St Lucie Press.
43. Wilson BA: Ecological validity of neuropsychological
assessment: Do neuropsychological indexes predict
performance in everyday activities? Appl Preventive
Psychol 2(4):209-215, 1993.
 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:
1. Understand how visual information is processed by
the central nervous system.
2. Understand how everyday living is affected if visual
and spatial impairments are present.
3. Be aware of procedures to perform a visual screen-
ing after a brain injury.
4. Implement at least five intervention strategies
focused on decreasing activity limitations and par-
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
Functional Activities
The visual system is commonly impaired after brain
damage. Typical visual impairments include visual
field deficits, loss of ocular alignment or control,
diplopia, and changes in visual acuity.2,47 Further
complex impairments include spatial relations
impairments as is discussed later, visual agnosia
(see Chapter 7), neglect of visual information con-
tralateral to the brain injury (see Chapter 6), and so
pation in daily activities, visual information must
be correctly received and recognized.
The ultimate function of visual processing is to
support participation in daily activities via appro-
priate motor and/or cognitive response. There
exists a relationship between visual impairments
after acquired brain damage and difficulties with
activities of daily living (ADLs), increased risk of
falls, and poor rehabilitation outcome.17 Visual pro-
cessing involves a complex system of peripheral

45
46 cognitive and perceptual rehabilitation: Optimizing function

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

Visual field
Right visual Left visual
hemifield hemifield

Nasal
hemiretina
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
A
Superior optic
Visual radiation
association
cortex

Primary visual Central Inferior Visual

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

Defects in
visual field of
Left eye Right eye

1
Left Right

1 2
2 Optic nerve
Optic chiasm
3 Optic
tract 3
4

4
Optic Lateral
radiation geniculate
body
5 5

6
6

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-
forming a functional activity can be attributed to one
or several underlying impairments that must be differ-
entiated. A person who is having difficulty searching
for paperclips in a cluttered drawer may be present-
ing with poor visual acuity (a decrease in the clarity
of vision) versus living with figure-ground impair-
ment (the inability to differentiate foreground from
background), necessitating visual acuity testing prior
to developing an intervention plan. Similarly, a per-
son who misses the glass when pouring juice from a
container may be presenting with a spatial relations
impairment related to judging depth or distance versus
living with diplopia (double-vision) versus living with
monocular vision (information is only obtained via
one eye). Finally, not being able to identify an object on
a bathroom sink by vision alone may be an issue related
to decreased visual acuity versus living with a figure-
ground impairment (e.g., not able to identify a white
bar of soap on a white sink) versus living with poor
contrast sensitivity versus not recognizing the visual
information received by the cortex (visual agnosia).
 Chapter 3  Managing Visuospatial Impairments to Optimize Function 49
A correlation study of adults receiving occupa-
tional therapy who sustained a stroke examined the
relationship between basic visual functions (defined
as acuity, visual field deficits, oculomotor skills, and
visual attention or scanning) and higher level visual-
perceptual processing skills such as visual closure and
figure-ground discrimination. The study suggested
that a positive relation exists (r = 0.75) between basic
visual functions and visual-perceptual processing
Box 3-1 Components of a Vision Screening
The following is a description of vision screening processes,
which should be administered in a well-illuminated room
free of glare and reflection.
1. Distance Visual Acuity
Equipment: Distance acuity chart (Snellen chart),
occluder or eyepatch, 20-foot measure
Setup: Fixate distance acuity chart on a well-lighted wall
at client’s eye level 20 feet away.
Procedure: Cover the client’s left eye with occluder or
patch. Ask the client to identify letters on the 20/40
line. If the client appears confused by the lines and
letters, cover all other lines on the chart and expose
only the line being used. If necessary, expose only
one letter at a time. If the client continues to have
problems, attempt to test visual acuity using the Lea
Symbols Test. Continue until the individual misses
more than 50% of the letters on a line. Cover the
client’s right eye with occluder or patch and repeat
the steps. Record acuity as last line in which the
individual can successfully identify more than 50%
of the letters.
Functional implications: If visual acuity is poorer than
20/40 or if a two-line difference or more is evident
between the two eyes, a referral is necessary and
corrective lenses may need to be prescribed.
2. Near/Reading Visual Acuity
Equipment: Near acuity chart, occluder or eyepatch,
16-inch measure.
Setup: Hold a near acuity chart in a well-lit room
16 inches away.
Procedure: The test card is held 16 inches from the
person being tested. The test is performed with the
client wearing his or her corrective lenses if they are
normally used. Binocular vision is tested. The small-
est size able to be read correctly is recorded.
Functional implications: The results of the test will give
an idea of the detail that can be discriminated. Near
tasks include craft and leisure activities, personal
care and hygiene, some work tasks, and reading.
skills. The authors further concluded that the results
suggest that evaluation of visual-perceptual process-
ing skills must begin with assessment of basic visual
functions so that the influence of these basic visual
functions on performance in more complex tests
can be taken into consideration.47 Therefore it is rec-
ommended that a visual screening occur prior to or
in conjunction with a full cognitive and perceptual
evaluation (Box 3-1). Examples of components of a
3. Ocular Mobility
Equipment: Penlight
Setup: Have client sit facing therapist. Penlight should
be approximately 12 inches from the eyes. Do not
shine the light directly into the eyes; instead direct
the light so that it is pointing slightly above eye level
at the brow.
Procedure: Ask the client to follow the penlight and move
it in a large H pattern to the extremes of gaze. Then
move the penlight in a large O pattern. Allow the client
to fixate on the light for 10 seconds before moving it.
Functional implications: Observation of pursuits
should be smooth and precise without anticipating
responses. Note visual fatigue or stress and whether
the client reports diplopia (double vision). Observe
whether the client looks away, loses the target, or
squints or blinks excessively. Inability to attend to
visual tasks, difficulty reading or completing writing
tasks, and problems with spatial orientation during
walking may be displayed.
4. Near Point of Convergence
Equipment: Penlight and ruler
Setup: Practice this procedure on a partner to deter-
mine when the penlight is positioned at 2, 4, and 6
inches from an individual’s eyes.
Procedure: Slowly move the penlight toward the client
at eye level and between the eyes, making sure not
to shine the light in the eyes. Ask the client to keep
the eyes on the light and state when two lights are
seen. After this occurs, move the light another inch
or two closer and then begin to move it away. Ask
the client to state when only one light is seen. Watch
the eyes carefully and observe whether they stop
working together as a team—one eye may drift out-
ward. Record the distance at which the client reports
double vision and the recovery to single vision.
Functional implications: Double vision should occur
within 2 to 4 inches of the eyes. A recovery to single
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
eyestrain.
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-
strabismus.
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
Procedure:
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  
the examiner and client are at the same level.
  Test each eye individually, being careful to patch
the other eye. Examiner two closes one eye and
instructs the client to “fixate and keep looking at my
open eye. Examiner one will be showing you one
or more fingers very quickly. Don’t try to look at the
fingers. Keep looking at my open eye and when you
see a finger or fingers, tell me how many you see.”
Examiner one presents one or two fingers
randomly for a 1-second duration to each quadrant
of the visual field of the client’s unpatched eye.
The fingers in the upper quadrant point down, and
those in the lower quadrant point up. The fingers
are presented 18 inches from the client and at
approximately 20 degrees from the line of fixation.

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
field testing, ocular range of motion or control, ocu-
lar alignment, contrast sensitivity, and the like. These
skills are often considered the foundation skills for
visual processing.2,53,54
Specific visuomotor abilities that should be
assessed include the following:
• Fixation: The ability to steadily and accurately
gaze at an object of regard (e.g., examining the
detail of a painting in a museum).
• Pursuits: The ability to smoothly and accurately
track or follow a moving object (e.g., watching
your dog run through the yard).
• Saccades: The ability to quickly and accurately
look or scan from one object to another (e.g.,
reading or watching a soccer game and trying to
locate a certain player).
• Accommodation: The ability to accurately focus
on an object of regard, sustain focusing of the
eyes, and change focusing when looking at dif-
ferent distances (e.g., maintaining focus when
you look from up from a textbook to a clock and
back to the textbook).
• Vergence: The ability to accurately aim the eyes
at an object of regard and to track an object as
it moves toward and away from the person (e.g.,
watching people walking toward you [conver-
gence] and away from you [divergence] in the
mall).
The Brain Injury Visual Assessment Battery
for Adults (biVABA)55 is an example of a battery
that includes standardized assessments for evalu-
ation of the visual functions important in ensur-
ing that visual perceptual processing is accurately
completed:
• Visual acuity (distant and reading)
• Contrast sensitivity function
• Visual field
• Oculomotor function
• Visual attention and scanning
Managing Visual Acuity Impairments
Assessment of visual acuity has been described in
Box 3-1. Visual acuity refers to clarity and sharp-
ness of sight. It is commonly measured using the
Snellen chart (or text cards for near acuity) and
noted, for example, as 20/20, 20/60, 20/200, and
so on. Modifications such as using picture charts
or a “tumbling E” chart are available for those
with aphasia. A visual acuity of 20/20 means that
a person can see detail from 20 feet away the same
as a person with normal eyesight would see from
the same distance. If a person has a visual acuity
of 20/60, that person is said to see detail from 20
feet away the same as a person with normal eye-
sight would see it from 60 feet away. Visual acuity
becomes impaired in various refractive conditions
(i.e., impaired focusing of the image on the retina),
the most typical being myopia (nearsighted), hyper-
opia (farsighted), astigmatism (mixed), and pres-
byopia (age-related decrease in acuity).2 Chia and
associates9 found that noncorrectable visual acuity
impairment (defined as acuity less than 20/40) was
associated with reduced functional status and well-
being as measured by the Medical Outcomes Study
Short Form-36 (SF-36) (a measure of quality of life,
see Chapter 1). Tsai and colleagues51 documented a
relationship between poor visual acuity and depres-
sion using the Geriatric Depression Scale. Visual
52 cognitive and perceptual rehabilitation: Optimizing function
impairment was specifically associated with feelings
of worthlessness and hopelessness.
A decrease in visual acuity can result in multi-
ple difficulties in all functional domains. Examples
include difficulty reading labels on pill bottles, doing
crosswords, unsafe driving, increased fall risk, and
so on. A focus on this impairment is warranted to
improve participation in daily activities. In general if
visual acuity is worse than 20/40, a referral to an eye
care specialist is warranted for evaluation of prescrip-
tive lenses.2 Other interventions are in line with low-
vision rehabilitation techniques. They are pragmatic
yet effective and have been outlined by Warren56:
• Increase illumination: In general increasing the
amount of light can improve function. Particular
attention should be placed on areas of high risk,
where activities requiring precision are per-
formed such as cooking, sorting pills into a pill
box, and needlework. Task-specific lighting is
recommended. Warren warns a about maintain-
ing the balance between increasing the amount
and intensity of illumination while not increas-
ing glare and recommends halogen, fluorescent,
and full-spectrum lights to eliminate casting
shadows.
• Increase contrast: Specifically background col-
ors that contrast with objects used for function.
Examples are purchasing colored soap to place
on a white sink, using dark placemats and white
dishes, and placing strips of colored tape on the
edge of steps.
• Decrease background pattern: Increased patterns
on household objects can further increase the
difficulty of finding necessary objects. For exam-
ple, finding a white sock on a patchwork quilt is
much more difficult than finding the same sock
on a solid colored bedspread.
• Decrease clutter and organize the environment:
A focus should be placed on a having necessary
objects placed out neatly and not overlapping.
• Increase size: Commercially available magnifica-
tion devices, labeling with bold markers, reprint-
ing instructions or daily planners in larger fonts,
changing personal computer settings to a larger
font are just a few example of this intervention.
Managing Visual Field Deficits with
an Emphasis on Hemianopsia
The visual fields extend approximately 65 degrees
upward, 75 degrees downward, 60 degrees inward,
and 95 degrees outward when the eye is in the for-
ward position.15 Aloisio2 summarizes that:
• The visual fields are essential areas of the visual
system that allow the individual to orient effec-
tively to stimuli in specific areas of space.
• In terms of function, they are used when ­driving,
walking, reading, eating, and in all daily living
skills.
• In terms of impairment, inferior field loss causes
difficulty with mobility, including poor balance,
tendency to trail behind others when walking,
walking next to walls and touching them for bal-
ance, trouble seeing steps or curbs, shortened
and uncertain stride while walking, and trouble
identifying visual landmarks. In addition, supe-
rior field deficit causes difficulty in seeing signs,
reading and writing; misreading of words, poor
accuracy, slow reading rate, inability to follow
lines of text, and inaccurate check writing are
additional difficulties.
Hemianopsia, or hemianopia or hemiopia,
means “half-blindness” or a loss of half the fields
of vision in both eyes.38 Homonymous visual field
impairments are seen frequently in the clinic after
an acquired brain injury. Thirty percent of all cli-
ents with stroke and 70% of those with a stroke
involving the posterior cerebral artery present
with hemianopsia. In addition, those with sub-
arachnoid hemorrhages, intracerebral bleeds, and
head trauma also commonly present with this
impairment.34
Zhang and coworkers60 examined the medi-
cal records of more than 900 people present-
ing with visual field loss. The authors found that
37.6% were complete homonymous hemianopsias,
whereas 62.4% were incomplete. Homonymous
quadrantanopsia (29%) was the most common
type of incomplete hemianopsia, followed by
homonymous scotomatous defects (13.5%), par-
tial homonymous hemianopsia (13%), and hom-
onymous hemianopsia with macular sparing
(7%). The causes of homonymous hemianopsias
included stroke (69.6%), head trauma (13.6%),
tumor (11.3%), after brain surgery (2.4%), demy-
elination (1.4%), other rare causes (1.4%), and
unknown etiology (0.2%). The authors found
that the lesions were most commonly located in
the occipital lobes (45%) and the optic radiations
(32.2%). Almost every type of hemianopsia was
found in all lesion locations along the retrochias-
mal visual pathways.
The amount and distribution of visual field loss
(nasal, temporal, inferior, superior, homonymous,
etc.) depends on the location of the lesion. If the
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
will be that of monocular visual loss. Damage to the
optic tract will result in contralateral hemianopsia.
If damage occurs posterior to the lateral genicu-
late body, the typical presentation is that of either
quadrantanopsia or hemianopsia depending on the
lesion site (see Figure 3-3). Although the character-
istics of visual field defects can be helpful in lesion
location, specific visual field defects do not always
indicate specific brain locations.60
Zihl62 summarized that those living with hemi-
anopsia cannot process visual information as com­
pared with those with intact visual fields. Specifically,
they demonstrate numerous visual refixations, have
inaccurate saccades and disorganized scanning,
require longer visual search times, and omit relevant
objects in the environment. In addition, they focus on
their intact hemifield; their saccades are less regular,
less accurate, and too small to allow rapid, organized
scanning or reading.35 The majority of basic and
instrumental activities of daily living (IADL) have
the potential to be adversely affected without proper
intervention. Reading may be particularly problem-
atic. For example, in those living with a complete
right homonymous hemianopsia, rightward sac-
cades during text reading are disrupted (“hemianop-
sic alexia”), which disrupts the motor preparation of
reading saccades during text reading.25
In terms of recovery, Zhang and coworkers59 lon-
gitudinally followed 254 clients with homonymous
hemianopsia secondary to a variety of brain lesions.
The authors documented spontaneous visual field
deficit recovery in less than 40% of the cases. They
also noted that the likelihood of spontaneous recov-
ery decreased with increasing time from injury to
initial visual field testing (p = 0.0003). The prob-
ability of improvement was related to the time since
injury (p = 0.0003) with a 50% to 60% chance of
improvement for cases tested within 1 month after
injury. This chance for improvement decreased to
about 20% for cases tested at 6 months after sur-
gery. In most cases, the improvements occurred
within the first 3 months after injury. The authors
warned that spontaneous improvement after 6
months should be interpreted with caution because
it may be secondary to improvement of the disease
or to improvement in the client’s ability to perform
visual field testing reliably. They recommended that
visual field rehabilitation strategies should most
likely be initiated early after injury.
The most objective test for mapping the
available field is perimetry. This automated test is
usually conducted while the person being tested
is seated and looking straight ahead at a central
target. The person is instructed to press a buzzer
when he or she becomes aware of a small light
within the visual field. The accuracy of the test
depends on the person’s being alert and able to
concentrate on the central target. The results from
this test are printed out by the computer, objectively
mapping blind spots in the visual field. A screening
technique that grossly measures the visual fields is
a confrontation test, which is described in Box 3-1.
Although it is common for hemianopsia to occur
in conjunction with neglect, there exists a double
dissociation between the two impairments—each
can occur separately or coexist (see Chapter 6). As
compared with those living with neglect, awareness
of visual filed deficits tends to be better. Nonetheless,
clients may benefit from awareness training to
make connections between how this impairment
will affect a variety of functional activities as well as
understand the importance of compensating for it
(see Chapter 4).
Several interventions are available to those living
with visual field loss. The methods are compensa-
tory in nature. These methods include learning ocu-
lomotor compensation strategies, strengthening the
person’s attention to the blind hemifield, improv-
ing the ability to direct gaze movements toward the
involved side, exploring the involved side more effi-
ciently, improving saccadic exploration toward the
blind hemifield, using prisms, and so on.*
Some of the most useful approaches to the treat-
ment of hemianopsia are based on compensating
for visual field loss by oculomotor compensation.
This training involves psychophysical techniques
aimed at strengthening the client’s attention to
the blind hemifield and improving their ability to
explore the visual field with saccadic movement.6
Kerkhoff18 suggests three types of saccadic train-
ing: train people to make broader searches (“visual
search field”) in the blind hemifield, train people to
make large-scale eye movements toward the blind
hemifield, and train people to make small-scale eye
movements with the goal of improving reading.
In terms of specifically training reading, the
minimum visual field that is required for reading is
2 degrees to the left and right of fixation. This is the
area where the text is seen clearly and covers 10 to 12
letters of print at a distance of 25 cm. For fluent read-
ing, the visual span must be extended in the reading
direction up to 5 degrees or 15 letters. People with
hemianopsia need a minimum of 5 degrees to both
*References 18, 34, 35, 56, 61, 62.
54 cognitive and perceptual rehabilitation: Optimizing function
sides of fixation to read normally. Less than that
amount affects people differently based on whether
they are living with a right or a left hemianopsia.
Less than 5 degrees preempts proper reading of a
given line of text by those with right hemianopia
and decreases the ability to locate the beginning of
the next line of text by those with left hemianop-
sia.48–50 Those with right hemianopsia tend to per-
form worse on reading tasks and take longer to
respond to treatment. Pambakian and Kennard35
suggest teaching to perceive each word as a whole
before reading it. They specifically suggest that those
with left hemianopsia should shift their gaze first to
the beginning of the line and the first letter of every
word in that line. In contrast, those with right-sided
hemianopsia are discouraged to read a word before
they have shifted their gaze to the end of it. Wang57
reported the case of a 65-year-old woman who pre-
sented with a right homonymous hemianopsia sec-
ondary to a left occipital lobe tumor. She was most
concerned about her inability to read sheet music
and developed an effective compensatory strategy
to improve her reading ability. By turning her sheet
at right angles (i.e., left-to-right became above-to-
below) she was able to read a line almost as prior to
the loss of vision. Another possible intervention to
assist those with hemianopsia to participate fully in
reading tasks is to teach the use of a ruler to assist
in keeping track of each line of reading and using
the ruler to increase the ­accuracy of the saccadic eye
movements.
Specifically training visual search strategies is
also recommended. Pambakian and associates36
examined 29 subjects with homonymous visual field
deficits. Using a videotape, visual search images were
projected on a television in subjects’ homes for 20
sessions over a 1-month period. Prior to beginning
the search, subjects fixated on a target in the mid-
dle of the screen. Random targets were projected
among distracters and subjects indicated when they
appeared. During the training they were encour-
aged to not move their heads. The researchers found
that the subjects had significantly shorter mean
reaction times related to visual search after train-
ing (p < 0.001). The improvements were confined
to the training period and maintained at follow-up.
In addition, subjects performed ADL tasks signifi-
cantly faster after training and reported significant
subjective improvements. The researchers found no
enlargement of the visual field, but there was a small
but significant enlargement of the visual search
fields. Findings led the authors to conclude that
people with homonymous field deficits can improve
visual search with practice and that the underlying
mechanism may involve the adoption of compensa-
tory eye movement strategies.
Compensatory visual field training has been
tested by Nelles and colleagues.31 The authors exam-
ined 21 subjects with hemianopsia. Compensatory
visual field training was accomplished using a 1.25
by 3.05–m training board with right and left side-
wings. Forty red lights were distributed across the
board in four horizontal lines with 10 lights in
each line. Clients sat 1.5 m away from the board
so that visual fields of subjects were filled out by
the board. The subject’s heads were kept midline.
When the stimulus of the light was presented, the
subjects reacted by pressing a button. Training was
carried out under two conditions: (1) subjects were
required to fixate on a central point on the board
and to react to single visual stimuli and (2) multi-
ple stimuli were randomly presented on the board.
Clients were asked to identify a target stimulus
(e.g., square of four lights) in each hemifield with
use of exploratory eye movements, but without
head movements. Detection of and reaction time to
visual stimuli were measured during the two con-
ditions. The subjects showed an improvement of
detection and reaction time during condition two,
but minimum or no change during condition one.
Improvements were maintained 8 months after
training. Activity of daily living skills also improved
in all clients. Of note was that the size of scotoma
(blind area) on computerized perimetry remained
stable. Training improved detection of and reaction
to visual stimuli without a change of the visual field
impairment.
Pambakian and coworkers34 suggest three steps
to improving visual exploration. People with hemi-
anopsia should first practice making large, quick
saccades (of amplitude 30 to 40 degrees) into their
blind field, to enhance the overshoot of the target.
They are then taught to scan for targets among dis-
tracters in a systematic way. Finally these strategies
are practiced during real-world activities. These
strategies have been tested by Zihl,61 whose subjects
increased their visual field searches from 10 to 30
degrees after four to eight sessions. More recently,
Kerkhoff and colleagues19 had similar findings after
examining 92 people with hemianopsia and 30 with
additional neglect. Treatment focused on the prac-
tice of large saccades to targets in their blind hemi-
field. Additional focus was on adopting a systematic
scanning strategy, either horizontal or vertical scan-
ning. In addition, the subjects practiced search-
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
size increased from 15 to 35 degrees in those liv-
ing with hemianopsia. Those with neglect required
25% more training over 2 to 3 months to achieve
a similar result. At follow-up, almost 2 years later,
there were no further significant changes. The effect
of the treatment was independent of variables such
as time since lesion, type of field defect, field spar-
ing, and client age. Two noteworthy findings were
that those with more severe impairments benefited
most from training and that the mean number of
required treatment sessions increased dramatically
with the frequency and extent of head movements
during training. Pambakian and Kennard35 note
that this finding contradicts the assumption that
head movements are helpful to the compensatory
mechanisms for those with hemianopsia as is some-
times claimed. The concept of using excessive head
movements to compensate for a visual field deficit
warrants further investigation.
Optical devices such as prisms also have been
used for those with visual field loss. When a prism
is applied to glasses it shifts the peripheral image
toward the central area of the retina. Rossi and asso-
ciates43 examined the effects of using 15-diopter
press on Fresnel prisms on subjects with homony-
mous hemianopsia and neglect. They found signifi-
cant improvements on impairment tests of visual
perception such as the Motor Free Visual Perception
Test, Line Bisection, and Letter Cancellation tests.
They found no difference in ADL and mobility
scores as measured by the Barthel Index. These
findings make sense because the improvements
were found only in tabletop measures (i.e., mea-
sures that by definition do not encompass large
visual fields). The visual image is only subtly shifted
when wearing a prism, perhaps not enough to make
a positive change in activities such as gait or wheel-
chair mobility, which require broader visual scans.
Tabletop ADL have not been objectively tested, but
based on these findings perhaps activities such as
balancing a checkbook, doing a crossword puzzle,
or leisure reading may be positively affected. On the
other hand, several problems are related to wearing
prisms including double vision, a potential blocking
of the central field, discomfort, disturbances in spa-
tial orientation, and confusion from the distorted
visual image. Prisms may consist of a straight-edged
segment of press-on prism applied to the side of the
field loss on both lenses or round prisms applied to
the lens over one eye. Consultation with an optom-
etrist, ophthalmologist, or neuro-ophthalmologist
is mandatory.
Managing Diplopia
Diplopia, or double vision, is an all too common
visual impairment after a neurologic event. During
intact processing of visual information, when we
look at an object with both eyes, the visual image
falls on the fovea (a spot located in the center of
the macula, which is responsible for sharp central
vision) in each eye and a single image is perceived.
When the eyes are not in alignment, the object we
are looking at falls on the fovea in one eye and on
an extrafoveal location in the other eye. When this
occurs two images are perceived (i.e., binocular
diplopia).37,44 Diplopia typically resolves completely
with monocular vision (i.e., covering one eye). If
diplopia is present with monocular viewing, it is
unlikely to be neurologic in origin.44 Diplopia may
present as the following11,44:
• Horizontal (secondary to impaired abduction
or adduction of an eye involving the lateral or
medial rectus or both)
• Vertical (secondary to impaired elevation or
depression of the eye)
• Worse in a particular directional gaze (sugges-
tive of ocular motility being impaired in that
direction)
• Worse while viewing objects far away (usually
found in conjunction with impaired abduction
or divergence of the eyes)
• Worse while viewing near objects (usually found
in conjunction with impaired adduction or
convergence)
Binocular diplopia is most likely caused by “ocu-
lar misalignment” that can be gross or subtle and
warrants investigation as to the cause by an optom-
etrist or neuro-ophthalmologist. The most com-
mon causes of misalignment of the visual axes are
extraocular muscle dysfunction (see Figure 3-2).11
Ocular alignment should be evaluated in those
living with diplopia. Strabismus, or tropia, is a vis-
ible turn of one and may result in double vision.
The person is unable to keep the eye straight with the
power of fusion. In strabismus one eye may turn out-
ward (exotropia), inward (esotropia), upward (hyper-
tropia), or downward (hypotropia).2 Stra­bismus may
be noncomitant strabismus (the amount of mis-
alignment depends on which direction the eyes are
pointed) or comitant (the amount of turn is always
the same regardless of whether the person is look-
ing up, down, right, left, or straight ahead). Newly
acquired strabismus from a neurologic insult is usu-
ally noncomitant (i.e., the eye turn changes depend
on the direction in which the eyes are looking).
56 cognitive and perceptual rehabilitation: Optimizing function
Aloiso2 states that “strabismic disorder may result
in an inability to judge distance, underreaching or
overreaching for objects, covering or closure of one
eye, double vision, head tilt or turn, “spaced-out”
appearance, difficulty reading, and avoidance of
near tasks.” The term phoria is used when there is
tendency for the eye to deviate but is controlled with
muscular effort. It is not noticeable when a person is
focusing on an object.56 The eyes remain straight as
long as fusion is present.
In terms of assessing diplopia, scanning assess-
ments such as convergence and ocular range of
motion or ocular mobility should be examined to
help determine the weak ocular muscle(s).2,15 Ocular
mobility and convergence assessments as described
in Box 3-1 should be evaluated to determine the
available ocular range of motion and the observed
range of motion lags. During the assessment the cli-
nician should be aware of the corresponding mus-
cles responsible for the patterns of movements:
• The medial rectus adducts and rotates the eyes
inward.
• The lateral rectus abducts and rotates the eyes
outward.
• The superior rectus uses elevation and intorsion
to move the eyes upward.
• The inferior rectus uses depression and extor-
sion to move the eyes downward.
• The superior oblique uses depression and intor-
sion to rotate the eye downward and outward.
• The inferior oblique uses elevation and extor-
sion to rotate the eye upward and outward (see
Figure 3-2).2,14
In addition, the cranial nerves that innervate the
various muscles should be considered. The lateral
rectus is innervated by the abducens nerve (cranial
nerve VI). The medial, inferior, and superior recti
and the inferior oblique muscles are innervated
by the ocular motor nerve (cranial nerve III). The
superior oblique muscle is innervated by the troch-
lear nerve (cranial nerve IV).2,14
Involvement of cranial nerve III results in exotro-
pia, exophoria, convergence insufficiency, accommo-
dative insufficiency, ptosis, and a fixed and dilated
pupil. The affected eye is in a down and out position.
Damage to the cranial nerve IV results in hypertropia,
vertical diplopia, and limited downward gaze. Finally
damage to cranial nerve VI manifests as esotropia,
esophoria, divergence insufficiency, horizontal diplo-
pia, and limited abduction of the affected eye.2,11
In terms of assessment, the Cover-Uncover Test is
based on evoking a fixational eye movement and is
appropriate for those living with diplopia. If a ­person
is living with an ocular misalignment, only one of the
eyes fixates on the particular object while the other
eye deviates. If the fixating eye is covered, the deviat-
ing eye must refixate in order to be aligned with the
particular object. In the cover-uncover test, the per-
son fixates on a distant object, then covers one eye.
The examiner observes whether the uncovered eye
makes a fixational movement, and notes the direc-
tion of the movement. Then the occluder is removed
and placed in front of the other eye. Again the exam-
iner observes for fixational movements of the uncov-
ered eye. If both eyes are aligned, no movement will
be seen during the cover-uncover test (i.e., the test is
negative). A positive test is documented if the uncov-
ered eye moves to take up fixation. If refixation is
observed, it can be assumed that under binocular
viewing conditions the eye is not aligned with fixa-
tion, and a deviation is present. Based on the direction
of the affected eyes, movement when the nonaffected
eye is covered can indicate the type of misalignment.
Inward movement of the uncovered eye indicates an
exotropia, whereas an outward movement is an eso-
tropia. A vertical deviation may be either a hypotro-
pia or a hypertropia, depending on whether the eye
moves up or down.2,11,56 The Alternate Cover Test is
more dissociating than the cover-uncover test and it
may demonstrate phoria more readily.11 In the alter-
nate cover test, the eyes are rapidly and alternately
occluded—from one eye to the other and then back
again. This procedure causes breakdown of the bin-
ocular fusion mechanism and will reveal refixation
movements of each eye at the moment of uncover-
ing. If no tropia is present and the uncovered eye
shows refixation during the ­alternate cover test, the
client presents with phoria.
Holmes and coworkers16 developed a valid, reli-
able, and responsive questionnaire to quantify
diplopia. This self-report measure asks, “Do you
always, sometimes, or never see double?” for seven
gaze positions (straight ahead, up, downstairs, right,
left, reading, any position). The diplopia question-
naire score then ranges from 0 (no diplopia) to 25
(constant diplopia everywhere) and can easily be
rescaled to 0 to 100 by multiplying the score by 4
(Figure 3-4).
In terms of interventions, the overall goal of
managing diplopia is to establish clear and comfort-
able binocular single vision to support engagement
in meaningful activities. A typical way to manage
diplopia is to apply a patch (i.e., full occlusion or
“pirate patching”) over one eye. This technique
does in fact result in single vision but causes sev-
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
Total
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-
cebo vision therapy/orthoptics as treatments for
symptomatic convergence insufficiency in adults
ranging from 19 to 30 years of age by way of a ran-
domized multicenter trial. The intervention lasted
12 weeks. There were three arms of the trial. The
first arm was pencil pushups, in which the sub-
ject was instructed to hold a pencil at arm’s length
directly between his or her eyes, and an index card
was placed on the wall 6 to 8 feet away. Each subject
was instructed to look at the tip of the sharpened
pencil and to try to keep the pencil point single while
moving it toward the nose. If one of the cards in the
background disappeared, the person was instructed
to stop moving the pencil and blink his or her eyes
until both cards were present. The client was told to
continue moving the pencil slowly toward the nose
until it could no longer be kept single and then to
try to regain single vision. If the person was able to
regain single vision, he or she was asked to continue
moving the pencil closer to the nose. If single vision
could not be regained, the client was instructed to
start the procedure again. The exercises were per-
formed 20 times, three times per day (approximately
15 minutes per day) for 12 weeks.
In the second arm, the vision therapy/orthoptics
group received therapy administered by a trained
therapist during a weekly, 60-minute office visit,
with additional procedures to be performed at
home for 15 minutes a day, five times per week for
12 weeks. The exercise protocol46 included accom-
modative facility, Brock string exercises, vecto-
grams, computer-assisted orthoptics, and so on.
In the third arm—the placebo office-based vision
therapy/orthoptics—clients received therapy admin-
istered by a trained therapist during a 60-minute
office visit and were prescribed procedures to be per-
formed at home, 15 minutes, five times per week for
12 weeks. The procedures were designed to simulate
real vision therapy/orthoptics procedures without
the expectation of affecting vergence, accommoda-
tion, or saccadic function. Examples included using
stereograms monocularly to simulate vergence ther-
apy, computer vergence therapy with no vergence
changes, and monocular prism (instead of plus and
minus lenses) to simulate accommodative treatment.
The authors found that only clients in the vision
therapy/orthoptics group demonstrated statistically
and clinically significant changes in the near point
of convergence (p = 0.002) and positive fusional ver-
gence (p = 0.001). In addition, clients in all three treat-
ment groups demonstrated statistically significant
improvement in symptoms with 42% in ­office-based
vision therapy/orthoptics, 31% in office-based placebo
vision therapy/orthoptics, and 20% in home-based
pencil push-ups. Although the vision therapy/orthop-
tics group was the only treatment that produced clini-
cally more than half of the clients in this group were
still symptomatic at the end of treatment, although
their symptoms were significantly reduced.
Rawstron and colleagues42 systematically reviewed
the current evidence regarding the efficacy of eye
exercises. The authors reviewed 43 refereed stud-
ies (14 were clinical trials [10 controlled studies], 18
review articles, 2 historical articles, 1 case report, 6
editorials or letters, and 2 position statements from
professional colleges). Based on their review, the
authors summarized that “eye exercises have been
purported to improve a wide range of conditions
including vergence problems, ocular motility dis-
orders, accommodative dysfunction, amblyopia,
learning disabilities, dyslexia, asthenopia, myopia,
motion sickness, sports performance, stereopsis,
visual field defects, visual acuity, and general well-
being. Small controlled trials and a large num-
ber of cases support the treatment of convergence
insufficiency. Less robust, but believable, evidence
indicates visual training may be useful in develop-
ing fine stereoscopic skills and improving visual
field remnants after brain damage. As yet there is
no clear scientific evidence published in the main-
stream literature supporting the use of eye exercises
in the remainder of the areas reviewed, and their
use therefore remains controversial.”
Visuospatial and Spatial Relations Impairments
Participating in daily living tasks in a meaningful
and safe manner relies on higher-order visual pro-
cessing such as perceiving depth, interpreting spa-
tial relations, and differentiating foreground from
background, for example. (Table 3-1). Visuospatial
impairments have been reported to be one of the
most common impairments observed after stroke
with a prevalence reported as high as 38%.32 These
deficits have also been reported in those living with
Huntington’s disease,26 Parkinson’s disease,28 trau-
matic brain injury,30 and multiple sclerosis.39
The presence of visuospatial impairments has
been associated with a significant increase in falls,33
decreased performance of basic ADL and mobil-
ity after stroke as measured by the Barthel Index,32
impairments in both ADL and motor function in
those living with Parkinson’s disease,27 and difficul-
ties with dressing such as putting one’s arm in the
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
(stereopsis) system that interprets
depth information from a
viewed scene and builds
a three-dimensional
understanding of that
scene
Spatial relations Ability to process and
interpret visual
information about where
objects are in space;
the process of relating
objects to each other and
the self
Right/left discrimination Ability to use/apply the
concepts of left and right
Topographic The ability to use
orientation visuospatial (and
memory) skills to support
wayfinding or route
finding
Figure-ground Inability to distinguish
discrimination objects in the foreground
(foreground from objects in the
from background background
discrimination)
Pouring water into a glass, Relies primarily on binocular
catching a ball, stepping vision but also relies on
up or down a curb, monocular cues (light and
reaching for cooking shading, color, relative
equipment with accuracy size).
during meal preparation, Those living with monocular
parking a car, etc. vision and strabismus will
have difficulty perceiving
depth.
Orienting clothing to your Rule out ideational and motor
body, applying paste to apraxia (see Chapter 5)
a toothbrush, orienting/
aligning your body in
space during a transfer,
orienting dentures and
glasses to your body
Indoor and outdoor mobility
during wayfinding,
performing math tasks
and calculations
Following directions related Differentiate between
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
clinic”)
Finding your way via See Chapter 7
ambulation, wheeled
mobility, or driving in
familiar environments;
learning new routes
Locating a white napkin Rule out decreased visual
on a white table, acuity and related basic
finding a scissors in visual skills
a cluttered drawer,
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.
(Continued)
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-
spatial impairments documented “three main
themes comprising six characteristics of how the
physical world was experienced in a new, unfamil-
iar, and confusing way that interfered with the par-
ticipants’ occupational performance and with their
experiences of being an individual “self-­person.”
Specific everyday problems that the participants
reported included confusion related to space and
objects, difficulty reaching for objects, feelings
that one’s arms were too short, not being able to
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-
culty finding everyday objects, and difficulties with
wheelchair maneuvering, for example.
The majority of common instruments to mea-
sure the presence of spatial dysfunction use two-
dimensional contrived tasks such as overlapping
figures, design copying, and so on. The Motor Free
Visual Perception Test (MVPT)10 is only one exam-
ple of this level of impairment testing. The abil-
ity of these types of test to predict performance of
everyday tasks performed in context is not clear,
and results should be interpreted with caution.8,29
Specifically validity data have not been collected
comparing MVPT scores with real-world tasks
requiring visual perception (see Chapters 1 and 2).29
For example, a retrospective study examined 269
individuals living with a stroke who completed the
MVPT and an on-road driving evaluation. The
MVPT scores ranged from 0 to 36, with a higher
score indicating better visual perception. A struc-
tured on-road driving evaluation was performed
to determine fitness to drive. A pass or fail out-
come was determined by the examiner based on
driving behaviors. The author’s results indicated
that using a score on the MVPT of less than or
equal to 30 to indicate poor visual-perception
and more than 30 to indicate good visual percep-
tion, the positive predictive value of the MVPT in
identifying those who would fail the on-road test
was 60.9%. The corresponding negative predictive
value was 64.2%. The authors concluded that the
predictive validity of the MVPT is not sufficiently
high to warrant its use as the sole screening tool in
identifying those who are unfit to undergo an on-
road evaluation.21
An error analysis approach has been suggested to
document the effects of impairments on daily living
skills.3,5,52 The Árnadóttir OT-ADL Neurobehavioral
Evaluation (A-ONE)3–5 is one of a select group
of standardized assessments that document the
effects of spatial impairments on daily living tasks
such as mobility, feeding, grooming, and dress-
ing. Specific impairment test items that are scored
based on functional observations include spa-
tial relations, visuospatial agnosia, impaired right
and left discrimination, and topographic orienta-
tion. The Assessment of Motor and Process Skills
(AMPS)12,13 may be used to document functional
limitations of those living with a variety of impair-
ments including visual and spatial impairments
(see Chapter 1). The Structured Observational Test
of Function (SOTOF)23,24 is a valid and reliable tool
that assesses the following:
• Occupational performance (deficits in simple
ADL)
• Performance components (perceptual, cogni-
tive, motor, and sensory impairment)
• Behavioral skill components (reaching, scan-
ning, grasp, sequence)
• Neuropsychological deficits (spatial relations
apra­xia, agnosia, aphasia, spasticity, memory
loss)
• Specific visual and spatial impairments (in
addition to the above impairments), includ-
ing figure-ground discrimination, position in
space, form constancy, spatial relations, depth
and distance perception, visual acuity, visual
attention, visual scanning, visual filed loss, and
neglect. These impairments are detected by the
structured observation of simple ADL (eat-
ing from a bowl, pouring a drink and drink-
ing, upper body dressing, washing and drying
hands).
This relatively quick tool aims to answer the fol-
lowing questions:
• How does the subject perform ADL tasks?
• What behavioral skill components are intact?
Which have been affected by neurologic
damage?
• Which perceptual, cognitive, motor, and sensory
impairments are present?
• Why is function impaired?
Although presented here, the SOTOF is appro-
priate for a variety of the problem areas discussed
in future chapters as well.
Despite the prevalence of these impairments
and the substantial effect on function, little empir-
ical evidence is available to guide interventions
focused on decreasing activity limitations and par-
ticipation restrictions. It has been suggested that a
functional approach is the most appropriate inter-
vention for this population.4,52 This may consist of
task-specific training, strategy training, and envi-
ronmental modifications (Table 3-2). It also has
been suggested that interventions that consist of
engaging clients in everyday occupations that are
presented to challenge the underlying impairment
should be incorporated into treatment.1,4,7 Abreu
and colleagues1 have proposed an integrated func-
tional approach. In this approach, areas of occupa-
tion and context are used to challenge processing
skills. With this integrated functional approach,
treatment may be focused on a subcomponent
skill such as spatial, but daily occupations are used
as the modality. Box 3-2 lists potential activity
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
discrimination.
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
localization.
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
1. Name three compensatory interventions that
may be used for a person with decreased per-
formance in grooming secondary to spatial
impairment.
2. What are the components of a visual screening?
3. Describe the clinical reasoning process to deter-
mine why a person cannot locate a spoon in a
utensil drawer.
4. Describe three different methods of visual occlu-
sion that may be used with a person presenting
with diplopia.
5. What are the potential impairments and the
effect on function if a person develops a pathol-
ogy that adversely effects the dorsal stream
(occipitoparietal pathway)?
References
1. Abreu B et al: Occupational performance and the
functional approach. In Royeen CB, editor: AOTA
self-study series: cognitive rehabilitation, Rockville, Md,
1994, American Occupational Therapy Association.
2. Aloisio L: Visual dysfunction. In Gillen G, Burkhardt
A, editors: Stroke rehabilitation: a function-based
approach, ed 2, St Louis, 2004, Mosby.
3. Árnadóttir G: The brain and behavior: assessing
­cortical dysfunction through activities of daily living,
St Louis, 1990, Mosby.
4. Árnadóttir G: Clinical reasoning with complex
perceptual impairment. In Unsworth C, editor:
Cognitive and perceptual dysfunction: a clinical rea-
soning approach to evaluation and intervention,
Philadelphia, 1999, FA Davis.
5. 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.
6. Bolognini N, Rasi F, Coccia M, et al: Visual search
improvement in hemianopic clients after audio-visual
stimulation, Brain 128(Pt 12):2830-2842, 2005.
7. Brockmann-Rubio K, Gillen G: Treatment of cog-
nitive-perceptual impairments: a function-based
approach. In Gillen G, Burkhardt A, editors: Stroke
rehabilitation: a function-based approach, ed 2,
St Louis, 2004, Elsevier Science/Mosby.
8. Brown GT, Rodger S, Davis A: Motor-Free Visual
Perception Test-Revised: an overview and critique,
Br J Occup Ther 66(4):159-167, 2003.
9. Chia EM, Wang JJ, Rochtchina E, et al: Impact of
bilateral visual impairment on health-related qual-
ity of life: the Blue Mountains Eye Study, Invest
Ophthalmol Vis Sci 45(1):71-76, 2004.
10. Colarusso RP, Hammill DD: Motor-free visual percep-
tion test, ed 3, Novato, Calif, 2003, Academic Therapy
Publications.
11. Danchaivijitr C, Kennard C: Diplopia and eye
movement disorders. J Neurol Neurosurg Psychiatry
75(Suppl 4):24-31, 2004.
12. Fisher AG: Assessment of motor and process skills.
vol. 1: development, standardization, and administra-
tion manual, ed 5, Fort Collins, Colo, 2003, Three
Star Press.
13. Fisher AG: Assessment of motor and process skills. vol. 2:
user manual, ed 5, Fort Collins, Colo, 2003, Three
Star Press.
14. 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.
15. Gutman SA, Schonfeld AB: Screening adult neurologic
populations, Bethesda, Md, 2003, AOTA Press.
16. Holmes JM, Leske DA, Kupersmith MJ: New methods for
quantifying diplopia, Ophthalmology 112(11):2035-2039,
2005.
17. Jones SA, Shinton RA: Improving outcome in stroke
patients with visual problems, Age Ageing 35:560-565,
2006.
18. Kerkhoff G: Neurovisual rehabilitation: recent devel-
opments and future directions, J Neurol Neurosurg
Psychiatry 68:691-706, 2000.
19. Kerkhoff G, Münssinger U, Haaf E, et al: Rehabilitation
of homonymous scotomas in clients with postgenicu-
late damage of the visual system: saccadic compensa-
tion training, Restor Neurol Neurosci 4:245-254, 1992.
20. Kerkhoff G, Stogerer E: Recovery of fusional conver-
gence after systematic practice, Brain Inj 8:15, 1994.
21. Korner-Bitensky NA, Mazer BL, Sofer S, et al: Visual
testing for readiness to drive after stroke: a multicenter
study, Am J Phys Med Rehabil 79(3):253-259, 2000.
22. Lampinen J, Tham K: Interaction with the physical
environment in everyday occupation after stroke: a
phenomenological study of persons with visuospatial
agnosia, Scand J Occup Ther 10(4):147-156, 2003.
23. Laver AJ: Clinical reasoning with simple perceptual
impairment. In Unsworth C, editor: cognitive and
perceptual dysfunction: a clinical reasoning approach
to evaluation and intervention, Philadelphia, 1999, FA
Davis.
24. Laver AJ: The structured observational test of func-
tion, Gerontol Special Interest Sec Newslet 17(1),
1994.
25. Leff AP, Scott SK, Crewes H, et al: Impaired reading in cli-
ents with right hemianopia, Ann Neurol 47(2):171-178,
2000.
26. Lemiere J, Decruyenaere M, Evers-Kiebooms G, et al:
Cognitive changes in clients with Huntington’s dis-
ease (HD) and asymptomatic carriers of the HD
mutation—a longitudinal follow-up study, J Neurol
251(8):935-942, 2004.
27. Maeshima S, Itakura T, Nakagawa M, et al: Visuo­
spatial impairment and activities of daily living
in clients with Parkinson’s disease: a quantitative
assessment of the cube-copying task, Am J Phys Med
Rehabil 76(5):383-388, 1997.
66 cognitive and perceptual rehabilitation: Optimizing function
28. Marinus J, Visser M, Verwey NA, et al: Assessment
of cognition in Parkinson’s disease, Neurology 61(9):
1222-1228, 2003.
29. McCane SJ: Test review: motor-free visual perception
test, J Psychoeduc Assess 24(3):265-272, 2006.
30. McKenna K, Cooke DM, Fleming J, et al: The inci-
dence of visual perceptual impairment in clients with
severe traumatic brain injury, Brain Inj 20(5):507-518,
2006.
31. Nelles G, Esser J, Eckstein A, et al: Compensatory
visual field training for clients with hemianopia after
stroke, Neurosci Lett 306(3):189-192, 2001.
32. Nys GM, van Zandvoort MJ, de Kort PL, et al: Cognitive
disorders in acute stroke: prevalence and clinical deter-
minants, Cerebrovascular Dis 23(5-6):408-416, 2007.
33. Olsson RH Jr, Wambold S, Brock B, et al: Visual spatial
abilities and fall risk: an assessment tool for individu-
als with dementia, J Gerontol Nurs 31(9):45-53, 2005.
34. Pambakian A, Currie J, Kennard C: Rehabilitation
strategies for clients with homonymous visual field
defects, J Neuroophthalmol 25(2):136-142, 2005.
35. Pambakian AL, Kennard C: Can visual function be
restored in clients with homonymous hemianopia?
Br J Ophthalmol 81(4):324-328, 1997.
36. Pambakian AL, Mannan SK, Hodgson TL, et al:
Saccadic visual search training: a treatment for clients
with homonymous hemianopia, J Neurol Neurosurg
Psychiatry 75(10):1443-1448, 2004.
37. Pearce JM: Diplopia, Eur Neurol 53(1):54, 2005.
38. Pearce JM: Hemianopia, Eur Neurol 53(2):111, 2005.
39. Piras MR, Magnano I, Canu ED, et al: Longitudinal
study of cognitive dysfunction in multiple sclerosis:
neuropsychological, neuroradiological, and neuro-
physiological findings, J Neurol Neurosurg Psychiatry
74(7):878-885, 2003.
40. Politzer T: Visual function, examination, and reha-
bilitation in clients suffering from traumatic brain
injury. In Jay GW, editor: Minor traumatic brain
injury handbook, Boca Raton, Fla, 2000, CRC Press.
41. Politzer T: Introduction to vision and brain injury.
Retrieved May 1, 2007, from www.nora.cc/client_
area/vision_and_brain_injury.html.
42. Rawstron JA, Burley CD, Elder MJ: A systematic
review of the applicability and efficacy of eye exercises,
J Pediatr Ophthalmol Strabismus 42(2):82-88, 2005.
43. Rossi PW, Kheyfets S, Reding MJ: Fresnel prisms
improve visual perception in stroke clients with hom-
onymous hemianopia or unilateral visual neglect,
Neurology 40(10):1597-1599, 1990.
44. Rucker JC, Tomsak RL: Binocular diplopia. A practi-
cal approach, Neurologist 11(2):98-110, 2005.
45. Scheiman M, Mitchell GL, Cotter S, et al: A ran-
domized clinical trial of vision therapy/orthoptics
versus pencil pushups for the treatment of conver-
gence insufficiency in young adults, Optom Vis Sci
82(7):583-595, 2005.
46. Scheiman M, Wick B: Clinical management of binocu-
lar vision: Heterophoric, accommodative and eye move-
ment disorders, ed 2, Philadelphia, 2002, Lippincott
Williams & Wilkins.
47. Suchoff IB, Kapoor N, Waxman R, et al: The occur-
rence of ocular and visual dysfunctions in an acquired
brain-injured client sample, J Am Optom Assoc
70(5):301-308, 1999.
48. Trauzettel-Klosinski S: Reading disorders due to
visual field defects-a neuro-ophthalmological view,
Neuroophthalmology 27:79-90, 2002.
49. Trauzettel-Klosinski S, Brendler K: Eye movements
in reading with hemianopic field defects: the signifi-
cance of clinical parameters, Graefes Arch Clin Exp
Ophthalmol 236:91-102, 1998.
50. Trauzettel-Klosinski, S, Reinhard J. The vertical field
border in hemianopia and its significance for fixa-
tion and reading, Invest Ophthalmol Vis Sci 39:2177-
2186, 1998.
51. Tsai SY, Cheng CY, Hsu WM, et al: Association
between visual impairment and depression in the
elderly, J Formos Med Assoc 102(2):86-90, 2003.
52. Walker CM, Sunderland A, Sharma J, et al: The impact
of cognitive impairment on upper body dressing diffi-
culties after stroke: a video analysis of patterns of recov-
ery, J Neurol Neurosurg Psychiatry 75(1):43-48, 2004.
53. Warren M: A hierarchical model for evaluation
and treatment of visual perceptual dysfunction in
adult acquired brain injury, part 1, Am J Occup Ther
47(1):42-54, 1993.
54. Warren M: A hierarchical model for evaluation
and treatment of visual perceptual dysfunction in
adult acquired brain injury, part 2, Am J Occup Ther
47(1):55-66, 1993.
55. Warren M: Brain injury visual assessment battery
for adults, Birmingham, 1999, visABILITIES Rehab
Services.
56. Warren M: Evaluation and treatment of visual defi-
cits 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/Mosby.
57. Wang MK: Reading with a right homonymous hae-
mianopia, Lancet 361(9363):1138, 2003
58. 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.
59. Zhang X, Kedar S, Lynn MJ, et al: Homonymous
hemianopias: clinical-anatomic correlations in 904
cases, Neurol 66(6):906-910, 2006.
60. Zhang X, Kedar S, Lynn MJ, et al: Natural history of
homonymous hemianopia, Neurol 66(6):901-905, 2006.
61. Zihl J: Neuropsychologische rehabilitation. In Von
Cramon D, Zihl J, editors: Neuropsychologische reha-
bilitation: grudlagen, diagnostic, behandlungsver-
fahren, Berlin, 1988, Springer-Verlag.
62. Zihl J: Visual scanning behavior in clients with hom-
onymous hemianopia, Neuropsychologia 33:287-303,
1995.
 Chapter 4
Self-Awareness and Insight: Foundations for Intervention
Key Terms
Anosognosia Emergent Awareness
Anticipatory Awareness Insight
Awareness Intellectual Awareness
Denial Metacognition
Learning Objectives
At the end of this chapter, readers will be able to:
1. Begin to differentiate between a lack of awareness
and denial.
2. Understand how rehabilitation outcomes are
affected if a lack of awareness is present.
3. Describe at least two conceptual models used to
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-
awareness or unawareness, anosognosia, and denial.
Whereas nonimpaired self-awareness has been
defined as “the capacity to perceive the self in rela-
tively objective terms, while maintaining a sense of
subjectivity,” 66 Prigatano62,65 uses the terms impaired
self-awareness and anosognosia interchangeably and
uses the following definition:
“the clinical phenomena in which a brain dysfunctional
patient does not appear to be aware of impaired neuro-
logical or neuropsychological function, which is obvious
67
Online Awareness
Self-awareness
4. Be aware of various methods to objectively docu-
ment and quantify decreased awareness.
5. Implement at least five intervention strategies
focused on decreasing activity limitations, and par-
ticipation restrictions for those presenting with
decreased awareness.
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
widespread cognitive impairment.” 61
Other authors3,9 reserve the term anosognosia
for describing unawareness of physical deficits only
(i.e., not including cognitive impairments) such as
“anosognosia for hemiplegia” or “anosognosia for
hemianopsia.”
Although impaired self-awareness and anosog-
nosia clearly have been used as overlapping terms
in the literature, the term denial must be considered
separately. Psychological denial has been defined as
68 cognitive and perceptual rehabilitation: Optimizing function
“a subconscious process that spares the patient the
psychological pain of accepting the serious conse-
quences of a brain injury and its unwanted effects
on his or her life.”18 Complicating the matter is
that impaired self-awareness and denial may occur
together. Differentiation between denial (a psy-
chological method of coping) and lack of aware-
ness that is neurologically based is difficult because
some individuals present with both types of clinical
presentations (Table 4-1).43
To aid clinicians in this process, Prigatano
and Klonoff 65 developed the Clinician’s Ratings
Scale for Evaluating Impaired Self-Awareness and
Denial of Disability After Brain Injury. The tool
consists of two subscales: the Denial of Disability
(DD) subscale and the Impaired Self-Awareness
(ISA) subscale, designed to measure denial and  activities of daily living, memory activities, and
anosognosia, respectively. Interrater reliability for both
subscales is .77. The authors suggest a cutoff of 40 on
the DD subscale to identify participants in denial ver-
sus those who are not in denial (Figure 4-1).
Self-awareness is clearly related to and is one
component of metacognition or conscious knowl-
edge of cognitive processes inclusive of the ability
to monitor and regulate ongoing activities or pro-
cesses during task performance.35 It is a complex
issue and may be mediated by other factors such as
executive functions,10,37 memory deficits, and over-
Table 4-1 Characteristics of Denial and Self-Awareness
DenIal
Appears to be a psychological reaction
Clients demonstrate partial or implicit knowledge about
impaired function
Demonstrate resistance or anger when given feedback
regarding their limitations
Demonstrate an active struggle to work with new information
about themselves and may make rationalizations or
excuses
May be accompanied by reactions of depression or anger
and can co-occur with impaired self-awareness
Higher levels of denial are associated with greater use of
avoidant coping strategies, and greater use of these coping
strategies is related to higher levels of depression
For those with high levels of denial, ongoing psychological
support and monitoring may be needed
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.
all metacognitive skills (see Chapters 9 and 10). 
The impaired self-awareness does not affect all
areas of function equally. For example, it has been
found that people with brain injury report greater
physical as opposed to nonphysical impairments
such as cognitive or behavioral involvement. 72 The
common link is that those living with brain injury
underestimate difficulties in their everyday life.23,72
Fleming and Strong29 found that self-awareness was
most impaired for activities with a large cognitive
(work activities, scheduling daily activities, under-
standing new instructions, meeting daily responsi-
bilities) and socioemotional (handling arguments,
showing affection, recognizing if actions upset
someone else, not letting emotions affect daily
activities) component, and least impaired for basic
overt emotional responses. Toglia and Kirk91 sum-
marized the multiple problems that can contribute
to a lack of self-awareness (Table 4-2).
Neurologic Considerations
In general a lack of awareness has been attributed to
damage to frontal regions and connecting pathways,
particularly right hemisphere involvement.83 Those
with persistent (lasting months or years) impaired
self-awareness show evidence of brain damage that is
Lack of Self-Awareness
Appears to be rooted in neurologic dysfunction
Clients lack information about themselves
Are perplexed and surprised or confused when given
feedback regarding limitations
Exhibit a cautious willingness or indifference when asked
to work with new information about themselves
Can co-occur with denial
Is associated with other impairments such as decreased
initiation, planning, self-monitoring/regulation
For those with high levels of neurologic-based
unawareness, challenging occupations structured to
highlight problems may be used
 Chapter 4  Self-Awareness and Insight: Foundations for Intervention 69
often bilateral and asymmetric throughout the brain
and including the cerebellum and brainstem.63
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-
gia most frequently occurs in association with uni-
lateral right-sided or bilateral lesions of different
brain areas (cortical and/or subcortical). In addition,
it seems to be equally frequent when the damage is
confined to frontal, parietal, or temporal cortical
structures, and may also emerge as a consequence of
subcortical lesions. They also found that the prob-
ability of occurrence of anosognosia is highest when
the lesion involves parietal and frontal structures in
combination, if compared with other combinations
of lesioned areas. The authors hypothesized that this
pattern of lesions suggests the existence of a complex
cortical-subcortical circuit underlying awareness of
motor acts that if damaged can result in anosogno-
sia. Other researchers have concluded that impaired
self-awareness is associated with the number but not
with the location or volume of focal lesions early
after traumatic brain injury.75
Clinical Presentation
Decreased self-awareness had been documented in
multiple populations with acquired brain injury
including stroke, traumatic brain injury (TBI),
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.)
Parkinson’s disease (PD), and multiple sclerosis
(MS) and others.
Stroke
Anderson and Tranel2 found that in those liv-
ing with stroke, unawareness is associated with
cognitive impairment and varies based on hemi-
spheric involvement and impairment investigated.
Specifically, unawareness of motor deficit was doc-
umented in 28% of those with stroke (all with right
brain damage [RBD]), whereas unawareness of
cognitive deficits was documented in 72% of those
with stroke. Overall those with RBD had higher
mean levels of unawareness when other demo-
graphics were controlled for statistically.
Other studies have also documented a high inci-
dence of poststroke unawareness including 74%
(50% with mild impairment; 22% with moder-
ate impairment; 2% with severe impairment),40
50% to 64%,41 and approximately 40%.93 Lack of  
awareness can be selective in that a person with
multiple impairments may seem unaware of only
one particular impairment while appearing to be
fully aware of any others.9 Overall, it appears that
unawareness of cognitive deficits is much more
prevalent than unawareness of motor deficits in
this population.2,40
In their recent review of the literature related to
anosognosia and stroke, Jehkonen and associates42
(Continued)
70 cognitive and perceptual rehabilitation: Optimizing function
Figure 4-1—Cont’d
concluded that lack of awareness was more often
associated with right hemisphere damage, neglect
(see Chapter 6) and anosognosia co-occurred, and
anosognosia had predictive value on poor func-
tional outcome.
Hartman-Maeir and coworkers39 documented
the frequency of unawareness of disabilities after
stroke as 73.3% at admission and 42.1% at dis-
charge. They found that discharge unawareness in
the right hemisphere group was significantly asso-
ciated with lesions in the frontal and temporal lobes
and with lesion size, whereas unawareness in the
left hemisphere–damaged group was not associated
with any neuroanatomic variables. In another study,
Hartman-Maeir and colleagues38 documented
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
left hemispheric damage in a sample of 46 stroke
survivors. The majority of those with anosognosia
for hemiplegia secondary to the right hemispheric–
damaged group had large lesions involving the
frontal, parietal, or temporal lobes and had coex-
isting sensory deficits and unilateral spatial neglect.
Those with anosognosia for hemiplegia second-
ary to left hemispheric damage had predominantly
small subcortical lesions and no sensory or atten-
tional deficits. The authors concluded that underly-
ing mechanisms of this deficit may be different for
left and right hemisphere clients, therefore requir-
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
performance
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
The incidence of lack of self-awareness after TBI is
consistently high. Various samples have reported
incidences of 52% 50 and 68%.2 Approximately 30%
of those with severe TBI show residual impairment
of self-awareness months or years after injury.63
Parkinson’s Disease
Leritz and colleagues47 found that those living with
PD rate themselves as less impaired than caregiv-
ers on measures of ADL functioning. They con-
cluded that regardless of the side of the lesion, PD
may impair the ability to recognize and accurately
report physical deficits providing support to the
author’s hypothesis that reduced awareness is due
to frontal-subcortical dysfunction.
Multiple Sclerosis
Goverover and colleagues34 found that level of self-
awareness of neurobehavioral symptoms in MS
is related to level of cognitive impairment. The
authors also noted that the symptoms of depression
and anxiety reduced the accuracy of self-reporting
in this population.
Impaired Self-Awareness
and Outcomes
The following paragraphs summarize the empiri-
cal research that has examined the relationship
between self-awareness and outcomes.
• Unawareness at admission to inpatient reha-
bilitation is a predictor of discharge Functional
Independence Measure (motor) scores for those
with right hemisphere damage. Unawareness at
admission is a detrimental factor to achieving
adequate safety levels and independence in basic
ADL functions at the time of discharge from a
rehabilitation hospital.40 Sherer and coworkers74
also documented that admission Functional
Independence Measure scores are strongly asso-
ciated with degree of impaired self-awareness
after traumatic brain injury. That is, clients with
higher levels of functional independence have
more accurate self-awareness. In addition, level
of self-awareness is a good predictor of instru-
mental activities of daily living performance in
those living with brain injury.33
• Impaired self-awareness and functional status
at rehabilitation admission make independent
c­ ontributions to prediction of subjective well-
being in those living with traumatic brain injury.21
• Unawareness at discharge from stroke rehabili-
tation is a negative predictor of activity level as
measured by the Activity Card Sort at 1 year fol-
low-up, after controlling for the severity of ini-
tial disability level.39
• In a study76 of well-being among significant
others of people with multiple sclerosis, lack of
awareness of functional deficit as measured by
the discrepancy between the clients’ and signifi-
cant others’ reports of the clients’ functional abil-
ities is associated with poor well-being outcomes
and increases significant others’ supervisory bur-
den as clients attempt activities independently.
The presence of executive dysfunction and neu-
robehavioral disturbances in loved ones is also
related to poor well-being among significant
others. Level of relatives’ distress levels is also
correlated with levels of impaired self-awareness
in those living with traumatic brain injury.64
• Those with various brain etiologies who show
greater improvement in awareness are more
likely to obtain their rehabilitation goals.67
• Accuracy of self-awareness as measured by dis-
crepancy between client self-rating and clinician
rating is predictive of employability at dis-
charge from rehabilitation.74 Similarly, accurate
self-awareness is related to favorable employ-
ment outcome.71 Work status is significantly
correlated with scores on standardized mea-
sures of assessment (i.e., the Self-Awareness of
Deficits Interview and the Self-Regulation Skills
Interview).97
• Impaired awareness is significantly associated
with lower vocational and independent living
status, maladaptive behavior, greater distract-
ibility, and increased perseveration in those with
traumatic brain injury.92
• A study by Fleming and associates31 used a clus-
ter analysis to investigate the relationship among
self-awareness, emotional distress, motivation,
and outcome in adults with severe traumatic
brain injury. Groups were labeled as high self-
awareness, low self-awareness, and good recovery.
The high self-awareness cluster had significantly
higher levels of self-awareness, motivation, and
emotional distress than the low self-awareness
cluster but did not differ significantly in outcome.
The authors concluded that self-awareness after
brain injury is associated with greater motiva-
tion to change behavior and higher levels of
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
higher levels of depression has been documented
by others as well.32,94
• Impaired awareness is associated with executive
dysfunction and interpersonal difficulties51; con-
versely a higher level of intellectual awareness
is associated with greater performance on mea-
sures of executive function.53 Others6 argue that
the association between reduced behavioral and
social self-awareness and deficits in executive
function is not as consistent as once thought.
• Degree of error awareness is strongly correlated
with sustained attention capacity, even for when
severity of injury is controlled.48
• Those with behavioral disturbances after
a brain injury show significantly less self- 
awareness compared with those without behav-
ioral disturbances.6
• Lower levels of awareness (particularly online
awareness as described later) and strategy behav-
ior are associated with increased hopelessness.53
• People who lack an awareness of their limita-
tions in everyday functioning may be less moti-
vated to change their performance.85
• The level of self-awareness after acquired brain
injury is a useful prognostic index of the neuro-
psychological, psychopathologic, and functional
status.50
• Anosognosia for hemiplegia is related to an
inability to retain safety measures at discharge
from rehabilitation and presents a significant
risk for negative functional outcome in stroke
rehabilitation.38
• Although many authors find that lack of aware-
ness is persistent over time, there is some evi-
dence that improvements can be documented
during the first year of recovery after a neuro-
logic insult.29
• After a brain injury, those with less awareness
of their limitations tend to set less realistic goals
and have lower rehabilitation outcomes com-
pared with those with a more realistic view of
their limitations.22
• Awareness is linked to the ability to use compensa-
tory cognitive strategies to support daily living.20
Models of Self-Awareness
The pyramid model of self-awareness was devel-
oped by Crosson and associates18 (Figure 4-2).
Anticipatory
awareness
Emergent
awareness
Intellectual awareness
Figure 4-2  Awareness represented as a pyramid. Intellectual
awareness is the foundation for emergent and anticipatory awareness.
Some degree of emergent awareness is necessary for anticipatory
awareness. (From Crosson B, Barco PP, Velozo CA, et al: Awareness
and compensation in postacute head injury rehabilitation, J Head
Trauma Rehabil 4[3]:46-54, 1989.)
This model includes three interdependent types of
awareness.
1. Intellectual awareness: The ability to understand
at some level that a function is impaired. At the
lowest level, one must be aware that one is ­having
difficulty performing certain activities. A more
sophisticated level of awareness is to recognize
commonalities between difficult activities and
the implications of the deficits. Crosson and
associates18 hypothesize that factors that may
contribute to impaired intellectual awareness
include decreased knowledge of the manifesta-
tions of brain injury, deficits in abstract reason-
ing, and severe memory loss. Refers to knowing
you have a problem.
2. Emergent awareness: The ability to recognize a
problem when it is actually happening. Intellectual
awareness is considered a prerequisite to emer-
gent awareness in this model because one must
first recognize that a problem exists (knowing
you are experiencing a problem when it occurs).
Emergent awareness is included in the concept of
online awareness or monitoring of performance
during the actual task.
3. Anticipatory awareness: The ability to antici-
pate that a problem will occur as the result of
a particular impairment in advance of actions.
Intellectual awareness and emergent aware-
ness are considered prerequisites to anticipatory
awareness in this model because one must first
recognize that a problem exists and be aware that
a problem is occurring to successfully anticipate
a potential problem (knowing in advance you
have a problem that will affect future ­function).
 Chapter 4  Self-Awareness and Insight: Foundations for Intervention 75
Table 4-3 Awareness and Compensations
Substantial Compensations
Awareness Deficit Available
Intellectual awareness External compensation
deficit
Emergent awareness External compensation
deficit Situation compensation
Anticipatory awareness External compensation
deficit Situation compensation
Recognition compensation
No substantial awareness External compensation
deficit Situation compensation
Recognition compensation
Anticipatory compensation
From Crosson B, Barco PP, Velozo CA, et al: Awareness and compensa-
tion in postacute head injury rehabilitation, J Head Trauma Rehabil 4(3):
46-54, 1989.
Anticipatory awareness is included in the con-
cept of online awareness.
Those with brain injuries may be impaired across
all three awareness domains51 or may present with
better skills in one or more domains of awareness.
Crosson and associates18 further applied this model
to the selection of compensatory strategies and cat-
egorized compensations appropriate to each type
of awareness (Table 4-3). They classified compen-
satory strategies according to the way their imple-
mentation is triggered:
• Anticipatory compensation: Applied only when
needed, this term refers to implementation of
a compensatory technique by anticipating that
a problem will occur (i.e., requires anticipatory
awareness). An example is a person who needs
groceries for the week and is aware that because
busy environments result in increased memory
and attention deficits decides to defer shopping
until 7 pm when the local store is not as busy.
• Recognition compensation: Also applied only
when needed, this term refers to strategies that
are triggered and implemented because a per-
son recognizes that a problem is occurring (i.e.,
requires emergent awareness). An example is
asking a person to speak slower because you
realize that you are not processing information
quickly enough and are having difficulty follow-
ing the conversation.
• Situational compensation: This term applies to
compensatory strategies that can be triggered
by a specific type of circumstance in which an
impairment may affect function. The strategies
are taught to be consistently used every time a
particular event occurs. An example is a student
who, secondary to memory impairments after a
traumatic brain injury, tape records all lectures
in class. Although there are times when this may
not be necessary (e.g., a particularly slow-mov-
ing and limited-content lecture), the strategy
is used anyway because this type of compensa-
tion does not rely on the judgment of the cli-
ent. Intellectual awareness is necessary to use
this strategy because one must be aware that a
deficit exists in order to integrate a strategy to
overcome it.
• External compensation: This type of compensa-
tion is triggered via an external agent or involves
an environmental modification. Examples include
alarm watches, posted lists of steps related to meal
preparation, and so on.
Abreu and colleagues1 empirically tested the hier-
archy proposed by Crosson and associates18 in a study
of self-awareness after acute brain injury. They exam-
ined awareness related to performance of three func-
tional tasks (dressing, meal planning, and money
management). A series of questions rated on a Likert
scale were used to ascertain awareness: “Are you aware
of any changes in your ability to perform the follow-
ing task since your injury?” (intellectual awareness),
“How well do you predict you will do on the follow-
ing task?” (intellectual awareness), “How well do you
think you did on the task?” (emergent awareness),
and “How do you think your performance on the
task might affect your ability to live independently,
work, and have fun?” (anticipatory awareness). Their
analysis revealed significant differences for all levels of
self-awareness across the three tasks. Although their
findings did not support the proposed hierarchy, the
authors caution that the questions used in their study
may not have been sensitive to the levels described in
the model and other means of operationalizing the
levels of awareness are necessary. A recent study doc-
umented a strong association between emergent and
anticipatory awareness.51
This model was constructively criticized and
expanded on by Toglia and Kirk.91 Their model, the
Dynamic Comprehensive Model of Awareness, sug-
gests a dynamic rather than a hierarchic relation-
ship. The model proposes a dynamic relationship
among knowledge, beliefs, task demands, and the
context of a situation based on the concept of meta-
cognition. This model differentiates between meta-
cognitive knowledge or declarative knowledge and
beliefs about your abilities prior to the task (incor-
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
situations

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
of tasks (i.e., during task performance), which inte-
grates aspects of emergent and anticipatory aware-
ness (Figure 4-3). A study that incorporated Toglia
and Kirk’s91 model into a comprehensive, multi-
dimensional approach to assessment of impaired
self-awareness supported the authors’ categoriza-
tion of awareness into metacognitive knowledge
versus online awareness.57
Finally, Fleming and Strong27 discuss a three-
level model of self-awareness:
1. Self-awareness of the injury-related deficits them-
selves such as cognitive, emotional, and physical
impairments (i.e., knowledge of deficits).
2. Awareness of the functional implications of
­deficits for independent living.
3. The ability to set realistic goals; the ability to
­predict one’s future state and prognosis.
Measuring Awareness
Most authors recommend that self-awareness should
be evaluated before initiating an intervention pro-
gram focused on retraining living skills. Findings
from standardized evaluations of self-awareness will
clearly guide intervention choices. For example, a
person who exhibits insight into an everyday mem-
ory deficit may be a candidate for teaching compen-
satory strategies such as using a diary or notebook
(see Chapter 9). However, a person who does not
realize he or she is presenting with a severe unilat-
eral neglect may not be able to learn compensatory
strategies but may require environmental modifica-
tions (e.g., all clothing hung on the right side of the
closet) to improve everyday function (see Chapter
6). In addition, ascertaining the level of insight to a
disability is one factor that may determine how moti-
vated one is to participate in the rehabilitation pro-
cess. In the most simplistic interpretation, one must
be aware and concerned about a deficit in everyday
function to be motivated to participate in what may
be a long and difficult rehabilitation process.
A variety of assessment measures are typically
recommended to ascertain a person’s level of self-
awareness, including questionnaires (self or clinician
rated); interviews; rating scales; functional observa-
tions; comparisons of self-ratings and ratings made
by others such as significant others, caretakers, or
rehabilitation staff; and comparisons of self-ratings
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
and cons58,81 and there is no universally accepted
method to assess the construct of awareness or
lack thereof. In addition, naturalistic observations
can provide further information related to how
decreased awareness interferes with performance
of everyday tasks. Tools such as the Assessment of
Motor and Process Skills,24,25 the Naturalistic Action
Test,36 and the Árnadóttir OT-ADL Neurobehavioral
Evaluation (A-ONE)3,4 are recommend (see Chapter
1) for further information regarding these outcome
measures.
Simmond and Fleming77 summarize that a
comprehensive and clinically relevant assessment
should:
• Be preceded by an assessment of intellectual
awareness (e.g., the Self-Awareness of Deficits
Interview as discussed following) as intellectual
awareness seems to be a prerequisite to online
awareness.
• Allow a client to rate his or her own performance
before, during, and after the assessment.
• Use meaningful activities.
• Use activities that allow enough flexibility to
challenge clients.
• Be goal focused. The assessment findings should
be used to work toward acceptance of a disability
followed by interventions to improve function.
Sohlberg further suggests that five assessment
questions should be answered to comprehensively
manage a lack of awareness. Sohlberg’s sugges-
tions for resources to answer each question follow
as well80:
1. What is an individual’s knowledge or understand-
ing of strengths and deficits? Sohlberg80 suggests
gleaning information from standardized ques-
tionnaires and rating scales as well as from inter-
views with the client and significant others.
2. How much of the problem is denial versus organi-
cally based unawareness? This complicated ques-
tion may be answered via a review of medical
history, cognitive assessment, standardized
questionnaires and rating scales, interviews with
the client and significant others, observations
(strategy use, use of prediction, self-evaluation,
and error response), and response to feedback.
As described earlier, Prigatano and Klonoff ’s65
Clinician’s Ratings Scale for Evaluating Impaired
Self-Awareness and Denial of Disability After
Brain Injury may be a useful tool to assist in
answering this question (see Figure 4-1).
3. Is unawareness generalized or modality specific and
does it accompany other cognitive impairments?
Similar to the previous question, Sohlberg80
­recommends collecting data from multiple
sources including a review of medical history,
cognitive assessment, standardized question-
naires and rating scales, interviews with the client
and significant others, and observations (strat-
egy use, use of prediction, self-evaluation, error
response, and response to feedback).
4. Does the individual consciously or unconsciously
accommodate changes in functioning? This ques-
tion may be answered via interviews with the
client and significant others, observations (strat-
egy use, use of prediction, self-evaluation, error
response, and response to feedback).
5. What are the consequences of awareness? Similar
to question four, this may be answered via inter-
views with the client and significant others, and
through observations (strategy use, use of predic-
tion, self-evaluation, error response, and response
to feedback).
The following paragraphs review a variety of
standardized assessments that provide clinicians
with objective data regarding impairments related
to awareness.
The Self-Awareness of Deficits Interview (SADI)30,78
is an interviewer-rated structured interview used to
obtain quantitative and qualitative data on the sta-
tus of self-awareness after brain injury. Specifically it
assesses a client’s level of intellectual awareness (the
ability to understand that a function is decreased from
the premorbid level and to recognize implications of
deficits). It includes three areas for questioning.
1. Self-awareness of deficits
2. Self-awareness of functional implications of
deficits
3. Ability to set realistic goals
Responses are rated on a 4-point scale (0 indicat-
ing no disorder of self-awareness, whereas 3 indicates
a severe disorder of self-awareness). More recently,
checklists that are filled out by significant others and
staff have been added to the SADI to assist in an over-
all understanding of the client’s awareness and to assist
with assigning scores (Figure 4-4 and Table 4-4).
The Self-Regulation Skills Interview (SRSI)55 is a
semistructured clinician-rated interview. Based on
the model by Crosson and associates18 discussed ear-
lier, the tool includes six questions that assess meta-
cognitive or self-regulation skills. The six questions
are applied to a main area of difficulty related to
everyday living (e.g., memory loss, poor attention
or concentration, etc.) as identified by the client.
The tool provides three indices: an awareness index,
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?

Prompts
Physical abilities (e.g., movement of arms and legs, balance, vision, endurance)?
Memory/confusion?
Concentrations?
Problem-solving, decision-making, organizing and planning things?
Controlling behavior?
Communication?
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?

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

SCORING

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

Section 1:
Self-awareness of deficits
Section 2:
Self-awareness of functional
implications of deficits
Section 3:
Ability to set realistic goals
Are you any different now compared
with what you were like before
your accident?
Does your brain injury have any
effect on your everyday life?
In what way?
What do you hope to achieve in the
next 6 months?
Do you think your brain injury will
have any effect on your life in 6
months’ time?
Please indicate whether your relative/friend/client
experiences any difficulties in the following areas
(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
injury?
Does your relative/friend/client experience any
difficulties in the following areas: driving, work,
risk-taking behaviors?
What type of support/assistance do you feel that
your relative/friend/client needs?
What does your relative/friend/client hope to
achieve in the next 6 months?
Do you believe that such goals are realistic? Why or
why not?
Have you encountered any difficulty setting realistic
rehabilitation goals in collaboration with your
client? If so, please describe (therapist version
only).

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
difficulty)?”
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
learned?”).

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

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-
ing and intellect, orientation, memory, speech and
language, and visual perception, and the client’s
opinion of his or her performance in the tests and
ability to return to normal activities. Unawareness
is determined by the discrepancy between the cli-
ent’s description of his or her abilities and mea-
surement of those abilities based on findings from
standardized neurologic and neuropsychological
instruments (Box 4-1).
The Assessment of Awareness of Disability
(AAD)44,84 is an assessment based on a semistruc-
tured interview, which is used in conjunction
with the Assessment of Motor and Process Skills
(AMPS)24,25 (see Chapter 1). It consists of general
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
III. A
 wareness of impairments of intellect or “thinking
have a stroke?”; (for HT patients) “Did you have an accident
ability”
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?”
SCORING
SCORING
3. Patient describes clear thinking without any notable
3. Patient explicitly denies the primary reason for
changes from the normal state.
hospitalization.
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?”
SCORING
SCORING
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.
V. Awareness of memory impairment
Ask, “Are you having any trouble with your memory?”
SCORING
3. Patient denies any problems or changes in memory.
2. Patient describes mild problems with memory, but denies
any significant problems with disorientation of memory.
1. Patient describes significant problems with memory.
VI. Awareness of speech or language problems
Ask, “How is your speech? Has it been affected at all? Do
you have any difficulty understanding what other people
say?”
SCORING
3. Patient denies any speech or language problems.
2. Patient describes mild speech or language problems
(e.g., word finding problems, slurring).
1. Patient complains of impaired comprehension, aphasic
speech, or severe dysarthria.
VII. Awareness of visual perceptual problems
Ask, “Are you having any trouble with your vision?”
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
after performance of each AMPS task (Box 4-2).
Similar to the AMPS, the AAD was developed to be
used with a client-centered and top-down approach
in intervention planning (see Chapter 1). The AAD,
in conjunction with the AMPS, is used to identify
areas in occupational performance of which the cli-
ent is more or less aware. It measures awareness of
disability by assessing the discrepancy between the
observed level of skill and the experience reported
by the person being tested. It provides information
for selecting, planning, and implementing different
intervention strategies. The AAD is also used for
measuring improvements in awareness of disabil-
ity over time. Preliminary testing of the instrument
was conducted with those living with a stroke.
Although most assessments that use question-
naires or interviews only measure intellectual
awareness, there are fewer standardized measures
that incorporate measures of online (anticipatory
and/or emergent) awareness).77 An exception is the
Self-Regulation Skills Interview described earlier.  with controls. In addition, despite making more
It is typically recommended that online awareness
be assessed via observations of task performance
coupled with questions from the clinician.77
SCORING
3. Patient denies any problems with visual perception.
2. Patient describes mild problems with visual perception.
1. Patient complains of significant visual perception impairment.
VIII. Posttest questions: Awareness of quality of test perfor-
mance and ability to return to normal activities
Ask (1) “How do you think you did on these tests today?”
(2) “Based on how you are doing now, do you think you
will be able to return to your normal activities in the next
several weeks?” (Specify activities based on the patient’s
current circumstances, i.e., employment, hobbies, activities
or daily living.)
SCORING
3. Patient indicates that test performances were normal
and that there will be no problem returning to normal
activities.
2. Patient indicates that either (a) test performance was
defective, or (b) that there will be difficulty returning to
normal activities, but not both.
1. Patient indicates that test performance was defective and
that there will be difficulty returning to normal activities
in the next several weeks.
For example, O’Keeffe and coworkers51 measured
online emergent awareness via asking participants
to indicate each time they made a mistake by say-
ing the word “hit” to demonstrate awareness of the
error during a cognitive task. The same researchers
assessed anticipatory awareness by having partici-
pants being tested predict their performance and
then compared the discrepancy between predicted
performance and actual performance using the
formula [(Prediction – performance)/prediction
× 100].
Hart and colleagues36 examined those with
brain injury as they completed everyday activities.
Errors on these tasks was scored as to whether
the subject corrected it and whether the subject
otherwise demonstrated awareness of the error.
Error scores were also compared with subjects’
responses to a questionnaire in which they rated
their own performance. The authors found that
those with TBI corrected and showed awareness of
proportionally fewer of their errors as compared
errors than control subjects, those with TBI did
not rate themselves as performing more poorly
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
4 p = The client has a completely realistic opinion about his
or her disabilities (can describe exactly his or her difficulties in
the Assessment of Motor and Process Skills [AMPS] task).
3 p = The client has a realistic opinion about his or her
disabilities in general, but cannot describe the difficulties
in detail.
2 p = The client has a somewhat unrealistic opinion
about his or her abilities (overvalues his or her abilities or
underestimates his or her disabilities).
1 p = The client has a very unrealistic opinion about his
or her abilities (greatly overvalues his or her abilities or
greatly underestimates his or her disabilities).
0 p = The client completely denies his or her disabilities.
Test Items (Questions)
1. How do you think you managed to perform the task if
you compare it with how you used to manage at home,
before you had your stroke?
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
be reliably measured during naturalistic action.
Jehkonen and associates42 recently reviewed the
methods used to assess anosognosia for noncognitive
impairments after stroke. Their review highlighted
many inconsistencies related to assessment. The most
commonly used assessments are discussed in the fol-
lowing paragraphs. The Anosognosia Scale suggested
by Bisiach and colleagues9 is frequently used to objec-
tify lack of awareness related to motor involvement
(hemiplegia) and visual field deficits after stroke. The
rating scale is as follows:
• Grade 0 (no anosognosia): The disorder is sponta-
neously reported or mentioned by clients follow-
ing a general question about their complaints.
• Grade 1: The disorder is reported only follow-
ing a specific question about the strength of the
client’s limbs
• Grade 2: The disorder is acknowledged only after
demonstrations through routine techniques of
neurologic examination
• Grade 3: No acknowledgment of the disorder
can be obtained
Cutting’s Anosognosia Questionnaire19 was
developed for the purposes of studying anosog-
nosia in clients with hemiplegia after stroke. The
instrument consists of general questions concern-
ing the disease and specific questions concerning
the affected limb.
2. Can you describe whether you experienced any specific
difficulties during the performance (in specific steps of
the task)?
3. Can you describe how you needed to do the task in a new
way compared with how you used to do it at home?
4. Can you describe how you managed to use your left and
right hand in this task? Did you have any difficulties?
5. Can you describe how you managed to move or trans-
fer your body during the task performance (stand, walk,
or use the wheelchair)? Did you have any difficulties? (If
transferring is not included in the AMPS task, the occupa-
tional therapist (OT) should ask how the client managed
to transfer when he or she came into the room before
the AMPS task).
6. Did you have any difficulties in remembering what you
should do or how you should organize the task, or to do
the steps in the right order?
7. Did you have any problems in seeing, finding, or locating
the objects you needed to use in the task?
• Why are you here?
• What is the matter with you?
• Is there anything wrong with your arm or leg?
• Is it weak, paralyzed, or numb?
• How does it feel?
• What is this? (arm picked up)
• Can you lift it?
• You clearly have some problem with this?
• Can’t you see that the two arms are not at the
same level? (asked to lift arms)
• Do you ever feel that it belongs to someone else?
• Do you ever call it names?
• Do you ever feel a strange arm lying beside you,
separate from the real arm?
Starkstein and colleagues’82 Anosognosia Ques­
tion­naire was developed to objectify anosognosia
for motor and visual deficits. The tool consists of
six general questions about the client’s motor and
visual deficits: Why are you here? What is the mat-
ter with you? Is there anything wrong with your
arm or leg? Is there anything wrong with your eye-
sight? Is your limb weak, paralyzed, or numb? and
How does your limb feel? In addition, it includes
five questions that are used when denial is elicited:
What is this? (arm picked up) Can you lift it? You
clearly have some problem with this? Can’t you see
that the two arms are not at the same level? (asked
to lift both arms), and Can’t you see that you have
a problem with your eyesight? (asked to ­ identify
90 cognitive and perceptual rehabilitation: Optimizing function
f­ inger movements in and out of the abnormal
visual field). Responses are rated as 1, no anosog-
nosia (current disorder spontaneously reported or
mentioned after a general question about the cli-
ent’s complaint); 2, mild anosognosia (current dis-
order reported only after a specific question about
the strength of the client’s limb or the presence
of visual field deficits); 3, moderate anosognosia
(current disorder acknowledged only after its dem-
onstration through the routine techniques of neu-
rologic examination); and 4, severe anosognosia
(no acknowledgment of the disorder after asking
the client about specific impairments and demon-
strating the existence of either motor or visual field
deficits).
Subsequent chapters will highlight assessments
that are used to ascertain awareness for specific
impairments such as the Catherine Bergego Scale5,7
to assess the awareness of the effect of neglect on
daily activities, the Dysexecutive Questionnaire14,95,96
to ascertain awareness related to dysexecutive symp­
toms, and the Cognitive Failures Questionnaire (see
Chapters 6, 8 and 10).13 Table 4-6 gives a summary
of assessments.
Interventions
Although most researchers and scholars agree that
interventions focused on improving awareness are
critical to maximize rehabilitations and that greater
awareness of deficits is associated with better treat-
ment outcomes,52 others have documented func-
tional changes via task-specific treatment without
concurrent improvements in awareness. The fol-
lowing paragraphs expand on these points. Overall,
there is a lack of empirical studies that have exam-
ined the effectiveness of various interventions
aimed at improving awareness. In addition, many
of the published studies have not included func-
tional outcomes.
Improving Awareness Using Occupation
Tham and associates86 developed an interven-
tion to improve awareness related to the effect of
neglect (see Chapter 6) on functional performance.
Purposeful and meaningful (for the participant)
daily occupations were used as therapeutic change
agents to improve awareness of disabilities. Specific
interventions included encouraging the ­participants
to choose motivating tasks as the modality of inter-
vention and discussions around task performance.
Examples include:
• Encouraging the participants to describe their
anticipated difficulties.
• Linking their earlier experiences of disability to
new tasks.
• Planning how they would handle new situations.
• Asking the participants to evaluate and describe
their performance.
• Asking participants to think about whether they
could improve their performance by performing
the task in another way.
• Providing feedback about the observed difficul-
ties including verbal feedback, discussion and use
of compensatory techniques that could improve
task performance.
• Providing opportunities for further task practice
using newly learned compensatory techniques.
• Utilizing video feedback to improve awareness
(see below).
• Utilizing interviews to reflect on and heighten
awareness.
Using this approach, awareness of disabilities and
ADL ability improved in all four participants, unilat-
eral neglect decreased in three participants, and sus-
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-
mance of ADL in clients with unilateral neglect.
Fleming and coworkers26 completed a pilot study
examining the effect of an occupation-based inter-
vention program on the self-awareness and emo-
tional status of four men after acquired brain injury.
Each participant received an individualized program
that focused on the performance of three client-
chosen occupations (e.g., writing a job application,
budgeting, meal preparation, playing lawn bowl-
ing, cooking with one hand, etc.) for which they had
decreased awareness according to significant oth-
ers. The intervention was based on Toglia’s multi-
contextual approach88,90 (see Chapter 1). Techniques
included providing a nonthreatening environment to
build positive therapeutic alliances, having the par-
ticipants analyze underlying skills, self-predict, self-
evaluate preoccupation and postoccupation, setting
“just the right challenge,” supported and structured
­occupational performance, brain injury education,
timely and nonconfrontive verbal feedback in a sand-
wich format (negative comments are preceded and
followed by positive feedback), and video feedback.
Repeated measures of participants’ self-awareness
and emotional status were taken preintervention and
postintervention, and analyzed descriptively. The
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
available

(Continued)
 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
functioning
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
tests
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)
performance

B ergeg o, 19957 Catherine Bergego Scale (CBS)
Azouvi, 20035 Examines the presence of neglect
related to direct observation
of functional activities such
as grooming, dressing,
feeding, walking, wheelchair
navigation, finding belongings,
positioning self in a chair, etc.
Wilson et al, Dysexecutive Questionnaire
199695 (DEX)
Burgess, et al, 20-item questionnaire sampling
199614 everyday symptoms
associated with executive
function impairments;
self-rating and ratings by
significant others versions are
available
Broadbent et al, Cognitive Failures Questionnaire
198213 Self-report measure of the
frequency of lapses of
attention and cognition in
daily life
Adults with unilateralBoth conventional statistics
neglect and Rasch analysis
suggest that the CBS
is valid, and that the
10 items define a
homogeneous construct
Concurrent validity:
correlates well with pen-
and-paper tests; more
sensitive than pen-and
-paper tests
Those presenting Scores by independent
with executive raters correlated
dysfunction significantly with both
secondary to subtests and overall
neurologic scores on the Behavioral
disorders such Assessment of the
as head injury, Dysexecutive Syndrome
stroke, Parkinson’s (BADS)
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
well
Used with multiple Predicts car accidents,
populations workplace safety,
including those falls, etc.
with brain injuries
Chapter 4  Self-Awareness and Insight: Foundations for Intervention
Interrater: 0.59-0.99 Activity limitations Has been used as a
self-assessment with
results compared with
therapist ratings to
objectify anosognosia
(lack of awareness)
Test-retest: 0.7 using a Impairments assessed DEX-C is available to use
Huntington’s disease during reflection of with children
sample everyday functioning Self-rating and ratings by
Cronbach’s alpha = >0.8 significant others are
using a sample of those compared to ascertain
with Parkinson’s disease level of awareness
Stable test-retest reliability Activity limitations Includes items related to
memory, attention, and
executive dysfunction
Self-rating and ratings by
significant others are
compared to ascertain
level of awareness
(Continued)
93

Table 4-6 Recommended Outcome Measures of Awareness—Cont’d
Author Instrument
Árnadóttir, 19903; A-ONE:
20044 Árnadóttir Occupational Therapy-
ADL Neurobehavioral Evaluation
Structured observation of
basic activities of daily living
(ADL) including feeding,
grooming and hygiene,
dressing, transfers and
mobility to determine the
effect of multiple underlying
impairments, neglect on these
tasks
Fisher, 200324,25 Assessment of Motor and
Process Skills (AMPS),
An observational assessment that
is used to measure the quality
of a person’s ADL assessed
by rating the effort, efficiency,
safety, and independence of
16 ADL motor and 20 ADL
process skill items
Includes choices from 85 tasks
Population Validity
16 years and older Content: via expert review
with central and literature review
nervous system Concurrent: Barthel Index,
involvement Katz Index, Mini Mental
Status Examination
Valid for multiple diagnoses
including: stroke, brain
tumor, dementia, etc.
3 years old and up Strong validity and
and difficulties appropriate to use with
related to multiple diagnoses and
occupational cultures
performance
94
cognitive and perceptual rehabilitation: Optimizing function
Dimension Based
on International
Classification of
Reliability Function (ICF) Comments
Inter-rater: 0.84 Impairments and Includes item related to
Test-retest: 0.86 activity limitations insight
Use behavioral
observations
Scoring criteria captures
ability to self-correct
or not.
Requires training.
Cronbach’s alpha range Activity limitations Provides information
from 0.74 to 0.93 related to how
Test-retest range from 0.7 impairments of motor
to 0.91 and process skills affect
everyday living
Requires training
 Chapter 4  Self-Awareness and Insight: Foundations for Intervention 95
s­ upport for the effectiveness of the program in
facilitating participants’ self-awareness, although
baseline and follow-up data indicated a complex and
inconsistent picture. Of note is that slight increased
anxiety was found to accompany improvements in
participants’ self-awareness in all four cases and slight
increases in depressive symptoms were noted for three
participants. These findings are consistent with the
literature discussed earlier focused on the relationships
between emotional status and awareness as well as the
interconnections of denial and self-awareness.
Landa-Gonzalez45 describes a multicontextual88,90
(see Chapter 1), community reentry occupational
therapy program focused on awareness training
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
injury. His impairments consisted of decreased
insight, planning, mental flexibility, problem solving,
and memory. The client showed some level of intel-
lectual awareness but his emergent and anticipatory
awareness were severely impaired. Interventions
were carried out in the home and community
and consisted of metacognitive training, explora-
tion and use of effective processing strategies, task
gradations, and practice of functional activities in
multiple environmental contexts. Awareness train-
ing was carried out in conjunction with daily activ-
ities such as self-care, cooking, household chores,
banking, shopping, planning vacations, and so on.
Specific strategies such as self-prediction using a
rating scale, self-monitoring for error detection, role
reversal, and the use of checklists to facilitate orga-
nization were used. Feedback was given related to
planning and monitoring skills, and discrepancies
between predicted scores and actual performance
were used. Results showed improvements in the cli-
ent’s awareness level, enhancement of occupational
function, increased satisfaction with performance,
and a decrease in the level of attendant care.
Video Feedback to Improve Awareness
Video feedback has been used to increase awareness
of errors made secondary to unilateral neglect (see
Chapter 6). Tham and Tegner87 compared the effects
of a video procedure and a conventional verbal pro-
cedure in giving subjects feedback on their neglect
behavior during a contrived task, the baking tray
task. After watching the video of their performance,
subjects were asked to comment on their own per-
formance and results, as was the therapist. In addi-
tion, they were asked to develop strategies to improve
performance, and the therapist gave ­suggestions on
using tactile discrimination with the right hand to
find the left edge of the tray and systematically place
the “buns” from left to right. Both groups were pro-
vided with the same compensatory strategy. Short
term follow-up three hours later revealed that the
video feedback group improved significantly on the
baking tray test without generalization to other mea-
sures, whereas conventional training had no effect
on the task or on other neglect measures.
Soderback and colleagues79 had similar results
in an earlier study that focused on functional tasks.
Using a single-case research experimental pretest,
posttest, and follow-up design, three household
tasks were assessed, and the clients’ neglect behav-
During the intervention, the subjects watched the
film, which was stopped by the occupational ther-
apist where the neglect behavior was significant.
Through dialogue, the subjects were led to perceive
and interpret their neglect behavior, and strategies
for relearning and remediation were recommended.
The program was deemed to be effective for relearn-
ing functional tasks.
Use of a Game Format
Zhou and coworkers99 tested the feasibility of using
a game format to teach information about acquired
brain injury. The authors examined three adult males
with brain injuries as they were trained in knowl-
edge of brain injury residuals, using a trivia game
format to present training information. Questions
were divided into categories that represented typi-
cal impairments and residuals after brain injury
(e.g., “What difficulty might you have if you can-
not remember information presented a few seconds
ago?” and “What does decreased frustration toler-
ance mean?”). Using a multiple baseline experimen-
tal design, the study found that all three participants
increased their percentage of correct responses in
the study areas of: behavior emotion, cognition,
communication, and physical and sensory residuals.
Further analyses revealed that subjective data related
to the effect of these improvements on participant
functioning were not consistent.
Chittum and associates16 also used a board game
format to teach awareness to adults with acquired
brain injury who exhibited serious unwanted behav-
iors. It used an individualized training package based
on specific needs of each participant in conjunc-
tion with a game format in order to more specifi-
cally target individual client awareness of personal
cognitive and behavioral deficits. The authors felt
96 cognitive and perceptual rehabilitation: Optimizing function

that a focus on individual needs would not only be
more effective than focusing on general brain injury
behaviors but would reduce the time of the inter-
vention and therefore the frustration of participants.
Training focused on knowledge (e.g., “True or false:
Immediate memory includes recalling things that
happened hours ago”), comprehension (e.g., “How
does having decreased problem-solving skills affect
your life, and give an example from your life that
occurred recently”), and application using role-play
exercises (e.g., “Pretend I am your employer and I
just gave you a warning about not following through
with the task I had asked you to do several days
ago. How would you explain your failure to follow
through given your deficits?”). The game was pre-
ceded by a short group information and discussion
period teaching the members the behavioral or cog-
nitive deficit areas that affected the group. Correct
answers were reinforced in an individualized fash-
ion. Generalization was probed by asking questions
regarding behaviors that had not yet been taught. All
three participants responded favorably to training,
as evidenced by increases in percentage of questions
answered correctly during the game sessions and in
pregeneralization and postgeneralization probes in
both cognitive and behavioral categories.
Promoting Error Awareness and Self-Correction
During Functional Tasks
Ownsworth and colleagues54 used a single-case experi-
mental design to test an intervention to improve daily
function of a 36-year-old man 4 years after a severe
traumatic brain injury who demonstrated ­ long-term
a­ wareness deficits. The intervention involved a meta-
cognitive contextual intervention based on a con-
ceptualization of neurocognitive, psychological, and
socioenvironmental factors that may contribute to
awareness deficits. The intervention focused on improv-
ing error awareness and self-correction during cli-
ent-selected goals of cooking at home and performing
volunteer work. Interventions included the following:
• A systematic feedback approach was used to
target error behavior (self-monitoring and
­correction). Feedback was based on the “pause/
prompt/praise” technique.49 Specifically this
included delayed responses to errors detected by
the observer to provide an opportunity for the
participant to self-correct or attempt to correct,
using nonspecific prompts (e.g., “Can you stop
and tell me what you are doing?”) if error cor-
rection did not occur after the pause, and the
use of a specific prompt (e.g., “Can you check
the recipe and see what goes in the mixing bowl
first?”) if correction did not occur after the non-
specific cue. Of note is that Toglia89 also recom-
mend the use of systematic cues that were graded
from general to more specific as a method to cue
for insight, error detection, and strategy devel-
opment (Table 4-7).
• The therapists provided opportunities for the
client to identify and correct his errors or receive
systematic external prompts for correction as
above.
• Education was provided for the client’s social
supports.
• Opportunities for task-specific cooking practice
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?”
or “Tell me why you chose this answer/procedure.”
“That is not correct. Can you see why?”
“It is not correct because…”
“Try this [strategy]” (e.g., going slower, saying each step
out loud, verbalizing a plan before starting, or using a
checklist).
Task is altered. “Try it another way.”
Refocuses client’s attention to task performance and error
detection. Can client self-correct with a general cue?
Provides general feedback about error but is not specific.
Can client find error and initiate correction?
Provides specific feedback about error. Can client correct error
when it is pointed out?
Provides client with a specific, alternate approach. Can client use
strategy given?
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
observed his mother cooking as she made similar
errors. The client was encouraged to describe his
mother’s errors and corrective actions. This was
followed by the client making the same meal.
• An electronic timer was used to alert the client
to periodically check his recipe. The timer was
eventually withdrawn.
• Videotape feedback was used to allow the client
to observe his performance, identify his errors,
and describe corrective actions.
• Similar techniques were used to provide feed-
back on volunteer work activities.
The authors’ chosen outcome measures included
behavioral observation of error behavior and stan-
dardized awareness measures. The client demon-
strated a 44% reduction in error frequency and
increased self-correction. Although no spontane-
ous generalization was evident in the volunteer
work setting, specific training in this environment
led to a 39% decrease in errors. The client later
gained paid employment and received brief meta-
cognitive training in his work environment. Also
of note is that the client’s global self-knowledge of
deficits assessed by self-report was unchanged after
the program. The authors concluded that the study
provides preliminary support for a metacognitive
contextual approach to improve error awareness
and functional outcome in real-life settings.
An Awareness Intervention Program
Cheng and Man15 developed and evaluated a sys-
tematic intervention program for the management
of impaired self-awareness in people with trau-
matic brain injury. The authors randomly assigned
subjects to an experimental group (an Awareness
Intervention Program) and a control group (con-
ventional rehabilitation program) according to their
admission sequence. The Awareness Intervention
Program was delivered individually and focused on
the following:
1. Awareness of knowledge of personal deficits via
education and concrete and extensive feedback.
Specific topics included knowledge of disease
and resultant physical, cognitive, and functional
conditions. Participants were asked to report on
their conditions, and feedback was given to rein-
force the true clinical presentation.
2. Application of knowledge of deficits related
to real-world function via experiential exer-
cises to enhance awareness of changes in abil-
ity. The participants were asked to predict their
­ erformance on a functional task before per-
p
forming it. During task performance, the par-
ticipants were reminded to monitor their
performance. Feedback was given on comple-
tion of the task and participants were asked to
set short-term goals based on their performance
of the task.
3. Practicing the processes related to self-awareness
such as self-prediction, self-monitoring, judgment,
and practice of goal setting as described earlier.
Preintervention and postintervention outcome
measures taken from the two groups were com-
pared. The participants in the experimental group
demonstrated significant improvement in their
level of awareness as compared with the control
group. However, the functional outcomes of the
participants in experimental group did not show
significant differences. The authors concluded that
their program promoted improvement in the level
of self-awareness of people with traumatic brain
injury and that new programs can be further devel-
oped to extend carryover treatment effects to func-
tional improvement in daily activities.
Managing a Lack of Awareness of
Memory Deficits
Rebmann and Hannon68 examined the use of an
intervention for reducing unawareness of memory
deficits in adults with brain injury. The authors
defined unawareness as high predicted test scores
on a brief multiparametric memory test, relative
to actual test scores. The intervention consisted
of an estimation technique, feedback, and explicit
positive reinforcement for decreases in discrep-
ancies between predicted and actual scores to
reduce unawareness. During the intervention
phase, participants were shown what they pre-
dicted related to test performance as compared
with actual performance on the subtests (e.g.,
number of words recalled). Positive reinforce-
ment consisted of verbal praise and lottery tickets
contingent on decrease in the difference between
predicted scores and actual scores compared with
previous sessions. Verbal feedback using a prob-
lem-­solving approach and encouraging clients to
figure out why their predictions did not match
performance was used when differences between
scores were found. At the end of the intervention,
differences between participants’ predicted and
actual scores decreased over time, indicating that
participants were able to match their predictions
and their performance.
98 cognitive and perceptual rehabilitation: Optimizing function
Schlund69 examined an intervention for self-
awareness related to memory impairment, spe-
cifically, the effects of practice and feedback on
self-report and remembering. Several prospective
and retrospective self-reports were obtained by the
author, to allow an examination of reporting about
past or future recall. A memory questionnaire was
presented and the subject estimated the percentage
of correct answers attained or percent correct that
would be attained on the recall task. Each session
began with a 24-hour retrospective report (“What
percent correct did you get on the recall task yes-
terday?”). Next, a prospective report was obtained
(“What percent correct will you get on the recall
task today?”). The recall test was then completed
without feedback and followed by a retrospective
report (“Now that we have finished, what percent
correct did you get on the recall task?”). The thera-
pist then reviewed the subject’s performance, pro-
vided correct answers, and reviewed the accuracy of
reporting. Finally, after the feedback and review, a
prospective 24-hour report was obtained (“When
we do the recall task again tomorrow, what percent
correct will you get?”). Results showed that recall
improved and the magnitude of report-recall dif-
ferences was reduced with practice and feedback.
These studies related to awareness and memory
used contrived laboratory-type tasks. It is recom-
mended to instead use similar intervention proce-
dures but in the context of meaningful tasks such
as remembering a grocery list or a series of errands
that must completed in a day.
Behavioral Interventions
Bieman-Copland and Dywan8 argue that ­traditional
awareness rehabilitation approaches that make use
of direct feedback and education are often ineffective
because “they elicit more elaborated and entrenched
confabulatory beliefs as individuals are forced to
defend their position.” They tested an approach for
treating people with ­ anosognosia that combines
implementation of behavioral therapy techniques
with the development of a supportive and collabor-
ative therapeutic alliance. They presented case data
from a woman with profound anosognosia follow-
ing a TBI with right frontal involvement.
Targeted behaviors (reducing perseverative phone
calls and reducing sexually explicit and sugges-
tive behaviors) were decreased through behavioral
interventions, but the emphasis of treatment was on
the formation of trusting, nonconfrontational ther-
apeutic relationships. To decrease the number of
­ erseverative phone calls (which were documented
p
as up to 90 per day), a time-based strategy was used
in which the person was provided two half-hour
periods for placing phone calls and was encouraged
to generate reasons acceptable as to why these limits
were appropriate (e.g., polite to others). To limit sex-
ually explicit and suggestive behaviors, daily oppor-
tunities for feedback about the person’s behavior
were instituted focused on how others may perceive
specific instances. The staff did not link these behav-
iors to the brain injury but instead focused on that
these behaviors might be tolerated in a large city but
would not be appropriate or polite for a small town
such as where the rehabilitation facility was located.
The staff did not confront the client about her brain
injury and they did not collude with her confabula-
tions that she was not brain injured or that she had
no problems. The phrase “We’ll have to agree to dis-
agree on this point” was used frequently during the
intervention. Marked reductions in inappropriate
behaviors were achieved along with a return to sup-
portive community living. Of note is that despite
that positive behavior changes, there was no change
in level of awareness.
The authors concluded that a nonconfrontive
behavioral approach could be successful and is con-
sistent with the view that poor awareness is based
in altered neural systems. They feel that when con-
frontation is removed, clients do not have to defend
their position and they realize that support makes
them more effective in their day-to-day life, which
becomes further reinforcing. They further state that
“one can no more alleviate anosognosia by having
a person rehearsing their limitations than one can
alleviate amnesia by having clients rehearse word
lists.”
Use of Feedback
Coetzer and Corney17 examined those with trau-
matic brain and stroke to determine the effect
of providing feedback related to the individu-
al’s understanding of the injury (self-­awareness)
on subsequent levels of grief and awareness.
Participants and family members completed stan-
dardized measures of depression, awareness, and
grief, and reported difficulties after brain injury.
Participants were then given feedback regarding
to what extent their ratings differed from family 
members. The main finding of the study was
that feedback of self-awareness assessment data
resulted in a decrease of subjective reports of grief
among participants.
 Chapter 4  Self-Awareness and Insight: Foundations for Intervention 99

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

Box 4-3 Other Suggestions for Improving Awareness

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

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
Neurocognitive factors
Psychological factors
Socioenvironmental context
From Fleming JM, Ownsworth T: A review of awareness interventions in brain injury rehabilitation, Neuropsychol Rehabil 16(4):474-500, 2006.
Specific Factor Contributing to Awareness Deficits
Damage to the right hemisphere or parietal regions
(domain-specific awareness deficits), frontal systems
or diffuse brain injury (global awareness deficits and
difficulty self-monitoring and assimilating experiences into
self-knowledge)
Impaired executive functioning or significant cognitive
impairment contributing to the onset or maintenance of
awareness deficits
Information about self is partially or fully recognized but
may not be disclosed because of premorbid personality
characteristics or coping methods
Information about self is not disclosed because of concerns
about how such information will be used in the referral
context
Individuals have not had relevant information or meaningful
opportunities to observe postinjury changes
Cultural values affect individual’s understanding of the
assessment or rehabilitation process
100
Corresponding Treatment Guidelines and Intervention Components
Select key tasks and environments in which awareness behaviors are most
important within everyday activities and roles
cognitive and perceptual rehabilitation: Optimizing function
Provide clear feedback and structured opportunities to help people evaluate their
performance, discover errors, and compensate for deficits
Focus on habit formation through repetition and procedural or implicit learning
Specifically train for application outside the learning environment. Be realistic: some
people might be taught to recognize a mismatch but not retain this experience or
generalize learning
Group therapy, family education and environmental supports to provide external
compensation
Building the therapeutic alliance to initially get a “foot in the door” with an
individual and validate any frustration or distress
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
Clarify the rationale for the assessment or rehabilitation program and help
the person to identify any concerns (e.g., discuss the pros and cons of the
individual’s being involved in an assessment or rehabilitation program)
Consider the timing of the intervention and need for safe and supportive
opportunities to observe postinjury changes. Educate significant others to
provide appropriate feedback and support. Link people to support or educational
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
 Chapter 4  Self-Awareness and Insight: Foundations for Intervention 101
Ownsworth and coworkers56 investigated a
group support program designed to improve self-
awareness deficits and psychosocial functioning
in those with chronic acquired brain injury. The
group ­ program involved components of cogni-
tive rehabilitation, cognitive-behavioral therapy,
and social skills training. Participants selected
topics significant to their daily life. Specific tech-
niques included problem solving, self-reflection,
role-plays, developing compensatory strategies,
and practice of new behaviors. Components of the
group included an introduction to the topic (e.g.,
memory), defining the topic (e.g., What is mem-
ory?), changes that participants noted after brain
injury, difficulties in everyday life, and strategies
used to overcome everyday difficulties. Group
topics included attention/concentration, mem-
ory, emotions, stress, motivation and goals, work
­pursuits, social/leisure, self-confidence, and asser-
tiveness. Postintervention assessment indicated
that participants had significantly improved lev-
els of self-regulation skills and psychosocial func-
tioning. Relatives reported fewer emotional and
behavioral problems after the group interven-
tion. A 6-month follow-up assessment indicated
that participants had maintained the gains made
during the program. See Box 4-3 and Table 4-8
for further recommended strategies based on the
available published literature.
See Appendix 4-1 for a review of evidence-
based interventions for those living with awareness
deficits.
Review Questions
1. Describe how to begin to differentiate between
decreased awareness and denial.
2. Describe how to structure an intervention
focused on managing monthly bills to increase
awareness of poor short-term memory.
3. Describe the relationship between levels of self-
awareness and the ability to use various com-
pensatory strategies.
4. Design an intervention session using the tech-
niques of self-prediction, role reversal, and goal
setting.
References
1. Abreu BC, Seale G, Scheibel RS, et al: Levels of self-
awareness after acute brain injury: how patients’ and
rehabilitation specialists’ perceptions compare, Arch
Phys Med Rehabil 82(1):49-56, 2001.
2. Anderson SW, Tranel D: Awareness of disease states
following cerebral infarction, dementia, and head
trauma: standardized assessment, Clin Neuropsychol
3:327-339, 1989.
3. Árnadóttir G: The brain and behavior: assessing cor-
tical dysfunction through activities of daily living, 
St Louis, 1990, Mosby.
4. 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/Mosby.
5. Azouvi P, Olivier S, de Montety G, et al: Behavioral
assessment of unilateral neglect: study of the psy-
chometric properties of the Catherine Bergego Scale,
Arch Phys Med Rehabil 84(1):51-57, 2003.
6. Bach LJ, David AS: Self-awareness after acquired
and traumatic brain injury, Neuropsychol Rehabil
16(4):397-414, 2006.
7. 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.
8. Bieman-Copland S, Dywan J: Achieving rehabilitative
gains in anosognosia after TBI, Brain Cogn 44(1):1-5,
2000.
9. Bisiach E, Vallar G, Perani D, et al: Unawareness of
disease following lesions of the right hemisphere:
anosognosia for hemiplegia and anosognosia for
hemianopia, Neuropsychologia 24:471-482, 1986.
10. Bogod NM, Mateer CA, Macdonald SWS: Self-
awareness after traumatic brain injury: a comparison
of measures and their relationship to executive func-
tions, J Clin Exp Neuropsychol 9(3):450-458, 2003.
11. 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.
12. Borgaro SR, Prigatano GP, Alcott S, et al: The
Patient Distress Scale questionnaire: factor struc-
ture and internal consistency, Brain Inj 17(7): 
545-551, 2003.
13. Broadbent DE, Cooper PF, FitzGerald P, et al: The
Cognitive Failures Questionnaire (CFQ) and its
­correlates, Bri J Clin Psychol 21:1-16, 1982.
14. Burgess PW, Alderman N, Emslie H, et al: The dys-
executive questionnaire. In Wilson BA, Alderman N,
Burgess PW, et al, editors: Behavioural assessment of
the dysexecutive syndrome, Bury St. Edmunds, UK
1996, Thames Valley Test Company.
15. Cheng SK, Man DW: Management of impaired self-
awareness in persons with traumatic brain injury,
Brain Inj 20(6):621-628, 2006.
16. Chittum WR, Johnson K, Chittum JM, et al: Road
to awareness: an individualized training package for
increasing knowledge and comprehension of per-
sonal deficits in persons with acquired brain injury,
Brain Inj 10(10):763-776, 1996.
102 cognitive and perceptual rehabilitation: Optimizing function
17. Coetzer BR, Corney MJR: Grief and self-awareness
following brain injury and the effect of feedback as
an intervention, J Cogn Rehabil 19(4):8-14, 2001.
18. Crosson B, Barco PP, Velozo CA, et al: Awareness and
compensation in postacute head injury rehabilita-
tion, J Head Trauma Rehabil 4(3):46-54, 1989.
19. Cutting J: Study of anosognosia, J Neurol Neurosurg
Psychiatry 41(6):548-555, 1978.
20. Dirette D: The development of awareness and the
use of compensatory strategies for cognitive deficits,
Brain Inj 16(10):861-871, 2002.
21. Evans CC, Sherer M, Nick TG, et al: Early impaired
self-awareness, depression, and subjective well-being
following traumatic brain injury, J Head Trauma
Rehabil 20(6):488-500, 2005.
22. Fischer S, Gauggel S, Trexler LE: Awareness of activ-
ity limitations, goal setting and rehabilitation out-
come in patients with brain injuries, Brain Inj 18(6):  for hemiplegia in stroke rehabilitation, Neurorehabil
547-562, 2004.
23. Fischer S, Trexler LE, Gauggel S: Awareness of activ-
ity limitations and prediction of performance in
patients with brain injuries and orthopedic disor-
ders, J Clin Exp Neuropsychol 10(2):190-199, 2004.
24. Fisher AG: Assessment of motor and process skills, vol.
1: development, standardization, and administration
manual, ed 5, Fort Collins, Colo, 2003, Three Star
Press.
25. Fisher AG: Assessment of motor and process skills, vol. 2:
user manual, ed 5, Fort Collins, Colo, 2003, Three
Star Press.
26. Fleming JM, Lucas SE, Lightbody S: Using occupa-
tion to facilitate self-awareness in people who have
acquired brain injury: a pilot study, Can J Occup Ther
73(1):44-55, 2006.
27. Fleming J, Strong J: Self-awareness of deficits follow-
ing acquired brain injury: considerations for rehabil-
itation, Br J Occup Ther 58(2):55-60, 1995.
28. Fleming JM, Strong J: The development of insight
following severe traumatic brain injury: three case
studies, Br J Occup Ther 60(7):295-300, 1997.
29. Fleming J, Strong J: A longitudinal study of self-  45. Landa-Gonzalez B: Multicontextual occupational
awareness: functional deficits underestimated by persons
with brain injury, Occup Ther J Res 19(1):3-17, 1999.
30. 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.
31. 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.
32. Gasquoine PG: Affective state and awareness of
­sensory and cognitive effects after closed head  sustained attention and error awareness in traumatic
injury, Neuropsychology 6(3):187-196, 1992.
33. Goverover Y: Categorization, deductive reasoning,
and self-awareness: association with everyday com-
petence in persons with acute brain injury, J Clin Exp
Neuropsychol 26(6):737-749, 2004.
34. Goverover Y, Chiaravalloti N, DeLuca J: The relation-
ship between self-awareness of neurobehavioral symp-
toms, cognitive functioning, and emotional symptoms in
­multiple sclerosis, Multiple Sclerosis 11(2):203-212, 2005.
35. Hacker DJ: Definitions and empirical foundations.
In Hacker DJ, Dunlosky, J, Graesser AC, editors:
Metacognition in educational theory and practice,
Hillsdale, NJ, 1998, Lawrence Erlbaum.
36. Hart T, Giovannetti T, Montgomery MW, et al:
Awareness of errors in naturalistic action after trau-
matic brain injury, J Head Trauma Rehabil 13(5): 
16-28, 1998.
37. Hart T, Whyte J, Kim J, et al: Executive function and
self-awareness of “real-world” behavior and atten-
tion deficits following traumatic brain injury, J Head
Trauma Rehabil 20(4):333-347, 2005.
38. Hartman-Maeir A, Soroker N, Katz N: Anosognosia
Neural Repair 15(3):213-222, 2001.
39. Hartman-Maeir A, Soroker N, Oman SD, et al:
Awareness of disabilities in stroke rehabilitation—a
clinical trial, Disabil Rehabil 25(1):35-44, 2003.
40. Hartman-Maeir A, Soroker N, Ring H, et al: Awareness
of deficits in stroke rehabilitation, J Rehabil Med
34(4):158-164, 2002.
41. Hibbard MR, Gordon WA, Stein PN, et al: Awareness
of disability in patients following stroke, Rehabil
Psychol 37(2):103-120, 1992.
42. Jehkonen M, Laihosalo M, Kettunen J: Anosognosia
after stroke: assessment, occurrence, subtypes and
impact on functional outcome reviewed, Acta
Neurologica Scandinavica 114(5):293-306, 2006.
43. 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.
44. Kottorp A, Tham, K: Assessment of Awareness of
Disability (AAD), manual for administration, scor-
ing, and interpretation, Stockholm, Sweden, 2005,
Karolinska Institutet, NEUROTEC Department,
Division of Occupational Therapy.
therapy intervention: a case study of traumatic brain
injury, Occup Ther Int 8(1):49-62, 2001.
46. Leathem JM, Murphy LJ, Flett RA: Self- and informant-
ratings on the patient competency rating scale in patients
with traumatic brain injury, J Clin Exp Neuropsychol
20(5):694-705, 1998.
47. Leritz E, Loftis C, Crucian G, et al: Self-awareness
of deficits in Parkinson disease, Clin Neuropsychol
18(3):352-361, 2004.
48. McAvinue L, O’Keeffe F, McMackin D, et al: Impaired
brain injury: implications for insight, Neuropsychol
Rehabil 15(5):569-587, 2005.
49. McNaughton S, Glynn T, Robinson V: Pause, prompt
and praise: effective remedial reading tutoring,
Birmingham, UK, 1987, Positive Products.
 Chapter 4  Self-Awareness and Insight: Foundations for Intervention 103
50. Noe E, Ferri J, Caballero MC, et al: Self-awareness
after acquired brain injury—predictors and rehabili-
tation, J Neurol 252(2):168-175, 2005.
51. O’Keeffe F, Dockree P, Moloney P, et al: Awareness
of deficits in traumatic brain injury: a multidimen-
sional approach to assessing metacognitive knowl-
edge and online awareness, J Clin Exp Neuropsychol
13(1):38-49, 2007.
52. Ownsworth T, Clare L: The association between
awareness deficits and rehabilitation outcome fol-
lowing acquired brain injury, Clin Psychol Rev 26(6):  York, 1991, Oxford University Press.
783-795, 2006.
53. Ownsworth T, Fleming J: The relative importance
of metacognitive skills, emotional status, and exec-
utive function in psychosocial adjustment follow-
ing acquired brain injury, J Head Trauma Rehabil
20(4):315-332, 2005.
54. Ownsworth T, Fleming J, Desbois J, et al: A meta-
cognitive contextual intervention to enhance error
awareness and functional outcome following trau-
matic brain injury: a single-case experimental design,
J Clin Exp Neuropsychol 12(1):54-63, 2006.
55. Ownsworth TL, McFarland KM, Young RM:
Development and standardization of the Self-  tency, Brain Inj 12(1):63-68, 1998.
regulation Skills Interview (SRSI): a new ­ clinical
assessment tool for acquired brain injury, Clin
Neuropsychol 14(1):76-92, 2000.
56. Ownsworth TL, McFarland K, Young RM: Self-
awareness and psychosocial functioning follow-
ing acquired brain injury: an evaluation of a group
support programme, Neuropsychol Rehabil 10(5):  73. Sherer M, Hart T, Nick TG: Measurement of impaired
465-484, 2000.
57. Pia L, Neppi-Modona M, Ricci R, et al: The anat-
omy of anosognosia for hemiplegia: a meta-analysis,
Cortex 40(2):367-377, 2004.
58. Port A, Willmott C, Charlton J: Self-awareness fol-
lowing traumatic brain injury and implications for
rehabilitation, Brain Inj 16(4):277-289, 2002.
59. Prigatano GP: Neuropsychological rehabilitation
after brain injury, Baltimore, 1986, Johns Hopkins
University Press.
60. Prigatano GP: Neuropsychological rehabilitation
and the problem of altered self-awareness. In von
Steinbuchel N, von Cramon DY, Poppel E, edi-
tors: Neuropsychological rehabilitation, Berlin, 1992,
Springer-Verlag.
61. Prigatano GP: Anosognosia. In Beaumont JG,
Kenealy PM, Rogers, MJC, editors: The Blackwell dic-
tionary of neuropsychology, Cambridge, Mass, 1996,
Blackwell.
62. 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.
63. Prigatano GP, Altman IM: Impaired awareness of
behavioral limitations after traumatic brain injury,
Arch Phys Med Rehabil 71(13):1058-1064, 1990.
64. Prigatano GP, Borgaro S, Baker J, et al: Awareness
and distress after traumatic brain injury: a relative’s
perspective, J Head Trauma Rehabil 20(4):359-367,
2005.
65. 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.
66. Prigatano GP, Schacter DL: Awareness of deficit after
brain injury:clinical and theoretical implications, New
67. Prigatano GP, Wong JL: Cognitive and affective
improvement in brain dysfunctional patients who
achieve inpatient rehabilitation goals, Arch Phys Med
Rehabil 80(1):77-84, 1999.
68. Rebmann MJ, Hannon R: Treatment of unawareness
of memory deficits in adults with brain injury: three
case studies, Rehabil Psychol 40(4):279-287, 1995.
69. Schlund MW: Self awareness: effects of feedback and
review on verbal self reports and remembering fol-
lowing brain injury, Brain Inj 13(5):375-380, 1999.
70. Sherer M, Bergloff P, Boake C, et al: The Awareness
Questionnaire: factor structure and internal consis-
71. Sherer M, Bergloff P, Levin E, et al: Impaired aware-
ness and employment outcome after traumatic brain
injury, J Head Trauma Rehabil 13(5):52-61, 1998.
72. Sherer M, Boake C, Levin E, et al: Characteristics
of impaired awareness after traumatic brain injury, 
J Clin Exp Neuropsychol 4(4):380-387, 1998.
self-awareness after traumatic brain injury: a com-
parison of the patient competency rating scale and
the awareness questionnaire, Brain Inj 17(1):25-37,
2003.
74. Sherer M, Hart T, Nick TG, et al: Early impaired self-
awareness after traumatic brain injury, Arch Phys
Med Rehabil 84(2):168-176, 2003.
75. Sherer M, Hart T, Whyte J, et al: Neuroanatomic basis
of impaired self-awareness after traumatic brain
injury: findings from early computed tomography, 
J Head Trauma Rehabil 20(4):287-300, 2005.
76. Sherman TE, Rapport LJ, Hanks RA, et al: Predictors
of well-being among significant others of persons
with multiple sclerosis, Multiple Sclerosis 13(20): 
238-249, 2007.
77. Simmond M, Fleming JM: Occupational therapy
assessment of self-awareness following traumatic
brain injury, Br J Occup Ther 66(10):447-453,
2003.
78. 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.
79. Soderback I, Bengtsson I, Ginsburg E, et al: Video feed-
back in occupational therapy: its effects in patients
with neglect syndrome, Arch Phys Med Rehabil
73(12):1140-1146, 1992.
104 cognitive and perceptual rehabilitation: Optimizing function
80. Sohlberg MM: Assessing and managing unawareness
of self, Semin Speech Lang 21(2):135-151, 2000.
81. Sohlberg MM, Mateer CA, Penkman L, et al:
Awareness intervention: who needs it? J Head Trauma
Rehabil 13(5):62-78, 1998.
82. Starkstein SE, Fedoroff JP, Price TR, et al: Anosognosia
in patients with cerebrovascular lesions: a study of
causative factors, Stroke 23:1446-1453, 1992.
83. Stuss DT, Anderson V: The frontal lobes and theory
of mind: developmental concepts from adult focal
lesion research, Brain Cogn 55(1):69-83, 2004.
84. Tham K, Bernsprang B, Fisher AG: Development
of the assessment of awareness of disability, Scand J
Occup Ther 6:184-190, 1999.
85. Tham K, Borell L, Gustavsson A: The discovery of
disability: a phenomenological study of unilateral
neglect, Am J Occup Ther 54:398-406, 2000.
86. Tham K, Ginsburg E, Fisher AG, et al: Training  96. Wilson BA, Evans JJ, Emslie H, et al: The devel-
to improve awareness of disabilities in clients with
unilateral neglect, Am J Occup Ther 55:46-54, 2001.
87. Tham K, Tegner R: Video feedback in the rehabili-
tation of patients with unilateral neglect, Arch Phys
Med Rehabil 78(4):410-413, 1997.
88. Toglia JP: Generalization of treatment: a multicon-
text approach to cognitive perceptual impairment
in adults with brain injury, Am J Occup Ther 45(6):  2005.
505-516, 1991.
89. Toglia JP: Attention and memory. In Royeen CB,
editor: AOTA self-studies series: cognitive rehabilita-
tion, Rockville, Md, 1993, American Occupational
Therapy Association.
90. Toglia JP: A dynamic interactional approach to cog-
nitive rehabilitation. In Katz N, editor: Cognition and
occupation across the life span, Bethesda, Md, 2005,
AOTA Press.
91. Toglia J, Kirk U: Understanding awareness deficits
following brain injury, Neurorehabil 15(1):57-70, 
2000.
92. Trudel TM, Tryon WW, Purdum CM: Awareness of
disability and long-term outcome after traumatic
brain injury, Rehabil Psychol 43(4):267-281, 1998.
93. Wagner MT, Cushman LA: Neuroanatomic and neu-
ropsychological predictors of unawareness of cog-
nitive deficit in the vascular population, Arch Clin
Neuropsychol 9(1):57-69, 1994.
94. Wallace CA, Bogner J: Awareness of deficits: emotional
implications for persons with brain injury and their
significant others, Brain Inj 14(6):549-562, 2000.
95. Wilson BA, Alderman N, Burgess PW, et al:
Behavioural assessment of the dysexecutive syndrome,
Bury St Edmunds, UK, 1996, Thames Valley Test
Company.
opment of an ecologically valid test for assessing
patients with dysexecutive syndrome, Neuropsychol
Rehabil 8(3):213-228, 1998.
97. Wise K, Ownsworth T, Fleming J: Convergent valid-
ity of self-awareness measures and their associa-
tion with employment outcome in adults following
acquired brain injury, Brain Inj 19(10):765-775, 
98. Youngjohn JR, Altman IM: A performance-based
group approach to the treatment of anosognosia and
denial, Rehabil Psychol 34(3):217-222, 1989.
99. Zhou J, Chittum R, Johnson K, et al: The utilization
of a game format to increase knowledge of residu-
als among people with acquired brain injury, J Head
Trauma Rehabil 11(1):51-61, 1996.
 Appendix 4-1
Evidence-Based Practice for Awareness Interventions

Table 1 Summary of Research

Participant
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
self-monitoring
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
behaviors
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)
performance
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
postinjury
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
awareness
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

(Continued)

105
106 cognitive and perceptual rehabilitation: Optimizing function

Table 1 Summary of Research—Cont’d

Participant
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
anoxia
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
subjects
Baking Tray Task + for 3/4 N/A Impairment
subjects
Sustained Attention + for 2/4 N/A Impairment
subjects
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
Scale
Hospital Anxiety and − N/A Impairment
Depression Scale
Landa- Case study Canadian + N/A Activity limitations
Gonzalez, Occupational
200145 Performance
Measure:
performance
Canadian + N/A Activity limitations
Occupational
Performance
Measure:
satisfaction
Kohlman Evaluation + N/A Activity limitations
of Living Skills
Self-Awareness + N/A Impairment
Checklist
 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
correctly
Percentage of + N/A Impairment
questions
answered
correctly during
generalization
probes
Ownsworth Single subject Decreased error + N/A Activity limitations
et al, 200654 design frequency during
cooking
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
Independence
Measure
Lawton Instrumental − NS Activity limitations
Activities of Daily
Living
Rebmann and Single subject Decreased differences + N/A Impairment
Hannon, design between predicted
199568 and actual
performance on
impairment-based
memory test

(Continued)
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
behaviors
Coetzer and Pretest-posttest Beck Depression + p < 0.05 Impairment
Corney, Inventory
200117 Clinician’s Rating + p < 0.05 Impairment
Scale for
Evaluating
Impaired
Self-Awareness
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
report)
Self-Regulation Skills + p < 0.01 Impairment
Interview
Sickness Impact + p < 0.05 Quality of life
Profile

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

109
110 cognitive and perceptual rehabilitation: Optimizing function
to perform the task, the implementation of a
movement sequence including timing and spa-
tial components of movement. A typical per-
son can plan and program movements to open
containers, cut with a knife, scoop or stir with a
spoon, manipulate a fork in the hand, and place
food in the mouth.
Execution of the task is the output of praxis and
relies on sufficient sensory and motor skills to exe-
cute the task—enough strength to lift the hand to
the mouth, no influence of tremor while drinking,
sensory feedback for a piece of bread in your hand.
A breakdown of the praxis skills (conceptual or pro-
duction errors) results in apraxia, whereas a break-
down in execution is attributed to a primary motor
or sensory deficit.3,4 Where the breakdown in func-
tion occurs (conceptual and/or production and/or
execution) dictates the use of different ­intervention
techniques.
Background
One of the frustrations of reviewing the literature
related to apraxia is the various definitions and
terminology used to describe apraxia.65 These dif-
ferences further emerge based on the country and
discipline of the authors. Even a cursory review
reveals the use of multiple terms related to apraxia,
such as ideational, motor, constructional, dressing,
ideomotor, kinetic, conduction, limb-kinetic, swal-
lowing, oral, bucco-facial, respiratory, conceptual,
frontal, axial, and oculomotor. Many of these terms
are describing the same impairment; some are used
to specify the body part affected by the impairment,
whereas several are subcomponents of others. Two
of the terms, dressing and constructional apraxia,
may be misleading and confusing. Although com-
monly described in the past, recent analysis of those
living with these particular subtypes of apraxia has
revealed the deficits may be better described as a
visuospatial deficits secondary to right hemispheric
lesions as opposed to a praxis deficit.23 For, example,
to dress efficiently and independently requires one
to be able to interpret spatial relations so that cloth-
ing is oriented to the body correctly.2,4 The contin-
ued use of these terms as a descriptor of apraxia
must be questioned. The decision as to which terms
to use in this chapter was based on a review of the
literature and an attempt to be consistent with the
rehabilitation literature that focuses the discussion
of apraxia on how the different types are related to
functional performance.2,4
Ideational Apraxia
Apraxia that is related to errors in content dur-
ing performance is termed ideational apraxia and
is defined as a breakdown of knowledge of what
is to be done to perform—results from loss of a
neuronal model or a mental representation about
the concept required for performance; lack of
knowledge regarding object/tool us. It also refers
to sequencing of activity steps or use of objects in
relation to each other.3,4 Some authors prefer the
term conceptual apraxia as opposed to ideational
apraxia57 particularly to focus on the problems
related to tool use.35 During functional obser-
vations in naturalistic settings, impaired use of
objects and problems related to the sequence of the
task are often observed together,2,4 so for this chap-
ter ideational and ­conceptual apraxia will be used
synonymously.
Árnadóttir,4 gives the following clinical examples
of ideational apraxia: The person does not know
what to do with toothbrush, toothpaste, or shav-
ing cream; uses tools inappropriately (e.g., smears
the toothpaste on face); and sequences activity steps
incorrectly so that there are errors in end result of
tasks (e.g., puts socks on top of shoes) (Figure 5-1).
The person does not know what to do related to
the task at hand and has an overall loss of the concept.
Clinical observations related to errors during task
performance may include the following2,4,14,34,48,51,55:
• Uses familiar objects/tools incorrectly: eats
soap, toothbrush is used as hairbrush, attempts
to place sock on head, attempts to maneuver
wheelchair by pulling on the arm rest, chews
on a washcloth, brings knife to mouth, does not
understand what to do with a cane or walker.
Difficulty relating objects to each other such as
the relationship between a toothbrush and paste.
This may occur in the presence of a person being
able to name the objects correctly.
• Tasks requiring use of multiple objects and that
are multistep are particularly difficult, for exam-
ple, a morning grooming routine, self-feeding,
or meal preparation
• Does not use object when it is culturally appro-
priate and available: uses finger to brush teeth,
eats with fingers when it is inappropriate, stirs
coffee with finger
• Performance latency (continues the task very
slowly)
• Does not initiate the task or does not perform
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.
(Continued)

• Organization and sequencing deficits such as
misordering or missing steps of the task result-
ing in an incorrect end product: washing with-
out water, attempting to drink milk without
opening the container, underwear is placed over
pants, disorganized workspace
• Perseveration: making the same mistakes over
and over and perseverating on components of a
task that was just completed
The conceptual errors and resulting clinical
behaviors described here are observed at the task
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
other deficits during the clinical reasoning pro-
cess. Comprehension must be considered and
­controlled because apraxia and aphasia may coex-
ist. Using the person’s own tools or objects and
performing a purposeful task in the appropriate
naturalistic ­ environment and at the appropriate
time of day decrease the need for substantial ver-
bal directions. Apraxia/aphasia relationships are
further described later. In addition, primary visual
deficits (such as acuity) and higher order visual
functions (such as visual agnosia or the inability
to recognize visual input) must also be considered
(see Chapters 3 and 7).
Allowing the person to attempt to recognize and
use objects appropriately through touch will help
determine the cause of the error. For example, dur-
ing a grooming evaluation at the sink, a man with
visual agnosia will not be able to recognize objects
through the visual system leading to him reaching
out for a comb when in fact the goal of the task is
to shave. He will be able to recognize the mistake
as he identifies the object via the tactile system.
If praxis is intact, he will either use the comb as a
comb or put the comb down and continue to search
for the razor. If ideational apraxia is the problem,
he may use the comb as a razor. Processing sites are
also different for apraxia (frontal and parietal lobe
dysfunction) and visual agnosia (occipital lobe dys-
function) and this information, if available, can be
used for clinical reasoning. Finally, a person with
severe ideational apraxia may not perform at all
(i.e., sit at the sink without doing anything). This
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
hand-over-hand guidance, may result in the person
“taking over” and completing the task without dif-
ficulty. This would not be consistent with ideational
apraxia because problems most often would persist
throughout the task. The areas of the cortex that, if
damaged, may result in conceptual errors include
the prefrontal and premotor cortex and the left
inferior parietal lobe.
Ideomotor Apraxia
While ideational apraxia is a result of a breakdown
in the conceptual praxis system, ideomotor apraxia,
synonymous with motor apraxia,2,4 is a disorder of
the production praxis system and may be defined
as the loss of access to kinesthetic memory patterns
so that purposeful movement cannot be produced
or achieved because of defective planning and
sequencing of movements, even though idea and
the purpose of task is understood.2,4
The person knows what to do related to the task
at hand and has the overall concept of what to do.
If language is intact and the person is questioned, he
or she can explain the purpose of the task at hand.
Instead, he or she cannot program, plan, or produce
the movements necessary to accomplish the task
despite having the sensory and motor skills to execute
the task. Clinical observations related to errors dur-
ing task performance may include the following*:
• Difficulties related to motor planning in general,
resulting in awkward or clumsy movements
• Difficulties when planning movements to cross
the body’s midline. For example, difficulty
*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
the bristles toward the hair.3,4
• Difficulty orienting the upper extremity or hand
to conform to objects such as picking up a juice
bottle with the radial side of the hand down or
via picking the bottle up with a pinch grip on the
lip of the bottle instead of a typical cylindrical
grip on the base
• Inflexible and static hand patterns such as not
being able to manipulate coins out of the palm of
the hand to insert them into a vending machine
or difficulty holding objects appropriately
• Difficulty sequencing movements such as the
sequence to get out of bed or off the floor, or
sequencing complex upper limb movements
such as picking up the phone and lifting it to
the ear
• Spatial orientation and spatial movement errors
such as moving scissors laterally instead of for-
ward or not spatially moving feeding utensils
correctly34
• Difficulty coordinating two or more joints, such
as coupling the shoulder and elbow movements
for cutting.54 In general, the more joints involved
in the tasks the more degraded the motor plan-
ning. In other words, an increase in degrees
of freedom worsens the clinical presentation
(Figure 5-2).
• Difficulty timing movement such as a delay in
initiation of movement, pauses, or difficulty
related to the speed of movement.
• Poor gesture production ability, particularly
when gesturing the use of an object (transitive
gestures)
• Using a body part as an object when asked to
pantomime use of an object. Usually, used as a
diagnostic screen for ideomotor apraxia
• Movements are imprecise.
The production errors and resulting clinical
behaviors described are observed at the movement
level (Figure 5-3). Clinicians must differentiate
between ideomotor apraxia and other deficits dur-
ing the clinical reasoning process. As discussed,
comprehension must be considered and controlled
for. In addition, the presence of sensory and motor
impairments must be considered. For example, loss
of joint position sense may result in awkward or
clumsy movements. Unlike those with ideomotor
apraxia, visual guidance markedly improves func-
tion in a person with sensory loss. As described
later, left hemispheric lesions usually result in bilat-
eral ideomotor apraxia. Although it is typical to
right side of the body (making it difficult to assess
for motor planning deficits), with a left-sided brain
injury, the left side of the body should be sensory
and motor spared. Testing the left side of the body
in these cases will control for superimposed sensory
and motor deficits.
Neurologic processing models have been pro-
posed to explain the production aspects of praxis.2,4,34
Under­standing the areas of the cortex responsible to
support motor planning will aid ­ clinicians in the
clinical reasoning process. Key areas include the
following:
• Left inferior parietal lobe (supramarginal gyrus
and angular gyrus): appears to be a storage area
related to knowledge of motor skills or storage of
motor plans. These “formulas for movement” or
learned time-space movement representations
or motor plans have been termed praxicons.34
When a skilled movement that has been previ-
ously learned such as shaving in an adult male is
to be carried out, the representation for the act
of shaving is retrieved and used to program the
premotor cortex.
• The arcuate fasciculus serves to connect the stor-
age area in the left parietal lobe to the premotor
area in the frontal lobe.
• Using the formulas for movement, the premo-
tor areas serve to selectively activate the motor
cortex because this area of the cortex uses infor-
mation from other cortical regions to select
movements appropriate to the context of the
action.
• The anterior fibers of the corpus callosum serve
to bring the shaving plans to the right hemi-
sphere if the left side of the body will be used in
the activity.
• The primary motor cortex then innervates the
muscle groups necessary to shave (Figures 5-4
and 5-5).
Clinically this is important because ideomotor
apraxia can occur if the formulas for movement in
the left parietal lobe are destroyed by a brain injury
or if lesions occur anterior to this area in the frontal
areas or the connecting pathways (i.e., disconnect-
ing the critical cortical areas). If neuroimaging data
are available, documented lesions in this area should
serve as a “red flag” as to the possible presence of
this impairment and the potential loss of function. 
In addition, the location of the lesion dictates the
distribution of the motor planning difficulties.
Lesions in the left hemisphere usually result in
bilateral motor planning problems, whereas lesions
114 cognitive and perceptual rehabilitation: Optimizing function

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

Elbow Flexion/Extension (�)

Elbow Flexion/Extension (�)

Elbow Flexion/Extension (�)

Flex
130 130 ion
Fle 130 130
xion

110 110

120 120

io n
90 90

ns
n te
nsio Ex
Exte
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 (�)

0.6
Wrist Velocity (m/s)

130

Wrist velocity (m/s)

0.5
1 130
0.4
110
0.3
0.5 120
90 0.2

0.1
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)

A
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

110
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 (�)

150
Wrist Velocity (m/s)

0.7
130 0.8
Wrist Velocity (m/s)

140

130 0.5 120 0.6

120
0.3 110 0.4
110

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)

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

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

Corpus callosum

Premotor
Premotor cortex
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,
Elsevier/Mosby.)

• An examination of 100 stroke survivors revealed
that for the group, 25.3% presented with apraxia;
specifically apraxia was present in 51.3% of those
with left-sided stroke and in 6% of those with
right-sided stroke.73
• Reviews of the literature consistently find that
this impairment occurs after left-sided brain
damage as opposed to right-sided damage.19
• The prevalence of apraxia among 492 first left
hemisphere stroke survivors in rehabilitation
centers was 28% (96/338) and was higher in
long-term care facilities at 37% (57/154).19
Apraxia has been documented in a variety of
­populations including left hemisphere–acquired
brain injury19 (errors related to content and
­planning), corticobasal degeneration37,45 (errors
related to planning), Alzheimer’s disease25,38,41
(errors related to content and planning), Parkinson’s
disease40 (errors related to planning), progressive
supranuclear palsy40 (content and planning errors),
and Huntington’s disease61 (planning errors).
Recovery patterns from apraxia also have been
examined. Findings related to recovery include the
following:
• Improvement from ideomotor apraxia may be
related to the site of the lesion, anterior lesions
may fare better.8
• An examination of recovery of 26 clients with
apraxia revealed that 13 remained apraxic 5 months
later.8
• Age, gender, aphasia, education level, and lesion
size do not seem to influence recovery from
apraxia.8
• In long-term limb apraxia recovery, the more
severe the initial impairment, the less complete
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
Left primary motor areaC Corpus collosumB
Control right side of body Right premotor areaB
Right primary motor areaC
Control left side of body
Figure 5-5  Flow of information while planning movements of
either side of the body. A, Lesions in this area result in bilateral
ideomotor apraxia. B, Lesions in this area result in unilateral (left)
ideomotor apraxia. C, Lesions in this area result in unilateral motor
impairments such as weakness or spasticity.
• Limb apraxia recovery showed no significant
correlation with recovery of language deficits.46
• Aphasia and apraxia seem to have related but
distinguishable recovery processes.46
• In a long-term follow-up study of a group
of 44 clients with ideomotor apraxia, the cli-
ents’ apraxia status was evaluated three times
(1.6 months, 9.4 months, and 27.9 months’ mean
time postonset). All but one client demonstrated
some recovery from apraxia between the first and
second examinations. After that point, very few
of the clients showed further recovery and 6 cli-
ents worsened. At all three examinations, clients
with anterior lesions had more severe apraxia,
but unlike previous studies, the degree of recov-
ery was not significantly different in the two
groups.7
• Limb apraxia and oral apraxia appears to follow
the same trajectory of recovery.7
• After the first few months of recovery, clients will
plateau.7
• Clients with apraxia who improve during the
rehabilitation stay on functional measures may
worsen when discharged home.9 This may be due
Ideomotor/Motor Left inferior parietal lobule
apraxia Left premotor frontal cortex
Left supplementary motor cortex
Anterior corpus callosum
Right supplementary motor area
Right premotor frontal area
Ideational apraxia Left inferior parietal lobe
Left premotor frontal cortex
Left prefrontal cortex
Corpus callosum
Right premotor frontal cortex
Right prefrontal cortex
Evaluative Considerations for
Differentiation of Apraxia Types
Does the client have an idea of what to do (ideation)?
Does the client know which objects to use (ideation)?
Does the client know how to perform or how to use the
objects (ideation)?
Do the movements appear to be clumsy (motoric)?
Can the client adjust grasp according to altered
­requirements during object use (motoric)?
Are there problems with sequencing and organization
of activity steps (ideation)?
Are there problems with sequencing of movements
(motoric)?
From Árnadóttir G: The brain and behavior: assessing cortical dysfunction
through activities of daily living, St Louis, 1990, Mosby.
to the specificity of training and/or the ­inability
to generalize. This issue may be addressed by
home visits by the team and client during the
rehabilitation process.9 A focus on home reha-
bilitation seems to be warranted based on this
finding.
Apraxia’s Relationship to
Other Impairments
Although apraxia may occur in isolation, it is typ-
ical to see patterns of impairments in those living
with apraxia. These include motor impairments,
“cognitive dementia-like impairments,” memory
difficulties, and comprehension difficulties.69 In
addition, it is typical to identify organization and
sequencing deficits.2,4 Most commonly, aphasia and
apraxia may occur together. Both impairments are
commonly seen in those living with left ­hemispheric
 Chapter 5  Managing Apraxia to Optimize Function 119

A B

C D
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-
tiguous cortical structures they often occur concur-
rently but the two may be dissociated (i.e., a client
may present with aphasia or apraxia, or both).44
Alexander and associates1 examined the rela-
tionship between aphasia and ideomotor apraxia
and concluded that those presenting with conduc-
tion aphasia and anomic aphasia were not signifi-
cantly apraxic compared with controls, and those
with global aphasia were significantly more apraxic
than all other groups. The method used to elicit the
apraxic behaviors influenced their findings as well.
There appears to be a stronger association between
Broca’s aphasia and ideomotor apraxia. There also
appears to be a stronger relationship with aphasia
and severe ideational apraxia.16 The combination
of apraxia and aphasia may compound the dif-
ficulties related to functional retraining. In addi-
tion, a hallmark of ideomotor apraxia is impaired
gesture production ability, a typical compensa-
tory technique used during the rehabilitation of
those with language impairments. From an assess-
ment and intervention perspective, the presence of   ticipate fully in the community. Specific findings
aphasia (particularly Wernicke’s/receptive ­ aphasia
and global aphasia) dictates the use of familiar
tasks, performed in logical environments, at the
appropriate time of day. Dressing practice during
an afternoon session in a therapy clinic or isolated
practice of object use in a therapy office does not
provide the contextual cues necessary to elicit func-
tional performance. This factor makes it impossible
to differentiate between the effects of apraxia or dif-
ficulties related to comprehension. Using a familiar
task in the appropriate environment circumvents
the need to use excessive verbal cues and at least
begins to control for the presence of aphasia.
Effect of Apraxia on Daily Life
and Rehabilitation Outcomes
Although the early literature discussed apraxia as
being an impairment observed only during specific
neurologic testing or during contrived clinical situ-
ations, it is now well recognized that apraxia does
have a substantial negative effect on an individual’s
ability to engage in meaningful activities and par-
include the following:
120 cognitive and perceptual rehabilitation: Optimizing function
• Apraxia affects behavior during meals. Foundas
and associates24 examined mealtime behaviors
of neurologically intact people as compared
with those with left brain damage (most with
apraxia) via videotapes. Even though all neu-
rologically intact people were found to proceed
through three specific phases of a meal (prepa-
ratory, eating, and cleanup), only 20% of those
with left brain damage did. All intact controls
had a preparatory phase, whereas only 40% of
those with apraxia did. In addition, those with
apraxia from left brain damage used fewer uten-
sils, were less organized, were less efficient, ate
haphazardly, placed too much or too little food
on the utensils, and demonstrated action deficits
(tool misuse, sequencing errors, etc.). A signif-
icant correlation was found between the sever-
ity of apraxia and difficulties observed with the
meal.
• Six months after discharge from hospitalization,
apraxia and the need for assistance with daily
activities are highly correlated. Those with apraxia
require more assistance than those with other
­neurologic impairments.64
• The absence of apraxia is a significant predictor
of the ability to return to work.59
• Apraxia severity is strongly related to meal prep-
aration competency.33
• Apraxia severity is moderately predictive of
caregiver and client reports of functional
independence.33
• People with ideomotor apraxia have increased
dependency in grooming, bathing, and toileting
relative to age-matched control subjects.32
• The number of errors made during basic ADL is
correlated with the severity of apraxia.29
• The number of errors made during complex
ADL is correlated with the severity of apraxia.28
• The relationship of severity of apraxia to long-
term dependency after rehabilitation is strong.9
• Learning of old and new skills is compromised
in those with apraxia and requires increased
repetitions.47,56
Clearly the presence of apraxia warrants special
attention from a rehabilitation perspective. Specific
assessment and intervention strategies are neces-
sary to improve functional performance in this
population.
Evaluation and Assessments
Two schools of thought exist related to the assess-
ment of apraxia. One is focused on diagnosing the
impairment of apraxia, whereas the other is focused
on how apraxia affects everyday living skills.
Although both are important, philosophically from
a rehabilitation perspective the latter should be
emphasized. The literature has typically focused on
diagnosing apraxia using nonfunctional tasks out
of context. These tests typically include ­ selections
from the following items34:
• Gesturing to command. Focusing on pantomime
of the use of tools, that is, transitive movements
(“Show me how you would use a hammer”)
and nonverbal communications or intransi-
tive moments (“Show me how you would wave
goodbye”).
• Gesture to imitation.
• Gesture or pantomime in response to seeing a tool.
For example, showing the person a toothbrush
and asking him or her to pantomime its use.
• Demonstrate tool use albeit not in the context of
a functional task.
• Imitation of the examiner using a tool.
• Discriminating correct and incorrect move-
ments of the examiner.
• Performing serial acts (putting batteries in a
flashlight and turning it on, making a sandwich,
etc.).
Many of the tests used to diagnose the presence
of apraxia were developed as research tools and
some that are commonly used in clinical settings
are not standardized. The following are examples
of standardized impairment tests used to make the
diagnosis of apraxia:
• Florida Apraxia Screening Test-Revised58: a
short screening of apraxia and part of the larger
Florida Apraxia Battery. It includes 30 items that
must be gestured to command. The test includes
20 transitive (requiring pantomime of a tool)
and 10 intransitive (not requiring a tool) items.
All are related to arm and hand movements and
can be done with one hand. Examples include
showing how to salute, go away, how to use a
scoop to serve ice cream, wave goodbye, stop, use
a salt shaker to salt food, and hitchhike. Scoring
is based on error type: content, temporal, spatial,
and others.
• Cambridge Apraxia Battery26: includes 11 items 
such as imitation of posture, imitation of seq­
uence, bilateral motor coordination, functional
object description, finger maze, and ­ manual
form perception.
• Kaufman Hand Movement Test6,39,49: a standard-
ized test that requires subjects to imitate 75 hand
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
­imitate 252 movements.
• Ideomotor Apraxia Test17: developed for older
adults, the test consists of demonstrating 10
gestures (3 one-handed symbolic gestures and  person’s ability to perform basic self-care, instru-
7 two-handed meaningless gestures).
• Movement Imitation Test15: includes 24 gestures
classified according to type of movement (finger
versus hand, symbolic vs. nonsymbolic gestures,
etc.).
• Diagnostic Test for Apraxia67,73: a test to diagnose
the presence of ideational and ideomotor apraxia
via demonstration of object use (ideational) and
imitation of gestures (ideomotor).
Impairment tests aimed at diagnosing the
impairment of apraxia must be interpreted with
caution from a rehabilitation perspective as they
are performed out of context and one cannot gen-
eralize poor test performance to real-world perfor-
mance (see Chapter 1). Therefore, from a clinical
rehabilitative practice perspective, they are recom-
mended as a screening only if they are to be used at
all. Those engaged in clinical research such as test-
ing the effectiveness of interventions for those living
with apraxia should consider using an impair-
ment test of apraxia in conjunction with objective
­ articipation restrictions, and quality of life.
p
Instead, from a rehabilitation perspective, the
focus of assessment should be on determining
if/how the presence of apraxia interferes with a
mental activities of daily living, work, and play/
leisure abilities. Árnadóttir,2-4 van Heugten and
colleagues,71 and Goldenberg and Hagmann29
have concluded that structured observation of the
errors that people make during functional activi-
ties is a valid method of assessing apraxia. Success
using this method of assessment is based on the
assumption that apraxia results in an observable
problem related to function, allowing people with
apraxia to make safe errors during task perfor-
mance, analyzing the errors to classify them based
on type of apraxia and error type, and using con-
sistent descriptive terminology and operational
definitions.2,4
van Heugten and colleagues68,70 and others have
documented at least three types of errors that can be
observed during structured observations of func-
tional tasks including content, temporal, and spatial
(Table 5-1). Identifying the error type enables clini-
cians to develop the appropriate intervention plan
(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 executing the task
Difficulty controlling the task
Content/object errors
Temporal errors
Spatial errors
Difficulty choosing the proper plan of action
Difficulty choosing the correct objects
Difficulty performing the plan
Inability to evaluate the results of the task
Inability to make corrections for mistakes
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)
Difficulty sequencing movements
Increased, decreased, or irregular speed of movements
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

the presence of disabilities resulting from apraxia.
Scoring is based on structured observation of ADL
and a client-chosen activity (Box 5-2).
Árnadóttir proposed a relationship between
the presence of impairments such as apraxia and
observable errors during a variety of daily living
tasks. Although these observations are typically
made in a nonstandardized manner (Table 5-2),
they also have been standardized (Table 5-3).
Review of Evidence-Based
Interventions to Improve
Activity and Participation for
Those Living with Apraxia
Empirical research focused on interventions for
those living with apraxia falls into two categories:
interventions focused on attempting to decrease
the apraxic impairment itself and those focused on
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.
adequately.
—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-
times assumed relationship that decreasing the
severity of apraxia will automatically result in
improved daily function. Examples of interven-
tions that have focused on treating the impairment
of apraxia include the following:
• Using tactile and kinesthetic stimulation in addi-
tion to visual and verbal mediation input, such
as deep pressure, sharp touch input, soft touch,
self-touch, and proprioceptive input10,11
• Practice of gestures42,50
• Practice of object use via conductive education53
These interventions have been tested by case stud-
ies that have concluded that in general the interven-
tions demonstrated only immediate changes in motor
performance without any carryover related to sen-
sory stimulation. The major limitation is that either
functional outcomes were not considered or changes
in functional performance were not observed for
these interventions. In addition, no generalizations
to untrained actions were noted. At this point they
cannot be recommended for use in clinical practice.
van Heugten66 states that “recovery from apraxia
is not a realistic goal for therapy. Instead, the aim of
rehabilitation should be to help the client develop
new patterns of cognitive activity through internal
or external compensatory mechanisms, or through
adaptation of tasks or environments.” The follow-
ing paragraphs review tested interventions that have
focused on decreasing activity limitations and par-
ticipation restrictions for those living with apraxia.
Strategy Training
van Heugten and colleagues70 described an inter-
vention study designed for use by occupational
therapists based on teaching clients strategies to
compensate for the presence of apraxia. The treat-
ment was focused on training activities that were
relevant to the individual client. The therapist and
client decided on which activities to focus. Interest
checklists were also used to choose activities in addi-
tion to focusing on activities that were important
to carry out in the future. Every two weeks other
­activities were chosen.
The focus of the intervention was error specific
and determined by the specific problems observed
during standardized ADL observations. Specifically,
interventions were focused on errors related to the
following:
• Initiation: inclusive of developing a plan of action
and selection of necessary and correct objects
• Execution: performance of the plan
• Control: inclusive of controlling and correcting
the activity to ensure an adequate end result
Difficulties related to initiation were treated via
specific instructions. Instructions were hierarchi-
cal in nature and could include verbal instructions,
 124
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
participation
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
survivors
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
diagnoses
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

125
126 cognitive and perceptual rehabilitation: Optimizing function
alerting the client with tactile or auditory cues,
­gesturing, pointing, handing objects, or starting the
activity together. Assistance was the intervention
provided when problems related to execution of
the activity occurred. Also hierarchical, assistance
could range from various types of verbal assist,
stimulating verbalization of steps, naming the
steps of the activity, to physical assistance such as
guiding movements. When having difficulty with
control (i.e., clients do not detect or correct the
errors they make during the activity), feedback was
provided. Feedback ranged from verbal feedback
related to knowledge of results to taking control
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,
depending on the patient’s level of functioning. The thera-
pist can use instructions, assistance, and feedback.
Instructions
The occupational therapist can give the following
instructions:
• Start with a verbal instruction.
• Shift to a relevant environment for the task at hand.
• Alert the patient by:
• Touching
• Using the patient’s name
• Asking questions about the instruction
• Use gestures, point to the objects.
• Demonstrate (part of) the task.
• Show pictures of the activity.
• Write down the instruction.
• Place the objects near the patient, point to the objects,
put the objects in the proper sequence.
• Hand the objects one at a time to the patient.
• Start the activity together with the patient one or more
times.
• Adjust the task to make it easier for the patient.
• Finally, take over the task because all efforts did not
lead to the desired result.
Assistance
The following forms of assistance can be given by the
therapist:
• There is no need to assist the patient during the
execution of the activity.
• Verbal assistance is needed:
• By offering rhythm and not interrupting performance.
• To stimulate verbalization of the steps in the activity.
• To name the steps in the activity or name the objects.
• To direct the attention to the task at hand.
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.
of the task and controlling for errors. The specific
strategy training ­intervention protocol is included
in Box 5-3.
This strategy training approach for apraxia has
been tested with promising results.70 A pretest-post-
test study design demonstrated significant improve-
ments and large effects for three different ADL
measures (Barthel Index, a standardized evaluation
of personal hygiene, dressing, preparing food and
a client-chosen activity, and an ADL questionnaire
that was filled out by therapists as well as clients).
In addition, significant improvements were docu-
mented on tests of apraxia (small-medium effects)
• Use gestures, mimics, and vary intonation in your speech.
• Show pictures of the proper sequence of steps in the
activity.
• Physical assistance is needed:
• By guiding the limbs.
• In positioning the limbs.
• To use the neurodevelopmental treatment method
(NDT).
• To use aids to support the activity.
• To take over until the patient starts performing.
• To provoke movements.
• Finally, take over the task.
Feedback
Feedback can be offered in the following ways:
• No feedback is necessary because the result is adequate.
• Verbal feedback is needed in terms of the result
(knowledge of results).
• Verbal feedback by telling the patient to consciously use
the senses to evaluate the result (tell the patient see,
hear, feel, smell, or taste).
• Physical feedback is needed in terms of the result
(knowledge of results):
• To evaluate the posture of the patient.
• To evaluate the position of the limbs.
• To support the limbs.
• Physical feedback is given by pointing or handing the
objects to the patient.
• Verbal feedback is needed in terms of performance
(knowledge of performance).
• Physical feedback is needed in terms of performance
(knowledge of performance).
• Place the patient in front of a mirror.
• Make video recordings of the patient’s performance and
show the recordings.
• Take over the control of the task and correct possible errors.
 Chapter 5  Managing Apraxia to Optimize Function 127
and motor function (small effects). Improved
ADL function was still significant after correct-
ing for the improvement on the apraxia measures,
motor measure, and time poststroke. Of the cli-
ents in this study, 84% perceived complete recovery
or ­ substantial improvement because of the inter-
vention. The authors concluded that the “therapy
programme succeeded in teaching clients com-
pensatory strategies, which enable them to func-
tion more independently.” Further analysis of these
data revealed that older age, the presence of addi-
tional cognitive impairments, and/or severe motor
impairment did not diminish the effects of the
strategy training intervention. In fact, the initially
more severely impaired clients showed the most
marked improvement.69 Of note is that although
the intervention did not explicitly focus on decreas-
ing the apraxic impairment, the strategy training
approach during participation in functional activi-
ties decreased activity limitations as well as severity
of impairment.
Donkervoort and coworkers18 also tested this
intervention via a randomized clinical trial compar-
ing usual occupational therapy to strategy training
integrated into usual occupational therapy. Blind
evaluators administered measures of ADL, apraxia,
and motor function pre- and postintervention.
Postintervention, those receiving strategy training
improved significantly on ADL observations (small
to medium effect size) as well as the Barthel Index
(medium effect size) as compared with those who
received usual care. Although a 5-month follow-
up did not demonstrate beneficial effects (i.e., the
groups were similar), it was noted that those in the
usual care group required continued ­occupational
therapy to obtain a corresponding level of improve-
ment. It is possible that this finding may reveal that
the strategy training approach improved the effi-
ciency of the rehabilitation process, but further
examination of this hypothesis is required. The
authors concluded that the trial “showed benefi-
cial effects of strategy training on ADL functioning
in left hemisphere stroke clients with apraxia. The
results suggest that the therapy programme is suc-
cessful in teaching clients compensatory strategies,
which enable them to function more ­independently,
despite the lasting effects of apraxia.”
A posthoc analysis of Donkervoort and cowork-
ers’18 data (Geusgens and associates27) focused on
whether the strategy training approach results in
transfer of training to untrained tasks. The hypoth-
esis is that in strategy training, transfer is expected as
the intervention is not focused on learning specific
tasks but on teaching clients new ways to cope with
and manage the impairments during performance
of tasks in general. The analyses revealed that both
intervention groups (traditional occupational ther-
apy [OT] and traditional OT combined with strat-
egy training) demonstrated significantly improved
scores on tasks that were not trained. Change scores
of the nontrained activities were significantly larger
in the strategy training group as compared with
usual occupational therapy. The authors hypothe-
sized that this success was secondary to the design of
the intervention (i.e., strategies are selected based on
the specific type of error each client makes during
engagement in ADL). Strategy training for apraxia
is considered a practice standard by the American
Congress of Rehabilitation Medicine.13
Errorless Completion and Training of Details
Goldenberg and Hagmann29 tested a method of spe-
cifically training ADL for those living with apraxia.
They specifically examined spreading margarine on
a slice of bread, putting on a T-shirt, and brushing
teeth or applying hand cream. Each of the activi-
ties was trained for 1 week by an occupational ther-
apist. Those not being trained were carried out
with maximal support and without specific train-
ing. When an activity was being trained, the focus
was on errorless completion of the whole activ-
ity. As opposed to trial-and-error learning, error-
less learning or completion is a technique in which
the person learns the activity by doing it. The ther-
apist intervenes to prevent errors from occurring
during the learning process. This technique also
has been used for those with memory impairments 
(see Chapter 9). Support from the therapist was pro-
vided at various stages of the activity until the client
could move through the area of difficulty on his or her
own. Specific interventions included the following:
• Guiding the hand through a difficult aspect of
the activity
• Sitting beside the client (parallel position) and
doing the same action simultaneously with the
client
• Demonstrating the required action and ask the
client to copy it afterwards
In addition, the intervention focused on train-
ing of details. This was aimed at directing the
­client’s attention to “the functional significance
of single perceptual details and to critical fea-
tures of the actions associated with them.” Specific
­difficult steps of the activity were trained using this
approach. To promote knowledge of object use, key
128 cognitive and perceptual rehabilitation: Optimizing function
details of ADL objects were explored and examined
such as the bristles on a toothbrush and the teeth
on a comb. Actions connected to the details were
then practiced (e.g., searching for and positioning
a shirtsleeve for a person with dressing difficulties)
outside of therapy. Specific necessary motor actions
also were practiced in other activities and contexts
(e.g., squeezing paint from tubes as a similar action
as squeezing toothpaste).
Goldenberg and Hagmann29 tested this inter-
vention by examining 15 clients with apraxia with
repeated measures of ADL function. Success of therapy
was based on the reduction of errors of specific tasks.
The authors differentiated between reparable errors
(the client succeeds in continuing the task) or fatal
errors (the client is unable to proceed without help or
the task is completed but did not fulfill its purpose).
Across the whole group, the number of fatal errors
decreased significantly, whereas the number of repa-
rable errors did not significantly change. The authors
also noted several clinically relevant observations:
• Even though therapy led to significant improve-
ments in trained ADL, there was no improve-
ment in ADL if left to spontaneous recovery.
• Long-term success of the intervention was based
on continued practice and ADL participation
after completion of the intervention.
• The success of the intervention seemed to be
based on teaching clients “instructions of use”
related to specific objects.
• Specific training can restore independence for
trained activities.
• There was no generalization from trained to
untrained tasks.
In terms of the lack of generalization to untrained
tasks, by definition the errorless component of the
intervention is in fact task specific and training of
details is aimed only at object use errors seen in
those living with apraxia and not other difficulties
encountered by this population.27 This may repre-
sent a limitation of the intervention, but ­ further
research is necessary.
Direct Training of the Whole Activity versus
Exploration Training
Goldenberg and colleagues28 developed and com-
pared two therapy interventions aimed at restoring
the ability to engage in complex ADL for those living
with apraxia. Exploration training was aimed at hav-
ing clients infer function from structure and solve
mechanical problems embedded in tasks. During
treatment, the therapist directs the client’s attention
to functionally significant details of the object (e.g.,
prongs on a fork, serrations on a butter knife, bris-
tles on a toothbrush, etc.). The therapist explained
the functional significance via verbal, gestural, and
pointing cues. The clients did not practice use of
the tools. Specific interventions related to explora-
tion training included explanation, ­ touching, and
­comparing objects with photographs.
The direct training focused on the client’s car-
rying out the whole activity with a minimum of
errors. The technique is similar to errorless comple-
tion as reviewed above and included guided move-
ments and the therapist sitting beside the client to
perform the task simultaneously. Particularly diffi-
cult components of the activity were practiced, but
the whole activity was always completed. Specific
interventions for direct training included guided
performance of the whole activity, passive ­guidance,
guidance by example, and rehearsal of steps.
Goldenberg and colleagues28 tested these inter-
ventions related to the training of four complex
ADL: preparing coffee from an automatic coffee
maker, fixing a carpet knife to cut out cardboard,
changing batteries on a tape recorder and playing
a cassette, and slicing bread followed by spreading
margarine and jam. Necessary objects were avail-
able as well as distracters (nonsensical objects not
related to the task at hand such as a toothbrush for
meal preparation). The authors found that explora-
tion training had no effect on performance, whereas
direct training resulted in a significant reduction of
errors and the amount of assist required to com-
plete the task. Follow-up 3 months later revealed
that gains were maintained. Although exploration
training was not found to be successful in this study,
it should be pointed out that the protocol did not
allow the clients to practice actual use of the objects
or the actions associated with them. Future stud-
ies should examine whether combining exploration
training with practice is more beneficial.
Of note was that the authors again documented
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
with different objects. They concluded that therapy
“should be tailored to the specific needs and desires
of the clients and their relatives, and it should be
tied as closely as possible to the normal environ-
ment of the client’s daily life. Otherwise, it runs
the danger of remaining a pure exercise of thera-
peutic efficiency which does not help the client to
master the challenges of daily life.” Similar to the
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
expected to occur).27 Nonetheless, the idea of trans-
fer of training remains controversial and should
be considered when developing an individualized
treatment program. At this point, only the strategy
training approach as discussed has been found to
result in generalization.
Task-Specific Training
Poole56 examined the ability of those living with
apraxia to master the technique of one-handed
shoe tying (commonly a necessary skill to be mas-
tered after brain injury). She compared those liv-
ing with a stroke without apraxia, those living
stroke with apraxia, and healthy adults. The task
was taught using published standardized pro-
cedures via demonstration and simultaneously
verbalizing instructions. Repetition of demonstra-
tions and instructions was used until the task was
achieved. The mean number of trials to learn the
task was higher for those with apraxia (M = 6.4)
as compared with those stroke survivors without
apraxia (M = 3.2) versus healthy controls (M = 1.2).
Although the number of trial required to learn the
task was greater, the majority of those with apraxia
were able to learn and retain the task.
Wilson72 documented a task-specific training
program for a young woman after an anoxic brain
injury. Two tasks focused on were drinking from
a cup and sitting on a chair followed by position-
ing it correctly at the table. Functional performance
was improved for this woman via the techniques of
breaking down the steps of the tasks followed by
practice of the steps, chaining procedures, and ver-
bal mediation. The author noted that ­generalization
to untrained tasks was not evident.
Smania and coworkers63 examined the effec-
tiveness of a behavioral training program consist-
ing of gesture-production exercises for those living
with apraxia via a randomized controlled trial.
Subjects with left-sided strokes averaging 5 months
post onset were included. The study compared
the experimental group with a control group who
received conventional treatment for aphasia. The
interventions consisted of the following:
• Transitive gesture training in which the client
was required to show the use of common tools
(i.e., a spoon) followed by the client being shown
a picture illustrating a transitive gesture (i.e.,
using a spoon), and then required to produce the
corresponding gestural pantomime, followed
by the client being presented a picture showing
a ­ common tool (i.e., a spoon), and then was
required to pantomime the use of that object.
• Intransitive-symbolic gesture training in which
the client was shown two pictures, one of which
illustrated a given context (i.e., a man eating a
sandwich), and the other showing a symbolic
gesture related to that context (i.e., the gesture
of eating). After the presentation, the client was
asked to reproduce the symbolic gesture shown
in the picture. Following this intervention, the
task was to produce the correct gesture (i.e.,
the gesture of eating) after the presentation of 
the context picture alone (i.e., a man eating a
sandwich), followed by the task of producing the
correct gesture (i.e., gesture of eating) after the
presentation of a picture showing a new, though
similar, contextual situation (i.e., a man eating
canned food with a fork).
• Intransitive-nonsymbolic gesture training in
which the client was asked to imitate meaning-
less intransitive gestures previously shown by
the examiner.
Multiple neuropsychological tests were used as
outcome measures including aphasia, verbal com-
prehension, intelligence, oral apraxia, constructional
apraxia, ideational apraxia, ideomotor apraxia, and
gesture recognition. The clients in the study group
achieved a significant improvement of performance
in both ideational and ideomotor apraxia tests. 
In addition, they showed a significant reduction of
errors committed during the apraxia tests. No sig-
nificant changes occurred in the control group. The
authors concluded that “the results show the pos-
sible effectiveness of a specific training ­programme
for the treatment of limb apraxia.” A follow-up to
this study62 involved further investigation of nine
clients in the study group and eight clients in the
control group 2 months after the end of the treat-
ment. The outcome measures used in the follow-
up evaluation were impairment-based apraxia tests
and an ADL questionnaire. The authors found that
those who received specific apraxia training not only
improved the ability to produce a wide range of ges-
tures but also required less assistance from caregiv-
ers during ADL. In other words they ­concluded that
training generalized to untrained tasks.
In summary, based on the available research
related to apraxia and consistent with the above
findings, Cappa and associates12 concluded that
“there is grade A evidence for the effectiveness of
apraxia treatment with compensatory strategies.
Treatment should focus on functional activities,
which are structured and practised using errorless
130 cognitive and perceptual rehabilitation: Optimizing function

learning approaches. As transfer of training is dif-
ficult to achieve, training should focus on specific
activities in a specific context close to the normal
routines of the clients. Recovery of apraxia should
not be the goal for rehabilitation. Further stud-
ies of treatment interventions are needed, which
also address if the treatment effects generalize to ­ 
non-trained activities and situations.”
Appendix 5-1 lists a summary of interventions.
These referenced studies provide clinicians
with guidance regarding how to design an ineffec-
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
that are necessary to perform secondary to neurologic
impairments) as the basis of the interventions (i.e., an
individualized task-specific approach).
• “Tap into” an individual’s routines and habits.
• Collaborate with the client and significant others/
caregivers in order to choose the tasks that will be
focused on and that will become the goals of therapy
(i.e., a client-centered approach).
• Practice these activities in the appropriate environments
and at the appropriate time of day (i.e., context specific
with full contextual cues).
• Use strategy-training interventions to develop internal
or external compensations during the performance of
functional activities. See Box 5-3.
• Focus interventions based on the errors that are made
during the task: initiation, execution, and or control
(i.e., error-specific interventions).
• Practice functional activities with vanishing cues.
• Provide graded assistance via graded instructions,
assistance, or feedback during task performance.
• Practice functional activities using errorless learning
(preempting the error via assistance) approaches.
• If physical guiding of the limbs is used during a task,
incorporate the suggested principles of guiding:
• The therapist should place his/her hands over the
client’s whole hand, down to the fingertips.
• Keep talking to a minimum.
• Guide both sides of the body when possible.
• Move along a supported surface to give the client
maximum tactile feedback.
• Involve the whole body in the task to challenge
posture.
• Provide changes in resistance during the activity.
• Allow the client to make mistakes to give
opportunities to solve problems.
• Encourage tactile exploration of functional objects
and tools to enhance performance as somatosensory
feedback from the tool may play a role in organizing
movements.
• Object affordances (the functional utility of particular
objects within a context) support motor performance.
Using meaningful objects and tasks will yield better
results than movements performed in isolation.
• Because those with apraxia have compromised learning
of old and new tasks, increased repetitions and practice
will be necessary. Goals should be scaled accordingly.
• Encourage practice of learned skills outside of therapy
and throughout the day.
• For those with ideomotor apraxia, experiment with
decreasing the degrees of freedom (i.e., number of
joints) used to perform the task. For example, encourage
a woman who is attempting to apply makeup to keep
her elbow on the table. Grade required functional
movements from simple to complex such as grading
from smoothing out a bedspread, to removing a pillow
from a pillowcase, to placing a pillow into a pillowcase,
to folding a large sheet, to making a bed, etc.
• Grade the number of tools and distracters used in a
task. For example, finger feeding (no tools), followed
by eating applesauce with only a spoon available,
followed by eating applesauce with the choice of one
to three utensils, followed by eating a meal requiring
the choice of various tools for different aspects of the
task (spoon to stir coffee, knife to cut and spread butter,
etc.), followed by a meal with the necessary and usual
utensils in addition to distracter tools such as comb,
toothbrush, etc.
• Grade the number of steps of an activity via chaining
procedures. The whole task should be completed for
each trial.
• Grade the number of tasks that will be performed in
succession such as during a morning routine.
• Use clear and short directions.
• Use multiple cues to elicit functions: visual
demonstration, verbal explanation, and tactile guiding.
• Demonstrate the task while sitting parallel to the person
with apraxia to help develop a visual model of the task
at hand.
• 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:
Stroke rehabilitation: a function-based approach, ed 2, St Louis, 2004, Elsevier/Mosby; Lin K, Wu C, Tickle-Degnen L, et al: Enhancing occupational per-
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
general are not commonly understood by the lay
community. In particular, it is difficult to watch a person
with apraxia function (e.g., using tools incorrectly),
and education as to the nature of the deficit for family
members is warranted early on.
• Make sure that caregivers understand that the behaviors
observed are not caused by a lack of motivation.
• Emphasize the importance of maintaining habits and
routines and keeping a consistent sequence of daily
activities.
functional limitations secondary to apraxia. Other
authors have made useful treatment suggestions
that warrant further empirical testing. Box 5-4 lists
further potential interventions based on these stud-
ies and the available literature. In addition, inter-
ventions and education for caregivers are crucial
and are included in Box 5-5.
Review Questions
1. How would ideational apraxia present dur-
ing a meal preparation? How would ideomotor
apraxia present during the same activity?
2. Which limbs would present with motor plan-
ning deficits if the left hemisphere is damaged?
3. What are the limitations to using impairment
based tests for apraxia such as “gesture on
command”?
4. What are the three specific interventions recom-
mended when using a strategy training approach
to treat apraxia?
5. How would a strategy training approach to
intervention be implemented during a morning
grooming session?
References
1. Alexander M, Baker E, Naeser M, et al: Neuro­
psychological and neuroanatomical dimensions of
ideomotor apraxia, Brain 115:87, 1992.
2. Árnadóttir G: The brain and behavior: assessing cor-
tical dysfunction through activities of daily living,
St Louis, 1990, Mosby.
3. Árnadóttir G: Evaluation and intervention with
complex perceptual impairment. In Unsworth C,
editor: Cognitive and perceptual dysfunction: a clini-
cal-reasoning approach to evaluation and interven-
tion, Philadelphia, 1999, FA Davis.
• Emphasize that more time will be needed to complete
daily activities and rushing should be avoided.
• Based on evaluation findings, teach caregivers
appropriate cueing strategies (gestures, tactile, visual,
and/or auditory) that enhance function.
• Emphasize the need to allow for independent
performance of at least part if not the whole
activity—educating as to the importance of not
overassisting.
4. 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/Mosby.
5. Ayres AJ: Developmental dyspraxia and adult onset
apraxia, Torrance, Calif, 1985, Sensory Integration
International.
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
9:449-455, 1987.
7. Basso A, Burgio F, Paulin M, et al: Long-term fol-
low-up of ideomotor apraxia, Neuropsychol Rehabil
10(1):1-13, Jan 2000.
8. Basso A, Capitani E, Della SS, et al: Recovery from
ideomotor apraxia: a study on acute stroke patients,
Brain 110(Pt 3):747, 1987.
9. Bjorneby E, Reinvang I: Acquiring and maintaining
self-care skills after stroke: the predictive value of
apraxia, Scand J Rehabil Med 17:75-80, 1985.
10. Butler J: Intervention effectiveness: evidence from
a case study of ideomotor and ideational apraxia, 
Br J Occup Ther 60(11):491-497,1997.
11. Butler J: Rehabilitation in severe ideomotor apraxia
using sensory stimulation strategies: a single-case
experimental design study, Br J Occup Ther 63(7): 
319-328, 2000.
12. Cappa SF, Benke T, Clarke S, et al: Task force on
cognitive rehabilitation. European Federation of
Neurological Societies. EFNS guidelines on cogni-
tive rehabilitation: report of an EFNS task force, 
Eur J Neurol 12(9):665-680, 2005.
13. Cicerone KD, Dahlberg C, Malec JF, et al: Evidence-
based cognitive rehabilitation: updated review of the
literature from 1998 through 2002, Arch Phys Med
Rehabil 86(8):1681-1692, 2005.
14. De Renzi E, Lucchelli F: Ideational apraxia, Neurocase
1:19, 1995.
15. De Renzi E, Motti F, Nichelli P: Imitating gestures:
a quantitative approach to ideomotor apraxia, Arch
Neurol 37:6-10, 1980.
132 cognitive and perceptual rehabilitation: Optimizing function
16. De Renzi E, Pieczuro A, Vignolo L: Ideational apraxia:
a quantitative study, Neuropsychologia 6:41-52, 1968.
17. Dobigny-Roman N, Dieudonne-Moinet B, Tortrat D,
et al: Ideomotor apraxia test: a new test of imitation
of gestures for elderly people, Eur J Neurol 5:571-578,
1998.
18. Donkervoort M, Dekker J, Fieneke C, et al: Efficacy
of strategy training in left hemisphere stroke patients
with apraxia: a randomized clinical trial, Neuropsychol
Rehabil 11(5):549-566, 2001.
19. Donkervoort M, Dekker J, van den Ende E, et al:
Prevalence of apraxia among patients with a first left
hemisphere stroke in rehabilitation centres and nurs-
ing homes, Clin Rehabil 14(2):130-136, 2000.
20. Duffy RJ, Watt JH, Duffy JR: The construct valid-
ity of the limb apraxia test (LAT): implications for
the distinction between types of limb apraxia, Clin
Aphasiology 22:181-190, 1992.
21. Fisher AG: Assessment of motor and process skills. vol.
1: development, standardization, and administration
manual, ed 5, Fort Collins, Colo, 2003, Three Star
Press.
22. Fisher AG: Assessment of motor and process skills. vol.
2: user manual, ed 5, Fort Collins, Colo, 2003, Three
Star Press.
23. Fitzgerald LK, McKelvey JR, Szeligo F: Mechanisms
of dressing apraxia: a case study, Neuropsychiatry
Neuropsychol Behav Neurol 15(2):148-155, 2002.
24. Foundas A, Macauley B, Raymer A, et al: Ecological
implications of limb apraxia: evidence from mealtime
behavior, J Clin Exp Neuropsychol 1:62-66, 1995.
25. Foundas A, Macauley B, Raymer A, et al: Ideomotor
apraxia in Alzheimer disease and left hemispheric
stroke: Limb transitive and intransitive move-
ments, Neuropsychiatry Neuropsychol Behav Neurol
12(3):161-166, 1999.
26. Fraser C, Turton A: The development of the
Cambridge apraxia battery, Br J Occup Ther 8:248-251,
1986.
27. Geusgens C, van Heugten C, Donkervoort M, et al:
Transfer of training effects in stroke patients with
apraxia: an exploratory study, Neuropsychol Rehabil
16(2):213-229, 2006.
28. Goldenberg G, Daumuller M, Hagmann S: Assessment
and therapy of complex activities of daily living in
apraxia, Neuropsychol Rehabil 11(2):147-169, 2001.
29. Goldenberg G, Hagmann S: Therapy of activities of
daily living in patients with apraxia, Neuropsychol
Rehabil 8(2):123-141, 1998.
30. Greene JD: Apraxia, agnosias, and higher visual
function abnormalities, J Neurol Neurosurg Psychiatr
76(Suppl 5):25-34, 2005.
31. Haaland K, Harrington D, Knight R: Spatial deficits
in ideomotor apraxia: a kinematic analysis of aiming
movements, Brain 122:1169-1182, 1999.
32. Hanna-Pladdy B, Heilman KM, Foundas AL:
Ecological implications of ideomotor apraxia: evidence
from physical activities of daily living, Neurology 60(3): 
487-490, 2003.
33. Harrington D, Haaland K: Assessing limb apraxia
and its relationship to functional skills, Rehabil R & D
Progr Rep 34:61– 62, 1996.
34. Heilman KM, Gonzalez Rothi LJ: Apraxia. In Heilman
KM, Valenstein E, editors: Clinical neuropsychology,
ed 4, New York, 2003, Oxford University Press.
35. Heilman K, Maher L, Greenwald M, et al: Conceptual
apraxia from lateralized lesions, Neurology 49:457-464, 
1997.
36. Hermsdorfer J, Mai N, Spatt J, et al: Kinematic
analysis of movement imitation in apraxia, Brain
119:1575-1586, 1996.
37. Jacobs D, Adair J, Macauley B, et al: Apraxia in corti-
cobasal degeneration, Brain Cogn 40:336-354, 1999.
38. Jacobs D, Adair J, Williamson D, et al: Apraxia and
motor-skill acquisition in Alzheimer’s disease are
dissociable, Neuropsychologia 37:875-880, 1999.
39. Kaufman AS, Kaufman NL: Kaufman assessment bat-
tery for children: administration and scoring man-
ual, Circle Pines, Minn, 1983, American Guidance
Service.
40. Leiguarda R, Pramstaller P, Merello M, et al: Apraxia
in Parkinson’s disease, progressive supranuclear palsy,
multiple system atrophy and neuroleptic-induced
parkinsonism, Brain 120:75-90, 1997.
41. Lucchello F, Lopez O, Faglioni P, et al: Ideomotor and
ideational apraxia in Alzheimer’s disease, Int J Geriatr
Psychiatry 8:413-417, 1993.
42. Maher L, Ochipa C: Management and treatment
of limb apraxia. In Gonzalez Rothi LJ, Heilman
KM, editors: Apraxia: the neuropsychology of action, 
pp. 75-91, Hove, United Kingdom, 1997, Psychology
Press.
43. McDonald S, Tate R, Rigby J: Error types in ideomo-
tor apraxia: a qualitative analysis, Brain Cogn 25:250-
270, 1994.
44. Meador K, Loring D, Lee K, et al: Cerebral lateraliza-
tion: relationship of language and ideomotor praxis,
Neurology 53:2028-2031, 1999.
45. Merians A, Clark M, Poizner H, et al: Apraxia differs
in corticobasal degeneration and left-parietal stroke:
a case study, Brain Cogn 40:314-335, 1999.
46. Mimura M, Fitzpatrick, Patricia M: Long-term
recovery from ideomotor apraxia, Neuropsychiatry
Neuropsychol Behav Neurol 9(2):127-132, 1996.
47. Motomura N, Seo T, Asaba H, et al: Motor learn-
ing in ideomotor apraxia, Int J Neurosci 47:125-130,
1989.
48. Motomura N, Yamadori A: A case of ideomotor
apraxia with impairment of object use and preserva-
tion of object pantomime, Cortex 30:167-170, 1994.
49. Neiman M, Duffy R, Belanger S, et al: Concurrent
validity of the Kaufman hand movement test as a mea-
sure of limb apraxia, Percept Mot Skills 79:1279-1282,
1994.
 Chapter 5  Managing Apraxia to Optimize Function 133
50. Ochipa C, Maher LM, Rothi LJG: Treatment of ideo-
motor apraxia, J Clin Exp Neuropsychol 2:149, 1995.
51. Ochipa C, Rothi L, Heilman K: Ideational apraxia:
a deficit in tool selection and use, Ann Neurol 25:  64. Sundet K, Finset A, Reinvang I: Neuropsychological
190-193, 1989
52. Ochipa C, Rothi LJ, Heilman KM: Conceptual apraxia
in Alzheimer’s disease, Brain 115:1061-1071, 1992.
53. Pilgrim E, Humphreys GW: Rehabilitation of a case
of ideomotor apraxia. In Riddoch J, Humphreys
GW, editors: Cognitive neuropsychology and cognitive
­rehabilitation, Hove, UK, 1994, Erlbaum.
54. Poizner H, Clark M, Merians A, et al: Joint coordina-
tion deficits in limb apraxia, Brain 118(1):227-242,
1995.
55. Poole J: Sequencing deficits in subjects with devel-
opmental dyspraxia and adult onset apraxia,
Neurorehabilitation 10:75-82, 1998.
56. Poole JL: Effect of apraxia on the ability to learn one-
handed shoe tying, Occup Ther J Res 18(3):99-104,
1998.
57. Raymer M, Ochipa C: Conceptual praxis. In Gonzalez
Rothi LJ, Heilman KM, editors: Apraxia: the neuropsy-
chology of action, pp. 75-91, Hove, United Kingdom,
1997, Psychology Press.
58. Rothi L, Raymer A, Heilman K: Limb praxis assess-
ment. In Gonzalez Rothi L, Heilman K, editors:
Apraxia: the neuropsychology of action, pp. 61-73,
Hove, United Kingdom, 1997, Psychology Press.
59. Saeki S, Ogata H, Okubo T, et al: Return to work
after stroke: a follow-up study, Stroke 26(3):399-401,
1995.
60. Schnider A, Hanlon R, Alexander D, et al: Ideomotor
apraxia: behavioral dimension and neuroanatomical
basis, Brain Lang 58:125-136, 1997.
61. Shelton P, Knopman D: Ideomotor apraxia in
Huntington’s disease, Arch Neurol 48:35-41, 1991.
62. Smania N, Aglioti SM, Girardi F, et al: Rehabilitation
of limb apraxia improves daily life activities in
patients with stroke, Neurology 67(11):2050-2052,
2006.
63. Smania N, Girardi F, Domenicali C, et al: The rehabil-
itation of limb apraxia: a study in left-brain-damaged
patients, Arch Phy Med Rehabil 81(4):379-388, 2000.
predictors in stroke rehabilitation, J Clin Exp
Neuropsych 10(4):363-379, 1988.
65. Tate RL, McDonald S: What is apraxia? The clini-
cian’s dilemma, Neuropsychol Rehabil 5(4):273-297,
1995.
66. van Heugten CM: Rehabilitation and management
of apraxia after stroke, Rev Clin Gerontol 11(2): 
177-184, 2001.
67. van Heugten C, Dekker J, Deelman B, et al: A diag-
nostic test for apraxia in stroke patients: internal
consistency and diagnostic value, Clin Neuropsychol
13:182-192, 1999.
68. 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.
69. van Heugten CM, Dekker J, Deelman BG, et al:
Rehabilitation of stroke patients with apraxia: the
role of additional cognitive and motor impairments,
Disabil Rehabil 22(12):547-554, 2000.
70. 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.
71. van Heugten C, Dekker J, Deelman B, et al: Measuring
disabilities in stroke patients with apraxia: a valid-
ity study of an observational method, Neuropsychol
Rehabil 10(4):401-414, 2000.
72. Wilson BA: Remediation of apraxia following an
anaesthetic accident. In West J, Spinks P, editors: Case
studies in clinical psychology, Bristol UK, 1988, John
Wright.
73. Zwinkels A, Geusgens C, van de Sande P, et al:
Assessment of apraxia: inter-rater reliability of a new
apraxia test, association between apraxia and other
cognitive deficits and prevalence of apraxia in a reha-
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

Participant
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
poststroke
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
mediation
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.

134
 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
observation
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
Index
Functional motor test No difference p < 0.13 Impairment
ADL: standardized + p < 0.03 Activity limitations
observation
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:
1. Differentiate among various types of neglect and
neglect and coexisting impairments.
2. Understand recovery patterns related to neglect.
3.  Understand how everyday living is affected by neglect.
4. Be aware of evaluation/assessment procedures related
to neglect.
5. Implement at least five intervention strategies
focused on decreasing activity limitations and par-
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
a brain lesion, when this failure cannot be attrib-
uted to either sensory or motor defects.”43 Unilateral
neglect is most often seen when right-side brain
damage occurs; therefore the most frequent clini-
cal presentation is that of left unilateral neglect.
Although the mechanisms underlying neglect are
still debated, a common hypothesis is that neglect is
related to attention-based impairments and has been
described as a lateralized attention deficit. Behaviors
observed during everyday activities lend support to
the attentional hypothesis, including the following:
• Not being aware of incoming stimuli on the side
opposite the brain lesion (e.g., hypoattentive to
the left side).
• A bias in attention to information presented on
same side of the lesion (e.g., hyperattentive to the
right side).
• Not being able to disengage from right-side
stimuli.
The fact that those living with neglect most often
present with left neglect also supports the ­attentional

136
 Chapter 6  Managing Unilateral Neglect to Optimize Function 137

hypothesis because the right hemisphere is thought
to be dominant for attention (Figure 6-1). That
being said, right unilateral neglect is possible.83
Beis and associates16 documented right neglect in
10% to 13.2% of those they examined. They con-
cluded that right neglect caused by left hemispheric
involvement is an elusive phenomenon and is less
consistent than right hemispheric neglect. In addi-
tion, the frequency of occurrence of right neglect
was, as expected, much lower than that reported in
a study using the same assessment battery in right
brain damage stroke ­clients. Árnadóttir8,9 cautions
that behaviors observed during everyday activities
that appear to be indicative of right neglect may in
fact be caused by other impairments such as ide-
ational apraxia (see Chapter 5) or comprehension
deficits.
In addition to the attentional hypothesis, those
presenting with unilateral neglect also may have
lost the representation of left space that is stored
in the right hemisphere because the brain injury
may lead to a destruction of this representation.
In other words, attention may not be directed to
the left side of space because the person no longer
has the knowledge that it exists.43,60 For example, if
a person with neglect is asked to describe a room
from memory, such as a familiar office, the level
of detail of the description may change based on
imagined vantage point. If the person imagines sit-
ting behind the desk, the description may be overly
focused on details of the right side of the office with
only a gross description (if any) of the left side of
the office. If the person then imagines a change in
viewed vantage point (e.g., imagine yourself fac-
ing the desk), the previously neglected descrip-
tion of the left side of the room will now be on the
right side and the person my able to describe it in
more detail than before. In addition, a person with
neglect may misplace the midpoint of an imagined
number line when asked to bisect it (e.g., stating
that five is halfway between two and six), with an
error ­pattern that closely resembles the bisection of
physical lines.102
Heilman and colleagues43 reviewed the litera-
ture related to anatomic areas related to neglect and
summarized that lesions in the following areas may
cause neglect (Figure 6-2):
• Inferior parietal lobe (temporoparietal-occiptal
junction) (most frequent)
• Dorsolateral frontal lobe
• Cingulate gyrus
• Neostriatum
• Thalamus
• 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
Figure 6-2  Lateral view of the right hemisphere. Lesions (as
determined by computed tomography [CT] scan) of 10 clients
with the neglect syndrome are superimposed. (From Heilman
KM, Watson RT, Valenstein E: Neglect and related disorders. In
Heilman KM, Valenstein E, editors: Clinical neuropsychology, ed 4, 
New York, 2003, Oxford University Press.)
Conceptual and Operational
Definitions
The following definitions are used throughout the
rest of this chapter:
• Unilateral spatial or extrapersonal neglect8,9:
Inattention to or neglect of visual stimuli pre-
sented in extrapersonal space of side contralateral
to a cerebral lesion as a result of visual-percep-
tual deficits or impaired attention. It may occur
independently or in conjunction with visual
Table 6-1 Spatial Aspects of Neglect During Functional Activities*
Type of Neglect
Personal or body neglect
Near extrapersonal (peripersonal [within
arms’ reach]) neglect
Far extrapersonal neglect
*Spatial neglect includes both near and far extrapersonal space.
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
controlled and relatively limited incoming stimuli,
a person with neglect may perform well and attend
to both the right and the left fields. The same person
may present completely differently (i.e., an increased
impact of the underlying neglect) during a commu-
nity reintegration session focused on walking in a
crowded environment.
Neglect Presentations
As mentioned, neglect can be perceptual (i.e., not
responding to contralateral sensory stimuli) or in
the absence of such sensory input, representational
(by imagining familiar scenes). Although it is most
common for these phenomena to occur together,
there is recent evidence that one may occur with-
out the other. In other words, there appears to be a
Functional Activity Difficulties
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
Cannot find objects on left side of sink
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
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
 Chapter 6  Managing Unilateral Neglect to Optimize Function 139
dissociation between the two presentations.59,60 One
may present with perceptual neglect or representa-
tional neglect or both.
From a clinical perspective, neglect may occur
within personal space (body neglect) or in extra-
personal space (spatial neglect). In addition, spa-
tial neglect can affect both near (peripersonal) or
far stimuli (see Table 6-1). Personal and extraper-
sonal can occur together or separately (i.e., they are
also dissociated).12,20,39,51 A person may fully attend
to his or her body during self-care (brushing both
sides of the mouth, dressing both sides of the body)
but not be able to “find” the soap located on the left
side of the sink. In this case the person is presenting
with extrapersonal/spatial neglect but not personal/
body neglect. Beschin and Robertson19 documented
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
neglect showed no personal neglect, whereas five
subjects exhibiting no extrapersonal neglect did
show personal neglect.
The term motor neglect refers to the underuse
of a contralesional limb that cannot be explained
by primary sensorimotor deficits.68 Documented
behaviors include the following (Box 6-1)48,68:
• When a task may be performed by the ipsile-
sional side, there will be underuse of the contral-
esional side.
• No or little involvement of the contralesional
limb in bimanual tasks.
• No or little involvement of the contralesional
limb in gesture.
• Relatively intact movement when encouraged
specifically to use the contralesional limb.
• When walking, the contralesional limb may
lag behind the ipsilesional limb, although
when attention is drawn to it, performance is
improved.
Another behavior commonly seen in those with
neglect is extinction. In extinction, a person fails to
detect contralesional stimulation that is accompa-
nied by ipsilesional stimulation (i.e. bilateral simul-
taneous stimulation), despite being able to detect
contralesional stimuli in isolation.54 In other words,
ipsilesional stimuli interfere with the processing of
contralesional stimuli.36 Extinction occurs because
the hemispheres are unbalanced in the way they
allocate attention as described above. The left, intact
hemisphere competes with and “wins over” the
damaged right hemisphere.For example, John pre­
sents with extinction after right hemispheric brain
Box 6-1 Functional Manifestations of
Motor Neglect or Extinction
Degraded performance of the left (usually) upper
extremity during bilateral activities such as cutting,
aspects of oral care (placing toothpaste on brush),
folding a sheet, opening a container, typing,
buttoning, chopping vegetables.
Loss of spontaneous use of the limb opposite the lesion
Dropping or “forgetting” about items in the left hand
as the right hand is engaged in activity. For example,
dropping the shopping bag that the left hand was
carrying as the right hand is engaged in retrieving keys
and opening a door or spilling a glass of water that
was in the left hand as the right hand is used to eat
Dragging of foot during gait activities and upright
function
damage and is sitting at the dinner table. Mary takes
the seat across from John and to his left (contra-
lateral to John’s brain lesion). For a while they are
having dinner alone and John can attend to Mary
and socialize with her. In the middle of the meal,
Peter sits across from John to his right (ipsilesional
to John’s brain injury). At this point, the extinc-
tion behaviors are observed. John will begin to not
attend to Mary and will focus attention on Peter.
This hyperattention to ipsilesional stimuli has been
described as a “magnetic” attraction that can’t be
overcome by cueing (Figure 6-3).36
Another manifestation of extinction is motor
extinction,67,68 which refers to reduced performance
of the contralesional limb during bilateral activ-
ity. Motor extinction is strongly related to motor
neglect as described earlier. When a person pres-
ents with motor extinction, the deficit is observed
as degraded performance of the contralesional limb
that either becomes apparent or worsens dispropor-
tionately when a simultaneous ipsilesional move-
ment is made (Figure 6-4).68 Examples of activities
that may be impeded secondary to motor extinction
including folding laundry, pulling up pants, etc.
Neglect and extinction often coexist but, albeit
rarely, they can also dissociate, suggesting that
they may have separate neural underpinnings.46,54
A recent lesion overlap study concluded that the
temporoparietal junction is the neural substrate
of visual extinction.46 It is important to screen for
extinction because its presence will affect the reha-
bilitation process. It may be particularly noted
during the performance of functional activities in
stimulating environments such as a lobby or store
140 cognitive and perceptual rehabilitation: Optimizing function

Mary Peter as information is “bombarding” both hemispheres.

John
A Frequency and Recovery Patterns
Mary
John
B of those receiving stroke rehabilitation present
Mary Peter
John
C of the disorder in rehabilitation clients varied
Figure 6-3  An example of potential functional manifestation of
extinction during mealtime. A, Typical behavior when extinction
is not present. John is able to attend to Mary, who is seated to
the left of John, as well as to Peter seated to his right. B, When
extinction is present, John (who has right hemispheric brain
damage) is able to attend to Mary who is seated to John’s left side
when they are dining alone. C, When extinction is present, John
will have difficulty attending to Mary to the left side of the table but
may be hyperattentive to Peter, who is seated to the right of John
as in this situation. Mary and Peter serve as double simultaneous
visual stimulation.
In these cases, a person with extinction may worsen
and be hyperattentive to the right (Box 6-2).
Several published studies have attempted to docu-
ment the frequency of neglect with various findings
including the following:
• Kalra and colleagues45 documented that 32%
with neglect.
• Halligan and coworkers41 reported that 48% of
right hemisphere stroke clients in rehabilitation
presented with neglect.
• Zoccolotti and associates101 found that estimates
with the test used from 26.7% to 52.0%, but
only 20% of clients had very severe neglect on
the basis of overall clinical judgment.
• Stone and colleagues83 reported a neglect inci-
dence of 75% in right hemisphere stroke survi-
vors 3 months after stroke.
• Azouvi and associates12 found that sensitivity
greatly varied depending on which test of neglect
was used ranging from 19% to 50.5%. More
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
able to attend to and identify tactile, visual, and/or audi-
tory stimuli that are presented to both sides of the body at
the same time. Note that prior to testing it must be ascer-
tained that the person being tested is able to detect incom-
ing sensory information on both sides. In other words, first
screen for homonymous hemianopsia, unilateral deafness,
or hemisensory loss.
Tactile
Double simultaneous tactile stimulation is tested by touch-
ing homologous parts (e.g., hands or shins) of the body on
one side, the other side, or both sides at once with the per-
son identifying which side or if both sides are touched with
their eyes closed. The examiner requests that the person
close the eyes and states, “Tell where I am touching you—on
the right side, the left side, or on both sides.” A normal
response is that the person can detect unilateral and bilat-
eral stimulation. If the client neglects one side during dou-
ble simultaneous tactile stimulation, tactile extinction is
present. For example, the person can detect being touched
only on the right side and only on the left side. When the
examiner touches both sides, the person being tested only
reports right-sided stimulation.
Visual
Double simultaneous visual stimulation is tested by provid-
ing visual input such as wiggling fingers in one visual field,
the other visual field, or both visual fields at once, with the
person identifying where movement is detected while the
eyes are focused forward on the examiner. The examiner
requests that the person being tested look at the examin-
er’s nose and states, “Tell which finger is moving—the right,
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
severe) in 36.2% of cases.
• Buxbaum and coworkers24 found that neglect was
present in 48% of right hemisphere stroke clients.
• In a community-based study of 602 consecutive
stroke clients, neglect was found in 23% of the
sample.64
Bowen and associates22 also reviewed the litera-
ture and found that the frequency of occurrence of
neglect in clients with right brain damage ranged
from 13% to 82%. The assessment method used
was one of the main factors explaining the discrep-
ancies between the different studies.22 As differing
methods of assessment are used, the frequency of
the left, or both.” A normal response is that the person
can detect unilateral and bilateral stimulation. If the client
neglects one side during double simultaneous visual stimu-
lation, visual extinction is present. For example, the person
can detect the moving finger on only the right side and only
on the left side. When the examiner moves both fingers, the
person being tested only reports right-sided stimulation.
Auditory
Double simultaneous auditory stimulation is tested by giving
auditory stimulation (a snapping sound) to one side of the
body, the other side, or both sides at once, with the person
identifying where the sound is heard. The examiner stands
behind the person being tested with the hands positioned
next to each ear. “Tell where you hear the snap sound—
on the right side, the left side, or on both sides.” A normal
response is that the person can detect unilateral and bilat-
eral stimulation. If the client neglects one side during dou-
ble simultaneous auditory stimulation, auditory extinction
is present. For example, the person can detect the snapping
only on the right side and only on the left side. When the
examiner snaps next to both ears, the ­person being tested
only reports right-sided stimulation.
Motor
Reduced performance of the contralesional limb during
bilateral activity is termed motor extinction. For testing,
the person is asked to make as many tapping movements
as possible under both unimanual and bimanual testing
conditions in 15 seconds. A person who shows a dispro-
portionately lower number of taps with the contralesional
limb under bimanual conditions is thought to demonstrate
motor extinction.
neglect varies with the tool used. Similarly, assess-
ments were performed at different times, and there is
some evidence that frequency varies according to the
timing of the assessment. Finally, neglect is variable
or inconsistent and not an “all or none” impairment.
It is commonly influenced by extraneous factors such
as fatigue, distractions, motivation, external cues,
task difficulty, density of stimuli, and so on.12,22
Recovery from neglect was recently examined by
Farne and colleagues,29 who examined a consecu-
tive series of right brain-damaged clients with and
without neglect via weekly tests in the acute phase
of recovery. They found that spatial attention def-
icits partially improved during the acute phase of
142 cognitive and perceptual rehabilitation: Optimizing function
the disease in less than half the clients investigated.
There was an improvement in left visuospatial
neglect at the chronic stage of the ­disease, but the
recovery was not complete.
Appelros and coworkers6 examined the ­recovery
process for different forms of unilateral neglect
­(personal neglect and neglect of far space). Subjects
were tested at 2 to 4 weeks, at 6 months, and at 1
year using the Behavioral Inattention Test (discussed
later) and a test for personal neglect. They found that
peripersonal neglect diminishes within 6 months,
but complete recovery occurred in only 13% of those
examined. Also the prognosis for personal neglect
and neglect of far space is better, with a recovery
ratio at 6 months of 52% and 46%, respectively. They
also found that a few of the subjects’ neglect status
deteriorated in the absence of recurrent stroke. The
authors concluded that it is practical to postpone
a neglect evaluation until a couple of weeks after a
stroke. At that point, many of the clients who ­present
with neglect are likely to retain it, although many will
also improve.
Effect of Unilateral Neglect on Daily
Life and Rehabilitation Outcomes
The presence of neglect has the potential to affect a
person’s ability to participate in many daily ­activities.
Basic as well as instrumental activities of daily living
may be adversely affected as well as work and leisure
pursuits.
Cherney and associates26 investigated the func-
tional aspects of those with neglect and found the
following:
• Clients made significant functional gains between
admission and discharge, as well as between dis-
charge and follow-up on the Functional
Independence Measure (FIM).
• Severity of neglect was correlated with total,
motor, and cognitive FIM scores at admission,
discharge, and follow-up.
• Those living with neglect had significantly more
days from onset to admission to rehabilitation
and a longer length of rehabilitation stay than
subjects without neglect.
• FIM outcomes were significantly different for
subject groups with more severe neglect.
• Both the presence of neglect and its severity were
significantly related to functional outcomes for
reading and writing.
• Clients with neglect show reduced overall and
cognitive-communicative functional ­ performance
and outcome than clients without neglect.
Kalra and coworkers45 examined 150 subjects
undergoing rehabilitation. They found that people
with visual neglect have greater activity limitations
than those without neglect. In addition, those with
neglect took longer to recover despite comparable
stroke pathology and severity of motor impair-
ment. Although other studies have documented
greater institutionalization for those with neglect,
Kalra and coworkers45 found that discharge des-
tination in those with neglect is comparable with
that of others of equal stroke severity managed on
a stroke unit.
Chen-Sea25 documented that those with concur-
rent personal and extrapersonal neglect were sig-
nificantly more impaired in activities of daily living
(ADL) performance as compared with those with
extrapersonal neglect and those with test results
within normal range on standardized neglect
testing.
Buxbaum and colleagues24 assessed 166 rehabili-
tation in patients and outpatients with right hemi-
sphere stroke with measures of neglect and neglect
subtypes, attention, motor and sensory function,
functional disability, and family burden. Those with
neglect had more motor impairment, sensory dys-
function, visual extinction, basic (nonlateralized)
attention deficit, and anosognosia than did those
without neglect. Neglect severity predicted scores
on the FIM and Family Burden Questionnaire more
accurately than did the number of lesioned regions.
They concluded that the neglect syndrome, rather
than overall stroke severity, predicts poor outcome
in right hemisphere stroke.
Katz and colleagues47 evaluated the effect of uni-
lateral spatial neglect on the rehabilitation outcome
and long-term functioning in ADL and instru-
mental ADL (IADL) of right hemisphere–dam-
aged stroke survivors. The authors administered
assessments of sensorimotor, cognitive impair-
ment, functional disability at admission to reha-
bilitation, discharge, and 6 months after discharge.
Based on their score on the Behavioral Inattention
Test (BIT), subjects were divided into two groups:
19 with neglect and 21 without neglect. They found
that both impairment and activity measures of
those with and without neglect were differentiated.
Neglect was associated with lower performance on
measures of sensorimotor and cognitive impair-
ment as well as on measures of basic and instru-
mental ADL. Differences were significant in all
testing periods. In addition, the recovery pattern of
those with neglect was slower. In both groups, the
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
is a major predictor of rehabilitation outcome from
admission to follow-up and that neglect is a major
source of stroke-related long-term disability.
Gialanella and associates37 examined whether the
presence of anosognosia or denial or lack of aware-
ness of deficits affects the rehabilitative prognosis
of hemiplegic subjects with neglect (see Chapter 4).
They examined 30 clients with left hemiplegia: 15
clients had neglect (N) and 15 had neglect and
anosognosia (N+A). Before rehabilitation, cog-
nitive FIM scores of group N were significantly
higher than those of group N+A, whereas motor
FIM scores and total FIM scores did not differ
between the two groups. After rehabilitation, cog-
nitive FIM scores, motor FIM, and total FIM scores
were statistically higher in group N than in group
N+A. Overall disability was lower in group N. The
authors concluded that the presence of anosognosia
worsens the rehabilitation prognosis in hemiplegic
subjects who also have neglect.
In terms of long-term outcome, it has been found
that neglect in the acute phase negatively affects dis-
ability after 1 year.3 Finally, those with a right-sided
bias are at risk for increased falls and wheelchair col-
lisions.94 Clinicians should consider the consistent
findings of these studies when planning rehabilitation
interventions including deciding on appropriate
length of stay for inpatients and “scaled-down”
short-term goals.
Patterns of Impairments
It is typical for those presenting with neglect to also
exhibit other impairments that will further impede
function. These include the following:
• Unilateral sensory loss. Tactile sensory loss is
more likely to occur in clients with neglect than
in those without neglect.24
• Unilateral loss of motor control. Those with
more severe neglect are more likely to have more
severe motor impairment.24
• Loss of postural control and postural alignment.87
Neglect has been implicated in the phenomenon
known as the “pusher syndrome.”67
• Topographical disorientation or difficulty finding
one’s way in space. Ambulation and wheelchair
mobility will be affected and is usually charac-
terized by a bias toward right-hand turns. Those
with neglect typically cannot find their rooms on
a unit and even within the room have difficulty
finding closets and bathrooms because they can-
not make use of left-sided environmental cues.
As discussed related to representational neglect,
those with neglect have difficulty describing a
familiar route from memory, particularly when
left-sided turns are involved. Guariglia and
Antonucci39 documented a specific navigational
impairment in right brain–­damaged subjects pre-
senting with representational neglect. Specifically
those with neglect had difficulty reorienting to
the room, and the target location was reached
only after getting lost and long and imprecise
wandering. The authors concluded that those
with neglect were unable to manipulate that men-
tal representation in order to reorient themselves
into the environment.
• General nonlateralized attention deficits. Those
with neglect are more likely to present with gen-
eralized attention disorders as well.24,75,101 See
Chapter 8.
• Anosognosia or a denial or lack of awareness of
deficits can occur in conjunction with neglect. In
addition, anosognosia and neglect usually present
together, but in some cases may be dissociated.11
Those with neglect have less awareness of their
deficits than those without neglect24 and anosog-
nosia is correlated with neglect severity.10,11 Both
neglect and anosognosia are predictors of func-
tional independence.3 When they occur together,
the prognosis worsens.37 A recent review revealed
that anosognosia or a lack of awareness is present
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-
tions discussed here are based on strategy training
approaches; therefore, a certain level of awareness
is a prerequisite to using these strategies. Awareness
training is the starting point of intervention, if
not successful, environmental modifications are
­necessary to improve function (see Chapter 4).
• Visual field deficits. Visual sensory loss is more
likely to occur in those with neglect than in
those without neglect.24 Visual field deficits such
as hemianopsia can occur in conjunction with
neglect or the impairments can present indepen-
dently.12 It is sometimes difficult to differentiate
between visual field deficits and neglect. Muller-
Oehring and associates55 investigated 11 subjects
with combined neglect/hemianopsia and 11 sub-
jects with pure hemianopsia via behaviors on a
visual search task with single or double stimula-
tion conditions. The second stimulus was either
the fixation point itself or a distracter appearing
in the hemifield opposite the target. The ­fixation
point did not worsen left-sided perception, but
144 cognitive and perceptual rehabilitation: Optimizing function
its disappearance led to a bias of exploration
toward the right side in those with neglect but
not in those with pure hemianopsia. A distracter
in the intact hemifield worsened the perfor-
mance to left-sided stimuli—those with neglect
behaved as if they were completely hemianopsic,
even in intact parts of the visual field. Further
suggestions to differentiate between impair-
ments are included in Table 6-2 (see Chapter 3).
Evaluation and Assessments
Similar to other cognitive and perceptual impair-
ments, instruments designed to test neglect are
focused either on documenting the presence of
neglect (i.e., diagnostic in nature) or on how the
presence of neglect affects daily functioning. The
latter issue is more relevant from a rehabilitation
perspective. Typical pen-and-paper tests that are
used to document the presence of neglect include
the following44:
• Star cancellations
• Letter cancellations
• Line bisection tests
Table 6-2 Suggestions to Differentiate Between Neglect and Visual Field Loss Based
on Analysis of Behaviors
Visual Field Loss
Objectively tested via confrontation testing (screening) or via
formalized perimetry testing (see Chapter 3)
Awareness of deficits emerge early in the recovery process
Compensatory strategies such as head turning and wide
saccades are observed early and relatively easily taught
Postural alignment is usually not affected
Sensory-based deficit
Visual deficit only
Effective compensatory strategies result in positive functional
outcomes
Cortical representation of the “whole real world” is intact
Movement into both hemifields is not affected
Extinction is not present
Early leftward eye movements noted
Not fully effective but consistent scanning patterns
Comparatively, not as severe a deficit
• Design copying tasks
• Drawing tasks such as a drawing a clock, house,
or flower
Using these types of tests exclusively is of concern.
Specifically, they focus only on peripersonal neglect
and their relationship to real-world performance is
questionable. People with normal performance on
pen and paper tests may demonstrate clinically sig-
nificant neglect in everyday life.5,82 Performance of
daily activities involves multiple motor, postural,
visual, and cognitive-perceptual skills (see discus-
sion on dual task performance in Chapter 2). It may
be that a test that attempts to single out an impair-
ment may not be sensitive enough to detect neglect
that would interfere during function. In addition,
it has been hypothesized that a person may be able
to compensate for neglect during a relatively short
and simple test but not have the same ability during
complex everyday function.
Azouvi and colleagues12 assessed the sensitivity of
different tests of neglect after right hemisphere stroke
(N = 206). Subjects were given a test battery includ-
ing an assessment of anosognosia, visual extinction,
assessment of gaze orientation, personal neglect, and
Neglect
Objectively tested using a battery of assessments to
identify body/personal, extrapersonal (near and far),
and motor neglect
Lack of awareness is more severe and persistent
Compensatory interventions are difficult, may require
multiple sessions, or may not be effective
Postural alignment of the head, neck, and trunk may bias
toward the right side
Attention-based deficit
Multiple sensory systems may be involved (visual, auditory,
tactile)
Functional outcomes tend to be poor as compared to those
without neglect
Decreased representation of the left side of space while
describing a room from memory
Resistance to moving actively (akinesia) or passively into the
left field
Long delays related to moving into the affected field
(hypokinesia)
Extinction may be present
Rightward-biased eye movements
Haphazard scanning patterns biased to the right
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
personal space. The subjects were compared with a
previously reported control group. A subgroup of
subjects received a functional assessment of neglect
in daily life situations (Catherine Bergego Scale)
(Figure 6-5). The authors found the following:
• The most sensitive pen and paper measure
was the starting point in the cancellation task
(i.e., a rightward orientation).
• The complete test battery was more sensitive
than any single test alone.
• Approximately 76% of clients presented some
degree of neglect on at least one measure.
• A critical finding from a rehabilitation perspec-
tive was that the functional assessment of neglect
in daily life was more sensitive than any other
s­ ingle measure of neglect and comparable to the
complete pen-and-paper battery.
• Functional neglect was considered as moderate
to severe in 36% of cases.
• Dissociations were found between extraper-
sonal neglect, personal neglect, anosognosia,
and extinction (i.e., they can exist together or in
isolation).
• Anatomic analyses showed that neglect was more
common and severe when the posterior associa-
tion cortex was damaged.
• The presence of neglect was task dependent.
• Tasks including a strong visual component were
the most sensitive.
• The automatic rightward orientation bias seemed
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
have been developed. As discussed in Chapter 1,
the Árnadóttir Occupational Therapy-ADL Neuro­
behavioral Evaluation (A-ONE)8,9 uses structured
naturalistic observations of basic ADL and mobil-
ity tasks to assess the effect of both body and spa-
tial neglect. Although not an impairment-based
test, the Assessment of Motor and Process Skills
(AMPS)31,32 objectively documents problematic
motor and process skills during the performance of
IADL and some basic ADL.
The Catherine Bergego Scale11,18 is a standard-
ized behavioral assessment of unilateral neglect. It is
based on a direct observation of the client’s behavior
in 10 everyday situations such as grooming, dress-
ing, eating, or wheelchair mobility. For each item, a
4-point scale is used, ranging from 0 (no neglect) to
3 (severe neglect). The total score ranges from 0 to
30 (see Figure 6-5). This functional assessment of
neglect in daily life has been found to be more sen-
sitive than any other single measure of neglect and
comparable to a complete pen-and-paper battery12.
A self-assessment version of the scale can be used to
objectify anosognosia/awareness (see Chapter 4).
The Behavioral Inattention Test (BIT)97 consists
of six conventional subtests—figure and shape copy-
ing, line crossing, star cancellation, letter cancellation,
line bisection, and representational drawing—as well
as nine behavioral subtests—telephone dialing, map
navigation, address and sentence copying, menu
reading, coin sorting, telling and setting the time,
picture scanning, card sorting, and ­ article reading.
The test has strong psychometric properties. Further
investigation42 of the behavioral subtests revealed
that seven of the nine subtests differentiated signifi-
cantly among subjects with visual neglect and those
without neglect (article reading and telling time did
not discriminate), whereas six of the nine subtests
correlated significantly with parallel performance
tasks or ADL checklist items. Picture scanning, map
navigation, and card sorting did not correlate with
similar tasks based on an ADL checklist.
The BIT uses simulated functional tasks performed
out of context to evaluate neglect. In addition the test
is only administered in the peripersonal space. The
Baking Tray Task4,14, 90 is similar in terms of testing for
neglect of peripersonal space using a simulated task.
The person being examined is required to spread out
cubes evenly across a board as if they were buns on a
baking tray. The Baking Tray Task seems to be a quick
and yet sensitive test, suitable for screening purposes
and longitudinal studies (Figure 6-6).
The Comb and Razor/Compact Test19 objectively
evaluates personal grooming behavior according to
the proportion of the total activity that is directed
to the left side of the body. The test is highly reli-
able, and more sensitive than previous diagnostic
techniques.19 The person is asked to comb his or
her hair and, during a 30-second period, the rater
categorizes each stroke according to whether it was
applied to the left or the right side of the head, or
was ambiguous. Similar 30-second observations are
documented for simulated shaving (men) or facial
compact use (women). For each person, a “left over
total” percent score is calculated for each of the
activities performed, according to the formula:
% Left = left strokes ÷ left + ambiguous + right strokes
A recent update of the test characterizes personal
neglect as a lateral bias of behavior rather than as a lat-
eralized deficit.53 These authors suggest an alternative
formula that indexes the magnitude and direction of
lateral bias as a proportion of the total activity:
% Bias = right − left strokes ÷ left + ambiguous
 + right strokes × 100
A rightward bias yields a positive percentage
score, whereas a leftward bias yields a negative per-
centage score. A score of zero indicates symmetric
performance.
The Comb and Razor/Compact Test is test of
personal neglect as is the Fluff Test,28 which objec-
tifies body exploration as 24 stickers are applied to
the right and left sides of the body (9 on the right
and 15 on the left) (Figure 6-7). The stickers are
applied while the person is blindfolded and the per-
son is asked to search for them while blindfolded
without a time limit. Normative data have been col-
lected and published.28
Bowen and associates21 have published preliminary
data on a functional test of neglect that is under devel-
opment. During this test participants must remove keys
from a rack, identify grocery items, wash their face, and
clean a tray as method to test for neglect in various spa-
tial domains. The authors report that further testing is
under way. Table 6-3 reviews various instruments used
for those with unilateral neglect summarized earlier as
well as the Wheelchair Collision Test69 used to screen
for behavioral manifestations of neglect.
Evidence-Based Interventions
Although the body of literature focused on testing inter-
ventions related to improving neglect continues to grow,
there continues to be a lack of well-designed and high-
quality studies.50 There is a particular lack of studies that
have tested the effect of intervention at the activity and
­participation levels of function. The following para-
 Chapter 6  Managing Unilateral Neglect to Optimize Function 147

B C

D E

F G
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
outcomes related to function, as well as various ­levels
of evidence.
Awareness Training
Tham and coworkers88 developed an intervention to
improve awareness related to the effect of neglect on
functional performance. Purposeful and meaningful
(for the participant) daily occupations were used as
therapeutic change agents to improve awareness of dis-
abilities. Specific interventions include the following:
• Encouraging the participants to choose motivat-
ing tasks as the modality of intervention.
• Discussions around task performance. Examples
include encouraging the participants to describe
148 cognitive and perceptual rehabilitation: Optimizing function
Right Left
A D G
H ipants. The authors concluded that training to
B E
C F
M S
N T
O U
P V
Q X
R Y
Figure 6-7  The Fluff Test. Placement of targets. (From Cocchini G,
Beschin N, Jehkonen M: The fluff test: a simple task to assess body
representation neglect, Neuropsychol Rehabil 11[1]:17-31, 2001.)
their anticipated difficulties and to link their ear-
lier experiences of disability to new tasks and to
plan how they would handle new situations, and
asking the participants to evaluate and describe
their performance and to think about whether
they could improve performance by doing the
task in another way.
• Provide feedback about the observed difficul-
ties including verbal feedback (describe to the
participant difficulties with reading and under-
standing the text in the left half of the page of the
newspaper), visual feedback (give visual guid-
ance to show the “neglected” text in the left half
of the page), and physical guidance.
• When participants could describe their difficul-
ties, the therapists and participants discussed
compensatory techniques that could improve
task performance.
• The participant performed the task again, using
the newly learned compensatory techniques.
• The home environment was used to confront
difficulties in familiar settings.
• Video feedback was used (see later).
• Interviews were used to reflect on and heighten
awareness.
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-
I improve awareness of disabilities might improve
the ability to learn the use of compensatory tech-
J
niques in the performance of ADL in clients with
K
unilateral neglect. Despite the well-documented
L relationship between a lack of awareness and
neglect, there is a clear lack of empirical evidence
to support the use of a particular strategy focused
on improving awareness. Video feedback (dis-
cussed later) has been used as an intervention to
assist in developing awareness related to neglect
behaviors that interfere with task performance
(see Chapter 4).
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
randomized trial, Weinberg and colleagues95 studied
the effects of an intervention consisting of 20 hours
of visual training (1 hour each day for 4 weeks in
reading, writing, and calculation) to promote left-
side scanning. The intervention group significantly
improved on impairment-based scanning mea-
sures as well as on academic reading tests. Similarly,
Gordon and associates38 examined the effects of
a perceptual remediation program that included
basic visual scanning, somatosensory awareness
and size estimation training, and complex visual-
perceptual organization. By discharge from reha-
bilitation, the experimental group showed greater
gains in all three types of perceptual functioning.
Positive functional effects of these types of interven-
tions have not been well documented.
Wiart and coworkers96 examined the effectiveness
of combined scanning and trunk rotation using a
specially designed device (Bon Saint Come’s device)
via a randomized controlled trial. The device uses a
pointer that comes into contact with specific targets
via voluntary trunk rotation. The intervention sig-
nificantly improved recent and chronic neglect as
objectified by standardized impairment measures,
as well as ADL function as measured by the FIM.

Table 6-3 Recommended Outcome Measures and Function-Based Neglect Assessments
Instrument and
Author Instrument Description
Standardized
assessments of basic
activities of daily living
(ADL)
Standardized
assessments of
instrumental ADL
(IADL)
Standardized
assessments of leisure
Standardized
assessments of
participation
Standardized
assessments of quality
of life
Behavioral Inattention Assessment for unilateral
Test (BIT), neglect using 6 pen-
Wilson, Cockburn, and-paper tests and 9
and Halligan, behavioral tests
198797;
Halligan, Cockburn,
and Wilson, 199140
Baking Tray Task, Clients are asked to
Tham and Tegner, spread out 16 cubes
199690; on a 75 × 50-cm
Appelros et al, 20044 board or A4 paper
(8.27 × 11.69 inches)
“as if they were buns
on a baking tray”
Dimension Based
on International
Population Validity Reliability Classification of Function Comments
Activity limitations See Chapter 1
Activity limitations See Chapter 1
Activity limitations See Chapter 1
Chapter 6  Managing Unilateral Neglect to Optimize Function
Participation restrictions See Chapter 1
Quality of life See Chapter 1
Adults with Strong concurrent Interrater = 0.99 Impairment Behavioral tests consist
unilateral validity between Test-retest = 0.99 Simulated activity of simulated tasks
neglect the pen-and-paper limitations An eight-item version83
secondary to test and behavioral and a three-item
acquired brain tests and between version44 has been
damage test results and ADL used clinically
observations and Measures peripersonal
performance neglect
Adults with Initial validity studies Test-retest = 0.87 Impairment measured via Sensitivity can be
unilateral conducted using simulated activity further enhanced
neglect modified versions of when it is used in
secondary to the BIT and a test of combination with
acquired brain personal neglect other tests
damage Measures peripersonal
neglect
(Continued)
149
 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
right).
The person must find
and remove the
targets from the
clothing
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
Independence
Measure
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

151
152 cognitive and perceptual rehabilitation: Optimizing function
Using an A-B-A (A refers to the nontreatment or
control phase of the experiment whereas B refers to
the treatment phase of the experiment) treatment-
withdrawal, single-subject experimental design,
Bailey and associates13 examined the effects of scan-
ning training on five older subjects with neglect.
Active scanning to the left was encouraged by a
therapist, using visual and verbal cues and mental
imagery techniques during reading, copying tasks,
and simple board games. Neglect was examined by
a blinded examiner using a star cancellation test,
line bisection test , and the Baking Tray Task. Three
of the five subjects who received scanning and cue-
ing showed a reduction in neglect in one or more
tests. This improvement was maintained during the
withdrawal phase.
Pizzamiglio and associates66 tested an interven-
tion to reduce scanning impairments in 13 sub-
jects with stable neglect symptoms. The training
consisted of four procedures: visuospatial scan-
ning (computer-based), reading and copying train-
ing (sentences and newspapers), copying of line
drawings on a dot matrix, and figure description of
simple and realistic scenes. The overall focus of the
intervention was to have the subjects actively and
sequentially scan various parts of the visual field.
After the intervention the group showed signifi-
cant improvements on several standardized neglect
impairment tests. In addition, the results on a func-
tional evaluation of neglect (including the items of
serving tea, use common objects, describing a com-
plex figure, and describing a room) pointed to the
generalization of improvements to situations simi-
lar to those of daily life. Seven subjects were exam-
ined several months after the end of therapy and
appeared stable on both standard and functional
tests of neglect. The authors also noted that sub-
jects only improved very slightly on a variety of
standard visuospatial tests, indicating the training
was ­specific to reducing the scanning impairment.
Similarly, Paolucci and colleagues61 studied the
effect of specific training for visual neglect on the
recovery of motor and functional impairment in
those with neglect secondary to stroke. The inter-
vention was consistent with Pizzamiglio and asso-
ciates66 described earlier. The subjects were assessed
by the Rivermead Mobility Index, Barthel Index,
and the Canadian Neurological Scale, completed
at 0, 2, and 4 months from the beginning of physi-
cal rehabilitation. One of the two groups of those
with neglect clients was randomly assigned to spe-
cific training for neglect, and the second group to
a general cognitive intervention; during the final 2
months of rehabilitation the types of training were
switched in the two groups. At the time of admission,
the two neglect groups performed at the same level
but after 2 months of rehabilitation, the group with
neglect training showed higher functional recovery
than the group with only general cognitive interven-
tion. When the latter group received neglect train-
ing, there was no longer any difference between the
two neglect groups. The recovery was documented
for both of the functional scales used but not for the
neurologic scale.
Antonucci and coworkers2 examined the effec-
tiveness of neglect rehabilitation training focused on
scanning training (the same protocol as described
by Pizzamiglio and associates66) for those with per-
sistent neglect via a randomized controlled trial. The
experimental group received treatment immedi-
ately after admission to a clinic, and the other group
received only general cognitive stimulation for the
same amount of time. Following the intervention, a
comparison showed significant improvement in the
experimental group based on standardized tests of
impairment as well as on a functional scale. The sec-
ond group was then given rehabilitation training for
neglect for the same amount of time, and obtained
similar improvement. The authors concluded that
the rehabilitation program produced significant
results that generalize to situations similar to those
of everyday life.
Attempts at retraining functional scanning
solely via computer assisted training have been
mostly unsuccessful thus far.17,70,76 Without a spe-
cific focus on generalization, scanning training
may be restricted to the task that was specifically
trained.92 Scanning training also has been inte-
grated into other interventions such as limb activa-
tion approaches and is discussed later. In summary,
scanning training has been documented to include
the following:
• Rotation activities (trunk, head/neck)
• Scanning while static
• Scanning while mobile (ambulation or wheel-
chair navigation)
• Using perceptual anchors (the left arm on the
table or a brightly colored strip of tape on the
left side of an activity)
• Specific reading, writing and mathematical
­calcualtions training
It may be concluded that scanning training
may not generalize automatically, empirical stud-
ies that have tested scanning training usually com-
bined training with other interventions making it
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
daily functional activities. It should be noted that
scanning training is considered a practice stan-
dard by the American Congress of Rehabilitation
Medicine.27
Lighthouse Strategy
A specific scanning protocol combing scanning
training with visual imagery that has been published
and tested is the Lighthouse Strategy (LHS). The
specific intervention is outlined as follows56-58:
• A cancellation test is administered during the
initial evaluation.
• The test is scored and the person is shown the
letters missed on the test.
• The therapist makes introductory statements
such as, “I teach a strategy to help people pay
better attention to their left [or right]. See how
you missed these on this side? I can help you fix
this problem.”
• The LHS is introduced as a strategy for help-
ing people pay better attention to their left and
right, and explained fully. The person is shown
a simple line drawing of the Cape Hatteras light-
house (Figure 6-8), with the light beams and
top lights highlighted with a yellow marker. The
­person is told to imagine that his or her eyes
and head were like the light inside the top of the
lighthouse, sweeping to the left and to the right
of the horizon to guide ships to safety. The per-
son is then asked to think about what would
­happen if the lighthouse only provided light to
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.)
the right (or left) side of the ocean and horizon.
The ­ therapist probes for consequences of the
lighthouse ­illuminating only one side.
• The picture of the lighthouse is placed on the
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-
son is asked to close the eyes while the therapist
sets up objects across the table in front of the per-
son. The person is asked to find these objects.
• Each time an object is missed, the person is
asked to turn the head “like a lighthouse, left and
right, like this” while the therapist demonstrates
the proper degree and pace of head turning. The
person is shown how to line the tip of the chin
first with the top of the right and then the top of
the left shoulder.
• The person is then asked to find the objects
again, this time using the LHS.
• A tactile cue such as a light tap on the left shoul-
der may be given in addition to the verbal cue.
• The person is asked to notice how many more
objects can be seen when the LHS is used.
• A copy of the lighthouse poster is placed on the
wall of the person’s room, to the right of the bed.
• All therapists are given copies of the poster and
asked to use it to cue the person when task per-
formance requires attention to both the right and
left fields (grooming, feeding, mobility, etc.).
Initial testing56 of the LHS was done with 16 adults
with stroke. The treatment group’s performance on
a cancellation test given at admission and discharge
was significantly improved (p = 0.002) as compared
154 cognitive and perceptual rehabilitation: Optimizing function
with controls matched for diagnoses, race, and age.
In addition, significant improvement (p = 0.007)
for those taught the LHS was documented in over-
all attention as measured by a facility rating scale
and reports by family and caregivers.
Further testing58 of the strategy was done on
10 people with unilateral neglect undergoing acute
rehabilitation for brain injury. The patients were
cued by their interdisciplinary treatment team mem-
bers to “be like horizon-illuminating lighthouses
and turn their heads left and right during functional
and therapy training tasks.” Those who were taught
the LHS as compared with waiting list controls per-
formed better and safer on route finding (p < 0.001),
walking or wheelchair use (p < 0.05), and problem-
solving (p < 0.05) tasks.
Limb Activation/Spatio-motor Cueing
Limb activation is based on the idea that any move-
ment of the contralesional side may function as a
motor stimulus, activating the right hemisphere
and improving neglect. It has been shown across
a series of studies that unilateral neglect can be
improved by encouraging clients to make even
small movements with some part of the left side of
their body, if these movements are performed in the
left hemispace. In general, the principle behind this
approach is to “find” the affected limb and encour-
age movements of the affected limb in the neglected
hemispace (i.e., spatio-motor cueing). It is hypoth-
esized that these movements lead to summation of
activation of affected receptive fields of two distinct
but linked spatial systems for personal and extra­
personal space, resulting in improvements in atten-
tional skills and appreciation of spatial relationships
on the affected side.45,72 A counter hypothesis is that
the movements in the left hemispace serve as per-
ceptual cues such as an anchor. Studies have dem-
onstrated a reduction in the severity of neglect
when subjects actively engage their left hand in a
task. One meta-analysis examining limb activation
approaches49 demonstrated large effect sizes for
both group and single subject studies.
Robertson and North73 described a case of severe
left visual neglect in which the client consistently
showed a reduction in visual neglect as tested by
a cancellation task, with left hand movements
in the neglected left hemispace. While reduction
did not occur when the left hand was moved pas-
sively, neglect was also reduced with left leg move-
ments. It was noted that hand movements in the left
hemispace reduced neglect for stimuli in far as
well as in peripersonal space. Another case study
­documented decreased neglect using this technique
as demonstrated by improved reading ability.
Robertson and associates74 documented three
case studies using left limb activation interventions.
The first study used a combination of perceptual
anchoring training (keeping the left arm at the left
margin of the activity engaged in and being encour-
aged to “find” the arm prior to the task) with left
arm activation procedures and produced improve-
ments on impairment tests as well as reading and
telephone dialing ability. The second used the same
method, but stimulated left arm activation using
a buzzer reminder system to maintain limb acti-
vation. Positive results were noted on impairment
tests and functional mobility skills. The third case
study focused on cueing for left arm activation with-
out explicit instructions for perceptual anchoring.
Positive results were noted on impairment tests.
Robertson and coworkers71 applied this interven-
tion to a 22-year-old man with a severe traumatic
brain injury. He was assessed on three different mea-
sures (hair-combing task, navigation task, and the
Baking Tray Task as described earlier). The inter-
vention focused on moving the left hand in the left
hemispace as cued by a buzzer system during tra-
ditional occupational therapy sessions involving
self-care instruction, reading, and so on. All three
measures of three different types of neglect—naviga-
tion (far space), hair combing (personal/body space),
and baking tray (peripersonal or reaching space)—
showed significant improvements coinciding with
the onset of limb activation training.
Wilson and coworkers99 examined the combined
effect of contralesional limb activation (tapping in
the left hemispace with the residual movement in
the left hand for 5 minutes) and sustained atten-
tion training (a loud noise to alert the subject dur-
ing task performance and encouraging the subject
to say the self-directed verbal cue “Attend!” aloud
followed by using the cue internally as training
continued) on impaired ADL via two single cases,
using time-series designs. The authors concluded
that combining both limb activation and sustained
attention training may produce additive effects.
They documented significant improvements in
both neuropsychological impairment measures
and in the independent performance of ADL. The
benefits were maintained during the post-training
period (Figure 6-9).
Samuel and colleagues80 assessed the efficacy of
voluntary activation of the left upper limb in the left
hemispace focusing on its generalizability to ADL,
 Chapter 6  Managing Unilateral Neglect to Optimize Function 155
Baseline Limb activation training
40
35
30
25
20
15
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
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
with chronic stroke who did not respond to previ-
ous scanning activities. Both cases had significant
treatment-related improvements on an impair-
ment test of neglect. More important, improvement
was ­ documented on neglect behavior in daily life
(Catherine Bergego Scale). The effect was main-
tained at 1-month follow-up. The authors concluded
that left limb activation (i.e., visuo-spatio-motor
cueing) may be efficient in severe neglect and may
help in obtaining generalization to ADL.
Kalra and associates45 conducted a randomized
controlled study to compare the use of a limb acti-
vation approach and an early emphasis of func-
tional training compared to treatment as usual
group defined as neurodevelopmental treatment
(NDT). Those in the experimental group showed
a trend toward higher Barthel scores at 12 weeks
(14 vs. 12.5) and a significant reduction in median
length of hospital stay (42 vs. 66 days).
Constraint-induced movement therapy (CIMT)84,86
was first applied to those with neurologic diagno-
ses more than 15 years ago. The intervention differs
from conventional physical rehabilitation in its dura-
tion and intensity. It involves training of the more
affected upper extremity by mass practiced of func-
tional tasks and shaping for 5-6 hours per day over
2-3 consecutive weeks. During therapy and for the
majority of waking hours during this period the less
affected extremity is constrained to induce increased
use of the more affected limb. Shaping techniques
consist of quantifying and frequent immediate feed-
Baseline Sustained attention training Baseline
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
back concerning improvements in the speed and
quality of movement; selecting tasks that are tailored
to address the motor deficits of the individual; use
of modeling, prompting, and cueing of task perfor-
mance; and systematically increasing the difficulty
level of the task performed in small steps.85 In addi-
tion, several techniques are used to achieve transfer
of improved motor function to the life situation.85,100
Whereas the impairment that is being treated has
been termed “learned nonuse,” or a failure to inte-
grate the effected limb into real-world activities
despite having the underlying potential, it is not clear
how or if “learned nonuse” and neglect are related.
The term motor neglect also is used to refer to the
underuse of a limb opposite a brain lesion that can-
not be fully explained by primary sensory and motor
deficits.67 CIMT has been recommend as a poten-
tial intervention for those living with neglect and is
­consistent with limb activation approaches.35,65
An obvious limitation to this approach is for those
living with combined impairments of neglect and left
hemiplegia. Although an earlier study73 did not find
any effects from passive limb movements, a more
recent study has. Frassinetti and colleagues34 exam-
ined whether a complex passive movement, such
as abduction and adduction of the arm, was able to
reduce neglect also when it was associated to simulta-
neous active right arm movements. The authors had
subjects perform an object cancellation test and a line
bisection test by using the right hand while the left
arm was passively moved. Subjects performed tasks
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 significant reduction of neglect with respect to the
baseline condition, and the improvement equally
affected the near and the far space. They concluded
that the improvement of visual neglect caused by a
left passive movement is related to proprioceptive
signals specifying left hand position.
Mental Imagery
Although limb activation approaches as described
may be useful for some, a large number of peo-
ple with right hemispheric damage live with both
neglect and left hemiplegia, making use of the inter-
vention as usually described difficult or impossible.
Mental imagery is an emerging rehabilitation tech-
nique that includes imagining the limb movements
without actually moving or practicing movements
in “the mind’s eye.”
McCarthy and coworkers52 investigated whether
imagined limb movements would reduce the extent
of neglect in clients with severe disabilities and
described application of this technique for two
cases. One person was living with the effects of a
stroke, the other with a traumatic brain injury. Both
were in the chronic stage and both presented with
dense left hemiplegia and left neglect.
The intervention consisted of the following exer-
cises performed first with the intact right arm, along
with the test administrator:
• Bend arm at elbow.
• Clench fist (participant asked to “think about
how the exercise feels”).
• Unclench fist.
• Stretch out arm.
• Stretch out fingers.
• Wiggle fingers.
• Pinch fingers and thumb together (again partici-
pant was asked to “think about how the exercise
feels”).
The exercises were performed twice. The subjects
were then asked to imagine performing these same
movements, first with the right arm and then with
the left arm. Subjects were asked to imagine making
these movements four times (e.g., “try to imagine
the fingers of your left arm wiggling” and “imagine
pinching your left fingers and thumb together”). All
therapists working with the subjects were encour-
aged to use this technique for all types of therapy
and while performing ADL. Neglect was assessed
with the following tests: line bisection, star cancella-
tion, and a scanning task. Although outcomes of the
intervention for the subject living with the effects of
a stroke were more successful, the authors conclude
that imagined activation of the left arm may signifi-
cantly reduce the severity of left neglect.
Smania and colleagues81 examined two subjects
with acquired brain injury and severe and chronic
unilateral neglect secondary to right brain damage.
The intervention consisted of both visual and move-
ment imagery exercises. Specific visual imagery
tasks included describing a familiar room in their
home from a particular vantage point, describing
a familiar route or path, describing a well-known
geographic area, and imaging a word and spelling
it backward. Cues were provided by the examiner
to focus on missed details (e.g., “Are you sure you
named all of the objects in the room?”). Movement
imagery tasks included imagining postures and
describing the position of the contralateral arm,
and imagining movement sequences using both
arms.
Outcomes were assessed via six neuropsycho-
logical tests of unilateral neglect, seven functional
tests (avoiding obstacles during mobility, describing
a room, reading a newspaper, serving coffee, playing
cards, using self-care objects, and recognizing bank
notes), assessing neglect behavior during daily life
conditions, and a questionnaire (filled out by rela-
tives) concerning the subject’s disability in the con-
text of the family that was attributable to neglect.
The outcome measures were recorded before, after,
and 6 months after the end of the experimental
training. The authors found that imagery train-
ing decreased the deficit in performance related to
neglect in both subjects. All of the outcome mea-
sures were positively influenced by the treatment.
In addition, the improvement was stable over a
6-month period, suggesting that the treatment
had a long-term effect. The use of mental ­imagery
to improve function seems to be promising and
warrants further investigation.
Partial Visual Occlusion
Interventions aimed at partially occluding visual
input via eye patching are also showing prom-
ise in the literature in terms of demonstrating
improved functional skill in those with unilateral
spatial neglect. Early work in this area by Butter
and Kirsch23 examined 13 stroke survivors with
left-sided neglect and documented improvement
in 11 of the 13 subjects from monocular patching
of the right eye in at least one (of five) impairment
tests of neglect. They also noted that the benefi-
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
monocular patching and/or lateralized visual
stimulation was examined. Although each inter-
vention had positive results, the two interventions
combined resulted in significantly larger benefits
than either alone. The authors concluded that
monocular patching, in conjunction with lateral-
ized visual stimulation, may significantly reduce
neglect in daily activities.
A study by Arai and associates7 examined 10
subjects with left neglect and investigated whether
using glasses shaded on the non-neglected side
would lead to a decrease in the severity of unilateral
neglect during pen and paper activities. The authors
found that improvement was mixed for each of the
three outcome measures (deviation from mark-
ing the middle of a 20-cm horizontal line, number
of lines left unmarked on the left-hand portion of
a page of 40 randomly oriented lines, and degree
of failure to copy a representation of a cube). One
subject was noted to have substantial and lasting
improvement in functional activities by wearing the
hemispatial sunglasses. Although somewhat prom-
ising results were obtained, the aforementioned
studies only used impairment tests of neglect.
In a randomized study, Beis and colleagues15
examined 22 subjects with left unilateral neglect.
Interventions included the use of right half-field
patches (n = 7), a right monocular patch (n = 7), and a
control group (n = 8). Patches were worn throughout
the day during inpatient rehabilitation (Figure 6-10).
Results of paired comparison tests showed significant
differences between the control group and the group
with the half-eye patches for the total FIM score and
objective measures of displacements of the right eye
in the left field. No significant differences were found
between the control group and the group with the
right monocular patch. The authors concluded that
patching the right half-field helped subjects initially
regain voluntary control over the neglect impair-
ment, thereby improving daily function. The authors
hypothesized that their intervention was successful
because wearing a patch over the two right hemifields
causes a right homonymous hemianopsia and acti-
vation of the right hemisphere in isolation, therefore
causing an increase in the level of attention. In addi-
tion, the authors hypothesized that covering the right
half-field helped establish a balance between the acti-
vation of the two hemispheres as well as improvement
in the mechanisms that control voluntary ­redirection
of the gaze.
Prisms
Prisms have been tested as intervention for those
living with unilateral neglect (and hemianopsia)
with mixed results. The prism is typically of the
plastic press-on type and is used to shift the visual
field. Specifically, the idea is to shift the peripheral
image toward the central retinal meridian.
Rossi and coworkers78 randomly assigned 39
clients with stroke and homonymous hemiano-
pia or unilateral visual neglect to treatment with
15-diopter plastic press-on Fresnel prisms or to
serve as controls. In terms of visual perception and
ADL, the groups were statistically comparable. The
prisms were worn for all daytime activities. After
4 weeks, the prism-treated group performed signifi-
cantly better than controls on the following tests of
visual perceptual impairment: Motor Free Visual
Perception Test, line bisection test, line cancella-
tion test, Harrington Flocks Visual Field Screener,
and tangent screen examination. In terms of mak-
ing a change in activity limitations, there was no
significant difference in Barthel Index (ADL)
scores. The authors concluded that treatment with
15-diopter Fresnel prisms improves visual percep-
tion test scores but not ADL function in stroke
­clients with homonymous hemianopia or unilateral
visual neglect.
The term prism adaptation refers to the phenom-
enon in which the motor system adapts to shifted
visuospatial information caused by prisms that
displace the visual field. Rossetti and associates77
investigated the effect of prism adaptation (wear-
ing prisms in conjunction with pointing activities)
on various neglect symptoms, including the com-
monly observed subjective midline shift to the right.
All subjects exposed to the optical shift of the visual
field to the right were improved on their manual
body-midline demonstration and on impairment
tests (cancellation tests, copying, and line bisec-
tion). The authors noted that this improvement
lasted for at least 2 hours after prism removal and
thus could be useful during rehabilitation.
Further testing the effectiveness prism adapta-
tion, Frassinetti and colleagues33 had seven subjects
perform a pointing task wearing base-left wedge
prisms inducing a shift of the visual field to the right
by 10 degrees. The presence of visual neglect was
assessed before the treatment and 2 days, 1 week,
and 5 weeks after treatment by using a standardized
battery that included a series of tests including the
BIT, cancellation test, reading test, room descrip-
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
the same tests at the same intervals as the experi-
mental clients. The results showed an improvement
in the experimental subjects’ performance, which
was maintained during the 5-week period after
treatment. The decrease in neglect was found in
impairment as well as in behavioral tests and in all
spatial domains. Control subjects did not show any
improvement in neglect. The authors concluded
that their findings show that prism adaptation is a
productive way of achieving long-lasting improve-
ments in neglect treatment.
Angeli and coworkers1 studied the effects of prism
adaptation and found that it resulted in an improve-
ment in reading ability, an increased left-sided
exploration of letter strings, and increased ampli-
tude of the first left-sided saccade. They concluded
that prism adaptation reduces the chronic oculomo-
tor orienting bias to the ipsilesional side, and as a
consequence clients are able to compensate for their
asymmetric distribution of spatial attention.
Although Farne and associates30 have concluded
that the effects of prism adaptation are very long
lasting and spread over a wide range of visuospatial
deficits, recent findings79 related to use the use of
prisms to manage neglect have not been consistent
and are at times conflicting. The intervention war-
rants further investigation related to the long-term
effects on function.
Video Feedback
Using videotaped feedback of task performance has
been suggested as a strategy to decrease the effects of
unilateral neglect. When viewing your own perfor-
mance on a TV screen during video playback, one
can see and attend to the neglected left side on the
right side of the TV monitor (i.e., neglect behav-
iors can be observed in the non-neglected space).
This may be a key therapeutic factor. In usual care,
the therapist describes the neglect behavior but the
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
processing them with the therapist may help insight
building and subsequent strategy formation.
Tham and Tegner91 compared the effects of a
video procedure and a conventional verbal procedure
in giving subjects feedback on their neglect behavior
during a contrived task, the Baking Tray Task. See
Figure 6-6. The task consists of symmetrically placing
16 wood blocks or “buns” on a wood board or baking
tray. Subjects in one group were trained with a video
feedback procedure and subjects in the comparison
group were trained with a conventional verbal pro-
cedure. After watching the video, subjects were asked
to comment on their own performance and results
as did the therapist. In addition, they were asked to
develop strategies to improve performance, and the
therapist gave suggestions on using tactile discrimi-
nation with the right hand to find the left edge of
the tray and systematically place the buns from left
to right. Both groups were provided with the same
compensatory strategy.
Three hours after the intervention, the subjects
were tested with four different neglect tests (line
cancellation task, figure copying task, line bisection,
and the Baking Tray Task) pre- and postintervention
to evaluate the effects of training. The video feed-
back group improved significantly on the Baking
Tray Task, as tested 3 hours after training (p < 0.02).
Conventional training had no effect on the task or
on the other neglect measures. Of note is that no
generalization effects from the videotaped Baking
Tray Task on other neglect tests were observed.
The authors suggest using the video feedback tech-
nique during functional tasks to enhance generaliza-
tion and to make the intervention more meaningful.
Soderback and associates82 had similar results in
an earlier study that did focus on functional tasks.
Using a single-case research experimental pretest,
posttest, and follow-up design, three household
tasks were assessed, and the clients’ neglect behavior
while performing these was video recorded. During
the intervention the subjects watched the film, which
was stopped by the occupational therapist when the
neglect behavior was significant. Through dialog,
the subjects were led to perceive and interpret their
neglect behavior, and strategies for relearning and
remediation were recommended.
Paul63 examined the effects of video feedback on
grocery-shelf scanning with three subjects with visual
neglect. Performance of the task was videotaped and
played back as a means of visual and auditory feed-
back focused on improving performance. Results
showed an improvement in performance measured
by time taken to complete the task and percentage of
accuracy for all three clients across the intervention
phase. Although performance declined in the follow-
up phase, some long-term carryover effect was noted
even after the video-assisted feedback was terminated.
Further investigation is warranted for this interven-
tion because it may have a facilitatory effect on aware-
ness building and eventual strategy training.
Computerized Training
Findings related to computerized assisted train-
ing for neglect have been mixed. Webster and
coworkers93 demonstrated positive results related
to improving wheelchair mobility skills. Twenty
right-handed subjects with left unilateral neglect
on screening measures were assigned to a com-
puter-assisted training (CAT) treatment group and
20 subjects who showed similar levels of unilateral
neglect on the screening measures were assigned to
a control group. All subjects were inpatients on an
acute rehabilitation unit and received rehabilitation
therapy. The treatment group received the experi-
mental CAT program, 12 to 20 sessions of about 45
minutes each. The program consisted of five mod-
ules, each of increasing complexity, to improve
attention to stimuli in the left hemisphere, and two
simulated wheelchair courses to propel a wheelchair
while avoiding obstacles. Modules included scan-
ning the full environment, coordinating scanning
with right upper extremity movements, detecting
stimuli in the hemispace, wheelchair simulation,
and training on obstacle avoidance. The outcomes
were computer tasks designed for the study, a real-
world wheelchair obstacle course, and incident
reports indicating falls and accidents. Those in the
experimental group performed significantly better
(i.e., fewer left-sided collisions) on the wheelchair
obstacles as compared with controls. They also had
fewer incident reports than controls during their
hospitalization.
Robertson and colleagues70 conducted a ran-
domized controlled trial (n = 36) of computer-
based rehabilitation to treat left neglect with blind
follow-up for 6 months. One group of 20 sub-
jects received a mean of 15.5 hours of computer-
ized scanning and attentional training, whereas the
other group of 16 subjects received a mean of 11.4
hours of recreational computing that were specifi-
cally selected to minimize scanning and timed atten-
tional skills. Blind follow-up at the end of training
and 6 months after the intervention revealed no
statistically or clinically significant results between
160 cognitive and perceptual rehabilitation: Optimizing function
groups. The authors argued against routine clinical
use of computerized training until further studies
are conducted.
Future studies may examine whether struc-
tured interventions on a computer are useful for
those that identify work-related or leisure-based
computer use as meaningful activities (i.e., task-
specific training in the use of computers for those
with neglect without the expectation of general-
ization). Overall, transfer of training from com-
puter-based training to real-world function may
be limited to near or very near transfer in terms of
generalizability.62
Sustained Attention Training
As discussed, unilateral neglect may coexist with
generalized (i.e., nonlateralized) attention defi-
cits. Robertson and coworkers75 hypothesized that
unilateral neglect could be improved by increas-
ing activation of the sustained attention system.
They trained eight subjects with chronic left
unilateral neglect to sustain their attention by a
self-alerting procedure partially derived from
self-instructional methods. Statistically signifi-
cant improvements in unilateral neglect as well
in sustained attention were found following sus-
tained attention training, without improvements
in control measures.
Wilson and Manly98 documented a case study that
used sustained attention training and errorless learning
techniques to effect improvements in self-care perfor-
mance in a woman presenting with chronic ipsilesional
personal and extrapersonal neglect, severe memory
disorder, and sustained and selective attention deficits.
A brief training procedure that was introduced during
daily fixed order self-care training resulted in signifi-
cant improvement in self-care as well as a persistent
amelioration of ipsilesional personal neglect even after
the end of the postintervention phase.
Sustained attention training (SAT) included the
following:
• Awareness training was first used to point out
neglect and attention impairments.
• Prior to the self-care training a SAT program
lasting approximately 2½ minutes was adminis-
tered daily for 10 days.
• The examiner provided an arousing cue (ran-
domly banging the desk) every 20 to 40 seconds.
• The person was prompted to say “wake up”
aloud, then subvocally, then silently via self-talk
and asked to raise a finger to indicate that she
had cued herself.
• The SAT was used in conjunction with the
Baking Tray Task to improve awareness.
• She then used the SAT routine (attending vocally,
subvocally, and then via self-talk) for 2½ min-
utes before starting a self-care program.
• Self-care was performed in a fixed order (Box 6-3).
Verbal and physical prompts were used to promote
errorless learning.
Improved self-care performance coincided with
the onset of brief SAT. There were significant reduc-
tions in the number of verbal, physical, and total
prompts required for self-care. The improvements
in performance were also maintained after the end
of the postintervention phase and at least 2 weeks
later. The authors concluded that there is tenta-
tive support for the use of SAT in conjunction with
errorless learning as an adjunct strategy. Of note
is that the improvements in personal neglect and
level of self-care prompts required occurred even in
the presence of ongoing disorientation and chronic
memory loss.
As already reviewed, preliminary findings related
to awareness training88 has documented improved
function, decreased neglect, and improved sus-
tained attention, whereas combined contralesional
Box 6-3 Activities of Daily Living
Program Using Sustained
Attention/Errorless Learning
TECHNIQUES to Improve Neglect
The woman was positioned each day at the sink, required
to remove her own nightdress, place a towel on her
knees, insert the plug and fill the sink, check the temper-
ature of the water, and turn the taps off as appropriate.
1. Wet facecloth and wring out excess, apply soap to
wash face. This sequence was repeated for trunk
and underarms. Finally, rinse facecloth and leave
to one side. Allow used water to drain from sink.
2. Turn on cold-water tap, wet toothbrush, apply
toothpaste, brush teeth, rinse and replace
toothbrush, and turn off cold tap.
3. Return to bed area, therapist to assist with bra
fastening as required, put on deodorant, assist
with buttons if required and put on a loose
leisure top. Assist with adjusting clothing again if
required.
4. Brushing hair and applying makeup—she was to
brush her hair in front of a mirror and apply lipstick.
She could receive help with makeup if necessary.
Data from Wilson FC, Manly T: Sustained attention training and errorless
learning facilitates self-care functioning in chronic ipsilesional neglect following
severe traumatic brain injury, Neuropsychol Rehabil 13(5):537-548, 2003.
 Chapter 6  Managing Unilateral Neglect to Optimize Function 161

Table 6-4 Sample Environmental Strategies to Improve Function in Those with Neglect
Function Strategies

Feeding Place food, utensils, napkin, etc. on the right side of plate and placemat. Note: This intervention
may be combined with the use of cue on the left side of the placemat such as a colored
anchor (strip of tape or Dycem) and/or the person’s left arm on the table to be used as a
spatio-motor cue. Situate person at the table so that other diners are biased to the right to
enhance socialization.
Table games Rotate the person’s chair 45 degrees to the left to place key game items in the intact field.
Situate person at the table so that other players are biased to the right.
Home management Organize closets, drawers, refrigerator, etc. so that the person’s necessary items are on
the right.
Bedside care Call bell always placed on right. Orient bed so that incoming stimuli (doorway, television,
seating) are in the right field.*
Mobility Place colored markers on furniture that may be an obstacle; post signs on right side of hall
“Turn left here”.

*In the acute stages, this may be controversial because the therapist may want to “force” the person to respond to the left side of the environment.

limb activation and sustained attention training 5. Name four environmental modifications that
have also demonstrated positive results related to can be used to decrease activity limitations in
decreasing neglect behaviors.99 those living with neglect.

Environmental Adaptations References

There are a group of people who will not recover
spontaneously or respond to “active” ­interventions
such as teaching a new strategy to perform a task.
Similarly, those who have poor awareness and
insight and who don’t respond to awareness train-
ing may not respond to interventions that require
self-generated compensatory strategies. In these
cases, a person’s functional performance may be
enhanced by implementing and teaching caregiv-
ers or family members environmental strategies
(Table 6-4).
Appendix 6-1 summarizes evidence-based inter-
ventions focused on improving function.
Review Questions
1. What are three behavioral examples of personal
(body) neglect, near extrapersonal neglect, and
far extrapersonal neglect?
2. To what does the term extinction refer? Name
two manifestations of extinction in daily life.
3. Describe three ways to implement left-limb acti-
vation interventions during a mobility training
session.
4. Why does neglect usually manifest in the left
visual field as opposed to the right?
1. Angeli V, Benassi MG, Ladavas E: Recovery of oculo-
motor bias in neglect patients after prism adapta-
tion, Neuropsychologia 42(9):1223-1234, 2004.
2. Antonucci G, Guariglia C, Judica A, et al: Effectiveness
of neglect rehabilitation in a randomized group
study, J Clin Exp Neuropsychol 17(3):383-389, 1995.
3. Appelros P, Karlsson GM, Seiger A, et al: Prognosis
for patients with neglect and anosognosia with spe-
cial reference to cognitive impairment, J Rehabil
Med 35(6):254-258, 2003.
4. 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.
5. Appelros P, Nydevik I, Karlsson GM, et al: Assessing
unilateral neglect: shortcomings of standard test
methods, Disabil Rehabil 25(9):473-479, 2003.
6. Appelros P, Nydevik I, Karlsson GM, et al: Recovery
from unilateral neglect after right-hemisphere
stroke, Disabil Rehabil 26(8):471-477, 2004.
7. Arai T, Ohi H, Sasaki H, et al: Hemispatial ­sunglasses:
effect on unilateral spatial neglect, Arch Phys Med
Rehabil 78(2):230-232, 1997.
8. Árnadóttir G: The brain and behavior: assessing cor-
tical dysfunction through activities of daily living,
St Louis, 1990, Mosby.
9. 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.
162 cognitive and perceptual rehabilitation: Optimizing function
10. Azouvi P, Marchal F, Samuel C, et al: Functional
consequences and awareness of unilateral neglect:
study of an evaluation scale, Neuropsychol Rehabil 6:
133-150, 1996.
11. Azouvi P, Olivier S, de Montety G, et al: Behavioral
assessment of unilateral neglect: study of the
­psychometric properties of the Catherine Bergego
Scale, Arch Phys Med Rehabil 84(1):51-57, 2003.
12. Azouvi P, Samuel C, Louis-Dreyfus A, et al: French
Collaborative Study Group on Assessment of
Unilateral Neglect (GEREN/GRECO), sensitivity
of clinical and behavioural tests of spatial neglect
after right hemisphere stroke, J Neurol Neurosurg
Psychiatry 73(2):160-166, 2002.
13. Bailey MJ, Riddoch MJ, Crome P: Treatment of
visual neglect in elderly patients with stroke: a
­single-subject series using either a scanning and
cueing strategy or a left-limb activation strategy,
Phys Ther 82(8):782-797, 2002.
14. Bailey MJ, Riddoch MJ, Crome P: Test-retest
­stability of three tests for unilateral visual neglect
in patients with stroke: star cancellation, line bisec-
tion, and the baking tray task, Neuropsychol Rehabil
14(4):403-419, 2004.
15. 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.
16. Beis JM, Keller C, Morin N, et al: French collabora-
tive study group on assessment of unilateral neglect
(GEREN/GRECO). Right spatial neglect after left
hemisphere stroke: qualitative and quantitative
study, Neurology 63(9):1600-1605, 2004.
17. Bergego C, Azouvi P, Deloche G, et al: Rehabilitation
of unilateral neglect: a controlled multiple-base-
line-across-subjects trial using computerised train-
ing procedures, Neuropsychol Rehabil 7(4):279-293,
1997.
18. 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.
19. Beschin N, Robertson IH: Personal versus extra-
personal neglect: a group study of their dissocia-
tion using a reliable clinical test, Cortex 33:379-384,
1997.
20. Bisiach E, Perani D, Vallar G, et al: Unilateral neglect:
personal and extra-personal, Neuropsychologia
24:759-767, 1986.
21. Bowen A, Gardener E, Cross S, et al: Developing func-
tional outcome measures for unilateral neglect: a pilot
study, Neuropsychol Rehabil 15(2):97-113, 2005.
22. Bowen A, McKenna K, Tallis RC: Reasons for the
variability in the reported rate of occurrence of
unilateral neglect after stroke, Stroke 30:1196-1202,
1999.
23. Butter CM, Kirsch N: Combined and separate
effects of eye patching and visual stimulation on
unilateral neglect following stroke, Arch Phys Med
Rehabil 73(12):1133-1139, 1992.
24. Buxbaum LJ, Ferraro MK, Veramonti T, et al:
Hemispatial neglect: subtypes, neuroanatomy, and
disability, Neurology 62(5):749-756, 2004.
25. Chen-Sea M: Unilateral neglect and functional
­significance among patients with stroke, Occup
Ther J Res 21(4):223-240, 2001.
26. Cherney LR, Halper AS, Kwasnica CM, et al:
Recovery of functional status after right hemisphere
stroke: relationship with unilateral neglect, Arch
Phys Med Rehabil 82(3):322-328, 2001.
27. Cicerone KD, Dahlberg C, Malec JF, et al: Evidence-
based cognitive rehabilitation: updated review of
the literature from 1998 through 2002, Arch Phys
Med Rehabil 86(8):1681-1692, 2005.
28. Cocchini G, Beschin N, Jehkonen M: The fluff test:
a simple task to assess body representation neglect,
Neuropsychol Rehabil 11(1):17-31, 2001.
29. Farne A, Buxbaum LJ, Ferraro M, et al: Patterns
of spontaneous recovery of neglect and associated
disorders in acute right brain-damaged patients,
J Neurol Neurosurg Psychiatry 75(10):1401-1410,
2004.
30. Farne A, Rossetti Y, Toniolo S, et al: Ameliorating
neglect with prism adaptation: visuo-manual
and visuo-verbal measures, Neuropsychologia 40:
718-729, 2002.
31. Fisher AG: Assessment of motor and process skills, vol.
1: development, standardization, and administration
manual, ed 5, Fort Collins, Colo, 2003, Three Star
Press.
32. Fisher AG: Assessment of motor and process skills, vol.
2: user manual, ed 5, Fort Collins, Colo, 2003, Three
Star Press.
33. Frassinetti F, Angeli V, Meneghello F, et al: Long-
lasting amelioration of visuospatial neglect by
prism adaptation, Brain 125(Pt 3):608-623, 2002.
34. Frassinetti F, Rossi M, Ladavas E: Passive limb move-
ments improve visual neglect, Neuropsychologia
39(7):725-733, 2001.
35. Freeman E: Unilateral spatial neglect: new treatment
approaches with potential application to occupational
therapy, Am J Occup Ther 55(4):401-408, 2001.
36. Geeraerts S, Lafosse C, Vandenbussche E, et al:
A psychophysical study of visual extinction: ipsile-
sional distractor interference with contralesional
orientation thresholds in visual hemineglect
patients, Neuropsychologia 43(4):530-541, 2005.
37. Gialanella B, Monguzzi V, Santoro R, et al:
Functional recovery after hemiplegia in patients
with neglect: the rehabilitative role of anosognosia,
Stroke 36(12):2687-2690, 2005.
38. Gordon WA, Hibbard MR, Egelko S, et al: Perceptual
remediation in patients with right brain damage: a
comprehensive program, Arch Phys Med Rehabil
66(6):353-359, 1985.
 Chapter 6  Managing Unilateral Neglect to Optimize Function 163
39. Guariglia C, Antonucci G: Personal and extra-
personal space: a case of neglect dissociation,
Neuropsychologia 30(11):1001-1009, 1992.
40. Halligan PW, Cockburn J, Wilson BA: The behav-
ioural assessment of visual neglect, Neuropsychol
Rehabil 1(1):5-32, 1991.
41. Halligan PW, Marshall JC, Wade DT: Visuospatial
neglect: underlying factors and test sensitivity,
Lancet 2(8668):908-911, 1989.
42. Hartman-Maeir A, Katz N: Validity of the Behavioral
Inattention Test (BIT): relationships with functional
tasks, Am J Occup Ther 49(6):507-516, 1995.
43. Heilman KM, Watson RT, Valenstein E: Neglect and
related disorders. In Hilman KM, Valenstein E, edi-
tors: Clinical neuropsychology, ed 4, New York, 2003,
Oxford.
44. Jehkonen M, Ahonen JP, Dastidar P, et al: How
to detect visual neglect in acute stroke, Lancet
351(9104): 727-728, 1998.
45. Kalra L, Perez I, Gupta S, et al: The influence of
visual neglect on stroke rehabilitation, Stroke 28(7):
1386-1391, 1997.
46. Karnath HO, Himmelbach M, Kuker W: The cor-
tical substrate of visual extinction, Neuroreport
14:437-442, 2003.
47. Katz N, Hartman-Maeir A, Ring H: Functional
disability and rehabilitation outcome in right
hemisphere damaged patients with and without
unilateral spatial neglect, Arch Phys Med Rehabil
80(4):379-384, 1999.
48. Laplane D, Degos JD: Motor neglect, J Neurol
Neurosurg Psychiat 46(2):152-158, 1983.
49. Lin KC: Right-hemispheric activation approaches
to neglect rehabilitation poststroke, Am J Occup
Ther 50(7):504-515, 1996.
50. Lincoln NB, Bowen A: The need for randomised
treatment studies in neglect research, Rest Neurol
Neurosc 24(4-6):401-408, 2006.
51. Marangolo P, Piccardi L, Rinaldi MC: Dissociation
between personal and extrapersonal neglect in a
crossed aphasia study, Neurocase 9(5):414-420, 2003.
52. McCarthy M, Beaumont G, Thompson R: The
role of imagery in the rehabilitation of neglect in
severely disabled brain-injured adults, Arch Clin
Neuropsychol 17:407-422, 2002.
53. McIntosh RD, Brodie EE, Beschin N, et al: Improving
the clinical diagnosis of personal neglect: a reformu-
lated comb and razor test, Cortex 36:289-292 2000.
54. Milner AD, McIntosh RD: The neurological basis
of visual neglect, Curr Opin Neurol 18(6):748-753,
2005.
55. Muller-Oehring EM, Kasten E, Poggel DA, et al:
Neglect and hemianopia superimposed, J Clin Exp
Neuropsychol 25(8):1154-1168, 2003.
56. 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.
57. Niemeier JP: Visual imagery training for patients
with visual perceptual deficits following right hemi-
sphere cerebrovascular accidents: a case study pre-
senting the Lighthouse Strategy, Rehabil Psychol
47(4):426-437, 2002.
58. Niemeier JP, Cifu DX, Kishore R: The lighthouse
strategy: improving the functional status of patients
with unilateral neglect after stroke and brain injury
using a visual imagery intervention, Top Stroke
Rehabil 8(2):10-18, 2001
59. Ortigue S, Megevand P, Perren F, et al: Double disso-
ciation between representational personal and extra-
personal neglect, Neurol 66(9):1414-1417, 2006.
60. Ortigue S, Viaud-Delmon I, Michel C, et al: Pure
imagery hemi-neglect of far space, Neurology
60:2000-2002, 2003.
61. Paolucci S, Antonucci G, Guariglia C, et al:
Facilitatory effect of neglect rehabilitation on the
recovery of left hemiplegic stroke patients: a cross-
over study, J Neurol 243(4):308-314, 1996.
62. Paul S: Effects of computer assisted visual scanning
training in the treatment of visual neglect: three
case studies, Phys Occup Ther Geriatr 14(2):33-44,
1996.
63. Paul S: The effects of video assisted feedback on a
scanning kitchen task in individuals with left visual
neglect, Can J Occup Ther 64(2):63-69, 1997.
64. Pedersen PM, Jorgensen HS, Nakayama H, et al:
Hemineglect in acute stroke—incidence and prog-
nostic implications. The Copenhagen Stroke Study,
Am J Phys Med Rehabil 76(2):122-127, 1997.
65. Pierce SR, Buxbaum LJ: Treatments of unilateral
neglect: a review, Arch Phys Med Rehabil 83(2):
256-268, 2002.
66. Pizzamiglio L, Antonucci G, Judica A, et al: Cognitive
rehabilitation of the hemineglect disorder in chronic
patients with unilateral right brain damage, J Clin
Exp Neuropsychol 14(6):901-923, 1992.
67. Punt TD, Riddoch MJ: Towards a theoretical under-
standing of pushing behaviour in stroke patients,
Neuropsychol Rehabil 12(5):455-472, 2002.
68. Punt TD, Riddoch MJ: Motor neglect: implications
for movement and rehabilitation, Disabil Rehabil
28(13-14):857-864, 2006.
69. Qiang W, Sonoda S, Suzuki M, et al: Reliability and
validity of a wheelchair collision test for screen-
ing behavioral assessment of unilateral neglect
after stroke, Am J Phys Med Rehabil 84(3):161-166,
2005.
70. Robertson IH, Gray JM, Pentland B, et al:
Microcomputer-based rehabilitation for unilateral
left visual neglect: a randomized controlled trial,
Arch Phys Med Rehabil 71(9):663-668, 1990.
71. Robertson IH, Hogg K, McMillan TM:
Rehabilitation of unilateral neglect: improving func-
tion by contralesional limb activation, Neuropsychol
Rehabil 8(1):19-29, 1998.
164 cognitive and perceptual rehabilitation: Optimizing function
72. Robertson IH, North N: Spatio-motor cueing in uni-
lateral left neglect: the role of hemispace, hand and
motor activation, Neuropsychologia 30(6):553-563,
1992.
73. Robertson IH, North N: Active and passive activa-
tion of left limbs: influence on visual and sensory
neglect, Neuropsychologia 31(3):293-300, 1993.
74. Robertson IH, North NT, Geggie C: Spatiomotor
cueing in unilateral left neglect: three case studies of
its therapeutic effects, J Neurol Neurosurg Psychiatry
55(9):799-805, 1992.
75. Robertson IH, Tegner R, Tham K, et al: Sustained
attention training for unilateral neglect: theo-
retical and rehabilitation implications, J Clin Exp
Neuropsychol 17:416-430, 1995.
76. Ross FL: The use of computers in occupational
therapy for visual-scanning training, Am J Occup
Ther 46(4):314-322, 1992.
77. Rossetti Y, Rode G, Pisella L, et al: Prism adaptation to
a rightward optical deviation rehabilitates left hemi­
spatial neglect, Nature 395(6698):166-169, 1998.
78. Rossi PW, Kheyfets S, Reding MJ: Fresnel prisms
improve visual perception in stroke patients with
homonymous hemianopia or unilateral visual
neglect, Neurology 40(10):1597-1599, 1990.
79. Rousseaux M, Bernati T, Saj A, et al: Ineffectiveness
of prism adaptation on spatial neglect signs, Stroke
37(2):542-543, 2006.
80. Samuel C, Louis-Dreyfus A, Kaschel R, et al:
Rehabilitation of very severe unilateral neglect by
visuo-spatio-motor cueing: two single case studies,
Neuropsychol Rehabil 10(4):385-399, 2000.
81. Smania N, Bazoli F, Piva D, et al: Visuomotor imag-
ery and rehabilitation of neglect, Arch Phys Med
Rehabil 78(4):430-436, 1997.
82. Soderback I, Bengtsson I, Ginsburg E, et al: Video
feedback in occupational therapy: its effects in
patients with neglect syndrome, Arch Phys Med
Rehabil 73(12):1140-1146, 1992.
83. Stone SP, Wilson B, Wroot A, et al: The assessment
of visuo-spatial neglect after acute stroke, J Neurol
Neurosurg Psychiatry 54(4):345-350, 1991.
84. Taub E, Miller NE, Novack TA, et al: Technique to
improve chronic motor deficit after stroke, Arch
Phys Med Rehabil 74:347-354, 1993.
85. Taub E, Uswatte G, King DK, et al: A placebo-con-
trolled trial of constraint-induced movement therapy
for upper extremity after stroke, Stroke 37(4):1045-
1049, 2006.
86. Taub E, Uswatte G, Pidikiti R: Constraint-induced
movement therapy: a new family of techniques with
broad application to physical rehabilitation—a clin-
ical review, J Rehabil Res Dev 36:237-251, 1999.
87. Taylor D, Ashburn A, Ward CD: Asymmetrical
trunk posture, unilateral neglect and motor per-
formance following stroke, Clin Rehabil 8(1):48-53,
1994.
88. Tham K, Ginsburg E, Fisher A, et al: Training to
improve awareness of disabilities in clients with uni-
lateral neglect, Am J Occup Ther 55(1):46-54, 2001.
89. Tham K, Kielhofner G: Impact of the social envi-
ronment on occupational experience and perfor­
mance among persons with unilateral neglect,
Am J Occup Ther 57(4):403-412, 2003.
90. Tham K, Tegner R: The baking tray task: a test of
spatial neglect, Neuropsychol Rehabil 6(1):19-25,
1996.
91. Tham K, Tegner R: Video feedback in the rehabili-
tation of patients with unilateral neglect, Arch Phys
Med Rehabil 78(4):410-413, 1997
92. Wagenaar RC, van Wieringen PC, Netelenbos JB,
et al: The transfer of scanning training effects in
visual inattention after stroke: five single-case stud-
ies, Disabil Rehabil 14(1):51-60, 1992.
93. Webster JS, McFarland PT, Rapport LJ, et al:
Computer-assisted training for improving wheel-
chair mobility in unilateral neglect patients, Arch
Phys Med Rehabil 82(6):769-775, 2001.
94. Webster JS, Roades LA, Morrill B, et al: Rightward
orienting bias, wheelchair maneuvering, and fall
risk, Arch Phys Med Rehabil 76(10):924-928, 1995.
95. Weinberg J, Diller L, Gordon WA, et al: Visual scan-
ning training effect on reading-related tasks in
acquired right brain damage, Arch Phys Med Rehabil
58(11):479-486, 1977.
96. Wiart L, Come AB, Debelleix X, et al: Unilateral
neglect syndrome rehabilitation by trunk rota-
tion and scanning training, Arch Phys Med Rehabil
78(4):424-429, 1997.
97. Wilson B, Cockburn J, Halligan P: Development of
a behavioral test of visuospatial neglect, Arch Phys
Med Rehabil 68(2):98-102, 1987.
98. Wilson FC, Manly T: Sustained attention train-
ing and errorless learning facilitates self-care func-
tioning in chronic ipsilesional neglect following
severe traumatic brain injury, Neuropsychol Rehabil
13(5):537-548, 2003.
99. Wilson FC, Manly T, Coyle D, et al: The effect of
contralesional limb activation training and sus-
tained attention training for self-care programmes
in unilateral spatial neglect, Restor Neurol Neurosci
16(1):1-4, 2000.
100. Wolf SL, Winstein CJ, Miller JP, et al: Effect of
constraint-induced movement therapy on upper
extremity function 3 to 9 months after stroke:
the EXCITE randomized clinical trial, JAMA
296(17):2095-2104, 2006.
101. Zoccolotti P, Antonucci G, Judica A, et al: Incidence
and evolution of the hemineglect disorder in
chronic patients with unilateral brain damage, Int J
Neurosci 47:209-226, 1989.
102. Zorzi M, Priftis K, Umilta C: Brain damage:
neglect disrupts the mental number line, Nature
417(6885):138-139, 2002.
 Appendix 6-1
Evidence-Based Interventions for Neglect Focused
on Improving Daily Function

Table 1 Summary of Research

Participant
Study Intervention Description Characteristics n Age

Tham et al, 200188 Awareness training focused on Adults with right-sided  4 Range: 58-76
performance of activities of strokes
daily living (ADL)
Wiart et al, 199796 Scanning training and trunk Adults with neglect 22 M = 66
rotation
Pizzamiglio et al, 199266 Scanning training, reading Adults with neglect 13 M = 63
and copying, line drawings, secondary to stroke
description of a scene and postevacuation
of hematomas
Paolucci et al, 199661 Scanning training, reading Adults with neglect 59 M = 61.5
and copying, line drawings, secondary to stroke
description of a scene
Antonucci et al, 19952 Scanning training, reading Adults with neglect 20 M = 67.7
and copying, line drawings, secondary to stroke
description of a scene
Niemeier et al, 200158 Lighthouse Strategy Adults with unilateral 10 Treatment and
neglect from stroke controls equivalent
or brain injury re: age
Robertson et al, 199274 Left limb activation Adults with subdural  3 Ages 30, 61, and 62
hematoma and stroke
Robertson et al, 199871 Left limb activation during Adult male with a  1 22
occupational therapy chronic severe
traumatic brain injury
Wilson et al, 200099 Left limb activation and sustained Adults with subara­  2 Ages 62 and 32
attention training chnoid hemorrhage
and stroke
Samuel et al, 200080 Left limb activation Adults with chronic  2 Ages 60 and 64
neglect secondary to
stroke
Kalra et al, 199745 Left limb activation versus Adults with acute stroke 47 M = 77
neurodevelopmental treatment
(NDT)
Smania et al, 199781 Visuomotor imagery Adults with neglect  2 Ages 71 and 73
secondary to stroke
Beis et al, 199915 Partial visual occlusion using right Adults with neglect 22 M = 51
half field patches secondary to right-
sided lesions
Frassinetti et al, 200233 Exposure to prisms, twice daily for Adults with chronic 13 M = 65
2 weeks right-sided strokes

(Continued)

165
166 cognitive and perceptual rehabilitation: Optimizing function

Table 1 Summary of Research—Cont’d

Participant
Study Intervention Description Characteristics n Age

Soderback et al, 199282
Webster et al, 200193
Wilson and Manly,
200398
Using video feedback to increase Adults with right  4 Ages 50, 65, 69,
awareness of unilateral neglect hemispheric stroke and 75
behaviors during instrumental
activities of daily living (IADL)
performance
Computer-assisted training Adults with unilateral 20 M = 59.53, SD = 9.38
neglect
Sustained attention training and An adult with traumatic  1 40
errorless learning brain injury

M, Mean; SD, standard deviation.

Table 2 Summary of Outcomes

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

Tham et al, 200188 Single-case Assessment of + for 4/4 N/A Impairment

experimental Awareness of subjects
A-B-A design Disability
Assessment of Motor + for 4/4 N/A Activity limitations
and Process Skills subjects
Cancellation test + for 3/4 N/A Impairment
subjects
Baking Tray Task + for 3/4 N/A Impairment
subjects
Sustained attention + for 2/4 N/A Impairment
subjects
Wiart et al, 199796 Randomized Functional + p < 0.03 Activity limitations
controlled trial Independence
Measure
Cancellation tests + p < 0.02 Impairment
Line bisection + p < 0.01 Impairment
Pizzamiglio et al, Pretest/posttest Letter cancellation + p < 0.0001 Impairment
199266 Line crossing + p < 0.004 Impairment
Reading + p < 0.0001 Activity limitations
Semistructured scale + p < 0.01 Activity limitations
of function
Paolucci et al, Randomized Rivermead Mobility + p < 0.01 Activity limitations
199661 controlled trial Index
Barthel Index + p < 0.05 Activity limitations
Canadian Neurological — NS Impairment
Scale
Antonucci et al, Randomized Letter cancellation + p < 0.001 Impairment
19952 controlled trial Line crossing + p < 0.005 Impairment
Reading + p < 0.007 Activity limitations
Semistructured scale + p < 0.005 Activity limitations
of function
 Chapter 6  Managing Unilateral Neglect to Optimize Function 167

Table 2 Summary of Outcomes—Cont’d

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

Niemeier et al, Pretest-posttest Route finding + p < 0.001 Activity limitations

200158 Walking or wheelchair + p < 0.05 Activity limitations
Problem-solving tasks + p < 0.05 Impairment
Robertson et al, Case study Cancellation + p < 0.02 Impairment
199274 Reading + p < 0.001 Activity limitations
Backward digit recall — — Impairment
Telephone dialing + p < 0.001 Activity limitations
Mobility ratings + p < 0.02 Activity limitations
Line orientation + p < 0.02 Impairment
Robertson et al, Case study Hair care + p < 0.001 Activity limitations
199871 Route navigation + p < 0.05 Activity limitations
(ambulatory)
Baking Tray Task + p < 0.001 Impairment
Wilson et al, Single subject Self-care + p < 0.01 Activity limitations
200099 design Picture scanning + p < 0.05 Impairment
Cancellation + p < 0.05 Impairment
Map search + p < 0.05 Impairment
Samuel et al, Case study Cancellation — — Impairment
200080 Line bisection + p < 0.043 Impairment
Catherine Bergego + Not reported Activity limitations
Scale
Kalra et al, 199745 Randomized Barthel Index + NS Activity limitations
controlled trial Length of stay + p < 0.001 —
Discharge destination — NS —
Cancellation + p < 0.01 Impairment
Body image + p < 0.01 Impairment
Smania et al, Pretest-posttest Impairment tests + p < 0.01 Impairment
199781 and follow-up of neglect
(cancellation,
drawing)
Functional measures + p < 0.05 Activity limitations
(serving coffee,
playing cards)
Relatives + p < 0.05 Activity limitations
questionnaires
regarding effect of
neglect on daily life
Beis et al, 199915 Randomized Functional + p = 0.01 Activity limitations
Independence
Measure
Eye movements + p = 0.02 Impairment
toward the left side
Frassinetti et al, Pretest-post test Behavioral Inattention + p < 0.01 Impairment and
200233 with matched Test simulated
controls activity
limitations
Cancellation + p < 0.01 Impairment
Reading test + p < 0.03 Activity limitations
Fluff test — NS Impairment
Room description + p < 0.01 Impairment
Objects reaching test + p < 0.01 Impairment

(Continued)
168 cognitive and perceptual rehabilitation: Optimizing function

Table 2 Summary of Outcomes—Cont’d

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

Soderback et al, Single case Performance of + N/A Activity limitations

199282 research household tasks
experimental Albert’s test (line + N/A Impairment
design cancellation)
Webster et al, Case control study Wheelchair obstacle + p = 0.00003 Activity limitations
200193 course
Falls and accidents + p = 0.023 Activity limitations
during mobility
Wilson and Case study Number of cues for + p < 0.001 Activity limitations
Manly, 200398 self-care
Comb and razor/ + Not reported Impairment
compact test
Line and letter + Not reported Impairment
cancellation
Star cancellation — Not reported Impairment
Subtests of the Test of — Not reported Impairment
Everyday Attention
Rivermead Behavioral — Not reported Impairment
Memory Test

*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; 
N/A, not applicable; NS, not significant
 Chapter 7
Managing Agnosias to Optimize Function

Key Terms
Agnosia Landmark/environmental agnosia Simultanagnosia
Amusia Object agnosia Tactile agnosia
Astereognosis Optic aphasia Topographical disorientation
Auditory agnosia Prosopagnosia Visual agnosia
Central achromatopsia Pure alexia
Color agnosia Pure word deafness

Learning Objectives
At the end of this chapter, readers will be able to:
1. Differentiate among various types of agnosia.
2. Be aware of evaluation/assessment procedures
related to agnosia.
3. Implement at least five intervention strategies
focused on decreasing activity limitations and par-
ticipation restrictions for those living with agnosia.

“The new visual perception of space of spaces and objects gave rise to feelings of confusion and of
insecurity when interacting with people or objects in everyday situations that had previously been
taken for granted. Objects were perceived as obstacles instead of tools. Difficulties that arose during
occupational performance were perceived as obstacles in the physical environment rather than the
person’s own limited capacity to perform.”18

T  he term gnosis refers to knowledge or knowing. 

 In contrast, agnosia refers to a loss of knowledge
and inability “to know.” Agnosia is a relatively rare
disorder as compared to impairments with higher
prevalence such as apraxia, memory loss, atten-
tion deficits, and so on. The hallmark of agnosia
is an inability to recognize incoming sensory stim-
uli. Examples include the loss of ability to recog-
nize objects, people, sounds, and shapes. In cases of
agnosia, the specific sense modality is not ­defective,
because the problem is related to ­ recognition not
sensory reception, nor is there any significant mem-
ory loss. Agnosia may be limited to one sensory
modality such as vision, hearing, or tactile ­sensation.
For example, a person may have difficulty in recog-
nizing an object as a fork or identifying a sound
as a sneeze. Agnosia can occur in those living with
stroke, dementia, developmental disorders, or mul-
tiple other neurologic conditions. It typically results
from damage to specific cortical ­ association areas.

169
170 cognitive and perceptual rehabilitation: Optimizing function
People with agnosia may retain their ­cognitive and
perceptual ­abilities in other areas. A typical clinical
­presentation includes the following:
• The primary sense (e.g., visual acuity, visual
fields, etc.) is intact.
• Despite the sense being intact, sensory informa-
tion is not recognized. For example, the person
with intact visual fields and acuity may look at a
telephone and perceive it as a box with a some-
thing (the receiver) on top of it and ask, “Is it a
wrapped gift?”
• Incoming information can be quickly recognized
by another sense. In the previous example, if the
phone rings or if the person is handed the receiver,
the phone will be identified without a problem.
Lissauer classically documented the major two
types of agnosia as apperceptive agnosia and asso-
ciative agnosia.19 This distinction remains empiri-
cally valid.13,25 Using visual agnosia as an example,
there are a variety of ways we recognize incoming
visual information. When looking at a banana we
can identify it by its shape, size, and color. In addi-
tion the incoming stimuli can trigger associated
stored memories and concepts as to the meaning of
a banana (e.g., eat for breakfast, a nutritious fruit).
Apperceptive agnosia refers to those who have a
measurable impairment at the visuoperceptual level
such as impaired perception of forms and shapes,
although basic sensory function remains intact. The
deficit occurs because the person cannot construct a
coherent visual percept of an object.9 These findings
can be observed on tests of basic perception such as
not being able to identify forms, shapes, patterns, or
sizes. Recognition deficits occur because of defective
perceptual processing. Because objects are not seen
properly secondary to the visuoperceptual impair-
ment, they are not recognized. This type of agnosia
occurs in those with noticeable perceptual deficits.
Associative agnosia refers to those who can-
not recognize incoming information despite intact
sensory function and a relatively intact basic per-
ception of forms and shapes. The person cannot
assign the correct meaning to visual stimuli that
are adequately perceived.9 Although perception
may not be completely intact, it is adequate to sup-
port recognition, but objects still are not properly
recognized. This type of agnosia occurs in those
without noticeable perceptual deficits. This type of
agnosia has been described this as “normal percep-
tion stripped of meaning.”21 In order for an object
to be recognized, two types of stored information
may be accessed: stored structural knowledge (i.e.,
stored representations of the structural properties
of objects) and semantic knowledge regarding the
object’s functions. It is hypothesized that in this
type of agnosia a person looks at an object such as a
violin and perceives it relatively normally, but asso-
ciated memories/concepts regarding the meaning
of violin are not activated. Therefore, the relatively
intact perception is rendered meaningless25 until
another sense is used to recognize the ­violin such as
somebody begins to play it.
Despite this distinction, the problems observed
in everyday life are consistent. For example, whether
a person can recognize objects on a desk secondary
to apperceptive or associative agnosia is somewhat
academic. Whatever the underlying mechanism,
this person will have difficulties engaging in work
tasks and will need to use compensatory strategies
to overcome their impairment.
Effect on Daily Life
Lampinen and Tham are two of only a few investiga-
tors who have examined how the presence of agno-
sia results in multiple problems related to everyday
function.18 Their study examined those living with
visual agnosia secondary to a stroke. Their findings
related to difficulties in everyday living include the
following:
• Participants described how they felt they lived in
an unfamiliar world. Specific examples included
experiences of confusion secondary to difficulties
recognizing familiar characteristics of the world.
In addition, the inner picture they had of famil-
iar objects did not correspond to what they were
seeing; experiencing the home environment as
unfamiliar; familiar objects are now unfamiliar;
inability recognizing friends and family; difficulty
finding objects; difficulties reading; experiencing
an attraction toward strong colors; and experi-
ences of paying increased ­attention to sounds and
events in the environment.
• Experiences of interacting with the world were
different when performing daily occupations.
Specifically objects were perceived as obstacles;
objects seemed to have a life of their own; wheel-
chairs were perceived as unruly and clumsy; and
maneuvering and mobility was difficult.
• Difficulties adapting to new problems they
were experiencing. Participants experienced
difficulty performing the simplest of tasks and
constantly striving for mastery. Generated strat-
egies to solve problems typically resulted in
failures. Participants also reported needing to
consciously maintain their concentration and
think about how they were going to perform the
activity.
 Chapter 7  Managing Agnosias to Optimize Function 171
Box 7-1 Difficulties During Everyday
Function and Agnosia
Visual (Object) Agnosia
Inability to find the razor on the sink despite adequate
scanning abilities. The razor can only be located by
touch.
Visuospatial Agnosia
Misjudging the distance while reaching for a cup
­resulting in an inappropriate endpoint (i.e., the hand
end up ­several inches from the cup).
Difficulties orienting a shirt to one’s body. See Chapter 3.
Tactile Agnosia
Difficulty with clothing fasteners despite intact motor
function.
Inability to recognize objects that are in one’s pockets
unless vision is also used.
Data from Árnadóttir G: The brain and behavior: assessing cortical dys-
function 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.
Árnadóttir also documented the relationship
between the presence of agnosia and difficulties
with everyday living (Box 7-1).1,2
Conceptual and Operational
Definitions
The two broad categories discussed above include
multiple subtypes of agnosia that interfere with
visual, auditory, or tactile processing (Table 7-1).
Visual agnosia refers to an inability to recognize
incoming visual information despite intact pri-
mary visual skills.1,2 Types of visual agnosia are cat-
egorized based on what a person cannot recognize
via vision. They may be a result of associative or
­apperceptive deficits and include the following:
• Object agnosia (an inability to recognize objects
in the environment)
• Prosopagnosia (poor face recognition)
• Simultanagnosia (inability to recognize whole
visual scenes)
• Color agnosia (inability to perceive colors)
• Visuospatial agnosia (difficulties perceiving spa-
tial relationships between one’s body and objects
or two objects) (see Chapter 3)
• Landmark agnosia (inability to recognize key
landmarks in the environment)
• Pure alexia (inability to recognize words/letters)
These subtypes of visual agnosia can occur together
or in isolation. A person living with ­ prosopagnosia
may not be able to recognize faces but may be able
to recognize objects on a desk. Similarly, a person
who cannot recognize objects on a desk may be able
to recognize faces. For example, McMullen and asso-
ciates report the case of H.H.20 H.H. presented with
a severe apperceptive visual agnosia for visually pre-
sented objects and alexia for words, but a spared abil-
ity to recognize faces. In contrast, De Renzi and
di Pellegrino reported the case of a woman who pre-
sented with prosopagnosia (an inability to recog-
nize faces) and alexia (an acquired inability to read
because letters and words are not recognized) but
was able to identify objects when visually presented.12
Identification of visually presented material may be
worse for some semantic categories as compared
with others. For example, Riddoch and Humphreys
documented the case of J.B., who was worse at nam-
ing living things (e.g., animals) than nonliving things 
(e.g., tools).25
Somatosensory agnosia presents as astereogno-
sis or tactile agnosia. Tactile agnosia refers to an
inability to recognize tactually presented objects
despite adequate sensory, attentional, intellectual,
and language abilities. In other words, it is purely
an associative impairment. This presentation is
rare.14 Astereognosis refers to a failure in complex
perceptual processing that results in an impairment
in tactile object recognition (i.e., there is an apper-
ceptive component3) and more common than a
pure tactile agnosia. For example, despite relatively
intact sensation, a person is unable to recognize an
object via touch because of the inability to perceive
rough or smooth, shape of the object, size, short,
and narrow.
Auditory agnosia is the inability to recog-
nize speech and nonspeech sounds despite intact
­hearing. Examples include the following3:
• Pure word deafness: Inability to comprehend
spoken language despite intact ability to read,
write, and speak
• Amusia: Inability to interpret musical sounds
and tones
• Auditory sound agnosia: Agnosia for nonspeech
sounds
The literature regarding recovery from agnosia is
limited. Current understanding of how one recovers
after the onset of agnosia is limited to well-designed
longitudinal case studies (Table 7-2).
Assessment
Bauer and Demery provide guidelines when evalu-
ating a person living with agnosia.3 Their two basic
principles are as follows:

Table 7-1 Terminology Related to Agnosia
Impairment Definition
Agnosia A general term that refers to failure to recognize
information or material that is presented through a
specific sensory channel that cannot be attributed to
a primary sense deficit, change in mental status, or
attention-based impairments. It refers to recognition
beyond reception.1,2
(Visual) Object Inability to recognize familiar objects (the most
agnosia common of the agnostic syndromes) in which clients
are impaired in naming regular objects and are
unable to describe them or mimic their use. Object
agnosias are further classified as either apperceptive
(the percept is not fully constructed) or
associative (the percept is relatively intact).6
Prosopagnosia Inability to recognize faces despite intact intellect and
recognition of other visual stimuli.
Simultanagnosia An inability to see more than one thing or more
than one aspect of an object at a time. Although
individual details may be correctly perceived, the
client is unable to relate the different details and
cannot discern what is being seen. They collect
piecemeal information when collecting visual
information. Dorsal simultanagnosia refers to not
being able to recognize more than one object at a
time and not being able to shift from one object to
another rapidly but most objects can be recognized.
Ventral simultanagnosia refers to the ability to
see multiple objects but the inability to recognize
multiple objects.13
Lesion Locations
Most typically in the association
areas adjacent to areas of the
cortex that receive sensory
input. See below for specific
locations based on the type of
agnosia.
Lateral and ventral aspects of
the occipitotemporal cortex
Ventral occipitotemporal lesions
(bilateral or right unilateral
lesions)
Left posterior temporal or
occipitotemporal cortex
(ventral simultanagnosia);
bilateral damage parietal
and superior occipital areas
(dorsal simultanagnosia).13
172 cognitive and perceptual rehabilitation: Optimizing function
Activity Limitations/Participation Restrictions
Overall recognition deficits of objects and information
necessary to support daily living. Examples include an
inability to recognize a key by the sound of it dropping
(auditory agnosia) vs. inability to recognize a coin in
your pocket (somatosensory agnosia) vs. inability to
recognize a coin on the table by sight (visual object
agnosia). See below.
A person can’t recognize/find needed objects in the
refrigerator, medicine cabinets, or on shelves, by
vision alone. Difficulty with shopping, playing board
games, etc.
Not able to identify family and friends via vision,
inability to identify staff members, can’t recognize
images of historic figures or celebrities by vision,
can’t recognize own reflection in a mirror. Substantial
difficulties within social settings and interpersonal
communications and relationships. May recognize
people by voice or other cues.
Inability to read, can only recognize one object at a place
setting, fragments and slowly processes pictures,
scenes, or photographs that are complex (e.g., a
magazine picture of the winner of horse race with the
jockey and owners may be seen as a photo of only a
horse), inability to count the number of people in a
room or pills in your hand, difficulty maneuvering in
a room and hitting furniture, inability to gather items
from the refrigerator that are needed for a recipe,
appearing as if blind, difficulties with wayfinding.
Agnosia for words An impairment limited to visually presented stimuli
or pure alexia (e.g., reading), but not to auditory stimuli. A failure
in the visual recognition of words.6
Color agnosia Inability to recognize colors even though the eyes are
(central capable of distinguishing them.
achromatopsia)
Visuospatial Visuospatial perception disorder resulting in distortion of
agnosia relationships between objects or objects and the self.
A component of spatial relations (see Chapter 3).1,2
Landmark A visual-perceptual failure to recognize landmarks
(environmental) including distinctive monuments and buildings
Left posterior temporal or
occipitotemporal cortex.13
V4 in the visual cortex.
Right inferior parietal lobe.1,2
Medial occipitotemporal regions;
parahippocampal gyrus.
An inability to read written material. If the material
is read to the person, he or she will be able to
comprehend the material (i.e., substitute auditory
processing to compensate for impaired visual
processing). May attempt to read letter by letter.
A person cannot perceive colors. The world may be
seen in shades of gray or black and white.25 A person
is unable to distinguish traffic lights; similar size and
shape fruits may be confused in the absence of color
cues, etc.
Difficulty orienting clothing to your body, difficulty
orienting to objects in space (placing toothpaste on
the toothbrush). Overshooting or undershooting
(incorrect endpoints) when reaching for objects on
the kitchen shelf.
Difficulty wayfinding (topographical disorientation).
Difficulty learning new routes and managing

Chapter 7  Managing Agnosias to Optimize Function

agnosia as well as places, streets, etc.23 A cause of Right hemispheric damage familiar environments. Easily gets lost. Note: these
topographical disorientation or a deficit in results in more severe difficulties can also be attributed to memory loss or
wayfinding. presentations.23,30 topographical amnesia as seen in those with medial
temporal lobe lesions.
Optic aphasia An inability to name visually presented objects despite Left posterior lesions including Not able to name an object but can pantomime or
good visual recognition nonverbally and good the occipital cortex and gesture its use as it can be recognized. The object can
naming ability when presented through another white matter; splenium. be named after touching it. The impact on daily life is
sense modality.13 Disconnection of intact visual not as severe as with the other impairments.
areas and intact naming
areas.
Somatosenory Difficulty perceiving objects through tactile stimulation Postcentral gyrus and superior Unable to identify objects in a pocket or handbag.
agnosia (tactile although basic tactile sensation is intact. and inferior parietal lobe. Unable to locate phone, slippers, or light switch when
agnosia and/or being awoken in the night.
astereognosis)

(Continued)

173

Table 7-1 Terminology Related to Agnosia—Cont’d
Impairment Definition
Auditory agnosia The inability to recognize specific sounds in the
context of intact hearing. This may include spoken
language (pure word deafness), music (amusia),
pitch, nonspeech sounds (auditory sound agnosia),
and emotional prosody. Comprehension of written
language, expressive language production, and
peripheral auditory function are intact.15
Pure word Inability to comprehend spoken language despite an
deafness intact ability to read, write, and speak.
Amusia Inability to interpret musical sounds and tones.
174 cognitive and perceptual rehabilitation: Optimizing function
Lesion Locations Activity Limitations/Participation Restrictions
Dominant unilateral lesions Difficulty identifying sounds in the environment (e.g.,
of Heschl’s gyrus (anterior baby crying, dog barking, phone ringing), difficulty
transverse temporal gyrus, interpreting pitch and music selections, difficulty
which is the primary auditory interpreting affect behind spoken language.
area) or bilateral lesions of
the superior temporal lobe.15
Bilateral cortical/subcortical Cannot understand spoken language but can read, write,
lesions involving the anterior and speak. In addition, nonspeech sounds such as a
part of the superior temporal siren may be recognized.
gyri with sparing of Heschl’s
gyrus on the left.3
While music interpretation is Loss of appreciation of music from a quality of life
usually considered a function perspective; loss of occupational role in professional
of the right hemisphere, both musicians and singers.
right- and left-sided lesions
have resulted in amusia
(right superior temporal
cortex, middle, and posterior
third of the left superior
temporal gyrus). Localization
is not clear.3,22
 Chapter 7  Managing Agnosias to Optimize Function 175
Table 7-2 Recovery from Agnosia
Study Participant(s)
Thomas et al, 200232 D.W., a 60-year-old male with visual
agnosia secondary to a head
injury sustained falling off of a
ladder during a seizure.
Riddoch et al, 199926 H.J.A., a 77-year-old male with visual
agnosia secondary to bilateral
occipital lesions from a posterior
cerebral artery stroke
Schiavetto et al, 199727 A.R., a child with associative visual
agnosia, prosopagnosia, and color
agnosia secondary to contracting
viral encephalitis at age 9.
Wilson and Davidoff, J.R., a 29-year-old woman with visual
199333 and tactile agnosia secondary to a
head injury.
Sparr et al, 199129 H.C., a 62-year-old female with
apperceptive agnosia for faces
and objects secondary to bilateral
occipital atrophy after an anoxic
event.
Kertesz, 197916 41-year-old female with visual
agnosia secondary to a head
injury
1. Rule out alternative explanations. Ruling out
the possibility that recognition deficit is a result
of another impairment such as sensory loss,
­inattention, aphasia, language impairment,
memory loss, or dementia. They remind us
Length of
Follow-up Outcomes/Findings
12 years D.W. was significantly better at identifying real
objects as compared to line drawings; he
presented with a category-specific agnosia
for living things that remained consistent
over the 12 years; he significantly improved
at identifying real nonliving objects over
the years, and his ability to store visual
knowledge declined over time.
12 years In terms of object recognition, H.J.A.
improved from 62% to 87% accurate for
real objects; recognition of line drawings
remained stable, only improving from
48% accurate to 54% accurate.
7 years A.R. showed limited behavioral
improvements. Improvements were
due to compensations such as using
spatial cues. Neuroanatomic correlates
remained stable over time. The authors
concluded that that cerebral plasticity
for visual processes mediated by the
right temporal lobe is limited.
10 years After the initial 7 months, J.R. demonstrated
recovery of real object recognition
(improving from 25% to 38% accurate),
object recognition from photographs
(improving from 5% to 35%), and line
drawing (improving from 3% to 10%
accurate). After 10 years, J.R. could
recognize 100% of real objects, 82% of
photographs, and 53% of line drawings.
In terms of tactile agnosia, after injury
J.R. could not identify any objects by
touch; at follow-up all objects were
identified by touch using both hands.
40 years After the first 6 months postinjury, only
H.C.’s prosopagnosia remained with the
exception of an inability to recognize
pictures if they were only briefly
presented. The 40-year follow-up showed
no recovery or worsening of symptoms
after the initial 6-month period.
9 years Recognition of real objects improved from
35% to 45% accurate. Her recognition
of line drawings remained constant
(10% to 9%).
that agnosia is modality specific and if multiple
senses are involved, it is probably indicative of
another impairment (Box 7-2).
2. Document the nature of the deficit. A variety
of tasks should be used to determine the nature
176 cognitive and perceptual rehabilitation: Optimizing function
Box 7-2 Clinical Reasoning Related to Agnosia
Differentiating between language impair-
ments (aphasia/word finding) and agnosia:
First and foremost it must be ascertained if auditory com-
prehension deficits are present by asking the person to
follow one-, two-, and three-step commands. Using the
example of a person not being able to name an apple on
a kitchen counter by vision alone, it is important to decide
if this is language impairment such as anomia (poor word
finding) or visual object agnosia. A person with agnosia and
without language impairment will not be able to describe
an object by circumlocution, description, or gesturing func-
tion as a result of not being able to recognize the object.3
In addition, if allowed to touch or taste the apple it will be
recognized and named. Those with agnosia and without lan-
guage impairment will not exhibit word-finding deficits in
conversation, can generate lists of specific categories (e.g.,
listing items needed for a Thanksgiving dinner), and can sup-
ply words that correspond with definitions (“He was the first
President of the United States” facilitates retrieval of “George
and scope of the deficit. For example, multi-
ple types of visual stimuli should be evaluated
including common objects, faces of staff or  with associative agnosias will perform these tasks
well-known celebrities, colors, words, traffic
signs, and ­geometric forms.
Burns also reminds clinicians that basic assess-
ments related to alertness, sensation, language, and
intelligence should be completed before the agnosia
assessment.8 She describes two key components of
the evaluation process:
1. If able, obtain a verbal description of what a per-
son sees, hears, or feels depending on the type of
agnosia that is suspected. When asked to identify
objects by touch or sight or sounds, the person
will misidentify or may state, “I don’t know.” The
object or sound should then be presented simul-
taneously in two sense modalities. For example, if
a camera cannot be identified by vision alone, the
person should be asked to handle the camera while
looking at it to hasten identification. Similarly, if a
person cannot identify the sound of a phone ring-
ing, he or she should be allowed to see the phone
while it is ringing to assist in sound identification.
2. Differentiate between apperceptive and associa-
tive agnosias. Burns suggests using copying and
matching tasks to make this differentiation.8 She
summarizes that those with apperceptive agno-
sias will not be able to match two identical stim-
uli such as written words, pictures, sounds, or
objects because these stimuli are not perceived
correctly. In addition they cannot match an
Washington”). Finally, they will be able to demonstrate use of
objects not in their presence via gesture (e.g., “Show me how
to use a toothbrush” will lead to a correct gesture but “Show
me what to do with the object you see on the ­counter” will
not be correct because it is not recognized).3
If a person cannot name the object (anomic error) but
can recognize it, he or she will be able to demonstrate use
of the object via gestures or use language to demonstrate
recognition (“Eve ate this fruit; it is a fruit that is red” to
describe an apple). Touching or tasting the apple may not
facilitate finding the correct word.
Differentiating between visual ­ impairments
and agnosia:
Primary visual skills such as acuity and visual fields must
be tested first (see Chapter 3). This is critical because agno-
sia is a recognition problem not a deficit in receiving visual
information. If primary visual skills are intact and an object
is still not recognized, the clinician should lean toward the
presence of agnosia.
object to its drawing, copy it, repeat a word, or
imitate a sound. However, she states that those
normally as basic perception of these stimuli is
generally intact. But she emphasizes that they
cannot match different examples of the stimu-
lus. Examples include not being able to match a
closed and open umbrella (visual), match two dif-
ferent doorbells (auditory), or match a small and
large coin through touch (tactile). This inability
to match different examples of stimuli is a result
of the person’s inability to infer meaning from
the stimuli. Table 7-3 lists procedures related to
assessment of specific subtypes of agnosia.
Interventions
Interventions related to agnosia are scarce in the
published literature. Overall interventions that are
focused on improving awareness of deficits (see
Chapter 4) and compensatory strategies that use
other senses and intact cognitive skills to com-
pensate for deficits appear to be the most effective
approaches. Overall there is a severe lack of pub-
lished reports that objectively test the effectiveness
of interventions for those with agnosia. The follow-
ing paragraphs aim to provide guidance in treating
this population based on available clinical trials and
published case studies (Appendix 7-1).
Tanemura reported (see Appendix 7-1) the pro-
cess of recognizing objects using kinesthetic sense in

Table 7-3 Standardized and Nonstandardized Assessment Procedures for Agnosias
Type of Agnosia
Tactile agnosia/astereognosis
(Visual) Object agnosia
Visuospatial agnosia
Prosopagnosia
Pure alexia
Central achromatopsia (color agnosia)
Simultagnosia
Pure word deafness
Landmark (environmental) agnosia
Data from Bauer RM, Demery JA: Agnosia. In Heilman KM, Valenstein E, editors: Clinical neuropsychology, ed 4, Oxford, 2003, University Press; and Burns
MS: Clinical management of agnosia, Top Stroke Rehabil 11(1):1-9, 2004.
a person with visual agnosia.31 Activities consisted
of those that required gazing, visual pursuit biman-
ual tasks, discrimination of figures and grounds, and
use of tactile and kinesthetic senses, specifically:
• Activities that required gazing and visual pur-
suits such as sketching and coloring
• Activities that required discrimination of figures
and grounds and enabled use of tactile and kin-
esthetic senses (i.e., combining visual pursuits
and kinesthesia such as woodcarving, leather
crafts, and metal carving)
• Activities that did not require continuous visual
processing such as mosaic works
• Recreational activities such as fishing
The author hypothesized that the person learned
to recognize figures by using kinesthetic sense to
trace them with finger and eye movements. In other
words, the person recognized figures by integrating
visual information with information perceived by
the kinesthetic sense.
Behrmann and colleagues reported the results of
retraining visual recognition in a person with visual
Chapter 7  Managing Agnosias to Optimize Function 177
Assessment Procedures
Identification of common objects via touch. Examples include identifying what is in
your pocket or handbag without vision.
Identification of common and familiar items on a table such as a fork, cup, pencil,
comb.
Standardized: the Árnadóttir Occupational Therapy-ADL Neurobehavioral
Evaluation (A-ONE) (see Chapter 1)1,2
Standardized: A-ONE (see Chapters 1 and 3).1,2
Identification of well-known celebrities or figureheads from photographs in
magazines (ensure that the person being tested is familiar with the person in the
photograph via questioning such as “Who is John F. Kennedy?”)
Identification of family and friends in photo albums or in person (preferred)
Standardized: Benton Facial Recognition Test5
Reading words and identifying letters
Identification of colors in a magazine, signage, or paint chips
Standardized: Farnsworth-Munsell 100-Hue Test17
Description of pictures (the person will be able to describe details but not the
integrated whole). For example, if viewing a picture Michelangelo’s David, he or
she will describe arms, legs, head, etc. Similarly, if a backyard (or picture of one)
is being viewed, the person may report trees, a swing, etc. In both cases, the
global aspects are not seen.
Inability to understand spoken words or repeat words/sentences. The person is
able to read and understand what is read. He or she does not make aphasic
errors or present with word-finding deficits while speaking.
Recognition and discrimination of buildings, identifying famous buildings and
landscapes, using and drawing a map30
agnosia as well as the possibility of ­ generalizing the
training to other objects and faces (Figure 7-1).4  
The program focused on teaching a young man to rec-
ognize novel three dimensional objects (“Greebles”)
by basic features such as the orientation of parts of the
“Greebles”(e.g., appendages pointing up or down). The
authors documented increased accuracy and reaction
time of recognizing trained novel objects. The training
generalized to untrained novel objects and untrained
common objects although facial ­ recognition ability
degraded over the training period.
Seniow and coworkers published a case study
that described the beneficial results of a rehabil-
itation program designed for a person that sur-
vived a gunshot more than 1 year after the head
trauma.28 The trauma resulted in bilateral dam-
age of the parieto-occipital regions. Impairments
included visual agnosia (the most profound def-
icit in this case), apraxia, visuospatial disorders,
and linguistic deficits. The rehabilitation program
consisted of remediation and adaptation via com-
puter-based tasks (focused on nonverbal memory,
178 cognitive and perceptual rehabilitation: Optimizing function
Figure 7-1  Examples of the stimuli used in the pre- and posttraining functional imaging studies. Epochs included blocks of 20 gray-scale
images of (A), Greebles, (B), common objects, and (C), faces. (From Behrmann M, Marotta J, Gauthier I, et al: Behavioral change and its
neural correlates in visual agnosia after expertise training, J Cogn Neurosci 1[4]:554-568, 2005.)
visual-perception, and visuospatial tasks) paper-
and-pencil exercises (e.g., draw and copy tasks),
and occupational therapy focused on real-life
activities with the goal of improved function. The
client’s progress was assessed as improvement in
performance in standardized tests and computer-
based tasks. After the program, the client’s func-
tioning significantly improved as measured by
psychological tests and computer-based tasks as
well as the evaluation of the client’s quality of life
and performance of daily activities.
In terms of tactile object recognition, Yekutiel
and Guttman conducted a controlled trial of
retraining sensory function of the hand in those
with chronic stroke.34 Sensation in the involved
hand was tested before and after the intervention
period. The treated group showed large and signifi-
cant gains on all sensory tests, whereas no change
occurred in the control group. The largest gain was
related to tactile object recognition. The specifics of
the intervention included the following:
• Identifying the number of touches, lines, num-
bers, or letters drawn on the arm and hand
• “Finding” the involved thumb with vision
occluded
• Discrimination of shapes, weights, textures of
objects placed in the hand
• Passive drawing in which the clinician “draws”
on the client’s palm and the person attempts to
recognize what is drawn using a series of cue
cards. This progresses to the clinician writing
messages on the person’s hand.
They concluded that somatosensory deficit can
be alleviated even years after stroke and that reha-
bilitation for stroke clients should include sensory
retraining for those with sensory deficit.
Davis and Coltheart examined a compensa-
tory intervention for topographical disorienta-
tion.11 Topographical disorientation or difficulty
in finding one’s way from one location to another
is an impairment that occurs in conjunction
with other impairments such as visual field loss,
visual or visuospatial agnosia, landmark agnosia,
memory deficits, and so on.7 This study exam-
ined the effects of a rehabilitation program on
the topographical functioning of a 46-year-old
female who presented with symptoms of topo-
graphical disorientation related to impairment
of some aspects of both memory and space per-
ception. The intervention focused only on the
woman’s difficulty in acquiring new topograph-
ical information and focused on a small area of
her hometown. She was taught simple mnemonic
techniques designed to increase the meaning-
fulness and association of the selected material.
The first strategy was focused on the acquisi-
tion of street names using a mnemonic strategy 
(e.g., Durham Street was “dirty ham”).
Mnemonics that were personally meaning-
ful were used. The second part of the interven-
tion focused on chunking the names of the streets
into two sentences rather than 14 pieces of inde-
pendent information. The technique also focused
on helping the person remember the locations of
the street. The sentences were constructed so that
streets were remembered in spatial order such as
north to south or east to west. Using the technique,
she showed significant improvement in her recall of
the names and locations of selected streets, and she
retained this information well at a delayed posttest.
The authors also found that she successfully applied
this knowledge in daily living although there was
 Chapter 7  Managing Agnosias to Optimize Function 179
no evidence of spontaneous generalization of
her mnemonic technique to other locations. The
authors concluded that intervention strategies can
be highly effective and efficient if they are founded
on a sound understanding of the client’s cognitive
strengths and deficits, allowing the intervention to
be precisely targeted.
Box 7-3 More Interventions for Agnosia Based on the Literature
Visual Agnosia
Teach compensation via the use of other senses such as
tactile information.
Teach awareness of deficits (see Chapter 4) focusing on
consequences of the impairments because those with
visual agnosia may underestimate the consequences of
the deficit.27
Teach recognition of figures and shapes by kinesthetic
sense combined with visual information.31
Teach tracing with eyes and fingers such as tracing letters
to improve recognition.31
Moving an object or moving the head relative to an unrec-
ognizable object and tracing the outline may facilitate
recognition.16 Encourage head movements when exam-
ining objects and encourage examining objects related
to depth cues.10,32
Teach the use of spatial and location cues to recognize
objects, people, etc. Examples include organizing a bed-
room or classroom so that needed objects are assigned
to specific spatial locations such as school clothes on the
right side of the dresser and casual clothes on the left.27
Teach the use of unique identifying features and idiosyn-
cratic cues to assist recognition (e.g., color or shape).27
Use knowledge of relevant and critical features to iden-
tify objects. For example, when looking for Swiss cheese
in the refrigerator, focus on color (white) and shape
(cube shaped) to narrow down the number of objects
that must be examined.
Teach a piecemeal reconstruction approach using feature-
by-feature analysis.27
Teach reliance on verbal memory skills and verbal reason-
ing to interpret the piecemeal visual information into
a whole (e.g., “it’s a person, no it’s a dress, it’s short, it
must be a shirt”).27
Use color cues, labels, or textures on objects or environ-
ments (e.g., Velcro on the phone receiver or red tape on
doorknobs).8,18
Encourage overt verbalization of the visual characteristics
of objects before producing a name.9
Practice identification of real objects vs. line drawings. Real
objects are more easily recognized than drawings or
pictures. Focus attention to depth cues, surface texture,
and colors.32 Real objects provide cues based on surface
detail (different luminance and textures), color shades,
and provide depth information.10
Burns8 makes the following anecdotal yet practi-
cal treatment suggestions:
• Develop awareness of the deficit. This may be
achieved by presenting a stimulus in the affected
sense modality (e.g., vision) followed by let-
ting the person experience the stimulus in an
uninvolved sense modality (e.g., touch). Burns
Use landmarks such as a sofa to route find.18
Use cues from other people to help generate a strategy. For
example, if during a meal one can’t find utensils, watch-
ing others during the meal may help locate these items.18
Alexia
Read via letter tracing.8
Trace letters on the palm of the hand.
Use books on tape.
Use text to speech software programs such as Kurzweil
1000TM or RealSpeakTM.
Pure Word Deafness
Teach use of contextual cues, intonation, gestures, and
facial expressions.8
Use written directions and information.
Prosopagnosia
Use gait clues to identify people (e.g., speed, sound of
shoes).27
Teach voice recognition.4,27
Use clothing sounds or clues to recognize.4
Use localization clues (e.g., Ann sits behind me in the
classroom and John is to my right).27
Highlight distinguishing features such as eye color, a scar,
or mustache.8
Topographical Disorientation Secondary
to Agnosia and Related Disorders
Teach navigation in home environments by always starting
at the same point such as the front door.8
Focus on past memories of the home to assist in naviga-
tion or relearning directions using kinesthetic and
­vestibular cues.
Use color markers on key rooms (e.g., a blue circle is my
room).
Teach the use of kinesthetic memory for route finding such
as the number of turns or steps.27
Tactile Agnosia and/or Astereognosis
Begin practicing with identifying simple shapes via tactile
information. Practice recognition of two-dimensional
and three-dimensional objects because recognition may
not be consistent.24
Use combined tactile and visual recognition.
180 cognitive and perceptual rehabilitation: Optimizing function
s­ uggests that several repetitions will begin to
build awareness of the experienced difficulty.  used at a family gathering to increase participa-
In addition, the person’s chief complaints should
be repeated often and interpreted. For example:
“You said that you can’t find change in your
purse. How do you find it? By looking at it,
right?”
• Compensate with alternate modalities. Examples
may include combining touch and vision to
locate grooming items on the sink, tracing let-
ters to recognize words, recognizing people via
their voices, and using written directions for
those with pure word deafness.
• Use verbal strategies. Used with visual agno-
sia, the person is taught to verbalize what is
being seen to aid in recognition and identifica-
tion. For example, “It is red and round. Is it an
apple?”
• Use alternate cues. Burns gives examples such
as identifying someone via a crooked tooth or
beard, combining voice with facial characteris-
tics, or using color cues and textural cues to rec-
ognize items. Examples include placing Velcro
on the knob of a door that should be avoided
such as the garage or placing a red label on the
bottle of daily vitamins.
• Organizational strategies. Caretakers should
organize living environments to increase ease
of living. Burns gives suggestion such as match-
ing clothing items on hangers, placing items that
are used together in the same location or drawer,
labeling storage areas, placing color codes or tac-
tile cues on drawers, and organizing the refrig-
erator for consistency (e.g., milk is always on the
top right shelf).
• Safety concerns. The person living with agnosia
should carry an identification card and emer-
gency contacts and a beeper or phone. In addi-
tion, sharp, poisonous, or other dangerous
objects should be locked away. Provide super-
vision during kitchen activities and community
activities.
• See Box 7-3 for other potential interventions uti-
lized with this population.
Review Questions
1. What is the difference between apperceptive
agnosia and associative agnosia?
2. Name at least three subtypes of agnosia that
affects visual processing.
3. Give three examples of how visual object agnosia
can result in activity limitations.
4. List three compensatory strategies that may be
tion of those living with prosopagnosia.
5. Define and describe topographical disorientation.
REFERENCES
1. Árnadóttir G: The brain and behavior: assessing cor-
tical dysfunction through activities of daily living, 
St Louis, 1990, Mosby.
2. 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.
3. Bauer RM, Demery JA: Agnosia. In Heilman KM,
Valenstein E, editors: Clinical neuropsychology, ed 4,
New York, 2003, Oxford University Press.
4. Behrmann M, Marotta J, Gauthier I, et al: Behavioral
change and its neural correlates in visual agno-
sia after expertise training, J Cogn Neurosci 17(4): 
554-568, 2005.
5. Benton AL, Sivan AB, Hamsher K, et al: Contributions
to neuropsychological assessment, New York, 1994,
Oxford University Press.
6. Biran I, Coslett HB: Visual agnosia, Curr Neurol
Neurosci Rep 3(6):508-512, 2003.
7. Brunsdon R, Nickels L, Coltheart M: Topographical
disorientation: towards an integrated framework
for assessment. Neuropsychol Rehabil 17(1):34-52,
2007.
8. Burns MS: Clinical management of agnosia, Top
Stroke Rehabil 11(1):1-9, 2004.
9. Carlesimo GA, Casadio P, Sabbadini M, et al:
Associative visual agnosia resulting from a discon-
nection between intact visual memory and semantic
systems, Cortex 34(4):563-576, 1998.
10. Chainay H, Humphreys GW: The real-object advan-
tage in agnosia: evidence for a role of surface and
depth information in object recognition, Cogn
Neuropsychol 18(2):175-191, 2001.
11. Davis SJC, Coltheart M: Rehabilitation of topograph-
ical disorientation: an experimental single case study,
Neuropsychol Rehabil 9(1):1-30, 1999.
12. De Renzi E, di Pellegrino G: Prosopagnosia and
alexia without object agnosia, Cortex 34(3):403-415,
1998.
13. Farah MJ: Visual agnosia, ed 2, Cambridge, Mass,
2004, MIT Press.
14. Gerstmann J, Benke T [Translator]: Pure tactile agno-
sia, Cogn Neuropsychol 18(3):267-274, 2001.
15. Hattiangadi N, Pillion JP, Slomine B, et al: Characteristics
of auditory agnosia in a child with severe traumatic
brain injury: a case report, Brain Lang 92(1):12-25,
2005.
16. Kertesz A: Visual agnosia: the dual deficit of per-
ception and recognition, Cortex 15(3):403-419,
1979.
 Chapter 7  Managing Agnosias to Optimize Function 181
17. Kinnear P, Sahraie A: New Farnsworth-Munsell 100
hue test norms of normal observers for each year of
age 5-22 and for age decades 30-70, Brit J Ophthalmol
86:1408-1411, 2002.
18. Lampinen J, Tham K: Interaction with the physical
environment in everyday occupation after stroke:
a phenomenological study of persons with visuo-
spatial agnosia, Scand J Occup Ther 10(4):147-156,
2003.
19. Lissauer H: Ein Fall vol Seelenblindheit nebst einem
Beitrag zur Theorie derselben [A case of visual agno-
sia with a contribution to theory], Archiv Psychiatr
21:222-270, 1890. Translated in Shallice T, Jackson M:  case study, Brain Inj 17(8):701-713, 2003.
Lissauer on agnosia, Cogn Neuropsychol 5:153-192,
1988.
20. McMullen PA, Fisk JD, Phillips SJ, et al: Apperceptive
agnosia and face recognition, Neurocase 6(5):  30. Takahashi N, Kawamura M: Pure topographical
403-414, 2000.
21. Milner B, Teuber HL: Alteration of perception
and memory in man: reflections on methods. In
Weiskrantz L, editor: Analysis of behavioral change,
New York, 1968, Harper and Row.
22. Pearce JM: Selected observations on amusia, Eur
Neurol 54(3):145-148, 2005.
23. Rainville C, Joubert S, Felician O, et al: Wayfinding
in familiar and unfamiliar environments in a case
of progressive topographical agnosia, Neurocase
11(5):297-309, 2005.
24. Reed CL, Caselli RJ, Farah MJ: Tactile agnosia: under-
lying impairment and implications for normal tactile
object recognition, Brain 119(Pt 3):875-888, 1996.
25. Riddoch MJ, Humphreys GW: Visual agnosia, Neurol
Clin 21(2):501-520, 2003.
26. Riddoch MJ, Humphreys GW, Gannon T, et al:
Memories are made of this: the effects of time on stored
visual knowledge in a case of visual agnosia, Brain 122 
(Pt 3):537-559, 1999.
27. Schiavetto A, Decaile J, Flessas J, et al: Childhood
visual agnosia: a seven-year follow-up, Neurocase
3(1):1-17, 1997.
28. Seniow J, Polanowska K, Mandat T, et al: The cogni-
tive impairments due to the occipito-parietal brain
injury after gunshot: a successful neurorehabilitation
29. Sparr SA, Jay M, Drislane FW, et al: A historic case
of visual agnosia revisited after 40 years, Brain 114 
(Pt 2):789-800, 1991.
disorientation—the anatomical basis of landmark
agnosia, Cortex 38(5):717-725, 2002.
31. Tanemura R: Awareness in apraxia and agnosia, Top
Stroke Rehabil 6(1):33-42, 1999.
32. Thomas RM, Forde EM, Humphreys GW, et al: 
A longitudinal study of category-specific agnosia,
Neurocase 8(6):466-479, 2002.
33. Wilson BA, Davidoff J: Partial recovery from visual
object agnosia: a 10 year follow-up study, Cortex
29(3):529-542, 1993.
34. Yekutiel M, Guttman E: A controlled trial of the
retraining of the sensory function of the hand
in stroke clients, J Neurol Neurosurg Psychiatry
56(3):241-244, 1993.
 Appendix 7-1
Evidence-Based Practice for Agnosia Focused on Improving
Daily Function
Table 1 Summary of Research
Study Intervention Description
Tanemura, 199931 Recognizing objects using
kinesthetic sense during
functional activities
Behrmann et al, Recognition training for novel
20054 objects, common objects,
and faces
Seniow et al, 200328 Comprehensive rehabilitation
via computer-based tasks,
pen-and-paper exercise, and
function-based occupational
therapy
Yekutiel and Guttman, Sensory retraining of the hand
199334 after stroke including tactile
object recognition
Davis and Coltheart, Compensatory strategies to
199911 improve topographical
disorientation
M, mean.
182
Participant Characteristics n Age
An adult male with infraction of 1 56
bilateral cerebral arteries
An adult male with visual agnosia 1 24
secondary to a closed head
injury after a motor vehicle
accident
Adult male with bilateral damage 1 28
of the parieto-occipital regions
secondary to a gunshot wound
Adults with chronic stroke (at least 20 M = 64 (range
2 years post) and resultant 44–81)
sensory loss
Adult woman with a deterioration 1 46
in cognitive function
 Chapter 7  Managing Agnosias to Optimize Function 183

Table 2 Summary of Outcomes

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

Tanemura, Case study Visual-perception test for + N/A Impairment

199931 agnosia
Behrmann et al, Case study Identifying trained novel + p < 0.01 Impairment
20054 objects
Identifying untrained novel + p < 0.01 Impairment
objects
Identifying untrained + p < 0.01 Impairment
common objects
Identifying untrained faces — p < 0.01 Impairment
Seniow et al, Case study Glasgow Outcome Scale + Not reported Activity limitations
200328 Disability Rating Scale + Not reported Activity limitations
Computer-based task + p < 0.05 Impairment
performance
Neuropsychological + Not reported Impairment
measures
Yekutiel and Nonrandomized Tactile object recognition + p < 0.0001 Impairment
Guttman, controlled trial (30 objects)
199334
Davis and Case study Recall of street names + p < 0.01 Impairment
Coltheart, Recall of street locations + p < 0.01 Impairment
199911 Knowledge of landmarks + p < 0.001 Impairment
Community + N/A Activity limitations
mobility/driving

* 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; N/A,
not applicable.
 Chapter 8
Managing Attention Deficits to Optimize Function

Key Terms
Arousal Attentional switching Selective attention
Alternating attention Distractibility Sustained attention
Attention Divided attention Vigilance

Learning Objectives
At the end of this chapter, readers will be able to:
1. Differentiate among various types of impairments
of attention.
2. Understand how everyday living is affected depend-
ing on the type of attention deficit present.
3. Be aware of evaluation/assessment procedures related
to attention.
4. Develop an evidence-based intervention plan
focused on decreasing activity limitations and par-
ticipation re­strictions for those living with impair-
ments of attention.

“We believe that many interesting and yet unexplored questions about attention arise when attention
is considered from the perspective of the real world. For example, what is the function of attention in
everyday situations?…What role does attention play in social interactions? How does attention differ
among individuals and cultures? These are just a few of the many interesting questions that have
been, up to this point, largely ignored.”26

A  ttention in its various forms is one of the most 

 important and basic functions of the human
brain and it constitutes the basis for other cognitive
processes. The integrity of the attention system is
considered a prerequisite of all other higher cogni-
tive systems such as memory, executive functions,
and so on.40 In particular, basic memory func-
tions such as working memory (see Chapter 9) are
dependent on intact attention processes.14,16 If one
does not attend to incoming information and can-
not hold information in mind, information will not
be remembered and cannot be used to guide appro-
priate behaviors or successfully complete daily
activities.33 It comes to follow that attention skills
serve as a cognitive foundation and are a prerequi-
site to engage in most if not all meaningful activi-
ties and any impairment of the attention processes
will result in observable difficulties in everyday life,
which may in fact decrease quality of life.
Attention impairments are observed and reported
in those with a variety of traumatic and nontrau-
matic brain injuries including but not ­limited to even

184
 Chapter 8  Managing Attention Deficits to Optimize Function 185
mild traumatic brain injuries,13 stroke,45 and mul-
tiple sclerosis.48 In fact, even in the early stages, those
living with multiple sclerosis show a lengthened
reaction time for simple and focused attention.48
Although recovery of attention processes has been
reported from 1 to 3 months after injury, attention
deficits also seem to be a persistent cognitive defi-
cit lasting long after the initial neurologic insult.13
From an everyday living perspective, caretakers of
those living with stroke and traumatic brain injury
frequently report that attention impairments are
persistent and interfere with real-world function.
A relationship exists between the presence of atten-
tion impairments and decreased functional recov-
ery from a rehabilitation perspective6,45 as well as
capacity to return to work9 and the amount of doc-
umented motor recovery.45 This relationship may
in part be a result of the recently documented sub-
stantial amount of time that is required to engage
in and attend to functional retraining methods after
a neurologic insult if one is to make a significant
change in motor status.60
During task performance, impairment of atten-
tion results in increased rates of off-task behavior
(e.g., looking up and away from the task at hand,
engaging in unsolicited conversations, etc.) as com-
pared with controls. Those with attention impair-
ments are markedly less attentive than controls both
in the presence of distractions (noise, movements)
and in their absence.58 Further compounding this
problem is a relationship between attention impair-
ment and a lack of awareness of errors (see Chapter 4).  cally, neocortical activations are observed in the
McAvinue and associates31 investigated the pro-
cesses of error awareness and sustained attention
in those with traumatic brain injury (TBI). They
found the following:
• In comparison to controls, TBI participants dis-
played reduced sustained attention and aware-
ness of error.
• The degree of error awareness was strongly cor-
related with sustained attention capacity, even
when severity of injury was controlled for.
• Error feedback significantly reduced errors.
• TBI leads to impaired sustained attention and
error awareness.
The finding of a significant relationship between
these two deficits in TBI suggests there may be a
link between these two processes.
Neurologic Background
In terms of neurologic processing, control of atten-
tion seems to be mediated by multiple brain regions
including subcortical substrates, the brainstem, and
cortical structures.13,14 More specifically, those with
attention deficits have an impaired flow of informa-
tion in the frontal and parietal cortex in addition
to the temporal lobe, the cerebellum, the thalamus,
and structures within the brainstem. The right
hemisphere seems to have a particular and domi-
nant role in promoting attention. Damage to the
right hemisphere results in unilateral spatial atten-
tion deficits, decreased alertness and arousal, and
decreased sustained attention.30 The right prefron-
tal cortex appears to be particularly important in
mediating attention. Specific findings of neuroim-
aging studies aimed at localization of attentional
networks include the following:
• During a visual sustained attention task, activa-
tion of the right middle frontal gyrus and right
parietal lobe is detectable across functional
imaging modalities.28
• The right hemisphere seems to play a special part
in human attention because damage to the right
hemisphere results in lateralized attention defi-
cits or neglect (see Chapter 6 and Figure 6-1).37
• Positron-emission tomography (PET) studies
of human attention have documented local-
ized increases in blood flow in the prefrontal
and superior parietal cortex primarily in the
right hemisphere, regardless of the modality or
­laterality of sensory input.37
• Visuospatial attention tasks evoke largely over-
lapping patterns of neural activation, specifi-
right anterior cingulate gyrus, in the intrapari-
etal sulcus of right posterior parietal cortex, and
in the mesial and lateral premotor cortices.36
Because of the distributed neurologic network
of structures that promote attention, attention defi-
cits are commonly seen in the majority of static and
progressive neurologic disorders including head
trauma, stroke, multiple sclerosis, and tumor as
noted earlier.30 Depending on the area of the brain
that is damaged, various attention deficits may be
observed (Table 8-1).
Posner and Peterson43 proposed the existence of
three main functionally and anatomically distinct
attentional control subsystems27:
1. An orienting system related to sensory events
that rely on the posterior brain areas (superior
parietal lobe and temporoparietal junction, in
addition to the frontal-eye fields). This system
is involved in the selection of relevant sensory
information. This subsystem brings attention
to a specific location in space and generates
186 cognitive and perceptual rehabilitation: Optimizing function
Table 8-1 Terminology Related to Attention Impairments
Attention Component Definition
Attention Voluntary control over more automatic brain
systems so as to be able to select and
manipulate sensory and stored information
briefly or for sustained periods38
Arousal A state of responsiveness to sensory stimulation
or excitability
Dependent on a widely distributed neural
network including prefrontal areas and
neurotransmitter systems3,54
Selective attention The type of attention involved in the processing
and filtering of relevant information in the
presence of irrelevant stimuli44
The efficiency with which people can search and
focus on specific information while ignoring
distracters46
Because selective attention is critical for encoding
information into memory (see Chapter 9),
retaining and manipulating information in
working memory, and successfully executing
goal-directed behavior, a deficit in selective
attention could contribute to the numerous
cognitive deficits observed in those living with
neurologic impairments.44
This skill is linked to prefrontal and underlying
anterior cingulated areas.
Sustained attention Used to support tasks that require vigilance
(vigilance) and the capacity to maintain attention
over time.2 There is a relationship
between impaired sustained attention
and error awareness31 as well as with
working memory to hold and manipulate
information.50
Many times this construct is measured by time
spent on task.57
In adults this attention component is linked to
prefrontal function in the right hemisphere
as well as white matter.46
Attentional switching or The ability to switch attention flexibility from
alternating attention one concept to another. Related to cognitive
flexibility.
The ability to change attentive focus in a flexible
or adaptive manner.1,34
The ability to move between tasks with different
cognitive requirements.50
This skill appears to be a function of the
prefrontal cortex as well as the posterior
parietal lobe, thalamus, and midbrain.34
Functional Examples
See later for examples of the specific
components of attention
Decreased responsiveness to incoming
visual, auditory, or tactile cues during
task performance
Requires noxious or extreme sensory
stimuli (e.g., a cold washcloth applied
to the face) to elicit a behavioral
response
Attending to one conversation during a
party
Studying outside with the noise of traffic
and children playing
Attending to a therapist’s instructions and
cues in a crowded therapy clinic
Making dinner while the children are
watching TV in the background
Attending to a board game during recess
Being able to attend to long conversations,
instructions, class lessons, television
shows, or movies
Attending to playing a game of chess
Balancing a checkbook
Watching your child on the playground
While typing a paper, a friend comes into
your room to discuss a completely
different topic; when the conversation is
over, you return to typing
Cooking, taking care of a crying child, then
returning to cooking
A unit clerk at the hospital alternating
between flagging orders on the medical
chart, answering the phone, and writing
down phone messages
 Chapter 8  Managing Attention Deficits to Optimize Function 187

Table 8-1 Terminology Related to Attention Impairments—Cont’d

Attention Component Definition Functional Examples

Divided attention Dividing attention between two or more tasks
simultaneously
Dual tasking or multitasking
The capacity to attend to two competing stimuli
simultaneously2
Deficits occur when limited attentional resources
are divided between two sources
Distractibility A breakdown in selective attention
An inability to block out environmental or
internal stimuli when one is trying to
concentrate on performing a particular task
A symptom of prefrontal damage, particularly the
dorsolateral cortex30
Field-dependent behavior Distracted by and acting on an irrelevant impulse
that interferes with activity performance and
takes over goal-directed activity
Includes both an attention and perseveration
component3
Neglect (a lateralized See Chapter 6
attention deficit)
Making toast and tea at the same time
Talking on the phone while shopping
Playing cards while discussing the events
of the day
Noise in the hallway takes away your
attention while taking notes during a
class
Inability to attend during a therapy session
because of being distracted by watching
someone else’s session
While performing oral care, a person
becomes distracted by a light switch;
the person then stops the oral care
activity while turning on and off the
light switch (i.e., not relevant to the task
at hand)3
See Chapter 6

­ erceptual awareness. It reflects involuntary ori-

p • Frontal lobe damage in brain-injury clients
enting or automatic processing. Performance of
this system is determined by reaction time in
responding to the detection of stimuli.
2. An executive system focused on selection,
involving multiple structures (anterior cin-
gulate, lateral prefrontal cortex, and the basal
ganglia). This system is responsible for exercis-
ing control over lower-level cognitive functions
and resolving conflicts. The system is promi-
nent in detecting signals for focal or conscious
attention. Breakdown in this system results in
difficulty managing tasks that require divided
attention, screening out interfering stimuli, and
­responding to novelty.
3. An alerting or sustained attention system involv-
ing the frontoparietal regions responsible for
achieving and maintaining sensitivity to incom-
ing stimuli. Impairments related to this system
result in short attention spans.
Dockree and colleagues17 summarize the
following:
• Attention deficits are among the most commonly
observed deficits following brain injury.
• Damage to the frontal lobes of the brain particu-
larly the white matter connecting frontal, pari-
etal, and striatal regions are, in part, responsible
for these deficits.
results in a tendency to drift from intended goals
and increases the frequency of action slips that
were unintended.
• Self-reports from traumatically brain-injured
clients reveal that problems with attention and
concentration rate among the highest com-
plaints for this client group.
Evaluation and Assessments
The usual and customary tests of attention include
pen-and-paper measures or laboratory-type tasks.
These include the Paced Auditory Serial Addition
Test (PASAT), Trail Making Test Part A, and the
Wisconsin Card Sorting Task. As discussed in pre-
vious chapters the question of ecologic validity
arises when using these measures as related to dif-
ficulties in generalizing results to everyday living
tasks (see Chapter 2). As discussed in Chapter 1,
measurement instruments that utilize structured
observations of daily function are recommended
for those focused on the functional rehabilitation
of individuals presenting with attention impair-
ments. Other recommended instruments that
are more specific to attention impairments are
discussed in the following paragraphs and are
­summarized in Table 8-2.
 188 cognitive and perceptual rehabilitation: Optimizing function
Table 8-2 Recommended Outcome Measures and Function-Based Assessments of Attention
Dimension Based
on International
Instrument and Classification of
Author Instrument Description Population Validity Reliability Function* Comments

Standardized Activity limitations See Chapter 1

assessments of basic
activities of daily living
(ADL)
Standardized Activity limitations See Chapter 1
assessments of
instrumental ADL
(IADL)
Standardized Activity limitations See Chapter 1
assessments of
leisure
Standardized Participation See Chapter 1
assessments of restrictions
participation
Standardized Quality of life See Chapter 1
assessments of
quality of life
Test of Everyday Considered an Developed for The subtests load on Test-retest: using the Impairments The normative sample was
Attention, ecologically valid test those 18 to 80 four factors (see text) normative sample tested via composed of 154 normal
Robertson et al, of various types of years of age Subtests are correlated version A and simulated individuals ranging from
199646 everyday attention with an acquired with typical version B ranged activities 18 to 80 years of age
such as sustained neurologic insult neuropsychological from 0.59 to 0.86 stratified by age (18-34,
attention, selective and others measures such as and version B to 35-49, 50-64, 65-80)
attention, attentional (schizophrenia, the Stroop, Trails version C ranged and education
switching, and divided Asperger’s B, Paced Auditory from 0.61 to 0.90 Subtests consist of
attention syndrome, etc.) Serial Addition Task, A sample of stroke simulated and contrived
Includes several subtests Digit Span, etc. survivors ranged tasks
from 0.41 to 0.90

Test of Everyday Considered an ecologically Children 6 to 16
Attention for valid test of various
Children, types of everyday
Anderson et al, attention such as
19982 sustained attention,
selective attention,
attentional switching,
and divided attention
Includes several subtests
Moss Attention An observational test of Those 15 years
Rating Scale, disordered attention
Hart et al, 200624; that includes 22 items
Whyte et al, 200355 at present
Produces three factor
scores and a total
score
Rating Scale of A short assessment Those with severe
Attentional of attention-based
Behaviour, impairments rated
Ponsford and via clinicians’
Kinsella, 199142 observations of
behaviors
Cognitive Failures Self-report measure Used with multiple
Questionnaire, of the frequency of
Broadbent et al, lapses of attention and
19828 cognition in daily life
Factor analysis is
years old with consistent with the
traumatic brain adult version. Four
injury and sustained attention
attention deficit subtests significantly
hyperactivity correlated with
disorder (ADHD) academic achieve­ment
(reading, spelling,
arithmetic)
Construct validity: Factor
and older with analysis revealed that
attention deficits the test measures a
secondary to brain single construct that is
injury the broad concept of
attention
Three correlated factors
were revealed:
restlessness/
distractibility, initiation,
and sustained/
consistent attention
Low to medium,
brain injury ages albeit significant
16 years and older correlations with
neuropsychological
measures of
attention (Stroop,
Symbol Digit
Modalities Test,
Choice Reaction
Time, Paced Auditory
Serial Addition Test)
Predicts car accidents,
populations workplace safety,
including those falls, etc.
with brain injuries
Test-retest Impairments The normative sample
reliabilities range tested via via was composed of 293
from 0.57 to 0.87 simulated children ranging from
activities 6 to 16 years of age
stratified by 6 age bands
Subtests consist of gamelike
tasks
Internal consistency: Impairment Rasch analysis of the
Cronbach’s alpha manifested instrument’s psycho­
= 0.95 during metric properties revealed
Rating between observation good person separation
occupational of everyday (5.69) and separation
Chapter 8  Managing Attention Deficits to Optimize Function
therapists and performance reliability (0.97)
physical therapists
= 0.68
Internal consistency: Impairment Although lower than
Cronbach’s alpha manifested intrarater reliability,
>0.92 during interrater reliability was
Intrarater reliability observation significant
>0.9 of everyday The authors noted that the
Interrater reliability performance observations were made
>0.5 in different contexts
(a busy occupational
therapy clinic versus
a quiet office), which
may explain the lower
coefficient
Stable test-retest Impairment Includes items related to
reliability manifested memory, attention, and
during everyday executive dysfunction
performance
189
(Continued)
 190 cognitive and perceptual rehabilitation: Optimizing function
Table 8-2 Recommended Outcome Measures and Function-Based Assessments of Attention—Cont’d
Dimension Based
on International
Instrument and Classification of
Author Instrument Description Population Validity Reliability Function* Comments

Attention Rating A self-report measure Those with mild Able to discriminate Not published Impairment This promising instrument
and Monitoring of the frequency of traumatic brain between those with manifested requires further
Scale, everyday problems injury mild traumatic brain during psychometric testing
Cicerone, 200214 related to attention injury and controls everyday
impairments performance
Árnadóttir Structured observation Those who are 16 Content: via expert Interrater: 0.84 Impairments Provides information
Occupational of basic ADL including years and older review and literature Test-retest: 0.86 Activity limitations related to how attention
Therapy-ADL feeding, grooming with central review affects everyday living
Neurobehavioral and hygiene, dressing, nervous system Concurrent: Barthel Includes items related to
Evaluation transfers, and mobility involvement Index, Katz Index, arousal, attention, and
(A-ONE), to detect the effect of Mini Mental Status distractibility
Árnadóttir, 19903; multiple underlying Examination Requires training
20044 impairments including Valid for multiple
decreased arousal, diagnoses including:
distractibility, and stroke, brain tumor,
decreased attention dementia
on these tasks
Assessment of An observational Those who are Strong validity and Cronbach’s alpha Activity limitations Provides information
Motor and assessment used 3 years old appropriate to range from 0.74 related to everyday living
Process Skills to measure the and older with use with multiple to 0.93 Requires training
(AMPS), quality of a person’s difficulties related diagnoses and Test-retest range
Fisher, 200320,21 occupational to occupational cultures from 0.7 to 0.91
performance assessed performance
by rating the effort,
efficiency, safety, and
independence of 16
motor and 20 process
skill items
Includes choices from
85 tasks
 Chapter 8  Managing Attention Deficits to Optimize Function 191
The Test of Everyday Attention (TEA)46,47
includes a range of subtests of everyday attention
based on simulated functional activities such as the
following:
• Map search: Subjects have to search for symbols
on a colored map. The score is the number out
of 80 found in 2 minutes and is used a measure
of selective attention.
• Elevator counting: Subjects are asked to pretend
they are in an elevator whose door-indicator is
not functioning. They therefore have to establish
on which floor they are by counting a series of
tape-presented tones as a measure of sustained
attention.
• Elevator counting with distraction: Subjects have
to count the low tones in the pretend elevator
while ignoring the high tones as a test of ­auditory
selective attention.
• Visual elevator: Subjects have to count up and
down as they follow a series of visually pre-
sented “doors” in the elevator (reversal task) as a
­measure of attentional switching.
• Auditory elevator with reversal: The same as the
visual elevator subtest except that it is presented
at fixed speed on tape.
• Telephone search: Subjects must look for key
symbols while searching entries in a simulated
classified telephone directory.
• Telephone search dual task: Subjects must again
search in the directory while simultaneously
counting strings of tones presented by a tape
recorder (dual task). The combined perfor-
mance of the telephone tasks gives a measure of
divided attention.
• Lottery task: Listening to, attending to, and iden-
tifying numbers during a broadcast of lottery
numbers.
The factor structure of the test matches well
with current evidence for a set of functionally
independent attentional circuits in the brain, and
includes factors for sustained attention, selec-
tive attention, attentional switching, and audi-
tory-verbal working memory.46,47 The test has
parallel forms and high test-retest reliability, and
correlates significantly with other measures of
attention. Subtests discriminate brain-impaired
groups including closed head injury,12 those with
Alzheimer’s disease, and those with progressive
supranuclear palsy. The map and telephone search
subtests of the TEA discriminate between those
with severe head injury and matched controls,
suggesting a deficit in visual selective ­ attention
following TBI.5
The Test of Everyday Attention for Children
(TEA-ch)2 is a valid and reliable battery of tests for
the assessment of attention in children between
the ages of 6 and 16 years. The tool uses gamelike
tests to assess different forms of attention including
selective, sustained, divided, and attentional switch-
ing as well as dual task performance. Two parallel
forms are included. The test allows comparison of
a child’s performance to the average performance
of children their own age within six age bands. The
tool has been used for children with attention defi-
cit hyperactivity disorder (ADHD) and TBI. A four-
subtest version can be used for screening. Subtests
include the following:
• Sky Search: A measure of selective/focused visual
attention and visual search. The task is to have
the child find and circle all the pairs of identical
spaceships on a sheet of paper among unpaired
distracters.
• Score!: A measure of sustained attention that
requires children to keep a count of the number
of “scoring” sounds they hear on a tape, as if they
were keeping the score on a computer game.
• Creature Counting: A measure of attentional
control and switching that requires children to
repeatedly switch between two simple activities,
counting upward and counting downward. They
are asked to count “aliens in their burrow,” with
periodic arrows informing them of the direction
to count.
• Sky Search DT: A measure of sustained-divided
attention that requires children to repeat the
Sky Search subtest under dual task conditions.
As they scan the picture they must also attend to
the tape player and count the number of scoring
sounds they hear on each trial.
• Map Mission: A measure of selective/focused
attention in which the child must search a map
to find as many of a particular symbol as ­possible
in 1 minute.
• Score! DT: A measure of sustained attention in
which children must again count the scoring
sounds with another task in the same, auditory
modality. As the child counts, he or she is asked
to monitor for an animal name that will occur
at some stage during the counting in a spoken
news report.
• Walk, Don’t Walk: A measure of sustained atten-
tion/response inhibition that requires the child
to learn two tones, one “go” and one “no go.”
As the child hears the “go” tone he or she places
a mark on the paper but must not mark when
hearing the “no go” sound.
192 cognitive and perceptual rehabilitation: Optimizing function

• Opposite Worlds: A measure of attentional con-
trol/switching that requires the child to make
cognitive reversals. In the Same World the child
is asked to follow a path naming the digits 1 and
2, which are scattered along it. In the Opposite
World the child has to do the same task except
this time say “one” when seeing a 2 and “two”
when seeing a 1.
• Code Transmission: A measure of sustained atten-
tion in which the child must sustain attention on
a series of spoken digits, the “code transmission,”
listening for a particular sequence of numbers. The
child then needs to report the number that came
immediately before the “code transmission.”
The Moss Attention Rating Scale (MARS)24,55
was developed after consulting with past stud-
ies, experts, and practicing clinicians. The authors
intended that the test represent multiple facets of
attention including arousal, alertness, orienting,
focused attention, internal/external distractibil-
ity, cognitive speed, sustained attention, vigilance,
working memory, attention span, shifting and
­ ividing attention, initiation, and the ability to direct
d
­attentional resources. In its present form it consists 
of 22 items, which are scored on a five-point scale
ranging from definitely true to definitely false based
on a clinician’s observations of an individual’s
attention-related behaviors during structured and
unconstrained interactions as well as general inter-
actions. It is a quantitative, observational measure of
disordered attention that may be used with clients
who are unable to complete traditional psychomet-
ric measures. Published research has suggested that
the MARS is composed of three factors (initiation,
restlessness/distractibility, and sustained attention)
within a unitary dimension of disordered attention.
Interrater agreement between occupational and
physical therapists is good, although the researchers
found that occupational therapists tended to score
individuals as slightly less attentive than physical
therapists. The researchers state this may be because
the therapists observe an individual doing differ-
ent types of tasks that require different amounts of
attention skills (Table 8-3).

Table 8-3 Items on the Revised Moss Attention Rating Scale and Their Associated Factors
Item* Factor

Is restless or fidgety when unoccupied RD

Sustains conversation without interjecting irrelevant or off-topic comments N/A
Persists at a task or conversation for several minutes without stopping or “drifting off” N/A
Stops performing a task when given something else to do or to think about N/A
Misses materials needed for tasks even though they are within sight and reach N/A
Performance is best early in the day or after a rest SC
Initiates communication with others IN
Fails to return to a task after an interruption occurs unless prompted to do so N/A
Looks toward people approaching N/A
Persists with an activity or response after being told to stop RD
Has no difficulty stopping one task or step in order to begin the next one N/A
Attends to nearby conversations rather than the current task or conversation RD
Tends not to initiate tasks that are within his or her capabilities IN
Speed or accuracy deteriorates over several minutes on a task, but improves after a break SC
Performance of comparable activities is inconsistent from 1 day to the next SC
Fails to notice situations affecting current performance (e.g., wheelchair hitting against table) N/A
Perseverates on previous topics of conversation or previous actions RD
Detects errors in own performance N/A
Initiates activity (whether appropriate or not) without cueing IN
Reacts to objects being directed toward him or her N/A
Performs better on tasks when directions are given slowly N/A
Begins to touch or manipulate nearby objects not related to task RD

From Hart T, Whyte J, Millis S, et al: Dimensions of disordered attention in traumatic brain injury: further validation of the Moss Attention Rating Scale,
Arch Phys Med Rehabil 87(5):647-55, 2006.
* Items are listed in the order in which they appeared in the 45-item research version.
IN, Initiation; N/A, not applicable (retained in the Moss Attention Rating Scale [MARS], but not included in any of the factor subscales); RD, restlessness/
distractibility; SC, sustained/consistent attention.
 Chapter 8  Managing Attention Deficits to Optimize Function 193

Ponsford and Kinsella41,42 developed the Rating
Scale of Attentional Behaviours. This 14-item scale
is rated by clinicians on a scale from 0 (not at all) to
4 (always) related to the frequency in which atten-
tion-based difficulties are noted during everyday
tasks. It includes a broad range of clinical behav-
iors such as slowness, distractibility, attention to
detail, alertness, selective attention, and sustained
­attention (Figure 8-1).
Broadbent and coworkers developed the Cog­
nitive Failures Questionnaire (CFQ) as a self-report
measure to assess the frequency of lapses of atten-
tion and cognition in everyday life.8 The CFQ con-
sists of 25 items that are scored by the client or
significant other. Both versions can be compared
to assess insight (see Chapter 4).23 The score is
based on the frequency of everyday mistakes and
ranges from 0 (never) to 4 (very often) (Figure 8-2).
Although not an exclusive assessment of attention,
it is consistently correlated with measures of atten-
tion,32 it is believed to be a measure of attentional
processing, and it has been used in the ­literature as

Figure 8-1  Rating Scale of Attentional Behaviour. (From Ponsford J, Kinsella G: The use of a rating scale of attentional behaviour,
Neuropsychological Rehabil 1[4]:241-257, 1991.)
194 cognitive and perceptual rehabilitation: Optimizing function

Figure 8-2  Cognitive Failures Questionnaire. (From Broadbent DE, Cooper PF, FitzGerald P, et al: The Cognitive Failures Questionnaire
[CFQ] and its correlates, Br J Clin Psychol 21:1-16, 1982.)

a measure of attention deficits.23 This being said, four-factor solution: memory, distractibility, blun-
the CFQ is clearly valuable to use for those with ders, and names. The first factor, memory, is made
other (or a combination of) cognitive impairments.  up of eight items and is related to memory errors
A recent factor analysis52 of the instrument reveals a or forgetfulness. The second factor, distractibility,
 Chapter 8  Managing Attention Deficits to Optimize Function 195
contains nine items and reflects the disturbance
of internally focused attention. The third factor,
blunders, is made up of seven items and is related
to social blunders. The fourth factor (forgetting
names) includes two items.
The Attention Rating and Monitoring Scale14
was developed to objectively document complaints
of attention difficulty that is common to those with
living with mild TBI. The scale includes 15 items
related to problems with concentration, mental
effort, and cognitive symptoms associated with
attentional difficulties. Examples include difficulty
concentrating in noisy or busy situations, becoming
very fatigued during activities in which you have to
pay attention, and so on. Rating is completed by the
participants while they reflect on how often they
have experienced each difficulty in their day-to-day  at minimizing cognitive demands and reducing
functioning over the past 2 weeks. A five-point scale
of 1 (never) to 5 (always) results in a score that
ranges from 15 to 75.
Interventions
Similar to interventions for those living with
other cognitive or perceptual deficits, impair-
ments of attention can be grouped into two major
categories:
1. Interventions focused on improving or reme-
diating the underlying attention deficit or
direct training of the components of atten-
tion. Interventions do not usually include
functional tasks. Instead they include labora-
tory-type tasks, pen-and-paper training, or
computer-based tasks. For example, a person
being treated listens to a number string and
is asked to press a buzzer whenever a particu-
lar number is heard. The tasks are chosen to
stimulate various components of attention.33   sion being “there is some indication that train-
A positive outcome is considered when the per-
son being trained improves on impairment-
based tests of attention such as trail making,
serial addition tasks, and so on. As improve-
ments on these tests are noted, a shift to the
use of functional activities is made to attempt
generalization of skills. Most studies related to
attention impairments focus on impairment-
based measures, but as described earlier, it is
questionable if these interventions translate to
meaningful improvement from the perspective
of everyday function or quality of life.
2. Interventions focused on improving living
skills and increasing participation despite the
­presence of the underlying attention deficits.
These interventions include training of a speci­
fic living skills integrating behavioral and learn-
ing strategies,38 and strategy training including
metacognitive strategies, compensations, and
modifying the environment to support func-
tion. Behavioral strategies are used to circum-
vent impaired attention functions in daily life.
Strategies include development of and compli-
ance with daily routines, increased reliance on
external information storage systems (such as
agendas and organizers), the use of note taking
or tape recording to record lengthy informa-
tion exchanges (such as lectures), and delin-
eating tasks to specific components to reduce
complexity.18 Overall, the strategies are aimed
the stress experienced by the person confronted
with impaired cognitive functioning.18 A posi-
tive outcome is considered when improvements
related to the performance living skills are noted
or reported.
Recent critical reviews have reached various
conclusions related to the effectiveness of rehabili-
tation techniques for attention deficits, but the gen-
eral trend is that practice of specific functional tasks
limited by attention impairments does improve
performance of these meaningful activities, but
there is less evidence to support the general use
of retraining underlying attention deficits. Recent
conclusions from evidence-based reviews include
the following:
• “Two trials were identified with 56 partici-
pants. The two trials showed a benefit of train-
ing on measures of alertness and sustained
attention. Only one trial included a measure
of functional independence and this showed
no significant effect of training.”29 The conclu-
ing improves alertness and sustained attention
but no evidence to support or refute the use of
cognitive rehabilitation for attention deficits
to improve functional independence following
stroke.”29
• “Specific-skills training significantly improved
performance of tasks requiring attention but
that the cognitive-retraining methods included
in the meta-analysis did not significantly affect
outcomes. These findings demonstrate that
acquired deficits of attention are treatable using
specific-skills training.”38
• “Rather than train underlying processes, another
approach that shows promising results in a
196 cognitive and perceptual rehabilitation: Optimizing function
few small studies is training clients on specific
functional skills, such as driving or vocational
duties. Finally, modifications to the environ-
ment, implementation of strategies, provision of
emotional support, and introduction of external
supports/aids are important parts of a rehabili-
tation program, especially as the client returns to
the home environment.”33
• “During the acute period of recovery and inpa-
tient rehabilitation, evidence is insufficient
to distinguish the effects of specific attention
training from spontaneous recovery or more
general cognitive interventions for clients with
moderate-to-severe TBI and stroke. Therefore,
specific interventions for attention during the
period of acute recovery are not recommended.
On the contrary, the availability of class I evi-
dence for attention training in the post-acute
phase after TBI is compatible with a grade A
recommendation.”10
• “The committee recommends that strategy train-
ing for attention deficits exhibited by subjects
with TBI be considered as a practice standard
during the postacute period of rehabilitation.
Results of studies in this area suggest greater
benefits on complex tasks requiring the regula-
tion of attention, rather than on basic aspects
of attention (e.g., reaction time or vigilance).
These results are consistent with the emphasis
on strategy training to compensate for attention
deficits in functional situations. There is insuf-
ficient evidence to support the use of specific
interventions for attention deficits during acute
rehabilitation.”15
Retraining Underlying Attention Deficits
Interventions focused on improving the underly-
ing attention deficits rely on repeated stimulation
of attentional systems via hierarchic attention
exercises.50 Using this method, attention is divided
into components that are targeted discretely. At
present the most commonly used intervention
is Attention Process Training (APT).50 APT is an
individualized application program of attentional
exercises of varying complexity in sustained,
selective, alternating, and divided attention using
hierarchically organized cognitive exercises such
as alphabetizing words in an orally presented
­sentence, detecting targets with distracter noises,
and so on. These exercises resemble neuropsy-
chological tests. They are completed with ­ self-
instruction training that is applied in situations
of daily life. A second version, APT-II, is available
to treat impairments in attention processing in
people with relatively mild cognitive disturbance,
such as postconcussion syndrome. APT-II con-
tains programs that address difficulties with sus-
tained attention, slowed information processing,
distractibility, shifting attention between tasks,
and paying attention to more then one source of
information at a time.35
Sohlberg and associates51 tested the effec-
tiveness of APT on adults with stable acquired
brain injuries exhibiting attention and working
memory impairments using a crossover design.
Condition A consisted of APT and condition B
consisted of therapeutic support including brain
injury education, supportive listening, and relax-
ation training. Outcomes were measured using
structured coded interviews and neuropsycho-
logical tests to determine the effect of the inter-
vention on daily life tasks and performance on
attentional networks involving vigilance, orient-
ing, and executive function. The authors found
the following:
• Most clients made improvements.
• Some of the gains were a result of practice from
repetitive administration of the tests.
• The type of intervention influenced the results.
The brain injury education seemed to be most
effective in improving self-reports of psycho-
social function, whereas APT influenced self-
reports of cognitive function and had a stronger
influence on performance of executive attention
tasks.
• Vigilance and orienting networks showed little
specific improvement because of therapy.
Although this study did not use a specific mea-
sure of functional performance (i.e., activities of
daily living [ADL], vocational skills, etc.), coded
structured interviews revealed positive perceptions
related to improved daily function from ­participants
and caretakers after APT (Box 8-1).
Park and Colleagues39 also evaluated the effec-
tiveness of APT and found that performance of
those with traumatic brain injuries improved after
training on the primary outcome measures (Paced
Auditory Serial Addition Task, Consonant Trigrams,
Beck Depression Inventory) but did not improve
significantly more than the performance of a con-
trol group who were given the outcome measures
twice, but no training. They concluded that direct
training does not improve the integrity of damaged
attention functions, but does result in learning of
­specific cognitive skills.
 Chapter 8  Managing Attention Deficits to Optimize Function 197
Box 8-1 Positive Perceptions Related to Improved Daily Function After Attention
Process Training
Examples of changes perceived to be related to treatment
given during structured interviews.
Comments following attention process train-
ing from participant interviews:
• I can remember phone numbers better (four
individuals).
• I can watch a whole movie.
• I read more (two individuals).
• School is a lot easier because I can read better and
pay attention more.
• I check my memory log more often.
• When I type up the poems I have written, I don’t
have to look back at the page for each word.
• I remember my appointments better.
• I am less rigid and ritualized about everything and
I don’t have to do stuff in the same way, like when
I clean the barn I can insert different steps and don’t
double-check everything.
From Sohlberg MM, McLaughlin KA, Pavese A, et al: Evaluation of attention process training and brain injury education in persons with acquired brain injury,
J Clin Exper Neuropsychol 22(5):656-676, 2000.
A recent study by Boman and coworkers7 exam-
ined the efficacy of cognitive rehabilitation in the
client’s home or vocational environment using a
pre/post follow-up design. The participant received
individual attention training with APT, training
for generalization for everyday activities, and edu-
cation in compensatory strategies for self-selected
cognitive problems. Treatment effects were evalu-
ated with neuropsychological and occupational
therapy instruments before and after the training
and after 3 months on impairment, activity, and
participation levels. The results indicated a positive
effect on some measures on impairment level, but
no differences on activity or participation levels at
follow-up.
In summary, interventions focused on improv-
ing the underlying attention deficit have been found
to reduce impairments. Unfortunately, the ability to
generalize these effects to more meaningful activities
has limited research support and warrants further
investigation related to the effects on activity limita-
tions and participation restrictions if they are to be
included in intervention plans focused on improv-
ing performance in daily activities. When discuss-
ing impairment-based approaches to the retraining
of attention Fasotti and associates19 summarized
that “the underlying ideas are that the target process
can be improved by repetitive stimulation [with a
so-called mental muscle building approach] and
Comments following attention process train-
ing from significant other interviews:
• She can hold on to a conversation better.
• She remembers more of her appointments on her own.
• Her reading is better.
• He is reading more.
Comments following placebo intervention
from participant interviews:
• I check my personal scheduler and e-mail more often.
• I check my calendar.
• I know more where I am going when I leave my place.
• I remember my appointments.
• I remember to put appointments in my book.
• Getting up in the morning feels easier.
Comments following placebo intervention
from significant other interviews:
• He remembers where he was sitting.
that this improvement might generalize to several
related skills in everyday life. Given the amount of
remedial programmess based on this approach and
the modest results obtained, especially with regards
to generalisation, both ideas appear to be contro-
versial.” Sohlberg and colleagues49 reviewed pub-
lished research related to direct attention training
and have developed practice guidelines (Table 8-4). 
From the perspective of improving everyday per-
formance, other interventions such as specific
functional skill retraining and strategy training
approaches hold promise.
Retraining Specific Functional Skills
Several published studies examine whether perfor-
mance of functional skills improves after training.
Outcomes are related to functional activities that
are presumed to require various attentional skills to
be successful.
Carter and coworkers11 examined the cognitive
skills and ADL performance of stroke survivors
before and after an ADL retraining and cognitive
skills remediation program (pen-and-paper train-
ing, auditory attention activities, functional per-
ceptual activities) administered by occupational
therapists. In addition to significant improvements
in both ADL (bed activities, transfers, locomotion,
dressing, hygiene, and feeding) and cognitive skills,
198 cognitive and perceptual rehabilitation: Optimizing function

Table 8-4 Guidelines for Direct Attention Training

From Sohlberg MM, Avery J, Kennedy M, et al: Practice guidelines for direct attention training, J Med Speech-Language Pathol 11(3):xix-xxxix, 2003.
Note: Class I, randomized controlled trials; Class II, prospective, nonrandomized controls or a clinical series with controls.
 Chapter 8  Managing Attention Deficits to Optimize Function 199
the authors found that the best correlate of clients’
ADL performance at discharge was performance on
an auditory attention task. Because subjects received
both ADL training and cognitive skill remediation
simultaneously and there was no control group, it is
difficult to decide which intervention was the main
therapeutic factor. Nonetheless, this study docu-
ments that specific functional skills can in fact be
improved after a neurologic insult that results in
cognitive impairment including impairment of
attention.
Kewman and associates25 examined an out-
come for brain-injured individuals focused on
improving driving skills. The intervention con-
sisted of a set of exercises (visuomotor tracking,
divided attention, successive increases in difficulty
level, performance feedback, and social reinforce-
ment) simulating specific cognitive and behav-
ioral aspects of motor vehicle operation using an
electric-powered scooter. Specific functional skill
training included driving the electric scooter on
various courses (figure-eight, straightaway, ser-
pentine, S-curves) and dual tasks performed while
driving such as calling out the name of signs.
Those receiving the experimental intervention
were compared with closed head–injured con-
trols of the same average age who received expe-
rience with the electric vehicle but no training
exercises, and with normal high-school students
who had drivers’ licenses and were trained in some
of the exercises such as divided attention. At the
conclusion of training, experimental subjects
showed improvements on the specific exercises,
and training resulted in improved performance on
tests of on-the-road driving when compared with
closed head–injured controls, who did not show
i­mprovement in their driving performance.
Wilson and Robertson59 published a case study
focused on training a male with a head injury to
reduce the frequency of attention slips during
reading before he attempted to return to work.
The home-based training consisted of reading a
novel at different times of the day. The authors
hypothesized that attention may have been dis-
rupted from the emotional and motivational
consequences of rereading words and sentences
multiple times. Rereading was thought to be
not only disruptive but also discouraging and
may have resulted in his using up limited work-
ing memory capacity by thoughts related to poor
performance. They further hypothesized that
the increased load caused by his secondary reac-
tions to poor performance could be lessened by
increasing his confidence and giving a sense of
control over the process of reading the material,
thereby resulting in improved attention because
of reduced secondary load on this limited capac-
ity system. Specific training methods included the
following:
• Simple behavioral shaping strategies aimed at
increasing the length of time that he could con-
centrate on reading without attentional slips.
This process started with brief relaxation and
deep-breathing training followed by the sub-
ject saying to himself, “Based on my past record 
I am pretty sure I can read for ___ seconds with-
out an attention slip.” If a slip occurred he was
instructed to forget about it and keep reading.
• To reproduce a typical work session that would
include distractions as well as to further increase
memory, a procedure termed “inoculation
against distraction” was used. The focus was
on maintaining attention in a situation that
included competing stimuli. The subject prac-
ticed reading in the presence of a background
speech-based radio program or a background
of audiotaped poetry. Attention slips were dealt
with by focusing on a wall and counting focused
breathing for two breaths before returning to
reading.
• Goal setting was used such as “aiming for no
more than two attention slips in a 3-minute
period” to track improvement.
Training initially led to his being able to read
a novel for 5 minutes without a slip when there
was no distraction. Further training against back-
ground noise led to a statistically significant reduc-
tion in frequency of attention slips while reading a
­technical textbook.
Glang and colleagues22 describes three case
studies in which direct instruction techniques were
used to teach students with brain injuries who par-
ticipated in a 6-week tutoring program. The sub-
jects were three children with closed head injuries
who exhibited significant learning problems and
multiple cognitive deficits including attention
deficits. Direct instruction is a behavioral tech-
nique that uses task analysis, modeling, shaping,
reinforcement or appropriate responses, and con-
tinuous assessment to document learning. It also
includes general case problem-solving strategies to
promote generalization, keeping instructions clear
and consistent, providing immediate practice with
difficult tasks, practice to ensure mastery of each
step of learning, and a review of skills to integrate
new skills with those previously learned. All three
200 cognitive and perceptual rehabilitation: Optimizing function
students made substantial academic progress as
demonstrated by data collected in their targeted
instructional areas (reading, language, math, and
keyboarding). The authors noted that gains were
seen in both discrete and more complex skills, and
some of the gains may have represented new learn-
ing. Also noted was that the aggressive outbursts of
one student were decreased substantially through
use of a self-monitoring technique in the context
of academic instruction. They concluded that the
results from these case studies suggest that direct
instruction is a promising approach for teaching
both academic and behavioral skills to students
with TBI.
In their meta-analysis of attention rehabilitation
after an acquired brain injury, Park and Ingles38
examined the two approaches to treat attention
­deficits after brain damage discussed above:
1. Directly retraining the damaged cognitive func-
tion or direct cognitive retraining. This approach
is used under the assumption that practice of
carefully selected exercises promotes recovery of
damaged neural circuits and restores function
in the impaired attentional processes themselves
with further assumption that the tasks mediated
by those circuits are then performed in a way that
is similar to non–brain-damaged individuals.
Intervention is then based on a series of repet-
itive exercises or drills in which they respond
to visual or auditory stimuli. This intervention
has received the most attention in the literature
related to interventions for those with attention
impairments.
2. Attempts to assist people with attention deficits
by having them learn or relearn how to perform
specific skills of functional significance (i.e., spe-
cific skill training). The premise here is that
that through carefully structured practice of
a specific skill that is impaired as a result of
brain damage, it is possible for individuals to
compensate and develop alternative neuro-
psychological processes that rely on preserved
brain functions (i.e., individuals learn to per-
form the skill in a way that is different than
non–brain-damaged individuals). In terms of
intervention, attention is trained either con-
currently with or in the context of the specific
skills. In addition, this approach applies behav-
ioral principles and an understanding of how
the attention impairment affects the various
skills.
Park and Ingles38 concluded that that specific-
skills training significantly improved ­ performance
of tasks requiring attention. In comparison,
c­ ognitive-retraining methods (i.e., those focused
on improving attention impairments out of con-
text) included in the meta-analysis did not signif-
icantly affect outcomes. Further analysis revealed
that overall performance improved for 69% of the
participants that received specific-skills training
(i.e., driving, ADL), whereas performance improved
in only 31% of those not trained. In terms of effect
size, the improvements in cognitive functions after
direct retraining were small, whereas the perfor-
mance improvements after specific-skills training
were medium or large. Their findings demonstrate
that acquired deficits of attention are treatable using
specific-skills training. The authors38 also proposed
clinical implications of their study, including the
following:
• Learning that occurs as a function of training is
specific and does not tend to generalize or trans-
fer to tasks that differ considerably from those
used in training. This specificity of improve-
ment was demonstrated in both the cognitive
retraining studies (i.e., large effects of practice
on the outcome tasks but no effects of training
when performance was assessed using pre-post
with control measures) and specific functional
skill retraining studies.
• Performance on a task after training will
improve to the extent that the processing oper-
ations required to complete that task overlap
with the processes engaged during training (i.e.,
performance will improve after training if the
training task is similar to the targeted outcome
measure).
• Many survivors of brain injury are impaired
when performing controlled cognitive pro-
cesses but are not when performing auto-
matic processes. As controlled processing is
heavily involved in the early stages of learn-
ing a skill and is less involved as a skill comes
to be performed more routinely with practice,
those rehabilittaion programs that reduce the
requirement for controlled processing dur-
ing learning may be the most effective. Park
and Ingles38 give the examples of reducing
the demands of controlled processing includ-
ing breaking down a complex functional skill
into simpler components, providing practice
on these components, and structuring training
in such a way that performance feedback can
be more easily interpreted. The authors rec-
ommend the technique of “shaping” as way to
train people with controlled processing deficits
 Chapter 8  Managing Attention Deficits to Optimize Function 201
because shaping links the difficulty of a task to
the person’s performance. As a result of using
the technique of shaping, the person may make
fewer errors and be able to interpret feedback
more easily.
• Rehabilitation procedures are to be based on a
set of learning principles.
Strategy Training
Fasotti and colleagues19 note that following severe
closed head injury, deficits in speed of informa-
tion processing are common resulting in a feeling
of “information overload” while performing daily
tasks. The authors tested an approach to manag-
ing slow information processing, time pressure
management (TPM). TPM uses alternative cogni-
tive strategies to support participation in real-life
tasks (cooking, conversation, etc.) while compen-
sating for delayed processing. The overall focus is
to teach people to give themselves enough time to
deal with life situations. Specific strategies used
to prevent or manage time pressure include the
following:
• Enhancing awareness of errors and deficient
performance
• Self-instruction training
• Optimizing planning and organization
• Rehearsing task requirements
• Modifying the task environment
• Using an overall strategy of “Let me give myself
enough time”
The specific interventions are based on memory,
attention, executive functioning, and environmen-
tal modification to either prevent or manage time
pressure (Table 8-5).
Table 8-5 The Cognitive Strategy Used in Time Pressure Management: Self-Instruction:
“Let me give myself enough time to do the task”
Questions to Be Asked
1.  Are there two or more things to be done at the same
time for which there is not enough time? If yes: go to
step 2, else just do the task.
2. Make a short plan of which things can be done before
the actual task begins.
3. Make an emergency plan describing what to do in case
of overwhelming time pressure.
4. Plan and emergency plan ready? Then use it regularly!
From Fasotti L, Kovacs F, Eling PATM, et al: Time pressure management as a compensatory strategy training after closed head injury, Neuropsychological
Rehabil 10(1):47-65, 2000.
The authors tested TPM via a randomized
trial (pretraining versus posttraining vs. follow-
up), examining those with severe closed head
injury. TPM training was compared with concen-
tration training in which verbal instruction was
the key element. Specific concentration strategies
included trying to focus, not getting distracted by
outside sounds and other information, not get-
ting distracted by irrelevant thoughts, and trying
to imagine things that are being said. The authors
found that whereas both treatments improved
task performance, TPM resulted in greater gains
than concentration training and seemed to gen-
eralize to other measures of speed and memory
function.
Engelberts and coworkers18 examined cognitive
rehabilitation strategies focused on attention train-
ing in those with epilepsy. Their study evaluated
the effectiveness of two commonly used methods
for attention deficits: the retraining method, aimed
at retraining impaired cognitive functions, and the
compensation method, aimed at teaching compen-
satory strategies while not considering neuronal
loss via a randomized controlled trial.
In the retraining method a computer task was
used. Clients were required to rehearse responses,
whereas task difficulty automatically increased with
improving client performance using a computer
task. The program was aimed at enhancing divided-
attention capacity in tasks increasing in complexity.
After each training session, feedback was given on
performance and progress over successive training
sessions. Using the compensation method, clients
were made aware of their attention and memory
failures in daily life. Subsequently, compensatory
rules were taught to compensate for these failures.
Main Objective
To recognize time pressure in the task at hand
To prevent as much time pressure as possible
Dealing with time pressure as quickly and effectively as possible
Urging the client to monitor himself or herself while using the
time pressure management strategy
202 cognitive and perceptual rehabilitation: Optimizing function
To generalize to everyday situations, daily home-
work exercises were given and then discussed with
the client in subsequent sessions.
Established and self-reported neuropsychologi-
cal outcomes and self-reported quality of life of
these groups were evaluated at pretraining, post-
training, and at a 6-month follow-up. The authors
found that neuropsychological outcomes related
to training, self-reported neuropsychological out-
comes, and quality of life at the 6-month follow-up
measurement point improved both in the retrain-
ing method group and the compensation method
group as compared with controls. The compensa-
tion method was more effective in improving self-
reported neuropsychological outcomes and quality
of life. The clients with active epilepsy benefited
more from both methods than did the seizure-free
clients.
Cicerone14 has published preliminary results
looking at the effectiveness of an intervention for
attentional deficits (“working attention”) after mild
traumatic brain injury. The intervention consisted
of the following:
• n-Back procedures: A series of verbal or non-
verbal stimuli is presented in a sequence while
the person must continually report the stimulus
occurring n number of stimuli previously. For
example, in the two-back condition, a series of
numbers is presented and the person must report
the digit that occurred two stimuli prior to the
current number. The procedure was ­carried out
using playing cards (Figure 8-3).
• Random generation of a self-generated response
prior to naming the relevant card in the n-back
task: For example, generating a random letter
triad prior to naming the card.
• Dual-task procedures: While performing the  a closed head injury. Specific complaints included
n-back task, the participants were involved in a
secondary task to be performed simultaneously
Figure 8-3  n-Back procedure. (From Cicerone KD: Remediation of “working attention” in mild traumatic brain injury, Brain Inj 16[3]:
185-195, 2002.)
(i.e., requiring further allocation of attentional
resources). Examples of secondary tasks included
shadowing audiotaped lectures and conversa-
tions, looking up numbers and entering them
into a database, and clerical tasks. Secondary
tasks were chosen based on real-life demands.
• The intervention emphasized the conscious
and deliberate use of strategies to effectively
allocate attentional resources and manage the
rate of information during task performance.
Techniques included verbal mediation, rehearsal,
anticipating task demands, and self-pacing
strategies.
• Self-monitoring effort during task performance.
The intervention was tested via a prospective
case-comparison design. Those treated were more
likely to exhibit clinically significant improve-
ment on measures of attention and reduction of
self-reported attentional difficulties in their daily
functioning. Cicerone14 concluded that the results
were “consistent with a strategy training model
of remediation, in which treatment benefits are
due to participants’ unproved ability to compen-
sate for residual deficits and adopt strategies for
more effective allocation of remaining attentional
resources.” He also highlights that “there was no
expectation that the client would derive any thera-
peutic benefit from being exposed to and practic-
ing these tasks. In fact, the therapeutic intervention
required intensive client-therapist interaction and
participation in activities beyond the specific tasks,
including cognitive self-monitoring, emotional
self-appraisal, and the imagined use of strategies in
real situations.”
Webster and Scott53 reported the case of H.D., a
24-year-old male construction worker, 2 years after
not being able to sit still, difficulty with tasks that
required extended times to perform, and ­ sexual
 Chapter 8  Managing Attention Deficits to Optimize Function 203
dysfunction secondary to intrusive nonsexual
thoughts. Based on testing, poor concentration and
attention were also causing memory impairments.
Treatment was based on a self-instruction program
to teach H.D. effective ways of preventing the dis-
ruption caused by both irrelevant thoughts and
overfocusing on initial elements of verbally pre-
sented material. Self-instruction statements were
used to prepare H.D. to listen and to ask for rep-
etition if his attention strayed. These included the
following:
• “To really concentrate, I must look at the person
speaking to me.”
• “I also must focus on what is being said, not on
other thoughts which may want to intrude.”
• “I must concentrate on what I am hearing at any
moment by repeating each word in my head as
the person speaks.”
• “Although it is not horrible if I lose track of con-
versation, I must tell the person to repeat the
information if I have not attended to it.”
In addition, he was taught to repeat to himself
subvocally. After he was able to paraphrase the state-
ments, paragraph recall tasks were used to teach
implementation of the strategies. Immediately after
treatment and at 18 months’ follow-up, he demon-
strated improved attention, resulting in increased
recall, increased sexual function, and improved job
performance.
Sohlberg and Mateer50 suggest the use of three
self-management strategies:
1. Orienting procedures: Encourage clients to con-
sciously monitor activities to avoid/control a
lapse in attention. Clients are taught to ask them-
selves orienting questions at various intervals
(possibly reminded by an alarm watch). These
include “What am I currently doing?” “What was
I doing before this?” and “What am I supposed
to do next?”
2. Pacing: Pacing is used to decrease task demands.
Scheduling uninterrupted work times is an
example. Sohlberg and Mateer give examples
such as include setting realistic expectations,
building in breaks, and self-monitoring fatigue
and attention.
3. Key ideas log: Clients are taught to quickly write
or tape record questions or ideas to address later
as to not interrupt the task at hand.
Strategy training is considered a practice stan-
dard for the postacute period of rehabilitation by the
American Congress of Rehabilitation Medicine.15
Intervention should focus on strategy training to
compensate for attention deficits in functional
situations. Box 8-2 and Figure 8-4 include further
­strategies to manage attention deficits.
The tables in Appendix 8-1 summarize evidence-
based interventions focused in decreasing activity
limitations and participation restrictions.
Lastly, from an intervention perspective, a true
team approach is encouraged, including team
members that can prescribe psychostimulants
to be used in conjunction with the procedures
described earlier. Via a randomized controlled
trial (N = 34) Whyte and colleagues56 found that
methylphenidate, at 0.3 mg/kg/dose, given twice
a day to individuals with attentional complaints
after moderate to severe traumatic brain injury,
seems to have clinically significant positive effects
on speed of processing, caregiver ratings of atten-
tion, and some aspects of on-task behavior in
naturalistic tasks. They also stated that further
research is needed to identify the optimal dose and
to extend these findings to less carefully selected
individuals.
Box 8-2 Strategies for Clinicians and
Caretakers
Avoid overstimulating/distracting environments.
Face away from visual distracters during tasks.
Wear earplugs.
Shop or go to restaurants at off-peak times.
Use filing systems to enhance organization.
Label cupboards and drawers.
Reduce clutter and visual distracters.
Use self-instruction strategies.
Use time pressure management strategies.
Teach self-pacing strategies.
Control the rate of incoming information.
Self-manage effort and emotional responses during tasks.
Teach monitoring or shared attentional resources when
multitasking.
Manage the home environment to decrease auditory
and visual stimuli. Keep radios and phones turned
off. Close doors and curtains. Keep surfaces, cabinets,
closets, and refrigerators organized and uncluttered.
Use daily checklists for work, self-care, and instrumental
activities of daily living.
Data from Cicerone KD: Remediation of “working attention” in mild
traumatic brain injury, Brain Inj 16(3):185-195, 2002; Fasotti L, Kovacs F,
Eling Paul ATM, et al: Time pressure management as a compensa-
tory strategy training after closed head injury, Neuropsychol Rehabil
10(1)47:-65, 2000; Michel JA, Mateer CA: Attention rehabilitation fol-
lowing stroke and traumatic brain injury, a review, Eura Medicophys
42(1):59-67, 2006; and Webster JS, Scott RR: The effects of self-
instructional training on attentional deficits following head injury,
Clin Neuropsychol 5(2):69-74, 1983.
204 cognitive and perceptual rehabilitation: Optimizing function

Figure 8-4  Patient handout: Attention strategies. (From Sohlberg MM, Mateer CA: Management of attention disorders. In Sohlberg MM,
Mateer CA, editors: Cognitive rehabilitation: an integrative neuropsychological approach, New York, 2001, Guilford Press.)

Review Questions References

1. How would decreased sustained, selective, and
divided attention affect a person’s ability to per-
form a meal preparation task?
2. How would you implement time pressure manage-
ment strategies for a college student who is having
academic difficulties secondary to a head injury?
3. Name and describe three proposed attentional
subsystems.
4. Name and describe three potentially useful
assessments for an adult with attention deficits
secondary to a traumatic brain injury.
1. Amos A: Remediating deficits of switching atten-
tion in patients with acquired brain injury, Brain Inj
16(5):407-413, 2002.
2. Anderson V, Fenwick T, Manly T, et al: Attentional
skills following traumatic brain injury in childhood:
a componential analysis, Brain Inj 12(11):937-949,
1998.
3. Árnadóttir G: The brain and behavior: assessing cor-
tical dysfunction through activities of daily living, 
St Louis, 1990, Mosby.
4. Árnadóttir G: Impact of neurobehavioral deficits on
activities of daily living. In Gillen G, Burkhardt A, 
 Chapter 8  Managing Attention Deficits to Optimize Function 205

editors: Stroke rehabilitation: a function-based
approach, ed 2, St Louis, 2004, Elsevier/Mosby.
5. Bate AJ, Mathias JL, Crawford JR: Performance on
the Test of Everyday Attention and standard tests of
attention following severe traumatic brain injury,
Clin Neuropsychol 15(3):405-422, 2001.
6. Blanc-Garin J: Patterns of recovery from hemiple-
gia following stroke, Neuropsychol Rehabil 4(4):  23. Hart T, Whyte J, Kim J, et al: Executive function and
359-385, 1994.
7. Boman IL, Lindstedt M, Hemmingsson H, et al:  tion deficits following traumatic brain injury, J Head
Cognitive training in home environment, Brain Inj   Trauma Rehabil 20(4):333-347, 2005.
18(10):985-995, 2004.
8. Broadbent DE, Cooper PF, FitzGerald P, et al: The
Cognitive Failures Questionnaire (CFQ) and its  validation of the Moss Attention Rating Scale, Arch
correlates, Bri J Clin Psychol 21:1-16, 1982.
9. Brooks N, McKinlay W, Symington C, et al: Return
to work within the first seven years of severe head
injury, Brain Inj 1(1):5-19, 1987.
10. Cappa SF, Benke T, Clarke S, et al: Task Force on
Cognitive Rehabilitation, European Federation of
Neurological Societies: EFNS guidelines on cogni-
tive rehabilitation: report of an EFNS task force, Eur
J Neurol 12(9):665-680, 2005.
11. Carter LT, Oliveira DO, Duponte J, et al: The relation-
ship of cognitive skills performance to activities of
daily living in stroke patients, Am J Occup Ther 42(7):  28. Lewin JS, Friedman L, Wu D, et al: Cortical localiza-
449-455, 1988.
12. Chan RC: Attentional deficits in patients with closed
head injury: a further study to the discriminative
validity of the test of everyday attention, Brain Inj
14(3):227-236, 2000.
13. Chan RC: Sustained attention in patients with mild trau-
matic brain injury, Clin Rehabil 19(2):188-193, 2005.
14. Cicerone KD: Remediation of “working attention” in
mild traumatic brain injury, Brain Inj 16(3):185-195,
2002.
15. Cicerone KD, Dahlberg C, Malec JF, et al: Evidence-
based cognitive rehabilitation: updated review of the
literature from 1998 through 2002, Arch Phys Med
Rehabil 86(8):1681-1692, 2005.
16. Cowan N: Attention and memory: an integrated
framework, New York, 1995, Oxford University
Press.
17. Dockree PM, Kelly SP, Roche RAP, et al: Behavioural
and physiological impairments of sustained atten-
tion after traumatic brain injury, Cogn Brain Res
20(3):403-414, 2004.
18. Engelberts NH, Klein M, Ader HJ, et al: The effec-
tiveness of cognitive rehabilitation for attention defi-
cits in focal seizures: a randomized controlled study,
Epilepsia 43(6):587-595, 2002.
19. Fasotti L, Kovacs F, Eling Paul ATM, et al: Time pres-
sure management as a compensatory strategy train-
ing after closed head injury, Neuropsychol Rehabil
10(1):47-65, 2000.
20. Fisher AG: Assessment of motor and process skills, vol. 1:
development, standardization, and administration man-
ual, ed 5, Fort Collins, Colo, 2003, Three Star Press.
21. Fisher AG: Assessment of motor and process skills, vol.
2: user manual, ed 5, Fort Collins, Colo, 2003, Three
Star Press.
22. Glang A, Singer G, Cooley E, et al: Tailoring direct
instruction techniques for use with elementary stu-
dents with brain injury, J Head Trauma Rehabil 7(4): 
93-108, 1992.
self-awareness of “real-world” behavior and atten-
24. Hart T, Whyte J, Millis S, et al: Dimensions of dis-
ordered attention in traumatic brain injury: further
Phys Med Rehabil 87(5):647-655, 2006.
25. Kewman DG, Seigerman C, Kintner H, et al: Simu­
lation training of psychomotor skills: teaching the
brain-injured to drive, Rehabil Psychol 30(1):11-27,
1985.
26. Kingstone A, Smilek D, Ristic J, et al: Attention,
researchers! It is time to take a look at the real world,
Curr Direc Psychol Sci 12(5):176-180, 2003.
27. Kinsella GJ: Assessment of attention following trau-
matic brain injury: a review, Neuropsychol Rehabil
8(3):351-375, 1998.
tion of human sustained attention: detection with
functional MR using a visual vigilance paradigm, 
J Comput Assist Tomogr 20(5):695-701, 1996.
29. Lincoln NB, Majid MJ, Weyman N: Cognitive reha-
bilitation for attention deficits following stroke,
Cochrane Libr 4:CD002842, 2006.
30. Manly T, Ward S, Robertson IH: The rehabilitation of
attention. In Eslinger PJ, editor: Neuropsychological
interventions: emerging treatment and management
models for neuropsychological impairments, New York,
2000, Guilford Press.
31. McAvinue L, O’Keeffe F, McMackin D, et al: Impaired
sustained attention and error awareness in traumatic
brain injury: implications for insight, Neuropsychol
Rehabil 15(5):569-587, 2005.
32. Meiran N, Israeli A, Levi H, et al: Individual ­differences
in self reported cognitive failures: the attention
hypothesis revisited, Pers Individ Dif 17(6):727-739,
1994.
33. Michel JA, Mateer CA: Attention rehabilitation fol-
lowing stroke and traumatic brain injury, a review,
Eura Medicophys 42(1):59-67, 2006.
34. Mirsky AF, Anthony BJ, Duncan CC, et al: Analysis
of the elements of attention: a neuropsychological
approach, Neuropsychol Rev 2(2):109-145, 1991.
35. Murray LL, Keeton RJ, Karcher L: Treating atten-
tion in mild aphasia: evaluation of attention process
training-II, J Commun Disord 39(1):37-61, 2006.
36. Nobre AC, Sebestyen GN, Gitelman DR, et al: 
Functional localization of the ­system for visuospatial
­attention using positron emission tomography, Brain
120(Pt 3):515-533, 1997.
206 cognitive and perceptual rehabilitation: Optimizing function
37. Pardo JV, Fox PT, Raichle ME: Localization of a human
system for sustained attention by positron emission
tomography, Nature 349(6304):61-64, 1991.
38. Park NW, Ingles JL: Effectiveness of attention reha-
bilitation after an acquired brain injury: a meta-anal-
ysis, Neuropsychology 15(2):199-210, 2001.
39. Park NW, Proulx G, Towers WM: Evaluation of the
attention process training programme, Neuropsychol
Rehabil 9(2):135-154, 1999.
40. Penner IK, Kappos L: Retraining attention in MS,  nitive failures questionnaire: evidence for dimen-
J Neurol Sci 245(1-2):147-151, 2006.
41. Ponsford JL, Kinsella G: Evaluation of a remedial pro-
gramme for attentional deficits following closed-head
injury, J Clin Exp Neuropsychol 10(6):693-708, 1988.
42. Ponsford J, Kinsella G: The use of a rating scale of
attentional behaviour, Neuropsychol Rehabil 1(4):241-
257, 1991.
43. Posner MI, Peterson SE: The attention system of the
human brain, Annu Rev Neurosci 13:25-42, 1990.
44. Ries M, Marks W: Selective attention deficits follow-
ing severe closed head injury: the role of inhibitory
processes, Neuropsychol 19(4):476-483, 2005.
45. Robertson IH, Ridgeway V, Greenfield E, et al: Motor
recovery after stroke depends on intact sustained
attention: a 2-year follow-up study, Neuropsychol
11(2):290-295, 1997.
46. Robertson IH, Ward T, Ridgeway V, Nimmo-Smith
I: The structure of normal human attention: the
Test of Everyday Attention, J Clin Exp Neuropsychol
2(6):525-534, 1996.
47. Robertson IH, Ward T, Ridgeway V, et al: Test of Everyday
Attention. In Crawford JR, Sommerville J, Robertson
IH, editors: Assessing the reliability and abnormality of
subtest differences on the Test of Everyday Attention,
Bri J Clin Psychol 36:609-617, 1997.
48. Schulz D, Kopp B, Kunkel A, et al: Cognition in the
early stage of multiple sclerosis, J Neurol 253(8):  60. Wolf SL, Winstein CJ, Miller JP, et al: Effect of
1002-1010, 2006.
49. Sohlberg MM, Avery J, Kennedy M, et al: Practice
guidelines for direct attention training, J Med Speech
Lang Pathol 11(3):xix-xxxix, 2003.
50. Sohlberg MM, Mateer CA: Management of atten-
tion disorders. In Sohlberg MM, Mateer CA, editors:
Cognitive rehabilitation: an integrative neuropsycho-
logical approach, New York, 2001, Guilford Press.
51. Sohlberg MM, McLaughlin KA, Pavese A, et al:
Evaluation of attention process training and brain
injury education in persons with acquired brain
injury, J Clin Exp Neuropsychol 22(5):656-676, 2000.
52. Wallace JC: Confirmatory factor analysis of the cog-
sionality and construct validity, Pers Individ Dif
37(2):307-324, 2004.
53. Webster JS, Scott RR: The effects of self-instructional
training on attentional deficits following head injury,
Clin Neuropsychol 5(2):69-74, 1983.
54. Whyte J: Attention and arousal: basic science aspects,
Arch Phys Med Rehabil 73(10):940-949, 1992.
55. Whyte J, Hart T, Bode RK, et al: The Moss Attention
Rating Scale for traumatic brain injury: initial psy-
chometric assessment, Arch Phys Med Rehabil
84(2):268-276, 2003.
56. Whyte J, Hart T, Vaccaro M, et al: Effects of methyl-
phenidate on attention deficits after traumatic brain
injury: a multidimensional, randomized, controlled
trial, Am J Phys Med Rehabil 83(6):401-420, 2004.
57. Whyte J, Polansky M, Fleming M, et al: Sustained
arousal and attention after traumatic brain injury,
Neuropsychologia. 33(7):797-813, 1995.
58. Whyte J, Schuster K, Polansky M, et al: Frequency
and duration of inattentive behavior after traumatic
brain injury: effects of distraction, task, and practice,
J Clin Exp Neuropsychol 6(1):1-11, 2000.
59. Wilson C, Robertson IH: A home-based interven-
tion for attentional slips during reading following
head injury: a single case study, Neuropsychol Rehabil
2(3):193-205, 1992.
 
constraint-induced movement therapy on upper
extremity function 3 to 9 months after stroke: the
EXCITE randomized clinical trial, JAMA 296(17): 
2095-2104, 2006.
 Appendix 8-1
Evidence-Based Interventions Focused on Improving
Daily Function and Participation for Those with
Attention Impairments

Table 1 Summary of Research

Participant
Study Intervention Description Characteristics n Age

Sohlberg et al, Attention process training Adults with stable brain 14 Group 1: M = 33.1
200051 injury Group 2: M = 38.1
Boman et al, Attention process training Adults with mild to 10 M = 47.5
20047 and compensatory training moderate brain injury
Carter et al, Retraining of activities Adults with a stroke 21 M = 68.6 (SD = 14.93)
198811 of daily living (ADL) diagnosis and various
in conjunction with cognitive impairments
cognitive skills retraining including attention deficits
Kewman et al, Exercises simulating specific Those with brain injury 35 M = 24.2
198525 cognitive and behavioral
aspects of motor vehicle
operation, using an
electric-powered vehicle
Wilson and Attention training to improve A male with a head injury 1 “Early 30s”
Robertson, reading and resultant attention
199259 impairments
Glang et al, Direct instruction techniques Children with brain injury 3 Ages 6, 8, 10
199222 during school-based
activities
Park and Ingles, Meta-analysis of attention Adults with acquired brain 30 studies TBI: M = 29.5, (SD =
200138 rehabilitation injury, stroke, and mixed with a total 4.7); stroke: M = 54.3,
etiologies of 359 (SD = 17.9); mixed:
participants M = 38.4, (SD = 15.5)
Fasotti et al, Time pressure management Adults with severe head 22 M = 26.1 (SD = 8.1)
200019 injury (chronic and
subacute) and slowed
information processing
as measured by three
tests of attention
Engelberts et al, Attention retraining method Adults with epilepsy 50 Retraining: M = 40.7
200218 versus the compensation receiving carbamazepine (SD = 8.7)
method monotherapy Compensation:
M = 41.6 (SD = 11.1)
Cicerone, 200214 Strategy training for Adults with attention 4 M = 31
remediating working deficits secondary to mild
attention traumatic brain injury
Webster and Self-instruction training to Adult with chronic head 1 24
Scott, 198353 overcome attention deficits injury

M, Mean, SD, standard deviation; TBI, traumatic brain injury.

207
208 cognitive and perceptual rehabilitation: Optimizing function

Table 2 Summary of Outcomes

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

Sohlberg Crossover design Self-reported + p < 0.05 Activity limitations

et al, 200051 changes in and impairments
attention,
memory, and
everyday
function
Paced Auditory + p < 0.05 Impairment
Serial Addition
Test
Neuropsychological + (except p < 0.05 Impairment
measures of high memory for
level executive letters)
attention
networks
Attention — — Impairment
Questionnaire
Brock Adaptive — — Impairment
Function
Questionnaire
Dysexecutive — — Impairment
Questionnaire
Boman et al, Pre-post/follow-up Attention process + p < 0.05 Impairment
20047 design training test
Digit Span Test — — Impairment
Claeson-Dahl — — Impairment
Memory Test
Rivermead + (at follow-up) p < 0.05 Impairment
Behavioral
Memory Test
Assessment of — — Activity limitations
Motor and
Process Skills
European — — Participation
Brain Injury restrictions
Questionnaire
Carter et al, Pretest/posttest Kenny Self-Care + p < 0.001 Activity limitations
198811 Evaluation
Cognitive skills + p < 0.001 Impairments
evaluation
Kewman et al, Nonrandomized On the road driving + Range of skills Activity limitations
198525 controlled trial skills improved from
p < 0.05 to
p < 0.001
Wilson and Single case study Attentional slips + p ≤ 0.025 Activity limitations
Robertson, while reading
199259
Glang et al, Case series Improved academic + N/A Activity limitations
199222 skills
 Chapter 8  Managing Attention Deficits to Optimize Function 209

Table 2 Summary of Outcomes—Cont’d

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

Park and Ingles, Meta-analysis Impairment + NS Impairment

200138 measures of
attention
Measures of specific + Significant Activity limitations
functional skills (95% CI)
Fasotti et al, Randomized Use of self- + p < 0.05 Activity limitations
200019 controlled trial management
strategies to
support task
performance
Measures of + p < 0.05 Impairment
memory
Measures of + p < 0.05 Impairment
attention
Engelberts et al, Randomized Divided Attention + p < 0.002 Impairment
200218 controlled trial Task
Auditory Verbal + p < 0.009 Impairment
Memory Test
Stroop Color-Word — NS Impairment
Test
Cognitive Failures + p < 0.007 Impairment/Activity
Questionnaire limitations
Short-Form Health + p < 0.027 Participation/quality
Survey (SF-36) of life
Cicerone, 200214 Case comparison Impairment-based + p < 0.0048 Impairment
design measures of
attention
Attention Rating + p < 0.021 Impairment/Activity
and Monitoring limitations
Scale
Webster and Casestudy Story Memory Test + N/A Impairment
Scott, 198353 Verbal memory + N/A Impairment
Self-report of sexual + N/A Activity limitations
functioning
Reading + N/A Activity limitations
Job performance + N/A Activity limitations

*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;
CI, confidence interval; N/A, not applicable; NS, not significant.
 Chapter 9
Managing Memory Deficits to Optimize Function

Key Terms
Anterograde Amnesia Long-term Memory Semantic Memory
Episodic Memory Metamemory Short-term Memory
Explicit Memory Prospective Memory Working Memory
Implicit Memory Retrograde Amnesia

L
Leea
arrn
n ii n
ngg O
Obb jj e
ecct
t ii v
vee ss
At the end of this chapter, readers will be able to: 3. Be able to use at least three standardized assess-
1. Define and discuss the various types of memory ments related to memory loss.
impairments. 4. Implement at least five intervention strategies focused
2. Understand how everyday living is affected if vari- on decreasing activity limitations and participation
ous memory impairments are present. restrictions for those living with memory loss.

“Memory impairment following brain injury is regarded as one of the most debilitating and handicapping
of cognitive deficits, frequently preventing return to work and independent living. Among the adverse effects are
limited autonomy, lack of social competence, and difficulties performing activities of daily life.”51

M emory impairments are one of the most

common consequences of brain injury. The
severity and type of memory loss vary based on the
structures affected. For example, damage to the hip-
pocampus may result in an inability to remember
knowledge and facts, and frontal lobe damage may
affect a person’s ability to manipulate information
that is being “kept in mind” such as performing
­calculations while balancing a checkbook.
Human memory is composed of multiple and
distinct systems65 that are required to support
daily activities and participate in the community.
Examples include remembering your significant
other’s birthday, remembering to take your medi-
cations, remembering to feed the dog, remember-
ing how to type, remembering events that occurred
during a vacation, and so on. Even this “simple”
list of memory tasks requires intact functioning of
multiple memory systems and includes knowledge
of facts and events, procedures, and remembering
future intentions. Clearly, memory serves as a key
cognitive support to facilitate independent living.

210
 Chapter 9 managing memory deficits to optimize function 211

The steps or stages of memory have been well
documented.5,63 The flow of these stages follows
(Table 9-1):
Attention → Encoding → Storage → Retrieval
The first critical aspect is to select the informa-
tion to which you will attend (see Chapter 8). This
is followed by coding or registering the informa-
tion for storage (where it can be practiced and pro-
cessed more deeply). When needed at another time,
information is retrieved by using a search strategy
consistent with how the information was coded
and stored. Two methods of retrieval include recall
(e.g., the person needs to remember the answer to
the question “Who is the president of the United
States?”) and recognition (e.g., “Is the president of
the United States Clinton, Gore, or Bush?”).
A classic model of human memory discusses
that information flows from the environment via
brief sensory memories (supported by perceptual
processing systems) into Short-term and limited-
capacity storage (Short-term memory) and even-
tually into permanent storage (i.e., Long-term
memory). Although still discussed, this model con-
tinues to be analyzed and critiqued.5 Sohlberg and
Matteer64 discuss different taxonomies related to
memory (Table 9-2):
• Time-dependent forms of memory such as
Short- and Long-term memory.
• Content-dependent forms of memory. Based on
the type of information being stored in Long-
term memory such as facts (semantic memory),
events (episodic memory), and procedures (pro-
cedural memory).
• Everyday memory such as prospective memory
(remembering future intentions) and metamem-
ory or the level of awareness related to memory
functioning.
Definitions
The terms working memory and Short-term memory
have been included in the literature for many years.
Some authors use these terms interchangeably,
whereas others discuss these as distinct but related
concepts. It is commonly discussed that Short-term
memory stores a limited amount of information for
a limited amount of time. In terms of the amount
of storage, the common thought has classically been
that a typical person has capacity to store seven
items plus or minus two,49 although this quantifi-
cation has been questioned. The unit of measure-
ment for Short-term memory capacity is called a
chunk, which can be a single digit or letter, a word,

Table 9-1 Stages of Memory

Stage of Memory Description Neuroanatomic Area of Function

Attention The processes that allow a person to gain access Brainstem

to and use incoming information. Inclusive Thalamic structures
of alertness, arousal, and various attention Frontal lobes
processes such as selective attention.
Encoding How memories are formed. An initial stage of Dorsomedial thalamus
memory that analyzes the material to be Frontal lobes
remembered (visual vs. verbal characteristics Language system (e.g., Wernicke’s area)
of information). Correct analysis of Visual system (e.g., visual association areas)
information is required for proper storage of
the information.
Storage How memories are retained Hippocampus bilateral medial temporal lobes
Transfer of a transient memory to a form
or location in the brain for permanent
retention/access
Retrieval How memories are recalled Frontal lobe
Searching for or activating existing memory
traces

Data from Sohlberg MM, Mateer CA: Memory theory applied to intervention. In Sohlberg MM, Mateer CA, editors: Cognitive rehabilitation: an
integrative neuropsychological approach, New York, 2001, Guilford Press.
212 cognitive and perceptual rehabilitation: Optimizing function
Table 9-2 Terminology Related to Memory Impairments
Term
Anterograde amnesia
Retrograde amnesia
Short-term memory
Working memory
Long-term memory (LTM)
Nondeclarative/implicit or
procedural memory
Declarative/explicit memory
Episodic memory
Semantic memory
Explicit memory
Definition
A deficit in new learning. An inability
to recall information learned after
acquired brain damage. An inability
to form new memories after brain
damage occurs.
Difficulty recalling memories formed and
stored prior to the disease onset. May be
worse for recent events as opposed to
substantially older memories.
Storage of limited information for a limited
amount of time.
Related to short-term memory and refers
to actively manipulating information
that is in short-term storage via
rehearsals.
Relatively permanent storing of information
with unlimited capacity.
Knowing how to perform a skill, retaining
previously learned skills and learning
new skills. Form of LTM.
Knowing that something was learned,
verbal retrieval of a knowledge base
such as facts and remembering
everyday events. Includes episodic and
semantic information. Form of LTM (see
following).
Autobiographic memory for contextually
specific events. Personally experienced
events. Form of declarative LTM.
Knowledge of the general world, facts,
linguistic skill, and vocabulary. (Note:
may be spared after injury.) Form of
declarative LTM.
Explicit memories consist of memories
from events that have occurred in the
external world. Information stored in
explicit memory is about a specific event
that happened at a specific time and place.
Examples of Everyday Behaviors
Not able to recall staff names, easily gets
lost secondary to topographical
disorientation, not able to recall
what occurred in therapy this morning,
difficulty learning adaptive strategies to
compensate for memory loss.
Inability to remember autobiographic
information (address, social security
number, birth order), not able to
remember historical events (war,
presidential elections, scientific
breakthroughs) and/or personally
experienced events (weddings,
vacations).
Difficulty remembering instructions related
to the use of adaptive equipment, not
able to remember the names of someone
just introduced at a dinner party, not
able to remember “today’s specials” in a
restaurant.
While playing a board game, unable to
remember and use the rules of the
game, not able to perform calculation
mentally while balancing the checkbook,
difficulty remembering and adapting a
recipe.
May affect declarative memory of knowledge,
episodes, and facts or nondeclarative
memories such as those related to skills
and habits.
Driving, playing sports, hand crafts,
learning to use adaptive activities
of daily living (ADL) equipment or a
wheelchair.
See episodic and semantic memory.
Remembering the day’s events, what one had
for breakfast, occurrences on the job, the
content of therapy sessions.
Remembering the dates of holidays, the name
of the president, dates of world events.
Remembering places and names, and various
words. See declarative memory.
 Chapter 9 managing memory deficits to optimize function 213

Table 9-2 Terminology Related to Memory Impairments—Cont’d

Term Definition Examples of Everyday Behaviors

Implicit memory Does not require conscious retrieval of the past. Memory of skills, habits, and subconscious
Knowledge is expressed in performance
without the person being aware of
possessing this knowledge. Consists of
memories necessary to perform events
and tasks, or to produce a specific type of
response.
Prospective memory Remembering to carry out future intentions.
Metamemory Awareness of your own memory abilities.
processes. See nondeclarative memory.
Remembering to take medications, return
phone calls, buy food, pick up children
from school, mail the bills. A critical aspect
of memory to support everyday living.
Knowing when you need to compensate for
memory capacity (making a list of errands,
shopping list, writing down a new phone
number or driving directions), recognizing
errors in memory, etc.

Data from Baddeley AD: The psychology of memory. In Baddeley AD, Kopelman MD, Wilson BA, editors: The essential handbook of memory
disorders for clinicians, Hoboken, NJ, 2004, John Wiley; Bauer RM, Grande L, Valenstein E: Amnesic disorders. In Heilman KM, Valenstein E,
­editors: Clinical neuropsychology, ed 4, New York, 2003, Oxford University Press; Markowitsch HJ: Cognitive neuroscience of memory, Neurocase
4(6):429–435, 1998; and Sohlberg, MM, Mateer CA: Memory theory applied to intervention. In Sohlberg MM, Mateer CA, editors: Cognitive rehabilitation:
an integrative neuropsychological approach, New York, 2001, Guilford Press.

a multiple-digit number, or a whole phrase if the
number or the phrase was previously learned. The
information held in Short-term memory includes
the following:
• Recently processed sensory input (auditory and
visual information).
• Information recently retrieved from Long-term
memory.
• The result of recent mental processing (working
memory).
In their empirical research related to working
memory and brain injury, Parente and associates53
state that working memory is not a simple passive
storage “vault” for incoming information but rather
an ability to actively manipulate information that
is in Short-term storage via rehearsals. Functional
examples include doing calculations or processing
driving directions someone is giving you while you
are lost.
Baddeley discusses working memory as a cog-
nitive process that is clearly functionally impor-
tant because it is a site of conscious mental effort.5
In working memory, information is encoded into
meaningful chunks, problems get solved, and infor-
mation “comes to mind.” He discusses that working
memory is composed of four components:
1. The “central executive” plans future actions, initi-
ates retrieval of Long-term memories (LTMs), uses
decision-making processes, integrates new infor-
mation, and serves as an attentional control system
(see Chapters 8 and 10).
2. The “phonological loop” is the speech- and
sound-related component of working memory
and holds verbal and auditory information.
3. The “visuospatial sketchpad” holds visual and
spatial information.
4. The “episodic buffer” is a multimodal temporary
and limited storage system that integrates infor-
mation with Long-term memory and chunks
information by taking advantage of prior knowl-
edge to package information efficiently and effec-
tively so that storage and retrieval are improved.
Parente and associates provide guidelines for
therapists to work with people with deficits in
working memory (Box 9-1).53
Long-term memory or relatively permanent stor-
age of memories has several components and sys-
tems (Figure 9-1) that can be classified as declarative
or explicit memory and nondeclarative or implicit
memory that is expressed in skills, habits, and simple
forms of conditioning (see Table 9-2).65 Declarative
memory is further classified as semantic memory or
214 cognitive and perceptual rehabilitation: Optimizing function
Box 9-1 Suggestions for Working with
Those with Working Memory
Deficits
Shorten the length of directions and instructions.
Use real-world functional tasks for training (e.g., adding
monthly bills as opposed to practice of rote number
strings).
Avoid fast speaking rates.
Place stress on target words during training to help
the person realize the key part of the instruction.
In addition, place key information at the beginning
and end of sentences.
Increase the automaticity of responding by extra
practice and rehearsal such as learning to transfer
from a wheelchair to a bed.
Use part-whole learning or break the task down
into components to promote overlearning of the
components.
Teach rehearsal strategies.
Data from Parente R, Kolakowsky-Hayner S, Krug K, et al: Retraining
working memory after traumatic brain injury, NeuroRehabilitation
13(3):157-163, 1999.
knowledge of facts and episodic memory or memory
of events. In addition, declarative memory allows
remembered material to be compared and con-
trasted.46,65 Those with traumatic brain injury tend
to perform poorly on tasks requiring verbal declara-
tive memory (e.g., statements of general knowledge
and personally experienced events).47
Nondeclarative memory occurs within special-
ized performance systems65 and includes the fol-
lowing concepts:
MEMORY
DECLARATIVE
FACTS EVENTS PROCEDURAL
(SKILLS
AND
HABITS)
MEDIAL TEMPORAL LOBE STRIATUM
DIENCEPHALON
Figure 9-1  Memory has several components and systems.  (From Squire LR: Memory systems of the brain: a brief history and current
perspective, Neurobiol Learn Mem 82:171-177, 2004.)
• Procedural memory: Refers to implicit knowl-
edge of skills and procedures or “how-to”
knowledge and includes acquiring perceptual-
motor skills.
• Priming: An improvement in a perceptual or
conceptual task when previously exposed to
the information. Priming is thought to hap-
pen in primary sensory areas and result from an
improvement in processing efficiency. Priming
results in decreased response time and increases
the probability of correct response. An example
is naming objects previously seen.
• Perceptual learning: Enables us to recognize and
identify stimuli (objects, sounds, odors, tastes,
textures).
• Simple classical conditioning, or Pavlovian condi-
tioning: Can be thought as learning to recognize
the association between stimuli. For example,
the classic example is a dog learning the associa-
tion between a bell and food. Responses can be
skeletal or emotional.
• Non-associative learning: Involves a single stimu-
lus and refers to a change in response to a stimu-
lus without association with a positive or negative
reinforcement. This type of learning includes
habituation or a decrease in a response elicited
by a stimulus as a result of repeated stimulation
such as being less startled by ongoing construc-
tion noise across the street. It also includes sen-
sitization or an increase in response elicited by
a stimulus as a result of stimulation (e.g., those
living in earthquake zones are sensitive to noise
and vibrations).
NONDECLARATIVE
PRIMING SIMPLE NONASSOCIATIVE
AND CLASSICAL LEARNING
PERCEPTUAL CONDITIONING
LEARNING
EMOTIONAL SKELETAL
RESPONSES RESPONSES
NEOCORTEX AMYGDALA CEREBELLUM REFLEX
PATHWAYS
 Chapter 9 managing memory deficits to optimize function 215
Prospective memory, or remembering to per-
form a task in the future, is a critical component of
independent living. This type of memory relies on
frontal lobe function and places high demands on
the working memory system.27 Examples include
remembering to buy soap on the way home,
remembering to do homework, taking medications
as scheduled, and remembering to buy a gift for an
upcoming birthday. These examples are in contrast
to retrospective memory or memory of past events
and facts and ability to remember previously pre-
sented material. Prospective memory can be time
based (e.g., remembering to take a pill at 4 pm) or
event based, which is related to remembering to
perform an action when an external cue appears
(e.g., when your boss comes in to work, remember
to tell him Jimmy called in sick). Time-based tasks
may be more difficult because they are not con-
nected to an external cue17 and require self-initiated
strategies. Another type of prospective memory is
activity based.43 Similar to event-based tasks, activ-
ity-based tasks include an external cue but do not
require the interruption of an activity in progress.
An example is remembering to turn off a light when
leaving the room. Those living with traumatic brain
injury (TBI) perform more poorly on time-, event-,
and activity-based prospective memory tasks as
compared to controls.61 Similarly, those with TBI
tend to have difficulties predicting how well they
will perform related to prospective memory tasks.
Specifically, they tend to overestimate how well they
will perform (see Chapter 4 related to awareness).42
There are six steps related to prospective memory 54:
1. Formation of an intention (e.g., I will pick up a
pepperoni pizza after work for dinner)
2. Remembering the intention
3. Remembering when to do it
4. Remembering to perform the action
5. Actually performing the action at the correct
time and place and in the correct manner
6. Remembering that task was performed after
completion
Ward and colleagues75 point out that in reality
prospective memory comprises both prospective and
retrospective components. For example, if you are to
buy a pizza after work you must remember to stop
at the pizza parlor (prospective memory) and then
remember what you wanted to buy (retrospective).
Presentation and Recovery Patterns
In a recent study of those with TBI-associated dif-
fuse axonal injuries, memory loss was one of the
most frequent impairments, reaching a moderate
to severe degree in half of the clients examined.58
Vakil’s71 review of memory loss after moderate to
severe TBI demonstrates that TBI affects a large
range of memory aspects and may be a consequence
of a more general cognitive deficit (i.e., memory
in clients with TBI is not selectively impaired).
Although Vakil71 did detect a subgroup of clients
that do meet the criteria of selective amnesia, the
most commonly impaired memory processes fol-
lowing TBI resembled the memory deficits reported
in clients following frontal lobe damage such as dif-
ficulties in applying active or effortful strategy in
the learning or retrieval process.
In an interview study of 13 children with mem-
ory impairments secondary to TBI, more than half
of the children experienced explicit/past recall and
prospective (remembering to do something in the
future) memory loss.75 Few of the children expe-
rienced implicit (procedural) memory loss. All
parents reported prospective forgetting by their
children and reported that this was of great con-
cern. Seven parents reported that their children had
difficulty remembering facts and events.
Stewart and coworkers66 investigated the inci-
dence and nature of memory impairment after
stroke (12 to 36 months post). Out of 193 clients
contacted in a postal survey, 113 replied that they
had experienced memory impairment following
the stroke. Seventy of these clients were assessed
on an adapted version of the Rivermead Behavioral
Memory Test, Warrington’s Recognition Memory
Test for words and faces, and an everyday mem-
ory questionnaire. Thirty-five of the clients were
impaired on one or more of the memory measures.
Sixteen cases had selective memory impairment and
typically had mild to moderate deficits, and only 3
were impaired across all three tests. The authors
summarized that the results suggest that memory
impairment following stroke does not necessarily
involve general memory impairment and that the
evidence for material-specific memory deficits was
much weaker.
Minden and associates compared the perfor-
mance of 50 people with multiple sclerosis (MS)
and 35 controls on a variety of memory tasks to
determine the nature and severity of memory def-
icits in the MS clients and the proportion of cli-
ents affected.50 They found significant differences
between clients and controls on almost all memory
tests: 30% of clients showed severe memory impair-
ment, 30% were moderately impaired, and 40%
were mildly or not impaired. In addition, memory
216 cognitive and perceptual rehabilitation: Optimizing function
dysfunction was related to impairment of other
cognitive functions, lower socioeconomic status,
chronic progressive type of MS, and use of anti-
anxiety medication, but not to severity of disability,
duration of MS symptoms, or depression.
Similarly, Whittington and colleagues investi-
gated the deficits in recognition, recall, and pro-
spective memory among those with Parkinson’s
disease (PD) as well as to ascertain whether task dif-
ficulty and disease severity moderate these deficits.77
Comparisons were made among 41 PD participants
without dementia, divided into early-stage and
advanced-stage groups, and 41 matched controls.
PD participants exhibited deficits in recognition,
recall, and prospective memory. The advanced-
stage PD group demonstrated greater deficits than
the early-stage PD group in all tasks. Finally, those
living with Huntington’s disease may also experi-
ence memory loss during the earliest stages of the
disease that progress over time. Evidence suggests
that new memories can be encoded but the diffi-
culty lies in the recall (i.e., the deficit is primarily a
retrieval deficit in this population).22
Effect of Memory Deficits on Daily Life
and Outcomes
The presence of cognitive impairment in general
tends to have an adverse effect on functional out-
comes. Specifically, the presence of cognitive deficits
including memory loss predicts overall functional
outcomes after stroke.45 In addition, there is an
association between poststroke depression and
cognitive impairment, specifically ­memory loss.35
It also has been found that recovery of memory
(and attention) in the acute stages of brain injury is
correlated with the real-world outcome of commu-
nity productivity such as return to work or school.
Recovery of memory serves as a sensitive predictive
index of measures of real-world outcomes 4 years
after brain injury.12 These findings make sense when
considering how memory supports participation in
daily activities. Examples include the following:
• Remembering to call to order lunch (prospective
memory)
• Remembering to write and mail bills on the first
of the month (prospective memory)
• Performing calculations while determining tax
and tip on a restaurant bill (working memory)
• Remembering your phone number when filling
out an application (declarative/explicit semantic
memory)
• Remembering what transpired during a meet-
ing this morning (declarative/explicit episodic
memory)
• Remembering the steps of turning on the com-
puter (implicit procedural memory)
• Learning a new technique to get out of bed
(implicit procedural memory)
• Learning to play a musical instrument (implicit
procedural memory)
• Learning to drive a power wheelchair (implicit
procedural memory)
Evaluation and Assessments
Traditional measures of memory have tended to
tabletop laboratory-style tools. Contrived tasks
commonly used are remembering a number string,
a list of words, the details of a drawn figure, and/
or paired associate learning (i.e., requiring a person
to recognize or recall recently presented material).
How the results of these tests relate to everyday
memory function is not clear and the associations
between scores on this type of test and reports
of everyday memory failures are not strong.67
Similarly, functional gains do not always correlate
with improvement in memory processes based on
objective testing.55
A comprehensive evaluation of how memory
impairments affect everyday function includes
the use of standardized assessments, nonstan-
dardized observations, standardized self-reports,
and standardized reports of caregivers and sig-
nificant others. The reliability and validity of self-
reports related to memory have been criticized in
the literature secondary to examinees’ having poor
awareness or difficulties remembering functional
deficits. The issue of validity may be more prob-
lematic for those with severe impairments. Even
so, self-report measures do provide clinicians with
information related to insight and awareness of
memory deficits (metamemory), which is criti-
cal information to obtain when planning inter-
ventions (see Chapter 4). Therefore self-report
measures are recommended to be used in conjunc-
tion with other measures of memory (both are
described later). A critical component that must
be included in a functional evaluation of mem-
ory is an evaluation of prospective memory. It is
argued that prospective memory (e.g., remember-
ing to keep a doctor’s appointment, buy grocer-
ies, walk the dog) is a fundamental component of
independent living and is an indicator of func-
tional memory capacity.41
 Chapter 9 managing memory deficits to optimize function 217
The Rivermead Behavioral Memory Test
(RBMT) is a more ecologically valid test that was
designed to assess memory skills related to every-
day situations. This test is used to predict everyday
life memory problems in those who are living with
brain damage.80 It is a valid and reliable test that
correlates well with traditional measures of learn-
ing and memory.44 It is a test of global memory that
includes items related to prospective memory and
is correlated with immediate learning and delayed
recall of new information with both verbal and spa-
tial memory measures.44 The instrument includes
the following subtests:
• Remembering an appointment
• Remembering a new short route (immediate
and delayed)
• Remembering to ask for a hidden personal
belonging
• Remembering to deliver a message
• Picture recognition
• Orientation and date
• Remembering information from a news article:
immediate and delayed
• Remembering a name
• Face recognition
Administration time is approximately 20 to 30
minutes. The instrument yields two scores includ-
ing a screening score that offers a simple way to
estimate whether a client is likely to have every-
day memory problems, and a profile score, a more
sensitive measure of change that indicates severity.
Four parallel forms of the test are available. Adult
norms are provided for ages 16 to 69 and 70 to 95.
The adult version also has been used successfully
with adolescents from 11 through 15 years of age.
A children’s version1,84 is also available for ages 5 to
10 years, 11 months. Modifications of the instru-
ment have been tested to control for perceptual def-
icits9 and language deficits.8 It tests both Short- and
Long-term memory for verbal and spatial informa-
tion as well as prospective memory (i.e., remember-
ing to do something in the future).
The original test was used to detect moder-
ate to severe impairments and did not detect mild
memory impairment. The Extended Rivermead
Behavioral Memory Test (ERBMT) increases the
level of difficulty by doubling the amount of mate-
rial to be remembered via combining material from
the four original forms of the original test to pro-
duce two parallel versions of the new extended test.
The ERBMT is designed to detect more subtle mem-
ory impairments. The sensitivity of the ERBMT
was assessed by comparing the performance of 26
middle-aged and 22 older adult subjects. The sub-
tests varied in their sensitivity to this small age dif-
ference, but when performance was assessed in
terms of scaled scores that allow an overall com-
bined measure of memory performance to be cal-
culated, the test proved sensitive and free of ceiling
and floor effects. The authors concluded that the
ERBMT provides a promising measure of everyday
memory in adults.13
Wills and coworkers78 examined the performance
of 16 brain-injured clients on both the RBMT and
the ERBMT. The performance of these clients on
the ERBMT was compared with matched controls.
Overall, the clients performed significantly worse
than the controls, and showed particular difficulty
in two subtests (recalling a route and remembering
to deliver a message). Those clients who scored in
the “normal” range on the RBMT could be further
differentiated on the basis of their ERBMT scores
into “good,” “average,” and “poor” performance cat-
egories. The clients’ performance was not signifi-
cantly associated with general intellectual ability.
The authors concluded that their results suggest
that the ERBMT was a useful clinical tool to aid
therapists in the assessment of subtle impairments
of everyday memory performance following brain
injury. The ERBMT has been adapted for those
with mobility impairments.7
The Contextual Memory Test was developed
to assess the awareness of memory capacity, strat-
egy of memory use, and recall (immediate and
delayed) in adults with memory impairments.70
More recently it has been used with children34 liv-
ing with brain injuries. It can be used with multiple
diagnoses including head trauma, multiple sclero-
sis, Parkinson’s disease, acquired immunodeficiency
syndrome (AIDS), and stroke (Box 9-2).
Box 9-2 Contextual Memory Test
Allows clinicians to objectify three aspects of memory
and screen for possible further evaluation:
1. Awareness of memory: via general questioning prior
to the assessment, predicting performance prior
to assessment, and estimating memory capacity
following performance.
2. Recall of 20 line-drawn aspects: immediate and
delayed (15 to 20 minutes) recall.
3. Strategy use: probe use of memory strategies,
and determines ability to benefit from strategy
recommended by the clinician.
Data from Toglia J: Contextual memory test, San Antonio, Tex, 1993,
Harcourt Assessments.
218 cognitive and perceptual rehabilitation: Optimizing function
The test includes two equivalent forms, each
with 20 line drawings of items related to a morn-
ing theme or a restaurant. During part one of the
assessment, the examinee is not told of the theme.
Following standardized questioning regarding
insight into memory capacity and prediction of
test performance, the examinee is shown the line
drawing for 90 seconds. Immediate recall of the line
drawings is tested. After 15 to 20 minutes delayed
recall of the 20 items is tested. Questions are asked
to determine awareness of performance and strat-
egy use to remember the items. If strategy use is
poor and recall scores are below the norm, part two
is administered.
Part two involves showing the examinee an
equivalent form of the test and informing them of
theme or context. Cued recall and recognition can
be used if the delayed recall falls below the norm.
The tool yields recall scores (immediate, delayed,
and total), awareness scores, and a total strategy
score. Normative data are published in the test
manual.
The Everyday Memory Questionnaire (EMQ)
originally consisted of 35 items, each describing a
particular memory failure that participants have
to rate for frequency of occurrence.67 It consists of
subjective, metamemory reports. Included are the
following areas:
• Speech: Includes 13 items such as forgetting
names, forgetting something that was told to
you, losing track of what someone is telling you,
mixing up details of a conversation
• Reading and writing: Includes four items such as
forgetting a sentence that was just read, forget-
ting how to spell a word
• Faces and places: Includes six items such as for-
getting where you put something, not recogniz-
ing family/friends, getting lost
• Actions: Includes six items such as forgetting a
routine, performing a routine twice by mistake,
forgetting what you did yesterday
• Learning new things: Includes six items such as
unable to learn a new skill, unable to remember
the name of a recent acquaintance, forgetting an
appointment
A revised version was published by Sunderland
and associates,68 incorporating 22 of the original
items and adding 6 new ones. The modifications
were implemented to increase the test’s validity and
the ease of self-administration. The response scale
was changed from relative frequencies to abso-
lute frequencies. A 20-item version also has been
used.51,66 The EMQ has been used with those ­living
with head injury, stroke, multiple sclerosis, and
older adults. Recent validity data suggested that the
EMQ could be useful with children at least as young
as 10 years.15 The instrument can be administered
to clients and/or significant others. A high degree
of consistency has been found between client and
significant other ratings on the short version of the
instrument.51
The Comprehensive Assessment of Prospective
Memory56,76 measures the frequency of prospec-
tive memory failures in addition to the perceived
amount of concern of these lapses in memory and
the reasons that people are successful (or not) in
performing prospective memory tasks. The instru-
ment includes both basic activities of daily living
(ADL) items (e.g., forgetting to eat a meal) and
instrumental ADL (IADL) items (e.g., forgetting
to buy an item at the grocery store) (Box 9-3). The
instrument can be administered as self-report mea-
sure or completed by a significant other.
The Prospective Memory Questionnaire (PMQ)29
is a valid and reliable self-report measure of three
aspects of prospective memory on a series of
nine-point scales. Questions measure Short-term
habitual, Long-term episodic, and internally cued
prospective memory (Box 9-4). The PMQ provides
a measure of self-reported errors in the previous
week, month, or year, depending on the specific
item. The scale ranges from one (least amount of
forgetting is evident) to nine (there is a great deal
of forgetting). The higher the score, the more
impaired is one’s prospective memory. The mea-
sure also includes questions related to techniques
used to remember and provides a measure of the
number of strategies used to aid in remembering.
The “techniques to remember scale” ranges from
one (few strategies used) to nine (a high number of
strategies used).
Smith and colleagues developed the Prospective
and Retrospective Memory Questionnaire
(PRMQ).62 The PRMQ is a public domain, 16-item
self-report measure of prospective and retrospec-
tive failures in everyday life. The PRMQ includes 8
items related to prospective memory and 8 related to
retrospective memory. The instrument contains an
equal number of items concerned with either self-
cued memory or environmentally cued memory,
as well as with Short- versus Long-term memory
(Table 9-3). Norms have been published for both
the self report version11 and for proxy ratings.10
The Cambridge Behaviour Prospective Mem­
ory Test/Cambridge Prospective Memory Test
(CAMPROMPT) can be administered in approxi-
 Chapter 9 managing memory deficits to optimize function 219

Box 9-3 Components of the Comprehensive Assessment of Prospective Memory Items

Basic Activities of Daily Living (ADL) Items
Not locking the door when leaving home.
Forgetting to have a shower or bath.
Performing a routine activity twice by mistake (e.g., putting
two lots of coffee in a cup).
Forgetting to eat a meal.
Forgetting to get money from the bank.
Accidentally forgetting to put an article of clothing on when
you get dressed (e.g., forgetting to put your socks on).
Forgetting to take your wallet or purse with you when you
leave the house.
Accidentally forgetting a grooming activity (brushing your
hair, shaving).
Leaving water taps on.
Accidentally forgetting to brush your teeth.
Instrumental Activities of Daily Living
(IADL) Items
Forgetting to buy an item at the grocery store.
Forgetting an appointment with your physician or therapist.
Leaving the iron on.
Forgetting to put the garbage bin out.
Forgetting a change in your daily routine (e.g., showing up
for a regular meeting when the regular meeting day has
been changed).
Mistakenly following your old routine, when it has been
changed (e.g., putting out rubbish at the wrong time
when the collection day has been changed).
Forgetting to water potted plants or the garden.
Forgetting to pass on a message.
Forgetting to take pills at the prescribed time.
Forgetting to take clothes off the line.
Problems remembering future personal dates, such as
birthdays.
Forgetting to make a telephone call you intended to make.
Forgetting to do cleaning chores.
Leaving out an ingredient you planned to use while
­cooking or preparing a meal.
Arriving at a shop and forgetting what you planned to buy.
Forgetting to mention a point you intended to make
­during a conversation.
Not remembering to pay bills.
Having to check whether you have done something you
have planned to do.
Forgetting to do the laundry.
Forgetting to meet a friend at the prearranged time.
Forgetting to post a letter.
Not remembering to check the water levels/tire pressure
of your car.
Forgetting to check your calendar or schedule.

Modified from Roche NL, Fleming JM, Shum DH: Self-awareness of prospective memory failure in adults with traumatic brain injury, Brain Inj 16(11):
931-945, 2002.

Box 9-4 Prospective Memory Questionnaire Subscales and Sample Items

Long-Term Episodic Scale—task is to be completed hours
or days after cue to perform it and occurs on an irregular
schedule
I forgot to send a card for a birthday or anniversary.
I forgot to return books to the library by the due date.
Short-Term Habitual Scale—task is to be completed
within a few minutes after cue to perform it and occurs
routinely
I forgot to lock the door when leaving my apartment or
house.
I forgot to put a stamp on a letter before mailing it.
Internally Cued Scale—task does not have a clear specific
external cue
I forgot what I wanted to say in the middle of a
sentence.
I was driving and temporarily forgot where I was going.
Techniques to Remember Scale—techniques used to help
one remember to perform a prospective memory task
I rehearse things in my mind so I will not forget to do
them.
I make sticky note reminders and place them in obvi-
ous places.

From Hannon R, Adams P, Harrington S, et al: Effects of brain injury and age on prospective memory self-rating and performance, Rehabil Psychol
40(4):289-298, 1995.

mately 40 minutes and is comprised of four time-
based and four event-based prospective memory
tasks.28 These include the following:
• Reminding the tester after 15 minutes not to for-
get a key
• Asking the tester for a newspaper after 20
minutes
• After working for 20 minutes on a filler task
(a nonverbal reasoning test taken from commer-
cially available books), the person is asked to
220 cognitive and perceptual rehabilitation: Optimizing function

Table 9-3 Proxy Version of the Prospective and Retrospective Memory Questionnaire Items
and Their Categorizations
Self-Cued vs.
Item Prospective vs. Short vs. Environmentally
Number Item Retrospective Long Term Cued

 1 Do they decide to do something in a Prospective Short term Self-cued

few minutes’ time and then forget
to do it?
 2 Do they fail to recognize a place they Retrospective Long term Environmentally cued
have visited before?
 3 Do they fail to do something they Prospective Short term Environmentally cued
were supposed to do a few
minutes later even though it is
there in front of them, like take
a pill or turn off the kettle?
 4 Do they forget something they were Retrospective Short term Self-cued
told a few minutes before?
 5 Do they forget appointments if they Prospective Long term Self-cued
are not prompted by someone
else or by a reminder such as a
calendar or diary?
 6 Do they fail to recognize a character Retrospective Short term Environmentally cued
in a radio or television show
from scene to scene?
 7 Do they forget to buy something Prospective Long term Environmentally cued
they planned to buy, like a birthday
card, even when they see the shop?
 8 Do they fail to recall things that have Retrospective Long term Self-cued
happened to them in the past few
days?
 9 Do they repeat the same story to the Retrospective Long term Environmentally cued
same person on different occasions?
10 Do they intend to take something with Prospective Short term Environmentally cued
them, before leaving a room or
going out, but minutes later leave it
behind, even though it is there
in front of them?
11 Do they misplace something that they Retrospective Short term Self-cued
have just put down, like a magazine
or glasses?
12 Do they fail to mention or give Prospective Long term Environmentally cued
something to a visitor that they were
asked to pass on?
13 Do they look at something without Retrospective Short term Environmentally cued
realizing they have seen it moments
before?
14 If they tried to contact a friend or Prospective Long term Self-cued
relative who was out, would they
forget to try again later?
15 Do they forget what they watched on Retrospective Long term Self-cued
television the previous day?
16 Do they forget to tell someone Prospective Short term Self-cued
something they had meant to
mention a few minutes ago?

From Crawford JR, Henry JD, Ward AL, et al: The Prospective and Retrospective Memory Questionnaire (PRMQ): latent structure, normative data and
discrepancy analysis for proxy-ratings, Br J Clin Psychol 45(Pt 1):83-104, 2006.
 Chapter 9 managing memory deficits to optimize function 221
switch to a second filler task after an additional
5 minutes
• Opening or closing the booklet of the filler task 3
minutes after the instruction was given
• Reminding the tester about five hidden objects
after the tester said the testing is over (at the end
of the session)
• Putting a briefcase under the desk after an alarm
rings, which was set to ring 5 minutes after the
beginning of the session
• Changing pens after having completed seven
filler assignments
• Giving an envelope with “message” written on it to
the tester when tester says that there are 10 minutes
left; instruction is given after the timer goes off
The authors modified the test, and it is now
commercially available. The new version includes
three time-based tasks and three event-based tasks
as well as norms collected from 212 controls and a
group of people with brain injury. A review of the
psychometric properties of these tests and others is
provided in Table 9-4.
Review of Evidence-Based
Interventions to Decrease
Activity Limitations and Participation
Restrictions for Those Living
with Memory Impairments
Interventions focused on those with memory def-
icits can be categorized as restorative approaches
to improve underlying memory deficits, strat-
egy training, use of nonelectronic memory aids,
and electronic memory aids or assistive technol-
ogy. Techniques aimed at improving the underly-
ing memory impairment such as memory drills
have been unsuccessful in terms of generalizing to
meaningful activities. In other words, an improve-
ment may be detected on a laboratory-based mea-
sure of memory without a corresponding change in
daily function or subjective memory reports.
As will be discussed below, the most promising
interventions to improve function in those living
with memory deficits rely at least partially on com-
pensatory techniques.When using a compensatory
approach, choosing the correct system of compen-
sation is critical (Figure 9-2). Kime suggests a com-
prehensive evaluation that includes the following 39:
• Severity of injury
• Severity of memory impairment
• Presence of comorbidities including physical
impairments, language deficits, and other cog-
nitive deficits
• Social supports
• Client needs (e.g., will the system be used for
work, home management, etc.)
Memory Notebooks and Diaries
Sandler and Harris documented positive results
from a case study that used a memory notebook to
improve daily function of an 18-year-old man with
an acquired brain injury.57 Improvements were
noted in the areas of using the memory notebook
to improve orientation as well as support everyday
living tasks such as morning activities of daily living
and simple IADL.
Sohlberg and Mateer have published a system-
atic, structured training sequence for teaching
individuals with severe memory impairments to
independently use a compensatory memory book.63
The training sequence they proposed incorporates
principles of learning theory as well as procedural
memory skills, which may be preserved in many
clients with even severe memory impairments.
Their paper describes the components of a func-
tional memory book (Table 9-5). In addition, they
describe a three-stage approach to using the note-
book (Table 9-6):
• Acquisition or how to use it
• Application or where and when to use it
• Adaptation or how to update it and use it in
novel situations
Sohlberg and Mateer highlight that successful
memory book training takes time, requires that all
staff and family need to be trained in its use, that the
person carry the book at all times, and that its use
is individualized and function based.63 They have
documented the effectiveness of this approach to
memory book training via a case study in which the
intervention was successfully used to support daily
living and employment despite persistent memory
deficits.
Donaghy and Williams suggested that the diary
or notebook include a pair of pages for each day of
the week.14 The notebook is set up to aid schedul-
ing things to do in the future and record activities
done in the past. Within each pair of pages the left-
hand page contains two columns, one with a time-
table for the day and the other, the to-do items. The
right-hand page contains the memory log. A “Last
Week” section at the back stores previous memory
log entries. A full-year calendar allows for appoint-
ments to be recorded. Donaghy and Williams14 have
published their training protocol and two case stud-
ies to support use of the notebook (Figure 9-3).

Table 9-4 Recommended Outcome Measures and Function-Based Memory Assessments
Instrument
and Author Instrument Description
Standardized assessments of
basic activities of daily living
(BADL)
Standardized assessments of
instrumental ADL (IADL)
Standardized assessments of
leisure
Standardized assessments of
participation
Standardized assessments of
quality of life
Rivermead Behavioral Ecologically valid test of
Memory Test, everyday memory
Wilson et al, 198980 Uses simulations of everyday
memory tasks
Contextual Memory Supplements memory
Test, Toglia, 199370 assessment by quickly
providing information
related to metamemory,
strategy use and recall
Population Validity
Those with memory Differentiates those
deficits ages 5 with brain injury
to 95 from controls
Moderately correlated
with multiple
impairment measures
of memory (r ranging
from 0.47 to 0.81) as
well as staff reports of
daily memory function
(r = 0.70)
Adults 18 years Correlated with the
and older Rivermead Behavioral
with memory Memory Test ranging
impairment from 0.80 to 0.84
secondary
to multiple
pathologies;
children ages 8
to 14 with brain
injuries
222 cognitive and perceptual rehabilitation: Optimizing function
Dimension Based
on International
Reliability Classification Function Comments
Activity limitations See Chapter 1
Activity limitations See Chapter 1
Activity limitations See Chapter 1
Participation restrictions
Quality of life See Chapter 1
Interrater: 100% Impairments and activity The original version is
agreement limitations used for those with
Parallel forms moderate to severe
range from impairments, whereas
0.83 to 0.88 an extended version
is available for those
with subtle memory
loss. Modifications
are available for
those with perceptual,
language, and
mobility impairments.
Parallel form Impairment Quick and portable
ranges from Normative data
0.73 to 0.81 provided
Test-retest ranges
from 0.85 to 0.94

Everyday Memory Subjective report of everyday Those with memory Significant correlations Cronbach’s alpha = Activity limitations Self-report or via proxy
Questionnaire, memory; a metamemory deficits secondary between questionnaire 0.899
Sunderland et al, questionnaire to multiple and everyday memory
198367; 198468 pathologies; checklist (client and
recently tested on relative versions)
children as young
as 10
Cambridge Objective test of prospective High face validity; Good reliability Impairment —
Behavioural memory differentiates between
Prospective those with and without
Memory Test/ brain injury; significant
Cambridge relationships between
Prospective test scores and a
Memory Test, number of retrospective
Groot et al, 200228 memory, attention, and

Chapter 9 managing memory deficits to optimize function

executive function tests
Comprehensive Assessment of prospective Typical young, middle- High face validity, sensitive Internal consistency Activity limitations Self-rated or proxy rated
Assessment memory related to BADL aged, and older to discriminating age- = 0.79 (BADL)
of Prospective and IADL adults and adults groups and 0.92 (IADL)
Memory, Roche with traumatic
et al, 200256; brain injury
Waugh, 199976
Prospective Memory Behaviorally anchored Adults with memory Correlates with other Internal consistency Impairments and activity
Questionnaire, self-rated evaluation of loss from brain measures of prospective = 0.92 Test-retest limitations
Hannon et al, prospective memory injury, etc. memory = 0.88
199529
Prospective and Measure of prospective and Those with memory Construct validity tested Internal consistency Impairments and activity Self-rated or proxy rated
Retrospective retrospective failures in loss impacting daily via confirmatory factor ranges from 0.80 limitations Norms are published
Memory everyday life function analysis to 0.92
Questionnaire,
Smith et al, 200062

(Continued )

223

Table 9-4 Recommended Outcome Measures and Function-Based Memory Assessments­—Cont’d
Instrument
and Author Instrument Description
Árnadóttir Structured observation of
Occupational basic ADL including feeding,
Therapy-ADL grooming and hygiene,
Neurobehavioral dressing, transfers and
Evaluation mobility to detect the effect
(A-ONE), of multiple underlying
Árnadóttir, 19903; impairments including short-
20044 term memory, long-term
memory, and disorientation
on these tasks
Assessment of Motor An observational assessment
and Process Skills, that measures the quality of
Fisher, 200319,20 a person’s ADL; assessed by
rating the effort, efficiency,
safety, and independence of
16 ADL motor and 20 ADL
process skill items. Includes
choices from 85 tasks.
224 cognitive and perceptual rehabilitation: Optimizing function
Dimension Based
on International
Population Validity Reliability Classification Function Comments
Those 16 years and Content: via expert review Interrater: 0.84 Impairments and activity Provides information
older with central and literature review Test-retest: 0.86 limitations related to how
nervous system Concurrent: Barthel Index, memory impairment
involvement Katz Index, Mini Mental affects everyday living
Status Examination. Requires training
Valid for multiple
diagnoses including
stroke, brain tumor,
dementia.
Those 3 years old Strong validity and Cronbach’s alpha Activity limitations Provides information
and up and appropriate to use with ranges from 0.74 related to everyday
difficulties related multiple diagnoses and to 0.93 living
to occupational cultures Test-retest ranges Requires training
performance from 0.7 to 0.91
 Chapter 9 managing memory deficits to optimize function 225

Extensive Needs of the patient Limited

Stabilized Acuity of injury Rapid recovery
Severe Severity of memory problem Mild
Mild Cognitive/language deficits Severe
Mild Physical impairments Severe
Good Support network Poor

MEMORY COMPENSATION SYSTEMS

Comprehensive systems Minimal systems
• Full-size daily • Mid-size daily • Mid-size weekly • Small weekly • Binder or notebook • Binder or notebook
dated pages dated pages dated pages dated pages without dated pages without dated pages
• Forms/checklists • Forms/checklists • Forms/checklists • 1 or 2 items per • Therapy schedule • Basic personal/
• Month-in-a-view • Month-in-a-view • Wristwatch day are tracked • Forms/checklists orientation
• To-do lists • To-do lists • Pillbox • Forms/checklists • Placards information
• Wristwatch • Wristwatch • Placards • Pillbox • Dry-erase board • Dry-erase board
• Pillbox • Pillbox • Timers • Placards
• Placards • Placards • Timers
• Timers • Timers
Figure 9-2  Detailed evaluation of client capabilities in many areas is necessary to define an appropriate memory compensation system.
(From Kime SK: Compensating for memory deficits using a systematic approach, Bethesda, Md, 2006, AOTA Press.)

Table 9-5 List of Possible Notebook Sections

Section Included Information

Orientation Narrative autobiographic information concerning personal data and/or information surrounding the
brain injury
Memory log Contains forms for charting hourly information about what client has done. Diary of daily information
Calendar Calendars with dates and times that would allow a client to schedule appointments and dates
Things to do Contains forms for recording errands and intended actions. Includes place to mark due date and
completion date.
Transportation Contains maps and/or bus information to frequented places such as work, schools, store, bank
Feelings log Contains forms to chart feelings relative to specific incidences or times
Names Contains forms to record names and identifying information of new people
Today at work Various forms have been adapted for specific vocation and settings that allow individuals to record
the necessary information to perform their job duties

From Sohlberg MM, Mateer CA: Training use of compensatory memory books: a three stage behavioral approach, J Clin Exper Neuropsychol 11(6):
871-891, 1989.

Table 9-6 Three-Stage Approach to Using the Notebook

Training Phase Description Efficiency Goal

Acquisition Learn names, purpose, and use of each notebook
section via question-answer format
Application Earn appropriate methods of recording in notebook
via role-play situations
Adaptation Demonstrate appropriate notebook use in naturalistic
settings via community training
100% accuracy on questions for 5
consecutive days
100% accuracy of response to three
role-play situations with no cueing
on 2 consecutive days
Receive a score of four for two
situations on 2 consecutive days

Modified from Sohlberg MM, Mateer CA: Training use of compensatory memory books: a three stage behavioral approach, J Clin Exper Neuropsychol
11(6):871-891, 1989.
226 cognitive and perceptual rehabilitation: Optimizing function
Figure 9-3  The left side of the book is a laminated page. It is for tracking future events (schedule and things to do). The right side of the
book is lined paper for tracking past events.  (From Donaghy S, Williams W: A new protocol for training severely impaired patients in the
usage of memory journals, Brain Inj 12:1061-1076, 1998.)
McKerracher and coworkers examined out-
comes comparing two types of memory notebooks
using an ABAB (A refers to the non-treatment or
control phase of the experiment while B refers to
the treatment phase of the experiment) single-case
experimental design.48 A standard diary, similar to
that of Sohlberg and Mateer63and a modified diary
as described by Donaghy and Williams14 were com-
pared. The main differences between the diaries
were that the standard diary contained a weekly
timetable and a separate to-do list. The modified
diary contained a daily timetable and a daily to-
do list on adjacent pages. The results indicated that
the person being taught to use the notebook com-
pleted more tasks using the modified diary. During
the 4 weeks of using the standard diary, only 1 of
20 prospective memory tasks was completed. While
using the modified diary, 15 of the 20 tasks were
completed.
Ownsworth and McFarland52 compared two
approaches to memory diary training:
• Diary-only training: This approach focused on
functional skill building and compensation
based task-specific learning. The subjects were
taught a behavioral sequence of making a diary
entry, checking it, and using the information as
needed.
• Diary and self-instructional training: This
approach emphasized training of the subject’s
capacity for higher level cognitive skills of self-
regulation and self-awareness. The subjects were
taught a WSTC strategy.
W: What are you going to do?
S: Select a strategy for the task.
T: Try out the strategy.
C: Check how the strategy is working.
The authors found that during the treatment
phase, those who were in the diary and self-instruction
 Chapter 9 managing memory deficits to optimize function 227

training group consistently made more diary entries,
reported fewer memory problems, compensated bet-
ter via strategy use, and made more positive ratings
associated with the efficacy of treatment. Figure 9-4
gives examples of outcome measures.
Schmitter-Edgecombe and associates evaluated
the effectiveness of a memory notebook interven-
tion for those with chronic (greater than 2 years)
and severe closed head injury and with documented
memory deficits.59 Eight participants were allocated
to receive either notebook training or support-
ive therapy. The notebook training procedure was
based on behavioral learning principles as well as
educational strategies to individualize instruction.
The intervention consisted of four stages (anticipa-
tion, acquisition, application, and adaptation) and
included didactic lessons, homework, and the use
of learning activity packets to help subjects use the
notebook sections (Tables 9-7 and 9-8).
Memory outcome measures were administered
before treatment, immediately after treatment,
and at a 6-month follow-up. At posttreatment, the
notebook training group reported significantly
fewer observed everyday memory failures on a daily
checklist measure compared with the supportive
therapy group. Although in the same direction, this
finding no longer reached significance at follow-
up. No significant treatment effects were found for

AGE:
SEX: M, F

The following questionnaire refers to memory problems that are common to many people.
Some, however, occur more frequently for different people. Please read each question
carefully and tick the response which most accurately shows how frequently such experiences
occur in your daily living.

A FEW A FEW
ONE OR MORE 2-6 TIMES TIMES A TIMES A
TIMES DAILY A WEEK MONTH YEAR NEVER

1. How often do you forget the

names of people minutes after
being introduced?
2. When calling someone that you
regularly call, do you ever have to
look up their number?
3. How often would you fail to
remember the address of someone
you frequently write to?
4. Think of times when someone has
given you directions to get to an
unfamiliar place. How often do you
forget these before you get there?
5. When you go out to run a few
errands, how often do you forget to
do at least one of them?
6. How often do you find at the end
of a conversation, that you forget
to bring up a point or question
that you had intended to?

Figure 9-4  A self-report memory questionnaire.  (From Ownsworth TL, Mcfarland K: Memory remediation in long-term acquired brain
injury: two approaches in diary training, Brain Inj 13[8]:605-26, 1999.)
(Continued)
228 cognitive and perceptual rehabilitation: Optimizing function

A FEW A FEW
ONE OR MORE 2-6 TIMES TIMES A TIMES A
TIMES DAILY A WEEK MONTH YEAR NEVER

7. How often are you unable to find

something that you put down only
minutes ago?
8. How often do you discover when
you have gone out, that you must
return for something that you left
behind?
9. If someone says that they have told
you something earlier, how often
are you unable to recall them
doing so?
10. When someone asks you to give a
friend a message, how often do you
forget to do so?
11. How often do you find that when
you want to introduce people you
know, that you can’t remember
someone’s name?
12. How often do you forget birthdays
or dates when you intended to do
something special?
13. When you want to remember a
story or an experience, how often
are you unable to do so?
14. If you need to know what the date
is, how often do you look it up or
ask someone because you can’t
remember?
15. How often do you think of
something a person told you, but
forget who said it?
16. Do you ever begin to tell someone
a story only to learn that you have
already told them?

Figure 9-4—Cont’d

laboratory-based memory impairment measures at learning. Interventions using an errorless learning

posttreatment or follow-up. Although findings are
to be interpreted with caution because of the small
sample size, the authors concluded that note-
book training has the potential to help individuals
­compensate for everyday memory problems.
Errorless Learning
Errorless learning is a learning strategy that is in
contrast to trial and error learning or errorful
approach are based on differences in learning abili-
ties. It is typical for people with memory impair-
ments to remember their own mistakes as results
of their own action more successfully than they
remember the corrections to their mistakes occur-
ring via explicit means (e.g., a therapist’s cue). In
other words, people may remember their mis-
takes but not the correction. With errorless learn-
ing a person learns something by saying or doing
it, rather than being told or shown by someone.

Table 9-7 Stages of the Notebook Training and the Learning Activities Packet (LAP) for
Each Stage
Goal
Stage 1: Anticipation
Pique interest in possible solution to
memory problems; concretely
identify memory weaknesses, and
demonstrate need for external aid
(sessions 1–3)
Stage 2: Acquisition
Learn names and purposes of notebook
sections; learn to use watch alarm to
cue use of the notebook and aid in
the establishment of an overlearned
routine (sessions 4–5)
Stage 3: Application
Learn and practice appropriate
procedures for recording information
in notebook through use of homework
assignments and role-play situations
(sessions 6–13)
Stage 4: Adaptation
Encourage use of acquired notebook
skills within novel settings through
use of homework assignments:
modify notebook for personal needs
(sessions 14–16)
From Schmitter-Edgecombe M, Fahy JF, Whelan JP, et al: Memory remediation after severe closed head injury: notebook training versus supportive therapy,
J Consulting Clin Psychol 63(3):484-489, 1995.
In addition, the person is not given the opportunity
to make a mistake (i.e., there are no mistakes to be
remembered). The hypothesis is that reduction or
prevention of incorrect or inappropriate responses
facilitates memory performance. The technique
is straightforward and involves preventing clients
from making any errors during learning via physi-
cal and verbal support or cues from the therapist.
Chapter 9 managing memory deficits to optimize function 229
LAP Purpose
Memory Define and discuss memory; identify
participants’ specific memory skills and
deficits
Remembering names Teach procedures for remembering
names that involve constructing a
“person memory,” engaging in “name
talk,” and recording a “name drawing”
in the notebook
Introduction to notebook Describe traditional approaches to
memory training; instruction on
notebook assembly; teach the purpose
of the five notebook sections
Scheduling appointments Teach how to use the notebook for
scheduling appointments and
planning activities; teach how
to use the calendar section
Current work and personal notes Teach how to use the current work
and personal notes sections; teach
procedures for cross-referencing
and setting appointments with
oneself
Main idea Teach three-step technique for identifying
the main idea of both written and
auditory information; provide
extensive practice exercises
Note-taking skills Teach how to write brief, accurate notes
Time management Teach use of the notebook as an aid to
time management and personal goal
setting
In other words reducing the use of trial and error
and avoiding mistakes. Errorless learning tech-
niques also have been successful with those living
with apraxia (see Chapter 5).
Although errorless learning continues to be
tested as a possible technique for the rehabilitation
of clients with memory impairment, the cognitive
processes responsible for improved retention of
230 cognitive and perceptual rehabilitation: Optimizing function

Table 9-8 List and Purpose of Memory Notebook Sections

Notebook
Section Purpose

Daily log Used to record, store, and retrieve information about daily activities; contained forms for charting
hourly information and scheduling appointments; contained forms for prioritizing a task list
Calendar Used for recording appointments and retrieving information about important meetings and upcoming
events
Names Used to record, store, and retrieve identifying information and “name drawings” of new people
Current work Used for recording specific procedures about work assignments that may be needed at a later date
Personal notes Used for recording important personal information such as personal goals or autobiographic
information; also used for recording addresses, birthdays, etc.

From Schmitter-Edgecombe M, Fahy JF, Whelan JP, et al: Memory remediation after severe closed head injury: notebook training versus supportive therapy,
J Consulting Clin Psychol 63(3):484-489, 1995.

information are not clear.69 Two theories have been
proposed, both of which focus on the distinction
between implicit and explicit memory. Tailby and
Haslam summarize that when errors occur, those
with memory impairments tend to repeat the same
errors across learning trials.69 This possibly occurs
because errorful learning relies on explicit memory
processes, which those with memory impairments
cannot apply (see Table 9-2). Explicit processes
allow for monitoring and elimination of errors,
and without this process a person cannot modify
responses during learning. Any error performed by
memory-impaired clients during errorful learning
may be repeated, resulting in reinforcement of an
incorrect response.
However, implicit memory may be spared
in those with memory impairments. Tailby and
Haslam state that “Implicit learning is well served
under errorless learning conditions, as by eliminat-
ing errors during learning the strongest response
will be the correct response and this would be the
only one reinforced.”69 The second theory proposes
that the benefits of errorless learning are supported
by residual explicit memory as opposed to implicit
processes.
Evans and colleagues18 presented nine experi-
ments, in three study phases, which tested the
hypothesis that learning methods that prevent the
making of errors (“errorless learning”) will lead
to greater learning than “trial-and-error” learning
methods among those who are memory impaired
as a result of acquired brain injury. Errorless learn-
ing techniques include the following:
• Providing the correct answer immediately: For
example, when showing a picture of ­ unfamiliar
face, the therapist would ask, “What is this ­person’s
name? His name begins with M; his name is
Michael.” The authors found that this technique
was beneficial for remembering names by first
letter–cued recall as compared to learning names
by trial and error.
• Backward chaining: Used to teach multistep
tasks, in this approach the therapist shows or
prompts all of the steps of the task. On the next
trial, all of the steps except for the last one are
demonstrated or prompted and the person being
taught the skill must demonstrate it. After each
trial, prompts are withdrawn and the technique
progresses until all of the steps are learned. The
authors found that this technique was beneficial
for learning names by first letter–cued recall as
compared to trail and error.
• Forward chaining: Also used to teach multiple
step tasks, the therapist prompts or demon-
strates the first step on the first trial, the first two
steps on the second trial, and continues until the
whole sequence is remembered.
• Combined imagery with errorless learning:
Associations between faces and names were
taught by having he subject create a mental
image based on facial features; for example, the
wave in the person’s hair looks like a W; his name
is Walter. The authors documented improved
free recall of names using this technique.
The authors’ results suggest that tasks and situ-
ations that facilitate retrieval of implicit memory
for the learned material (e.g., learning names with
a first letter cue) will benefit from errorless learn-
ing methods, whereas those that require the explicit
recall of novel associations (such as learning routes
or programming an electronic organizer) will not
benefit from errorless learning. The more severely
 Chapter 9 managing memory deficits to optimize function 231
memory-impaired clients benefited to a greater
extent from errorless learning methods than those
who were less severely memory impaired, but the
authors cautioned that this may apply only when
the interval between learning and recall is relatively
short.
Wilson and coworkers79 compared errorful and
errorless learning in the teaching of new informa-
tion to neurologically impaired adults with severe
memory problems. Those with memory impair-
ment scored significantly higher under the errorless
condition when learning word lists. In addition,
the authors examined errorless learning via five
single case studies in which five men with severely
impaired memories learned information analo-
gous to that needed in everyday life such as learning
names of objects and people, learning how to pro-
gram an electronic aid, remembering orientation
items, and learning new items of general knowl-
edge. In each case, errorless learning was superior
to errorful learning.
Andrewes and Gielewski2 documented a suc-
cessful return-to-work case study of a 28-year-old
woman with memory loss secondary to herpes
simplex encephalitis. The described interven-
tion embraced principles of errorless learning
and the breaking down of tasks into procedural
routines appropriate for nondeclarative memory.
The intervention highlighted the extensive use of
environmental cues including a procedural folder,
which led to habit learning and unsupervised
work in filing, checking in books on a computer,
and shelving of books. The person described
in the case gained employment as a part-time
assistant librarian in the library of a law firm.
Similarly, Hunkin and associates32 documented
the case of a 33-year-old man living with severe
memory loss secondary to viral encephalitis and a
resultant seizure disorder. Techniques of errorless
learning were used to teach him word-processing
skills. After training he was able to use the skills
acquired to perform the same tasks without any
instruction.
Clare and colleagues6 examined six subjects with
dementia (Alzheimer type) who received individu-
ally tailored interventions, based on errorless learn-
ing principles and targeted at a specific everyday
memory problem. Five of the subjects showed sig-
nificant improvement on the target measures (e.g.,
learning names of those in a social club, remem-
bering personal information, using a calendar)
and maintained this improvement up to 6 months
later. The authors concluded that it is feasible to
intervene with everyday memory problems in the
early stages of dementia of Alzheimer type and that
errorless learning may be useful in addressing these
problems.
A meta-analysis of errorless learning for treat-
ing memory loss was conducted by Kessels and de
Haan36 and documented a large and statistically
significant effect size for errorless learning treat-
ment. In addition, no significant effect size was
demonstrated for the vanishing cues method (i.e.,
teaching a skill by fading cues over time). It should
be noted that the majority of studies that were ana-
lyzed used laboratory-type impairment measures
such as word lists, face-name associations, and the
like.
Assistive Technology and Electronic
Memory Aids
Wilson and colleagues83 have tested a paging
(NeuroPage) system31 that uses paging technology
as a reminder system to reduce everyday memory
and planning problems for people living with brain
injury. Using an ABA (A refers to the non-treatment
or control phase of the experiment while B refers to
the treatment phase of the experiment) single case
experimental design, the efficacy of this interven-
tion was evaluated with 15 neurologically impaired
subjects with significant everyday memory prob-
lems because of a specific memory impairment or
because of problems with planning and organi-
zation secondary to frontal lobe damage. Results
indicated that there was a significant improvement
between the baseline and the treatment phases for
each subject as evidenced by an increased mean
percentage of completed daily tasks such as taking
medications or packing a lunch.
A randomized controlled trial 81 with a cross-
over design also has been conducted to examine
this intervention. This study included 143 peo-
ple ages 8 to 83 years. The subjects presented with
memory loss, planning deficits, impaired attention,
and organization problems secondary to traumatic
head injury, stroke, or developmental learning dif-
ficulties. The subjects and their caregivers were then
asked to go through a typical day to report problems
with which they might need help. The authors give
the following example: if the person did not know
what day it was on waking, it was suggested that a
message could be sent saying, “Good morning, Joe,
it is 7:30 am on Monday, November 21.” Only mes-
sages requested or agreed on by the subjects were
selected for transmission via the pager. Participants
232 cognitive and perceptual rehabilitation: Optimizing function
also chose the wording of the messages and could
modify these as necessary during the trial. The
authors found that more than 80% of those who
completed the trial were significantly more success-
ful in carrying out everyday activities (such as self-
care, self-medication, and keeping appointments)
when using the pager in comparison with the base-
line period. For most of these, significant improve-
ments were maintained when they were monitored
7 weeks after returning the pager.
The same research team recently published the
results of using a paging system with 63 people liv-
ing with brain injury (the 63 subjects comprised
a subgroup of the aforementioned 2001 study).82
A randomized control crossover design ran-
domly allocated people to group A (pager first) or
group B (waiting list first). Using a client-centered
approach, each subject chose the tasks for which
reminders were needed. During a baseline period,
successful task performance was monitored. Group
A achieved 47.14% of tasks and group B achieved
47.88%. People in group A then received a pager
for 7 weeks. During the last 2 weeks of this 7-week
period, task achievement was documented again.
Group A now achieved 71.80% of tasks and group
B (those on the waiting list) achieved 49.05% (no
different from baseline). Group A then returned the
pagers and group B received pagers. During the last
2 weeks of this stage, participants were monitored
once more. The subjects in group A had decreased
performance but remained statistically significantly
better than during the baseline (67.23%). Group B,
meanwhile, was now performing 73.62% of tasks.
The authors concluded that the paging system sig-
nificantly reduced the everyday memory and plan-
ning problems of people with TBI.
Van Hulle and Hux73 published case examples
focused on improved functioning via compensa-
tion for persistent memory deficits impeding inde-
pendent living after brain injury. The specific task
was independence in remembering to take regularly
prescribed medications. Interventions included
strategies applied to promote learning including
the following:
• Use of written reminders (individualized medi-
cation schedule cards)
• A wristwatch alarm that vibrated at preset times
and displayed a reminder message
• A digital voice recorder and alarm system that
beeps and presents an auditory message at preset
times during the day
After participation in the intervention program,
two of the three individuals demonstrated increased
independence in remembering to take medications.
The authors highlighted the varying responses of
people with traumatic brain injury to interven-
tion using compensatory strategies and assistive
technology.
Giles and Shore25 documented positive results
when using a handheld computer to promote par-
ticipation in daily living skills for a 25-year-old
woman who survived a massive subarachnoid hem-
orrhage requiring multiple surgical interventions
18 months earlier. The insult resulted in signifi-
cant memory impairment but preserved (normal)
intelligence. The computer that was used had the
following functions: time, calculator, diary, alarm,
memo pad, and a find command. The authors
noted that the alarm function was the most helpful
for this particular case. Using the handheld com-
puter, she performed 9 of 10 scheduled activities.
Use of the computer continued at least 3 months
after the intervention.
Kim and coworkers38 described the case of a
22-year-old man with deficits in memory and
executive function secondary to a traumatic brain
injury who was undergoing inpatient rehabilita-
tion. A palm-held computer was introduced as an
external memory aid. The alarm application feature
was the focus of this intervention. Using this device
the man demonstrated an immediate improvement
in the ability to attend every therapy session and ask
for every medication on his schedule.
Kim and associates37 documented the experience
of 12 people with brain injury during the outpatient
phase of rehabilitation using palm-held comput-
ers to assist with memory-dependent activities in
their everyday lives. Each subject was provided with
a palm-held computer-based memory aid capable
of generating audible and visible reminder cues.
Subjects were contacted for follow-up between
2 months and 4 years after initial trial use, and sur-
veyed as to the usefulness of the computer. Nine
clients found palm-held computers were useful
during supervised trials, and seven of nine clients
continued to use such devices after the trials had
ended. The authors commented that their experi-
ence with this technology has shown it to be use-
ful in a high proportion of clients for assisting with
memory-dependent functions.
A study by Wright and colleagues85 provides
clinicians with data regarding choosing different
types of computer memory aids. They compared
two styles of pocket computer memory aids to
support function for people who had sustained a
nonprogressive, closed brain injury. The ­ interface
 Chapter 9 managing memory deficits to optimize function 233
used provided a diary with auditory alarms, a
notebook, and links between diary entries and
specific note pages. One computer had a physi-
cal keyboard, the other did not. Twelve subjects
were given each computer for 2 months, with a
1-month gap between, in counterbalanced order.
The authors found that all participants could use
the memory aids, and most (83%) found them
useful, although amount of use varied widely.
Calculated predictors of use included use of other
reminding systems before joining the project, and
speed in calculator addition, which the authors
thought may reflect working memory. High users
preferred the computer with a physical keyboard;
low users made more entries with the palm-size
computer. The authors cautioned clinicians to dis-
tinguish ability to use from willingness to use.
van den Broek and coworkers72 trained five peo-
ple with acquired memory impairment to use a voice
organizer to decrease prospective memory errors.
The voice organizer records the person’s voice into
memory, allowing dictation into the device that will
be played back at a set day or time. When the mes-
sage is due, a beep sounds and the reminder mes-
sage is played by pushing a button. Performance
was assessed via a message-passing task (requiring
prospective recall after a delay of 9 hours) such as,
“The book needs to be returned to the library” and
recalling household chores (delay of 1 to 6 days). All
subjects improved on the message-passing task and
all but one improved their prospective recall related
to chores after the intervention. It is suggested that
a voice organizer may be useful in the rehabilitation
of prospective memory impairment.
Similarly, the use of a commercially available dig-
ital voice recorder as a voice output memory to cue
prospective memory was tested by Yasuda and asso-
ciates.86 The voice recorder used in the study could
output approximately 300 previously recorded mes-
sages at programmed (daily and weekly) times. The
spoken messages prompted various daily tasks for
eight clients with acquired memory impairments
secondary to brain damage. Tasks such as diary
writing, letter writing, attending therapy, dishwash-
ing, taking medications, doing embroidery, and
practicing word processing were selected for each
client. Main tasks were chosen and their comple-
tion was logged. Outcome data demonstrated that
the messages output by the voice recorder were
highly effective in prompting the main tasks for five
of the eight clients. The authors concluded that a
voice recorder has great potential to assist clients
with prospective memory impairment.
Wade and Troy74 published five case studies of
those with significant everyday memory prob-
lems who were taught to use a computer system
that sends reminder messages to standard mobile
phones. Analyzing measurements of diary-format
observations and qualitative feedback, the authors
concluded that the intervention showed promising
outcomes for all of the cases (Box 9-5).
Mnemonics
Mnemonic is a broad term that refers to any strategy
that is used to remember something. These include
rhymes, poems, acronyms, and imagery techniques.
Examples include the following:
• “Thirty days hath September…” rhymes or
poems to remember how many days are in each
month.
• To remember the order of the planets Mercury,
Venus, Earth, Mars, Jupiter, Saturn, Uranus,
Neptune, use a made up sentence or acrostic
such as My Very Educated Mother Just Served
Us Nachos.
• RACE as an acronym to remember institution-
based fire safety techniques of Remove, Alarm,
Confine, Extinguish or ROYGBIV to remember
the colors of the spectrum.
• Imagining placing the items you want to remem-
ber in specific locations in a room with which
you are familiar (method of loci).
Box 9-5 Assistive Technology for Those
with Memory Loss
Handheld computers
Paging systems
Voice recorders
Personal data assistants
Alarm watches
Electronic pill box
Microwave with preset times
Adaptive stove controls to turn off an electric stove
after a certain period of time or when heat becomes
excessive
A phone with programmable memory buttons
(affix ­pictures to the buttons)
A phone with buttons that are programmed to speak
the name of the person being called
A key locator attachment
Tape recorders used to cue a behavioral sequence such
as morning care
234 cognitive and perceptual rehabilitation: Optimizing function
• Combine images and names. Shirley Temple
has curly (rhymes with Shirley) hair around her
temples.
• Chunking information such as remembering a
list of numbers 2, 6, 5, 7, 4, 8 as 265 and 748.
• Developing a story to remember information.
A couple at a restaurant may order two steaks
well done, two glasses of red wine, water, bread,
and a side of green beans. The waiter may make
up a story, such as “Two cows [steaks] were walk-
ing through the vineyard [wine] on a hot sum-
mer day [need water]. Across the field they saw a
jolly green giant [green beans].”
Hux and colleagues 33 assessed the effective-
ness of three frequencies of intervention sessions
focused on using mnemonics and visual imagery
strategies to recall names of people: once per day,
two times per week, and five times per day. Subjects
included seven male TBI survivors ranging in age
from 28 to 40 years. Results showed that sessions
held daily and twice a week were more effective
than sessions held five times per day. Mnemonics
and visual imagery strategies were effective for four
of the seven participants, regardless of frequency
intervention sessions.
More research is required to determine if mne-
monic strategies are generalizable to untrained tasks
as well as providing information related to who is
an appropriate candidate. At this point it seems that
mnemonics are best suited to remember specific and
limited types of information (e.g., staff names).
Comprehensive Interventions
Kime and coworkers40 documented rehabilitation
interventions for a 24-year-old woman who exhib-
ited chronic dense memory loss secondary to status
epilepticus. In addition to other manifestations, her
memory impairment included having no recall of
what she wore from day to day and being unable
to find the toilet after 2 weeks in the rehabilitation
program. A multidisciplinary comprehensive pro-
gram of external cueing was established to com-
pensate via her preserved procedural memory. This
cueing included the following:
• Mnemonic cues to remember names written on
index cards including her own associated draw-
ing. The cues were practiced with Polaroid pic-
tures of staff, family, etc.
• Creating a photo album of experienced events
such as outings, which were then labeled.
• Use of a date book with appointment, action,
and summary sections for each day.
• A watch alarm that chimed hourly to remind her
to refer to the date book.
Results demonstrated enhanced functioning via
use of procedural memory. In addition, the authors
found that the client demonstrated increased inde-
pendent generalization of strategies and techniques
over time.
Fleming and associates21 described and tested
a prospective memory rehabilitation program for
those with brain injury that was based on a com-
pensatory training approach using a case series
design. Outcome measures included formal pro-
spective memory assessment, self-report, and mea-
sures of diary use. The intervention (Table 9-9)
included the following:
• Self-awareness of memory deficits training via
reality testing, and standardized tests of aware-
ness and self-regulation. These tests were used
to identify main concerns in regard to prospec-
tive memory training, provide a starting point
for discussion, and establish realistic goals. Tasks
in which the subjects were required to use self-
estimation and self-prediction were used to
promote experiential feedback. The authors
hypothesized that this would confirm the need
for training; therefore, compensatory strategies
would be more readily accepted.
• Selection of a memory organizational device.
Analysis of the individual’s physical, social, cog-
nitive, and emotional characteristics as well as
pragmatic issues such as color, size, and ease
of use was considered when choosing a device
(diary, pocket computer, etc.). The subject was
involved in shopping for and purchasing the
device.
• Analysis of cueing. Time was spent analyzing
which environmental cues served as a trigger to
prompt use of the device. Cues such as alarms,
calendars, watches, and daily activities such as
mealtime were used to trigger use of the device.
• Organizational strategies and environmen-
tal strategies to facilitate appropriate planning.
Sticky notes, labels, making lists, leaving items in
view, and prioritizing were incorporated.
• Generalization was promoted by having partici-
pants practice skills in multiple real-life environ-
ments. A strategy training video highlighting
scenarios such as forgetting to pay bills also was
used to have participants critique situations
and develop compensatory strategies. Skills also
were practiced at home and in the community.
Significant others were included in the training
sessions to assist with generalization.
 Chapter 9 managing memory deficits to optimize function 235
Table 9-9 Content of Sessions
Session Topic
1 Self-awareness training
2 Self-awareness training
3 Introduction to diary training
4 “A suitable diary”
5 “Teaching my family”
6 “My routine”
7 Prospective memory critique
8 Strategy generalization
From Fleming JM, Shum D, Strong J, et al: Prospective memory rehabilitation for adults with traumatic brain injury: a compensatory training programme,
Brain Inj 19(1):1-10, 2005.
The subjects improved on formal prospective
memory assessment and demonstrated successful
schedule use after the program. Self-report of pro-
spective memory failure fluctuated and the authors
hypothesized that this may have been reflective of
increased self-awareness.
Task-Specific Training
Giles and Morgan23 documented the case of young
male with herpes simplex encephalitis who pre-
sented with severe memory and organizational
impairments but average intelligence. The specific
task trained was personal hygiene. The interven-
tion program consisted of chaining nine discrete
activities (shaving, oral care, etc.) by using linking
phases. The phrases linked the performed activity
to the one that immediately followed (e.g., “teeth
cleaned, now shave”). The person was then asked
to repeat the phrase as a cue to initiate the activity,
which was followed by the behavioral techniques of
verbal praise and a tangible reward.
Giles and Shore26 published a case study describ-
ing a rapid method of teaching a severely brain-
injured client to wash and dress. The client was
injured in an automobile accident 8 months ear-
lier. He presented with severe memory impairment,
normal attention span, and poor immediate and
delayed recall. In addition, he remained dependent
Content
Self-Awareness of Deficits Interview (SADI)
Initial assessment feedback
Experiential prospective memory task (see Chapter 4)
Self-Regulation Skills Interview (SRSI)
Experiential prospective memory task (see Chapter 4)
Review of schedule formats, note-taking, and cues
Written agreement regarding diary use
Community outing to purchase diary
Client educates significant other about diary
Note-taking revision with role plays
Home visit to review routines, diary management, and organizational
strategies
Review of strategies
Video discussion activity
Meeting at a community venue
SADI repeated
Program evaluation and feedback to therapist
Debriefing and closure
in self-care after 5 months in an acute rehabilitation
unit. The intervention was carried out in a transi-
tional living facility. The intervention consisted of
an ADL sequence that was determined by the cli-
ent’s preinjury habits and responsiveness to cue-
ing. Washing and dressing was conceptualized as a
16-step program in which the staff would cue the
next step if behavior compatible with the next step
in the sequence was not evident within approxi-
mately 5 seconds of completion of the previous
step or behavior incompatible with production of
the next step in the behavioral chain was demon-
strated. Although the client’s physical and cognitive
status remained unchanged during the program,
which lasted for 12 treatment days, he did become
independent in washing and dressing. Initially
requiring between 25 and 30 instructions as well
as physical assistance to perform the tasks, the cli-
ent progressed to independence. Independence was
maintained at 6-month follow-up.
Similarly Giles and colleagues24 present ­ further
support for these specific retraining protocols.
Four clients out of 48 who met the study criteria
were treated with the washing and dressing proto-
col. Three had TBI, and one had brain injury after
cerebral bleed. All had moderate to severe memory
loss. The training program consisted of behavioral
observation, task analysis, consistent practice, and
cue fading. The Adaptive Behavior Scale was used
236 cognitive and perceptual rehabilitation: Optimizing function
to measure behavior change. The authors found
that three subjects achieved rapid independence in
washing and dressing (requiring 20 days, 37 days,
and 11 days of treatment), and one did not show
significant clinical improvement. Of note was that
all clients admitted to the facility during a 3-year
period and who required washing and dressing
retraining were treated with the same protocol.
The authors further concluded that the consecutive
series design prevented researchers from selecting
clients who they believed were good treatment can-
didates; therefore, the findings support the general
applicability of the training program.
The use of specific behavioral sequences in
addition to other adaptations such as checklists,
reminder phone calls, tape-recorded messages that
cued a behavioral sequence, and appointment books
have been found to improve hygiene and grooming
skills and use of daily planner.60
Use of Hands-On Occupation
Eakman and Nelson16 examined men with closed
head injuries who were either randomized to a
hands-on training group or to a verbal training
group focused on food preparation (making meat-
balls). Participants were asked to recall the steps of
the food preparation in order. Those in the hands-
on group had significantly more recall than those
in the verbal training group. The authors hypothe-
sized that the hands-on occupation group provided
sensory and perceptual meaning as well as symbolic
meaning, leading to enhanced recall. A study of
Box 9-6 Strategies for Significant Others
Understand that in many cases this impairment may not
be reversible.
Become very familiar with the specific type of com-
pensatory memory strategies that have been
prescribed.
Keep daily schedules as consistent as able. Stick with hab-
its and routines.
Simplify the environment by decreasing clutter and keep-
ing the living areas organized.
Decrease excessive environmental stimuli.
Help by organizing calendars, clocks, and reminders
posted around the house.
Be proactive in identifying potential safety issues.
Use short and direct sentences.
Make sure that the most important information comes at
the beginning the sentence.
healthy third graders30 also found that participants
were able to recall more information when engaged
in a hands-on teaching method as compared with
a demonstration method. The authors suggested
that the learning advantages of hands-on occupa-
tion are related to the enhanced sensory and per-
ceptual experiences and the feelings of success that
are characteristic of hands-on learning, as opposed
to passive forms of learning.
Appendix 9-1 examines the evidence for mem-
ory loss interventions focused on improving daily
function.
Interventions for those with memory impair-
ments must consider social networks as well.
Including significant others in all interventions may
be the key factor to ensure success (Box 9-6).
Review Questions
1. Name three consequences of impaired prospec-
tive memory.
2. Explain how objective memory assessments and
self-report measures of memory may be used to
complement each other.
3. How does one use working memory throughout
the day?
4. Name and describe four steps or stages of mem-
ory formation.
5. Name the components of a Baddeley’s working
memory model.
6. Name key components of an effective memory
book or journal.
Highlight, cue, and emphasize key aspects of communica-
tion (i.e., repeat, point, etc.)
Avoid conversations that rely on memory (i.e., keep con-
versations in the present).
Repetition of sentences may be inevitable.
Summarize conversations.
Remember that in many cases, intelligence may remain intact.
Keep “a place for everything and everything in its place.”
Use photographs, souvenirs, and other appropriate items
to help access memories.
Understand that fatigue, stress, sleep disorders, and
depression can exacerbate memory loss.
Keep back-up items (glasses, spare keys, etc.).
Help create to-do lists. Remind loved ones to check it off or
highlight the item when the task is completed.
Label items, drawers, and shelves.
 Chapter 9 managing memory deficits to optimize function 237
References
1. Aldrich FK, Wilson B: Rivermead Behavioural
Memory Test for Children (RBMT-C): a preliminary
evaluation, Br J Clin Psychol 30(Pt 2):161-168, 1991.
2. Andrewes D, Gielewski E: The work rehabilitation
of a herpes simplex encephalitis patient with antero-
grade amnesia, Neuropsychol Rehabil 9(1):77-99,
1999.
3. Árnadóttir G: The brain and behavior: assessing cor-
tical dysfunction through activities of daily living,
St Louis, 1990, Mosby.
4. 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/Mosby.
5. Baddeley AD: The psychology of memory. In
Baddeley AD, Kopelman MD, Wilson BA, editors:
The essential handbook of memory disorders for clini-
cians, Hoboken, NJ, 2004, John Wiley.
6. Clare L, Wilson BA, Carter G, et al: Intervening
with everyday memory problems in dementia of
Alzheimer type: an errorless learning approach,
J Clin Exp Neuropsychol 22(1):132-146, 2000.
7. Clare L, Wilson BA, Emslie H, et al: Adapting the
Rivermead Behavioural Memory Test Extended
Version (RBMT-E) for people with restricted mobil-
ity, Br J Clin Psychol 39(Pt 4):363-369, 2000.
8. Cockburn J, Wilson B, Baddeley AD, et al: Assessing
everyday memory in patients with dysphasia, Br J
Clin Psychol 29(4):353-360, 1990.
9. Cockburn J, Wilson BA, Baddeley AD, et al: Assessing
everyday memory in patients with perceptual defi-
cits, Clin Rehabil 4(2):129-135, 1990.
10. Crawford JR, Henry JD, Ward AL, et al: The Prospective
and Retrospective Memory Questionnaire (PRMQ):
latent structure, normative data and discrepancy
analysis for proxy-ratings, Br J Clin Psychol 45(Pt 1):
83-104, 2006.
11. Crawford JR, Smith G, Maylor EA, et al: The pro-
spective and retrospective memory questionnaire
(PRMQ): normative data and latent structure in a
large non-clinical sample, Memory 11:261-275, 2003.
12. Dawson DR, Levine B, Schwartz ML, et al: Acute pre-
dictors of real-world outcomes following traumatic
brain injury: a prospective study, Brain Inj 18(3):
221-238, 2004.
13. de Wall C, Wilson BA, Baddeley AD: The Extended
Rivermead Behavioural Memory Test: A measure of
everyday memory performance in normal adults,
Memory 2(2):149-166, 1994.
14. Donaghy S, Williams W: A new protocol for training
severely impaired patients in the usage of memory
journals, Brain Inj 12:1061-1076, 1998.
15. Drysdale K, Shores A, Levick W: Use of the every-
day memory questionnaire with children, Child
Neuropsychol 10(2):67-75, 2004.
16. Eakman AM, Nelson DL: The effect of hands-on
occupation on recall memory in men with trau-
matic brain injuries, Occup Ther J Res 21(2):109-114,
2001.
17. Einstein GO, McDaniel MA: Normal aging and pro-
spective memory, J Exp Psychol Learn Mem Cogn
16:717-726, 1990.
18. Evans JJ, Wilson BA, Schuri U, et al: A comparison
of “errorless” and “trial-and-error” learning methods
for teaching individuals with acquired memory defi-
cits, Neuropsychol Rehabil 10(1):67-101, 2000.
19. Fisher AG: Assessment of motor and process skills. vol.
1: development, standardization, and administration
manual, ed 5, Fort Collins, Colo, 2003, Three Star
Press.
20. Fisher AG: Assessment of motor and process skills.
vol. 2: user manual, ed 5, Fort Collins, Colo, 2003,
Three Star Press.
21. Fleming JM, Shum D, Strong J, et al: Prospective
memory rehabilitation for adults with traumatic
brain injury: a compensatory training programme,
Brain Inj 19(1):1-10, 2005.
22. Folstein SE: Huntington’s disease: a disorder of fam-
ilies, Baltimore, 1989, Johns Hopkins University
Press.
23. Giles GM, Morgan JH: Training functional skills
following herpes simplex encephalitis: a single case
study, J Clin Exp Neuropsychol 11(2):311-318, 1989.
24. Giles GM, Ridley JE, Dill A, et al: A consecutive series
of adults with brain injury treated with a washing
and dressing retraining program, Am J Occup Ther
51(4):256-266, 1997.
25. Giles GM, Shore M: The effectiveness of an electronic
memory aid for a memory-impaired adult of normal
intelligence, Am J Occup Ther 43(6):409-411, 1989.
26. Giles GM, Shore M: A rapid method for teaching
severely brain injured adults how to wash and dress,
Arch Phys Med Rehabil 70(2):156-158, 1989.
27. Glisky EL: Prospective memory and the frontal
lobes. In Brandimonte M, Einstein GO, McDonald
MA, editors: Prospective memory: theory and applica-
tions, Mahwah, NJ, 1996, Lawrence Erlbaum.
28. Groot YC, Wilson BA, Evans J, et al: Prospective mem-
ory functioning in people with and without brain
injury, J Clin Exp Neuropsychol 8(5):645-654, 2002.
29. Hannon R, Adams P, Harrington S, et al: Effects
of brain injury and age on prospective memory
self-­rating and performance, Rehabil Psychol 40(4):
289-298, 1995.
30. Hartman BA, Miller BK, Nelson DL: The effects
of hands-on occupation versus demonstration on
children’s recall memory, Am J Occup Ther 54(5):
477-483, 2000.
31. Hersh N, Treadgold L: NeuroPage: the rehabilitation
of memory dysfunction by prosthetic memory and
cueing, NeuroRehabilitation 4:187-197, 1994.
238 cognitive and perceptual rehabilitation: Optimizing function
32. Hunkin NM, Squires EJ, Aldrich FK, et al: Errorless
learning and the acquisition of word processing
skills, Neuropsychol Rehabil 8(4):433-449, 1998.
33. Hux K, Manasse N, Wright S, et al: Effect of training
frequency on face-name recall by adults with trau-
matic brain injury, Brain Inj 14(10):907-920, 2000.
34. Josman N, Berney T, Jarus T: Performance of children
with traumatic brain injury on the contextual mem-
ory test (CMT), Phys Occup Ther Pediatr 19(3/4):
39-51, 2000.
35. Kauhanen M, Korpelainen JT, Hiltunen P, et al:
Poststroke depression correlates with ­ cognitive
impairment and neurological deficits, Stroke 30(9):
1875-1880, 1999.
36. Kessels RP, de Haan EH: Implicit learning in memory
rehabilitation: a meta-analysis on errorless learning
and vanishing cues methods, J Clin Exp Neuropsychol
25(6):805-814, 2003.
37. Kim HJ, Burke DT, Dowds MM Jr, et al: Electronic
memory aids for outpatient brain injury: follow-up
findings, Brain Inj 14(2):187-196, 2000.
38. Kim HJ, Burke DT, Dowds MM, et al: Utility of a
microcomputer as an external memory aid for a
memory-impaired head injury patient during
in-patient rehabilitation, Brain Inj 13(2):147-150, 1999.
39. Kime SK: Compensating for memory deficits using
a systematic approach, Bethesda, Md, 2006, AOTA
Press.
40. Kime SK, Lamb DG, Wilson BA: Use of a compre-
hensive programme of external cueing to enhance
procedural memory in a patient with dense amnesia,
Brain Inj 10(1):17-25, 1996.
41. Kinsella G, Murtagh D, Landry A, et al: Everyday
memory following traumatic brain injury, Brain Inj
10(7):499-507, 1996.
42. Knight RG, Harnett M, Titov N: The effects of trau-
matic brain injury on the predicted and actual per-
formance of a test of prospective remembering, Brain
Inj 19(1):19-27, 2005.
43. Kvavilashvili L, Ellis J: Varieties of intention: some
distinctions and classifications. In Brandimonte M,
Einstein GO, McDonald MA, editors: Prospective
memory: theory and applications, Mahwah, NJ, 1996,
Lawrence Erlbaum.
44. Malec J, Zweber B, DePompolo R: The Rivermead
Behavioral Memory Test, laboratory neurocognitive
measures, and everyday functioning, J Head Trauma
Rehabil 5(3):60-68, 1990.
45. Man DW, Tam SF, Hui-Chan C: Prediction of func-
tional rehabilitation outcomes in clients with stroke,
Brain Inj 20(2):205-211, 2006.
46. Markowitsch HJ: Cognitive neuroscience of mem-
ory, Neurocase 4(6):429-435, 1998.
47. Mathias JL, Mansfield KM: Prospective and declar-
ative memory problems following moderate and
severe brain injury, Brain Inj 19(4):271-282, 2005.
48. McKerracher G, Powell T, Oyebode J: A single case
experimental design comparing two memory note-
book formats for a man with memory problems
caused by traumatic brain injury, Neuropsychol
Rehabil 15(2):115-128, 2005
49. Miller G: The magical number seven, plus or minus
two: some limits on our capacity for processing
information, Psychol Rev 63:81-97, 1956.
50. Minden SL, Moes EJ, Orav J, et al: Memory impair-
ment in multiple sclerosis, J Clin Exp Neuropsychol
12(4):566-586, 1990.
51. Olsson E, Wik K, Ostling AK, et al: Everyday memory
self-assessed by adult patients with acquired brain
damage and their significant others, Neuropsychol
Rehabil 16(3):257-271, 2006.
52. Ownsworth TL, McFarland K: Memory remediation
in long-term acquired brain injury: two approaches
in diary training, Brain Inj 13(8):605-626, 1999.
53. Parente R, Kolakowsky-Hayner S, Krug K, et al:
Retraining working memory after traumatic brain
injury, NeuroRehabilitation 13(3):157-163, 1999.
54. Passolunghi M, Brandimonte MA, Cornoldi C:
Encoding modality and prospective memory in chil-
dren, Int J Behav Dev 18: 631-648, 1995.
55. Quemada JI, Cespedes JMM, Ezkerra J, et al: Outcome
of memory rehabilitation in traumatic brain injury
assessed by neuropsychological tests and question-
naires, J Head Trauma Rehabil 18(6):532-540, 2003.
56. Roche NL, Fleming JM, Shum DH: Self-awareness of
prospective memory failure in adults with traumatic
brain injury, Brain Inj 16(11):931-945, 2002.
57. Sandler AB, Harris JL: Use of external memory
aids with a head-injured patient, Am J Occup Ther
46(2):163-166, 1992.
58. Scheid R, Walther K, Guthke T, et al: Cognitive
sequelae of diffuse axonal injury, Arch Neurol
63(3):418-424, 2006.
59. Schmitter-Edgecombe M, Fahy JF, Whelan JP, et al:
Memory remediation after severe closed head
injury: notebook training versus supportive therapy,
J Consult Clin Psychol 63(3):484-489, 1995.
60. Schwartz SM: Adults with traumatic brain injury:
three case studies of cognitive rehabilitation in
the home setting, Am J Occup Ther 49(7):655-667,
1995.
61. Shum D, Valentine M, Cutmore T: Performance of
individuals with severe long term traumatic brain
injury on time, event, and activity based prospective
memory tasks, J Clin Exp Neuropsychol 21(1):49-58,
1999.
62 . Smith G, Della Sala S, Logie RH, et al: Prospective and
retrospective memory in normal ageing and ­dementia:
a questionnaire study, Memory 8:311-321, 2000.
63. Sohlberg MM, Mateer CA: Training use of compensa-
tory memory books: a three stage behavioral approach,
J Clin Exper Neuropsychol 11(6):871-891, 1989.
 Chapter 9 managing memory deficits to optimize function 239
64. Sohlberg MM, Mateer CA: Memory theory applied
to intervention. In Sohlberg MM, Mateer CA, editors:
Cognitive rehabilitation: an integrative neuropsycho-
logical approach, New York, 2001, Guilford Press.
65. Squire LR: Memory systems of the brain: a brief his-
tory and current perspective, Neurobiol Learn Mem
82:171-177, 2004.
66. Stewart FM, Sunderland A, Sluman SM: The nature
and prevalence of memory disorders late after stroke,
Br J Clin Psychol 35:369-379,1996.
67. Sunderland A, Harris JE, Baddeley AD: Do laboratory
tests predict everyday memory? a neuropsychologi-
cal study, J Verbal Learn Verbal Behav 22(3):341-357,
1983.
68. Sunderland A, Harris JE, Baddeley AD: Assessing
everyday memory after severe head injury. In Harris
JE, Morris PE, editors: Everyday memory, actions, and
absent-mindedness, London, 1984, Academic Press.
69. Tailby R, Haslam C: An investigation of errorless
learning in memory-impaired patients: improving
the technique and clarifying theory, Neuropsychologia
41(9):1230-1240, 2003.
70. Toglia J: Contextual memory test, San Antonio, 1993,
Harcourt Assessments.
71. Vakil E: The effect of moderate to severe traumatic
brain injury (TBI) on different aspects of memory: a
selective review, J Clin Exp Neuropsychol 27(8):977-1021,
2005.
72. van den Broek MD, Downes J, Johnson Z, et al:
Evaluation of an electronic memory aid in the neu-
ropsychological rehabilitation of prospective mem-
ory deficits, Brain Inj 14(5):455-462, 2000.
73. Van Hulle A, Hux K: Improvement patterns among
survivors of brain injury: three case examples docu-
menting the effectiveness of memory compensation
strategies, Brain Inj 20(1):101-109, 2006.
74. Wade TK, Troy JC: Mobile phones as a new memory
aid: a preliminary investigation using case studies,
Brain Inj 15(4):305-320, 2001.
75. Ward H, Shum D, Dick B, et al: Interview study of
the effects of pediatric traumatic brain injury on
memory, Brain Inj 18(5):471-495, 2004.
76. Waugh N: Self report of the young, middle-aged, ­young-
old, and old-old individuals on prospective memory
self-rating performance, Honours thesis, Brisbane,
Australia, 1999, School of Applied Psychology,
Griffith University.
77. Whittington CJ, Podd J, Stewart-Williams S: Memory
deficits in Parkinson’s disease, J Clin Exp Neuropsychol
28(5):738-754, 2006.
78. Wills P, Clare L, Shiel A, et al: Assessing subtle memory
impairments in the everyday memory performance
of brain injured people: exploring the potential of
the Extended Rivermead Behavioural Memory Test,
Brain Inj 14(8):693-704, 2000.
79. Wilson BA, Baddeley A, Evans J, et al: Errorless learn-
ing in the rehabilitation of memory impaired people,
Neuropsychol Rehabil 4(3):307-326, 1994.
80. Wilson B, Cockburn J, Baddeley AD, et al: The devel-
opment and validation of a test battery for detecting
and monitoring everyday memory problems J Clin
Exp Neuropsychol 11(6):855-870, 1989.
81. Wilson BA, Emslie HC, Quirk K, et al: Reducing every-
day memory and planning problems by means of a
paging system: a randomised control crossover study,
J Neurol Neurosurg Psychiatry 70(4):477-482, 2001.
82. Wilson BA, Emslie H, Quirk K, et al: A randomized
control trial to evaluate a paging system for people
with traumatic brain injury, Brain Inj 19(11):891-894,
2005.
83. Wilson BA, Evans JJ, Emslie H, et al: Evaluation of
NeuroPage: a new memory aid, J Neurol Neurosurg
Psychiatry 63(1):113-115, 1997.
84. Wilson BA, Ivani-Chalian R, Besag FM, et al:
Adapting the Rivermead Behavioural Memory Test
for use with children aged 5 to 10 years, J Clin Exp
Neuropsychol 15(4):474-486, 1993.
85. Wright P, Rogers N, Hall C, et al: Comparison of
pocket-computer memory aids for people with brain
injury, Brain Inj 15(9):787-800, 2001.
86. Yasuda K, Misu T, Beckman B, et al: Use of an IC
recorder as a voice output memory aid for patients
with prospective memory impairment, Neuropsychol
Rehabil 12(2):155-166, 2002.
 Appendix 9-1
Evidence-Based Interventions for Memory Loss Focused on
Improving Daily Function

Table 1 Summary of Research

Participant
Study Intervention Description Characteristics n Age

Sandler and Harris, Memory notebook training
199257
Sohlberg and Mateer Memory notebook training based Male with a severe traumatic
198963 on learning theory and use of
intact procedural memory
McKerracher et al, Comparison of two formats of
200548 memory notebook retraining
Ownsworth and Comparison of memory diary
McFarland, 199952 training vs. diary plus self-
instructional training
Schmitter-Edgecombe Memory notebook training vs.
et al, 199559 supportive therapy
Andrewes and Comprehensive memory
Gielewski, 19992 rehabilitation highlighting
errorless learning techniques.
Hunkin et al, 199832 Teaching work skills using
errorless learning
Wilson et al, 199783 Paging system to reduce everyday Adults with memory, planning,
memory impairment
Wilson et al, 200181 Paging system to reduce everyday Those with memory, planning,
memory impairment
Wilson et al, 200582 Paging system to reduce everyday Those with chronic traumatic
memory impairment
Male with an acquired head 1 18
injury
1 19
brain injury with profound
memory loss in addition to
multiple other impairments
A male with a mild traumatic 1 46
brain injury sustained 1 year
earlier as well as a serious
head injury greater than
2 years prior; moderate
memory impairment
Those with acquired brain 20 M = 43.1
injuries, stroke, tumor, etc.;
average length of time since
injury was 15 years
Chronic and severe closed 8 M = 29.9 (9.3)
head injury and documented
memory impairments
A 28-year-old female with 1 28
memory loss secondary to
encephalitis
A 33-year-old male with severe 1 33
memory loss secondary
to viral encephalitis and
seizures
15 Range: 19–66
attention, or organization
problems secondary to
traumatic head injury,
stroke, etc.
143 M = 38.41 (SD =
attention, or organization 15.12) Range: 8–83
problems secondary to
traumatic head injury, stroke,
or developmental learning
difficulties
63 Range: 8–65
brain injury (subgroup from
2001 study)

240
 Chapter 9 managing memory deficits to optimize function 241

Table 1 Summary of Research—Cont’d

Participant
Study Intervention Description Characteristics n Age

Van Hulle and Hux, Memory compensations via Men with chronic traumatic 3 25, 30, and 33
200673 written reminders, alarm watch, brain injuries
and a digital voice recorder
Giles and Shore, Handheld computer Female with a massive 1 25
198925 subarachnoid hemorrhage
requiring several surgical
interventions
Kim et al, 199938 Microcomputer as a memory aid Male with traumatic brain 1 22
injury undergoing inpatient
rehabilitation.
Van den Broek et al, Voice organizer to manage Adults with memory loss 5 Range: 25–56
200072 prospective memory secondary to SAH, trauma,
impairments or encephalitis
Yasuda et al, 200286 Digital voice recorder as a Adults with brain injury 8 Range: 23–57
memory aid secondary to trauma, SAH,
tumor, or multiple infarctions
Kime at al, 199640 Comprehensive external cueing Adult female with chronic 1 24
dense memory impairment
secondary to status
epilepticus
Fleming et al, 200521 Compensatory training program Adults with traumatic brain 3 19, 36, and 52
injury 2 to 12 months
postinjury
Giles and Morgan, Task-specific training using An adult male with severe 1 Undergraduate student
198923 behavioral chaining memory and organization
impairments secondary to
herpes simplex encephalitis
Giles and Shore, Task specific training of washing An adult male who sustained a 1 20
198926 and dressing closed head injury 8 months
before the intervention
Giles et al, 199724 Task specific training of washing Adults with brain damage 4 Range: 20–34
and dressing secondary to trauma or
cerebral bleed
Eakman and Nelson, Hands-on occupation to improve Adult males with traumatic 30 M = 29.6
200116 recall brain injuries

Table 2 Summary of Outcomes

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

Sandler and Harris, Case study Orientation + N/A Impairment

199257 Routine activities + N/A Activity limitations
of daily living
Sohlberg and Mateer, Case study Use of the memory + N/A Activity limitations
198963 book to support
daily life tasks and
employment.

(Continued)
242 cognitive and perceptual rehabilitation: Optimizing function

Table 2 Summary of Outcomes—Cont’d

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

McKerracher et al, ABAB (A refers Completion of + (using N/A Activity limitations

200548 to the non- prospective modified
treatment or everyday notebook
control phase of memory tasks suggested by
the experiment Donaghy and
while B refers Williams)
to the treatment Beck Depression — (secondary to N/A Impairment
phase of the Inventory adverse life
experiment) events)
single case
Ownsworth and Randomized trial Percentage of + p < 0.05 N/A
McFarland, 199952 diary entries
Self-report memory + p < 0.05 Activity limitations
questionnaire
Memory strategy use + p < 0.05 N/A
scale
Mood state + (only for p < 0.05 Impairment
questionnaire Confusion-
Bewilderment
Scale)
Schmitter-Edgecombe Randomized Wechsler Memory No difference NS Impairment
et al, 199559 controlled trial Scale (4 items)
Rivermead No difference NS Activity limitations
Behavioral
Memory Test
Everyday Memory No difference NS Activity limitations
Questionnaire
Checklist of the + p < 0.05 Activity limitations
items on the
Everyday Memory
Questionnaire
(observed
everyday
memory failures)
Symptom No difference NS Impairment
Checklist 90
Andrewes and Case study Return to gainful + N/A Participation
Gielewski, 19992 employment restrictions
Hunkin et al, 199832 Case study Ability to word + N/A Activity limitations
process
Wilson et al, 1997 83 Single case design Percent completion of + p < 0.05 Activity limitations
(ABA: A refers daily tasks
to the non-
treatment or
control phase of
the experiment
while B refers
to the treatment
phase of the
experiment)
 Chapter 9 managing memory deficits to optimize function 243

Table 2 Summary of Outcomes—Cont’d

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

Wilson et al, 200181 Randomized Percent completion of + p < 0.001 Activity limitations
controlled trial daily tasks
(crossover)
Wilson et al, 200582 Randomized Percent completion of + p < .001 Activity limitations
controlled trial daily tasks
(crossover)
Van Hulle and Hux, Case study Independence in + N/A Activity limitations
200673 taking prescribed
medications
Giles and Shore, 198925 Case study (ABAC Performing specific + N/A Activity limitations
design: A refers household
to the non- activities at a
treatment or specific time
control phase of
the experiment
while B refers
to the first
treatment
phase of the
experiment and
C to the second
treatment
phase)
Kim et al, 1999 38 Case study Attending therapy + N/A Activity limitations
sessions
Asking for + N/A Activity limitations
scheduled
medication
Van den Broek Case study (ABA) Passing on a + N/A Activity limitations
et al, 2000 72 message
Remembering + N/A Activity limitations
household chores
Yasuda et al, 2002 86 Case study (ABA Percent completion + (for five of N/A Activity limitations
design) of selected daily the eight
living tasks subjects)
Kime at al, 1996 40 Case study Percent compliance + N/A Activity limitations
of checking
date book
Number of entries in + N/A Activity limitations
date book
Number of entries on + N/A Activity limitations
monthly calendar
Cambridge + N/A Impairment
Behavioural
Prospective
Memory Test
Fleming et al, 200521 Case studies Memory for + N/A Impairment
Intentions
Screening Test

(Continued )
244 cognitive and perceptual rehabilitation: Optimizing function

Table 2 Summary of Outcomes—Cont’d

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

Fleming et al, 200521 Comprehensive +/– (varied N/A Activity limitations

Assessment results)
of Prospective
Memory
Diary use + N/A Activity limitations
Sydney Psychosocial +/− (varied N/A Participation
Reintegration results) restrictions
Scale
Giles and Morgan, Case study Level of + N/A Activity limitations
198923 independence in
morning hygiene
routine
Giles and Shore, 198926 Case study Level of + N/A Activity limitations
independence
in dressing and
washing
Giles et al, 199724 Case series Adaptive Behavior + for 3 out of 4 N/A Activity limitations
Scale subjects
Eakman and Nelson, Randomized trial Recall of steps + p < 0.001 Activity limitations
200116 related to meal
preparation

* 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; N/A,
not applicable.
 Chapter 10
Managing Executive Function Impairments to Optimize Function
Key Terms
Awareness Organization
Decision Making Planning
Dysexecutive Syndrome Prefrontal Cortex
Initiation Problem Solving
Metacognition Self-monitoring
Learning Objectives
At the end of this chapter, readers will be able to:
1. Understand the various cognitive processes that are
termed executive functions.
2. Understand how everyday living is affected if a dys-
executive syndrome is present.
“…awareness of strengths and deficits, and executive functions are prerequisites for successful
functioning in any occupation, task, or activity.”54
E  xecutive functions is an umbrella term that refers to
complex cognitive processing requiring the coor-
dination of several subprocesses to achieve a particular
goal.31 This term has been defined as “a product of the
coordinated operation of various processes to accom-
plish a particular goal in a flexible manner”40 or “those
functions that enable a person to engage successfully
in independent, purposive, self-serving behavior.”63
These higher-order mental capacities allow one to
adapt to new situations and achieve goals. They include
multiple specific functions such as decision making,
problem solving, planning, task switching, modify-
ing behavior in the light of new information, self-
245
Self-regulation
Sequencing
Strategy
3. Be aware of evaluation and assessment procedures
related to testing executive functions in the context of
everyday living.
4. Implement at least five intervention strategies focused on
decreasing activity limitations and participation restric-
tions for those living with dysexecutive syndrome.
correction, generating strategies, formulating goals,
and sequencing complex actions.6,31,63,70 Unfortunately,
there is a lack of consistency in the published litera-
ture related to whether a particular function is execu-
tive.23 Table 10-1 gives an in-depth list of the 20 most
commonly reported dysexecutive symptoms as well as
reported frequencies of these symptoms. Clearly these
executive functions support engagement in daily life
activities and ­ participation in the community, most
important during new, non-routine, complex, and
unstructured situations87 (Table 10-2).
Indeed, recent studies examining meal prepara-
tion abilities in those with frontal lobe involvement
246 cognitive and perceptual rehabilitation: Optimizing function

Table 10-1 Frequencies of Reporting Dysexecutive Symptoms*

Clients Caregivers Scaled
Reporting Reporting Rank of Disagreement in
Symptom Problem (%) Problem (%) Disagreement† Rank‡

Poor abstract thinking 17 21 16.5 −9

Impulsivity 22 22 19.5 −10
Confabulation 5 5 19.5 +3
Planning 16 48  1 +8
Euphoria 14 28  5 +7
Poor temporal sequencing 18 25 15 −8
Lack of insight 17 39  3 +5
Apathy 20 27 13 −5
Disinhibition (social) 15 23 13 −3
Variable motivation 13 15 18 −7
Shallow affect 14 23 10.5 +1
Aggression 12 25  6 +6
Lack of concern 9 26  4 +9
Perseveration 17 26 10.5 −1
Restlessness 25 28 16.5 −6
Can’t inhibit responses 11 21  9 +4
Know-Do dissociation 13 21 13 −2
Distractibility 32 42  8 +1
Poor decision making 26 38  7 −3
Unconcern for social rules 13 38  2 +10

From Burgess PW, Simons JS: Theories of the frontal lobe executive function: clinical applications. In Halligan PW, Wade DT, editors: Effectiveness of
rehabilitation for cognitive deficits, Oxford, 2005, Oxford University Press.
*Only ratings of 3 or 4 (out of a maximum of 4) for each item on the Dysexecutive questionnaire (DEX) were considered as indicating a problem. These
correspond to classification of the symptom as “often” or “very often” observed. These results are based on data gathered as part of the study by Wilson
and colleagues.93
†
This number represents the rank size of the disagreements (in proportions reporting the symptom) between clients and controls, in which 1 = largest
disagreement, that is, 1 means that caregivers reported this symptom much more often than clients.
‡
This number reflects the relative disagreement in rank frequency of reporting between clients and controls, scaled from –10 to +10, with 0 being absolute
agreement in rank position of that symptom. On this scale, –10 means that this was a commonly reported symptom by clients, but not by caregivers; and
+1 means that caregivers reported this symptom frequently, but it was relatively uncommon for clients to report it.

Table 10-2 Examples of Executive Functions Related to Everyday Living: Preparing a Salad
Executive Function Associated Tasks

Initiation Starting the task at the appropriate time without overreliance on prompts
Organization Organizing the work space and performing the task efficiently (e.g., gathering necessary
vegetables at the same time from the refrigerator)
Sequencing Sequencing the steps of the task appropriately (e.g., gather tools and vegetables, wash
vegetables, chop and slice vegetables, mix in bowl, add dressing)
Problem solving Solving the problem of a using a knife that is too dull to slice

support this hypothesis. Godbout and associates44
examined executive functions and activities of
daily living (ADL) in 10 clients with excised frontal
lobe tumors who were compared with 10 normal
controls with a neuropsychological test battery, a
script generation task, and a complex multitask
ADL (planning and preparing a meal). The clients
manifested numerous basic executive deficits on
the pen-and-paper tests, were unimpaired on the
script generation task (despite an aberrant seman-
tic structure), and manifested marked difficulties
in the meal preparation task. They concluded that
the difficulties observed related to performing a
lengthy complex multitask ADL can be explained
 Chapter 10  Managing Executive Function Impairments to Optimize Function 247
by impairment of several executive functions, gen-
eralized slowness of performance, and paucity of
behavior. Similarly, Fortin and colleagues38 inves-
tigated executive functions and ADL in 10 clients
with frontal lobe lesions after a mild to severe
closed head injury (CHI) who were compared with
12 normal controls with a neuropsychological test
battery, a script recitation task, and a simulation of
a complex multitask ADL. The authors found that
the groups did not differ on any neuropsychologi-
cal test with nonparametric testing. However, the
CHI clients manifested marked anomalies in the
meal preparation task. Although small sequences
of actions were easily produced, large action sets
could not be correctly executed. They concluded
that an outstanding deficit in strategic planning
and prospective memory (see Chapter 9) appears
to be an important underpinning of the impair-
ment of ADL observed in CHI clients with frontal
lobe lesions. Similarly it has been found that com-
ponents of executive functioning such as categori-
zation and deductive reasoning abilities of persons
with brain injury are good predictors of instru-
mental activities of daily living (IADL) functional
performance.45
The executive functions act as a manager of other
cognitive processes such as attention, memory, and
language (see Chapters 8 and 9).65 Several authors
have used the analogy of a conductor of orches-
tra to describe the role of the executive functions’
interaction with other cognitive systems. As dis-
cussed in Chapter 9, Baddeley and Hitch proposed
a working memory model that has remained the
dominant view in the field of working memory.5,6
This model provides a good example of this inter-
action (Figure 10-1). The model includes compo-
nents including the central executive system (CES),
which acts as a supervisory system and controls the
flow of information from and to its subsystems that
include the phonologic loop and the visuospatial
sketchpad. The subsystems are short-term storage
Central executive
Phonological Visuo-spatial Episodic
loop sketchpad buffer
Figure 10-1  The Baddeley and Hitch Working Memory Model.
systems dedicated to a specific content (verbal and
­visuospatial). The concept of the CES is that of a
supervisory system that controls cognitive processes
and intervenes when necessary for correction. It is
responsible for coordinating the subsystems. The
tasks that place demands on the CES include plan-
ning, reasoning, error correction, troubleshooting,
and retrieval from long-term memory74.
Recently, Serino and coworkers84 investigated
whether cognitive impairment after traumatic
brain injury (TBI) can be considered a consequence
of a speed-processing deficit or an impairment of
the CES of working memory. The authors studied
37 people with TBI using a standardized battery of
neuropsychological tests evaluating speed process-
ing, sustained attention, short-term memory, work-
ing memory, divided attention, executive functions,
and long-term memory. The clients showed a
cluster of impairments including severe deficits
in working memory, divided attention, executive
functions, and long-term memory. Divided atten-
tion, long-term memory, and executive function
deficits significantly correlated with working mem-
ory, but not with speed-processing deficits. Further
analyses showed that a CES impairment and not a
speed-processing deficit predicted divided atten-
tion, executive functions, and long-term memory
deficits. Furthermore, the severity and the site of
brain lesions did not predict the level of CES or
speed-processing impairment. The authors con-
cluded that the cognitive impairment following TBI
seems to be caused by an impairment of the CES,
rather than a speed-processing deficit.
Other recent research on executive functions
suggests that the central executive is not as central as
conceived in the Baddeley and Hitch6 model. Rather,
there seems to be separate executive functions that
can vary largely independently among individuals68
and can be selectively impaired or spared by brain
damage. Because of this overlap and documented
relationship between memory, attention, awareness,
and executive functions, the reader is encouraged to
read Chapters 4, 8, and 9 to ensure a comprehensive
understanding of these impairments and how they
affect functional performance (Figure 10-2).
Another influential model of frontal lobe func-
tion and the executive system is that of a supervi-
sory attentional system (SAS). The term attention is
used broadly and refers to the allocation of process-
ing resources.20,71,85 The model demonstrates that
many daily life actions are handled with schema
(templates) of how the process should occur.
This model distinguishes two control-to-action
248 cognitive and perceptual rehabilitation: Optimizing function
Figure 10-2  Illustration of the interdependence of attention,
memory, and executive processes. (From Sohlberg MM, Mateer
CA: Management of dysexecutive symptoms. In Sohlberg MM,
Mateer CA, editors: Cognitive rehabilitation: an integrative
neuropsychological approach, New York, 2001, Guilford Press.)
mechanisms. The first, contention scheduling, is
involved in routine situations in which actions are
triggered automatically. The second, the SAS, is
needed in situations in which the routine selection
of action is unsatisfactory, and was conceived as car-
rying out a variety of processes allowing the genesis
of plans and willed actions. The “contention sched-
uler” deals with conflicts between schema based on
environmental input. The contention scheduler is
proposed to operate automatically in well-known
situations. Action (or lack thereof) occurs without
awareness. The SAS (synonymous with the con-
cept of “central executive” used within Baddeley’s
working memory theory) is a limited capacity sys-
tem that provides conscious attentional control
over novel situations and selects behaviors. In daily
life it is used for a variety of purposes, including
tasks involving planning or decision making, trou-
bleshooting in situations in which the automatic
processes are running into difficulty, novel situa-
tions, dangerous or technically difficult situations,
and situations in which strong habitual responses
or temptations are involved. Specifically the SAS
is described as a higher control system needed to
cope with planning, novelty, problem solving, and
inhibition. The concept of multitasking21 came out
of this model, because one has limited capacity to
attend to multiple incoming stimuli.
Lezak62,63 classifies the various forms of executive
disorders listed previously using a four-part schema:
1. Volition and goal formulation: Including self-
awareness, initiation, and motivation.
2. Planning: Including the ability to conceptualize
change, be objective, conceive alternatives, make
choices, develop a plan, and sustain attention.
3. Purposive action: To implement plans for goal
achievement including productivity, self-regulation,
switching, and sequencing of actions.
4. Performance effectiveness: Including quality
control, self-correction, monitoring, and time
management.
Cicerone and associates26 also present a schema
based on executive functions. It includes four
domains based on anatomy and evolutionary
development:
1. Executive Cognitive Functions (dorsolateral
prefrontal cortex): Involved in the control and
direction (planning, monitoring, activating,
switching, inhibiting) of lower-level functions.
Working memory (see Chapter 9) and inhibi-
tion mediate executive functions.
2. Behavioral Self-Regulatory Functions (ventral/
medial prefrontal area): Involved in emotional pro-
cessing and behavioral self-regulation when cogni-
tive analysis, habit, or environmental cues are not
sufficient to determine the best adaptive response.
3. Activation Regulating Functions (medial frontal
areas): Activation via initiative and energizing
behavior. Pathology results in decrease activa-
tion and drive, also known as apathy and abulia.
4. Metacognitive Processes (frontal poles): Per­
sonality, social cognition, and self-awareness as
reflected by accurate evaluation of one’s own
abilities as well as behaviors as compared to
objective evaluation or reports by significant
others (see Chapter 4).
People living with impairments of the executive
functions, or dysexecutive syndrome,24,94 ­ present
with impaired judgment, impulsiveness, apathy, poor
insight, and lack of organization, planning, and
decision making, as well as behavioral ­disinhibition
and impaired intellectual abilities. Specific behav-
ioral characteristics include impulsivity, poor atten-
tion, erratic response, lack of flexibility, and poor
self-control.74 Of note is that people living with
executive function impairment may perform nor-
mally on pen-and-paper tests of cognition but
unfortunately present with catastrophic everyday
problems that are particularly evident in situations
requiring multitasking and planning.86 From a
recovery perspective, the intactness (or lack thereof)
 Chapter 10  Managing Executive Function Impairments to Optimize Function 249

of the executive functions may determine whether
an individual with brain damage can compensate
for other deficits such as memory loss, neglect, and
so on.87
Neuropathology
Executive function impairments are commonly
observed in those living with stroke,7,59 subcortical
ischemic vascular disease,29 TBI (in adults as well
as in children23,60), frontal dementia,31 Alzheimer’s
disease,31 Parkinson’s disease,67,88 multisystem atro-
phy,31 progressive supranuclear palsy,77 Huntington’s
disease,57 acquired immunodeficiency syndrome
(AIDS)–dementia complex,31 and various psychiat-
ric diagnoses including schizophrenia92 and depres-
sion.4 Although impairments of the executive
functions seem to be common, prevalence studies
are lacking.81
The frontal lobes have long been regarded as the
higher control center (Table 10-3 and Figure 10-3).
In particular, the prefrontal area is considered when
discussing impairments of executive functions. The
prefrontal area is in a unique position to control
executive functions because81:
• This area of the cortex has more connections to
other brain areas than any other cortical region
• The frontal cortex is “metamodel” or receives
direct cortical input from other heteromodal associ-
ation areas (i.e., the regions can act on information
that has already been processed at lower levels)
• It is the only cortical region that integrates cog-
nitive and sensorimotor information with emo-
tional valences and internal motivations
• The frontal cortex is the only region capable of
integrating motivational, mnemonic, emotional,
somatosensory, and external sensory informa-
tion into unified and goal-directed action
Neuroimaging, with positron-emission tomog-
raphy (PET) and functional magnetic resonance
imaging fMRI, has confirmed this relationship31
although attempts to link specific aspects of exec-
utive functioning to discrete prefrontal areas have
been inconclusive. In addition, the prefrontal area
does not function in isolation. Posterior cortical
regions and subcortical structures collaborate with

Table 10-3 Areas of the Frontal Lobes: Subdivisions of the Prefrontal Cortex and
Associated Impairments
Subdivision Associated Impairments

Lateral orbitofrontal (supplied by the anterior Disinhibited

cerebral artery and the middle cerebral artery) Impulsive and poorly controlled emotional behavior
Socially inappropriate behavior
Poor impulse control
Labile
Poor social judgment
Euphoric
Impaired attention and increased distractibility
Risk assessment is necessary
Dorsolateral (supplied by the middle cerebral Impairments of working memory
artery) Decreased decision making, attention, and planning
Decreased procedural sequence learning
Impaired higher-order cognitive functions such as goal selection,
planning, sequencing, response set formation, set shifting,
self-monitoring, and self-awareness
Dysexecutive syndrome
Medial area (supplied by the anterior cerebral Decreased drive, motivation, and interest
artery) Apathetic
Reduced affect
Slow to respond. Attentional deficits

Data from Lamar M, Resnick SM: Aging and prefrontal functions: dissociating orbitofrontal and dorsolateral abilities, Neurobiol Aging 25(4):553-558,
2004; Lezak MD: Newer contributions to the neuropsychological assessment of executive functions, J Head Trauma Rehabil 8(1):24-31, 1993; Lezak
MD: Executive function and motor performance. In Lezak MD, Howieson DB, Loring DW, editors: Neurological assessment, New York, 2004, Oxford
University Press; Manchester D, Priestley N, Jackson H: The assessment of executive functions: coming out of the office, Brain Inj 18(11):1067-1081, 2004;
and Royall DR, Lauterbach EC, Cummings JL, et al: Executive control function: a review of its promise and challenges for clinical research. A report from the
Committee on Research of the American Neuropsychiatric Association, J Neuropsychiatry Clin Neurosci 14(4):377-405, 2002.
250 cognitive and perceptual rehabilitation: Optimizing function

Figure 10-3  Anatomy of the frontal lobes. A, Functional areas of the frontal lobe: lateral, medial, and inferior surfaces. B, Surface and
medial views of the brain, showing key regions of the prefrontal cortex. (A, From Arnadottir G: The brain and behavior: assessing cortical
dysfunction through activities of daily living, St. Louis, 1990, Mosby. B, From Hughes C: Executive function and development. In Hopkins
B, editor: Cambridge encyclopedia of child development, Cambridge, 2005, Cambridge University Press.)

the prefrontal cortex to mediate successful executive
processing.31 An emerging view suggests that execu-
tive function is mediated by dynamic and flexible
networks and include subcortical areas such as the
basal ganglia, posterior regions, and intact func-
tioning of corticostriatal circuitry.31,82
Outcomes and Relationship to
Other Impairments
Jorge and colleagues53 examined a group 91 clients
with TBI as well as 27 clients with multiple trau-
mas but without evidence of central nervous system
injury (control group). The clients’ conditions were
evaluated at baseline and at 3, 6, and 12 months
after the traumatic episode. Cognitive testing and
quantitative magnetic resonance imaging (MRI)
were performed at the 3-month follow-up visit. The
authors found that major depression is associated
with executive dysfunction, negative affect, and
prominent anxiety symptoms. They noted that the
neuropathological changes produced by TBI may
lead to deactivation of lateral and dorsal prefrontal
cortices and increased activation of ventral limbic
and paralimbic structures including the amygdala.
Rapoport and coworkers75 also led support to the
relationship between depression and impairment
of executive functions. These authors examined the
 Chapter 10  Managing Executive Function Impairments to Optimize Function 251

PD clients but did not show significant differences.

The authors concluded that major depression in PD
is associated with a qualitatively specific neuropsy-
chological profile that may be related to an altera-
tion of prefrontal and limbic cortical areas. They also
noted that their data suggested that those with minor
depression and major depression may represent
a gradual continuum associated with increasing
cognitive deficits.
As the current literature suggests that awareness
(see Chapter 4) and executive functions are both
functions of the frontal lobes, it follows that rela-
tionships between the two constructs exist. Bogod
and colleagues13 compared measurement of aware-
ness by the Dysexecutive Questionnaire (DEX)
(self-other rating scale) and the Self-Awareness of
Deficits Interview (SADI), a semistructured inter-
view measure in 40 adults who had sustained
TBI. Evaluation of awareness by these measures
was compared with tests of executive function-
ing and IQ. The SADI was strongly related to
all three measures of executive functioning used in
their study. Similarly, Hart and coworkers48 inves-
tigated the relationship between executive func-
tions and awareness of real-world behavioral and
­attentional dysfunction in people with moder-
ate and severe TBI and uninjured controls using
eight clinical measures of executive function
(combined in a composite score, the Executive
Figure 10-3—Cont’d
Composite EC), self, and significant other ratings
on the Dysexecutive Questionnaire (DEX) and the
Cognitive Failures Questionnaire (CFQ). Those
relationship between major depression and cogni- with TBI scored significantly worse on the EC
tive impairment following mild and moderate TBI. than controls and exhibited impaired self-­awareness
Seventy-four TBI clients were assessed for the pres- ­compared with controls. Control participants agreed
ence of major depression and completed a cognitive closely with their significant others on both the
assessment battery. Subjects with major depression DEX and CFQ scales, whereas the significant oth-
(28.4%) were found to have significantly lower ers of the TBI participants reported significantly
scores on measures of working memory, processing greater degrees of difficulty on both scales than did
speed, verbal memory, and executive function those living with TBI. Low-EC scorers within the TBI
compared with those without. group had significantly worse impaired self-­awareness
Costa and associates28 investigated the relation- than controls, lending support to the hypothesis
ships among major depression, minor depression that ­ executive function is related to ­impaired self-
and neuropsychological deficits (including execu- ­awareness in chronic, moderate to severe TBI. They
tive functions impairments) in 83 people living with noted that although executive function was associated
Parkinson’s disease (PD). Depression was evaluated with impaired self-awareness in their study, further
by the Beck Depression Inventory. Those with major research is needed to determine whether executive
depression performed worse than PD clients with- function deficits contribute in a causal fashion to
out depression on two long-term verbal episodic impaired self-awareness and which of the cognitive
memory tasks, on an abstract reasoning task, and operations within executive function are responsible
on three measures of executive functioning. Those for supporting self-awareness.
with minor depression performances on the same In terms of rehabilitation outcomes, the pres-
tests fell between those of the other two groups of ence of impairments of executive functions is
252 cognitive and perceptual rehabilitation: Optimizing function
significantly correlated with IADL performance and
level of care.80 In addition, measures of executive func-
tioning and verbal memory are strongly related to
measures of functional outcome 6 months after reha-
bilitation, as measured by the Community Integration
Questionnaire and Disability Rating Scale.47 Finally,
in their review of factors related to employment out-
come following traumatic brain injury, Ownsworth
and McKenna73 found that the factors most consis-
tently associated with employment outcome included
preinjury occupational status, functional status at dis-
charge, global cognitive functioning, perceptual abil-
ity, executive functioning, involvement in vocational
rehabilitation services, and emotional status.
Evaluation and Assessments
The usual and customary tests of executive dys-
function include pen-and-paper measures or
laboratory-type tasks. These include the Wisconsin
Card Sorting Task, Trail Making Test, and the Stroop
Test, among others. As discussed in previous chap-
ters and by others65 the question of ecologic valid-
ity arises when using these measures in addition to
difficulties in generalizing results to everyday living
tasks. These measures have only low to moderate
relationships to everyday skills. Recently Burgess
and associates19 published a critique of traditional
tests of executive function and called for the fur-
ther development of ecologically valid measures of
executive functions. Their concerns (among others)
include the following:
• Traditional tests were not developed to address
concerns of clinicians (i.e., to measure clinically
significant deficits in a way that makes the impli-
cations of the test scores clear).
• The situation that such tests as card sorting and
others present is so unlike everyday situations
that knowledge of performance on this type
of task is of very little help for assessment. The
predictive validity is uncertain and there is little
relevance to real-world performance.
• Traditional tests are highly structured and are
unlike many real-life situations that are ill struc-
tured and open ended.
• Traditional tests were developed for basic sci-
ence experimental brain research. As the clinical
context differs, the requirements of clinical mea-
surement instruments differ.
Additionally, standard clinical tests used to
assess executive impairments are considered too
structured and rater-led; therefore, they fail to
capture the common problems of initiation,
planning, and self-monitoring. As discussed in
Chapter 1, measurement instruments such as the
Assessment of Motor and Process Skills (AMPS)35,36
and the Árnadóttir Occupational Therapy-ADL
Neurobehavioral Evaluation (A-ONE)2,3 (which
includes test items such as organization and
sequencing, impaired judgment, concrete think-
ing, decreased insight, and impaired initiative) are
recommended instead for those focused on the
functional rehabilitation of individuals present-
ing with attention impairments because they are
more naturalistic and lifelike. Other recommended
instruments that are more specific to executive dys-
function are discussed in the following paragraphs
and are summarized in Table 10-4.
Executive Function Performance Test
The Executive Function Performance Test (EFPT)9
assesses executive function impairments via the
performance of real-world tasks including prepar-
ing or heating up a light meal (cooked oatmeal),
managing medications, using the telephone, and
paying bills. This fact alone makes the EFPT unique
because the majority of tests of executive functions
rely on contrived laboratory type tasks or simu-
lation of activities. The EFPT identifies what the
person can successfully accomplish. The EFPT is
based on Baum and Edwards’ previously published
Kitchen Task Assessment.8
The instrument uses a structured cueing and
scoring system to assess five executive functions:
(1) initiation of each task, (2) organization, (3)
sequencing the steps of the tasks, (4) judgment and
safety, and (5) task completion. The cueing system is
based on the progressive need for assistance observed
with increasing levels of cognitive impairment. The
level of cueing necessary to support task perfor-
mance is recorded; therefore, the score is indicative
of the participant’s capacity for executive function-
ing that has been observed during performance of
everyday living tasks. Five levels of cueing range
from 0 (“no cue required”) to 5 (“do for the partici-
pant”). A higher score indicates more severe execu-
tive function deficits. The score range is 0 to 25. The
scoring and information gleaned from administer-
ing the EFPT can be used to determine whether the
person being tested can live independently or can
help families and caretakers understand how to sup-
port (i.e., the type of timing of cues and support)
the performance of the person at home.

Table 10-4 Recommended Outcome Measures and Function-Based Assessments of Executive Functions
Instrument Instrument
and Author Description
Standardized assessments
of basic activities of daily
living (ADL)
Standardized assessments
of instrumental ADL
Standardized assessments
of leisure
Standardized assessments
of participation
Standardized assessments
of quality of life
Executive Function Assesses executive function Adults with neurologic
Performance deficits during the
Test (EFPT), performance of real-
Baum et al, in world tasks. The test uses
press9 a structured cueing and
scoring system to assess
initiation, organization,
safety, and task
completion
Behavioural Sensitive to those skills Adults with brain
Assessment involved in problem
of the solving, planning,
Dysexecutive judgment, and organizing
Syndrome behavior over an
(BADS), Wilson extended period. The
et al, 199693; battery is designed to
199894 assess capacities that
are typically required in
everyday living. Includes
subtests.
Dimension Based
on International
Classification of
Population Validity Reliability Function Comments
Activity limitations See Chapter 1
Activity limitations See Chapter 1
Chapter 10  Managing Executive Function Impairments to Optimize Function
Activity limitations See Chapter 1
Participation restrictions See Chapter 1
Quality of life See Chapter 1
Discriminates between High levels of internal Impairments and activity Highly recommended because
deficits including controls and those consistency: limitations the test uses real-world
stroke and multiple living with stroke Cronbach’s alpha = tasks that are necessary to
sclerosis. It also has Significant correlations 0.94 and interrater support independent living
been validated on between the EFPT and reliability (0.91)
those living with standardized measures
schizophrenia assessing working
memory, verbal
fluency, and attention
Differentiates between Cronbach’s alpha = 0.70 Impairments assessed Normative data available
injury. Has been brain-damaged and Interrater: ranges from during simulated The BADS for Children
used with those non–brain-damaged 0.88 to 1.00 everyday problem (BADS-C) is available to use
living with controls Test-retest: low to solving tasks with children ages 7 to 16
schizophrenia as High specificity moderate correlations Demonstrated relationship
well. Correlated significantly (may be explained to everyday executive
with traditional due to the novelty problems as reported
measures of executive of some test items, by relatives
functions i.e., not novel during
Predicts competency in the second testing
role functioning period)
253
(Continued)
 254 cognitive and perceptual rehabilitation: Optimizing function
Table 10-4 Recommended Outcome Measures and Function-Based Assessments of Executive Functions—Cont’d
Dimension Based
on International
Instrument Instrument Classification of
and Author Description Population Validity Reliability Function Comments

Dysexecutive A 20-item questionnaire Those presenting with Scores by independent Test-retest: 0.7 using a Impairments assessed DEX for Children (DEX-C)
Questionnaire sampling everyday executive dysfunction raters correlated Huntington’s disease during reflection of is available
(DEX), Wilson symptoms associated secondary to significantly with both sample everyday functioning Self-rating and ratings by
et al, 199693; with executive functions neurologic disorders subtests and overall Cronbach’s alpha = significant others are
Burgess, et al, impairments. Self-rating such as head injury, scores on the BADS >0.8 using a sample compared to ascertain level
199617 and ratings by significant stroke, Parkinson’s No associations between of those with of awareness
others’ versions are disease, Huntington’s self-report on the DEX Parkinson’s disease67
available disease, etc. Has and the BADS, most
been used with probably secondary to
those living with problems with insight
schizophrenia as well
Behavior Rating A measure that documents Adults 18 to 90 Significant correlations Internal consistency: Impairments assessed The original version was
Inventory an adult’s executive Used for those with with Frontal alpha ranges from during every day developed for children and
of Executive functions or self- developmental, Systems Behavior 73 to 0.98 for the function adolescents. A preschool
Function-Adult regulation in his or her systemic, Scale, Dysexecutive various scales version also is available.
Version (BRIEF), everyday environment neurologic, Questionnaire, and Test-retest ranges from Validity and reliability based
Roth et al, Includes both a self-report and psychiatric Cognitive Failures 0.82 to 0.94 on the adult version
200579 and an informant report disorders Questionnaire
Multiple Errands A naturalistic test of Those presenting Discriminates between Interrater: ranges from Impairment and activity Both community- and
Test, Shallice executive dysfunction with executive those with and without 0.81 to 1.00 limitations hospital-based versions are
and Burgess, based on multitasking dysfunction brain injury Cronbach’s alpha = 0.77 published. Note: validity
199186; Knight during a shopping secondary to brain Significantly related to and reliability data are
and Alderman, excursion damage traditional tests of frontal based on the hospital
200256; lobe dysfunction as well version
Alderman et al, as the BADS and subtests
20031 of the Test of Everyday
Attention and the DEX as
rated by others
Good ecologic validity
Good predictor of
executive impairments
that are evident during
everyday function

Profile of the Observational assessment
Executive done using three
Control System, methods: observation
Braswell et al, in naturalistic settings,
199315 observation in simulated
setting, and interview of
client, relative, or health
care team member
Cognitive Failures Self-report measure of the
Questionnaire, frequency of lapses of
Broadbent et al, attention and cognition
198216 in daily life
Executive Function Uses naturalistic
Route Finding observations of route
Task, Boyd and finding to detect
Sautter, 199314 dysexecutive symptoms
Árnadóttir Structured observation
Occupational of basic ADL including
Therapy-ADL feeding, grooming
Neurobehavioral and hygiene, dressing,
Evaluation transfers, and mobility to
(A-ONE), detect the effect of multiple
Árnadóttir, underlying impairments
19902; 20043 including organization
and sequencing, affective
disturbances, concrete
thinking, decreased insight,
decreased judgment,
impaired initiation, etc.
Adults and Discriminates between Interrater reliability Impairment and activity Requires further psychometric
adolescents those with and without using standard and limitations testing. Limited use in the
with executive brain injury weighted kappas published literature
dysfunction appears acceptable
Used with multiple Predicts car accidents, Stable test-retest Activity limitations Includes items related to
populations workplace safety, falls, reliability memory, attention, and
Chapter 10  Managing Executive Function Impairments to Optimize Function
including those etc. executive dysfunction
with brain injuries
Those with Discriminates between Interrater reliability: 0.94 Impairments and activity
dysexecutive those with and without limitations
syndrome head injury
secondary to Acceptable concurrent
brain damage and validity with other
older adults with constructs such as
cognitive decline verbal comprehension,
perceptual organization,
etc, as well as with the
Rivermead Behavioural
Memory Test and the
Mini Mental Status
Examination
Those 16 years and Content: via expert review Interrater: 0.84 Impairments and activity Provides information related
older with central and literature review Test-retest: 0.86 limitations to how impairment of
nervous system Concurrent: Barthel executive functions affects
involvement Index, Katz Index, everyday living
Mini Mental Status Requires training
Examination
Valid for multiple
diagnoses including
stroke, brain tumor,
dementia, etc.
255
(Continued )
 256 cognitive and perceptual rehabilitation: Optimizing function
Table 10-4 Recommended Outcome Measures and Function-Based Assessments of Executive Functions—Cont’d
Dimension Based
on International
Instrument Instrument Classification of
and Author Description Population Validity Reliability Function Comments

Assessment of An observational Three years old Strong validity and Cronbach’s alpha ranges Activity limitations Provides information related to
Motor and assessment that is used and up and appropriate to use with from 0.74 to 0.93 everyday living
Process Skills to measure the quality difficulties related multiple diagnoses and Test-retest ranges from Requires training
(AMPS), Fisher, of a person’s ADL to occupational cultures 0.7 to 0.91
200335,36 assessed by rating the performance
effort, efficiency, safety,
and independence of
16 ADL motor and 20
ADL process skill items.
Includes choices from
85 tasks
 Chapter 10  Managing Executive Function Impairments to Optimize Function 257
The EFPT has been found to be significantly
associated with scores on the Functional Behavior
Profile,46 a test that measures the overall capacity
to engage in tasks, social interactions, and prob-
lem solving. The tool has been used with those
living with dementia8 (the original Kitchen Task
Assessment) and those with multiple sclerosis,46
stroke,9 and schizophrenia.55
Behavioural Assessment of the
Dysexecutive Syndrome
The Behavioural Assessment of the Dysexecutive
Syndrome (BADS)93,94 includes items that are sen-
sitive to those skills involved in problem solv-
ing, planning, and organizing behavior over an
extended period of time. The battery is designed to
assess capacities that are typically required in every-
day living. It includes the six subtests that represent
different executive abilities such as cognitive flex-
ibility, novel problem solving, planning, judgment
and estimation, and behavioral regulation.72 The
subtests include the following93,94:
• Temporal Judgment: A test of judgment and esti-
mation. This test uses four questions to assess
a subject’s ability to estimate how long various
events (such as a dental appointment) last.
• Rule Shift Cards: A test of cognitive flexibility.
This tests the ability to change an established
pattern of responding by using familiar mate-
rials. In part 1 a response pattern is established
according to a simple rule (“Say yes to a red play-
ing card”). In part 2 the rule is changed (“Say
no to a black playing card”), and subjects have
to adapt their responses, inhibiting their original
response set. Playing cards are turned over one at
a time. Performance is measured by time taken
and number of errors.
• Action Program: This is a test of practical prob-
lem solving focused on the development of a
plan of action to solve a problem and the phys-
ical manipulation of the task as opposed to a
pen-and-paper task. A cork has to be extracted
from a tall tube, a result that can be achieved
only by the planned use of various other mate-
rials provided. Successful performance requires
five steps. Scoring is based on the number of
prompts given to complete the task.
• Key Search: A test of planning and behavioral
regulation in addition to a test of strategy forma-
tion. The task is focused on a common problem,
finding a lost item. Subjects are required to dem-
onstrate how they would search a field for a set
of lost keys, and their strategy is scored accord-
ing to its functionality and efficiency.
• Zoo Map: This is a test of planning as well as prob-
lem solving and behavioral regulation as well as
rule following. It provides information about sub-
jects’ ability to plan a route to visit 6 of a possible
12 locations in a zoo, first in a demanding open-
ended situation in which little external structure
is provided (i.e., structure your own plan), and
secondly in a situation that involves following a
concrete, externally imposed strategy.
• Modified Six Elements: This is a test of planning,
task scheduling, problem solving, and performance
monitoring and behavioral regulation. Subjects
have to schedule their time to work on six tasks
(such as dictation, arithmetic, and picture nam-
ing each with two parts) over a 10-minute period
bound by a rule of not performing two parts of the
same task consecutively. The test yields three mea-
sures: number of subtasks attempted, number of
rule breaks, and the maximum amount of time
spent on one subtask. The Six Elements Test also
has been used as a stand-alone test.66,86
The BADS is useful to assess everyday prob-
lems arising from impairments of the executive
functions. It seems to detect subtle difficulties in
planning and organization, particularly in those
individuals who appear to be cognitively intact
and function well in structured situations. This
makes the tool useful in assessing and preparing
clients for moves from hospital care into more
independent living situations. The measure has
moderate ecologic validity (the tasks are simu-
lated activities) and is able to predict role func-
tioning.72 A summary profile score is derived
for each of the six tests and these profile scores
are totaled to give an overall battery score. This
can be compared with the normative data from
216 control subjects ages 16 to 87 years, with
estimated IQs ranging from 69 to 129.93,94
Behavioural Assessment of Dysexecutive
Syndrome for Children
The Behavioural Assessment of Dysexecutive
Syndrome for Children (BADS-C)32 is a valid and
reliable battery of tests of executive functioning
for children and adolescents, with neurodevelop-
mental disorders such as attention deficit hyper-
activity disorder, pervasive development disorder,
and traumatic brain injury. It consists of six
tests that have been adapted and simplified from
the BADS for adults that assess inflexibility and
258 cognitive and perceptual rehabilitation: Optimizing function

­ erseveration, novel problem solving, impulsiv-

p Behavior Rating Inventory of Executive Function
ity, planning, and the ability to use feedback to
The Behavior Rating Inventory of Executive
regulate behavior. The BADS-C incorporates a
Function-Adult Version (BRIEF-A)79 is a stan-
variety of brief, developmentally sensitive tasks.
dardized measure of an adult’s executive functions
These tasks are similar to tasks required of chil-
or self-regulation in his or her environment. The
dren and adolescents in everyday life. The test is
instrument includes a self-report and an informant
appropriate for children ages 7 to 16 years. Norms
report. The informant version can be used alone
are available.
when the rated individual is unable to complete the
self-report form or has limited awareness of his or
Dysexecutive Questionnaire her own difficulties, or in conjunction with the self-
report form.
The 20-item DEX17,93,94 samples the range of prob-
The BRIEF-A is based on the original Behavior
lems commonly associated with the dysexecutive
Rating Inventory of Executive Function41-43 (Table
syndrome in four areas of likely change: emotional or
10-5), which was developed for children and ado-
personality changes, motivational changes, behav-
lescents and is composed of 75 items that measure
ioral changes, and cognitive changes. Reported
various aspects of executive functioning:
symptoms are described in layman’s terms. The
• Inhibit: The ability to resist or delay an impulse.
DEX is used many times as a supplement to the
• Self-monitor: Checking one’s own actions during or
BADS because it provides more qualitative data
shortly after a task to ensure attainment of the goal.
related to errors in goal-directed behaviors in daily
• Plan: Anticipate future events, set goals, and
life and is part of the BADS battery. Each item
develop appropriate steps ahead of time to carry
of the DEX is rated on a 5-point scale (0 = never
out a task or action.
to 4 = very often) representing problem severity.
• Organize: Establish and maintain order within
Items include, “I sometimes act without thinking,
an activity and carry out a task in a systematic
doing the first thing that comes to mind” and “I am
manner.
unconcerned about how I should behave in certain
• Shift: The ability to alter a problem-solving strat-
situations.”
egy during complex tasks, think flexibly, and
The DEX is available in two forms, one designed
switch or alternate attention.
to be completed by the client and one by a person
• Initiate: The ability to begin a task or activity
who has substantial contact with the person such
or the process of generating ideas or problem-
as a clinician, a relative, or caretaker. An extended
solving strategies.
65-item version also has been used and is able
• Emotional control: Concerns the emotional realm
to identify executive dysfunction in those with
of inhibiting and modulating responses.
acute TBI when completed by an occupational
• Working memory: The process of holding infor-
therapist or clinical neuropsychologist.10 Wilson
mation in mind for the purpose of completing a
and associates94 performed an exploratory factor
related task.
analysis that revealed three factors—behavior,
The clinical scales form the two broader indexes,
emotion, and cognition—whereas Burgess and
Behavioral Regulation and Metacognition, which
colleagues18 reported a five-factor solution based
form the overall summary score.
on the relative rated form: inhibition, intention-
ality, executive memory, positive affect, and neg-
ative affect. Mooney and coworkers70 examined Multiple Errands Test
the self-report version of the DEX using a clinical
and nonclinical sample and concluded that best The Multiple Errands Test (MET)86 is undertaken in
factor solution for this scale was found to be a a shopping complex that is basically unfamiliar to the
four-factor solution with factors best described as person being tested. The person is given three sets of
inhibition, intention, social regulation, and abstract tasks to perform comprising eight instructions, each
problem solving. Finally, examining a sample of with varying requirements. Tasks include buying
people living Huntington’s disease revealed three items, being at a place at a certain time, and obtaining
factors: cognition, self-regulation, and insight.51 pieces of information such as the price of a vegetable.
An impairment score is calculated by totaling The MET is unique in the multitasking
the scores (maximum = 80). See Table 10-1 for demands that it places on those being tested. The
sample items. tasks are presented as a general list of requirements.
 Chapter 10  Managing Executive Function Impairments to Optimize Function 259

Table 10-5 Behavior Rating Inventory of Executive Function (BRIEF) Sample Items
(Original Version)
Teacher Form
Parent Form Item- Item-Total Expert
Scale Sample Item Content Total Correlations Correlations Ratings (%)

Inhibit Interrupts others 0.63 0.82 100

Gets out of seat at the wrong 0.65 0.79 100
times
Gets out of control more than 0.70 0.82   77
friends
Shift Resists accepting a different 0.52 0.63 100
way to solve a problem
with schoolwork, friends,
chores, and so on
Becomes upset with new 0.62 0.71 100
situations
Acts upset by a change in 0.59 0.72 100
plans
Emotional control Overreacts to small problems 0.58 0.73 100
Has explosive, angry 0.59 0.75 100
outbursts
Mood changes frequently 0.62 0.79 100
Initiate Is not a self-starter 0.51 0.73 100
Needs to be told to begin a 0.48 0.68 100
task even when willing
Has trouble getting started on 0.54 0.69 100
homework or chores
Working memory When given three things to 0.60 0.72   88
do, remembers only the
first or last
Has trouble concentrating on 0.68 0.77   88
chores, schoolwork
Needs help from adult to stay 0.67 0.78 100
on task
Plan—organize Does not bring home 0.55 0.67 100
homework, assignment
sheets, materials, and
so on
Has good ideas but cannot 0.57 0.72   75
get them on paper
Gets caught up in details and 0.54 0.58 100
misses the big picture
Organization of Cannot find things in room or 0.60 0.82 100
materials school desk
Leaves a trail of belongings 0.71 0.77 100
wherever he or she goes
Leaves messes that others 0.69 0.78 100
have to clean up
Monitor Does not check work for 0.49 0.60 100
mistakes
Makes careless errors 0.58 0.61 100
Is unaware of how his or her 0.56 0.57 100
behavior affects or bothers
others

From Gioia GA, Isquith PK: Ecological assessment of executive function in traumatic brain injury, Dev Neuropsychol 25(1-2):135-158, 2004.
260 cognitive and perceptual rehabilitation: Optimizing function

The test also includes particular rules that cannot
be broken such as not entering a store unless you
need to buy something. The person being tested
must manage multitasking and must structure,
plan, and execute the tasks efficiently.65 Initial
testing found that those who did well on tradi-
tional tabletop tests of executive functions did
worse on the MET as compared with controls.86
Performance deficiencies included rule breaks
and inefficient task completion. A recent sim-
plified version1 was published in addition to a
version adapted for use in the hospital setting.56
This version consists of four sets of simple tasks
(12 subtasks in all), has concrete rules, and pro-
vides those being tested with an instruction sheet
(Figure 10-4, A). Instructors are read by the asses-
sor (Figure 10-4, B). Errors are categorized as one
of the following:

Figure 10-4  A, Multiple errands test instruction sheet given to participants. B, Multiple errands test instruction sheet. (From Knight C,
Alderman N, Burgess PW: Development of a simplified version of the multiple errands test for use in hospital settings, Neuropsychol
Rehabil 12(3):231-256, 2002.)
 Chapter 10  Managing Executive Function Impairments to Optimize Function 261
Figure 10-4—Cont’d
• Inefficiencies: A more effective strategy could
have been used.
• Rule breaks: A specific rule—either social or one
of the nine defined within the test—is broken.
• Interpretation failures: Requirements of the task
are misunderstood.
• Task failures: One of the 12 tasks was not completed.
It has been found that task failures on the hos-
pital version of the MET as well as patterns of rule
breaking on the simplified version are predictive of
everyday behavioral ratings of problems attributed
to executive dysfunction.1,56 Similarly, performance
on the hospital version of the MET correlates with
stroke survivors’ self-report of everyday abilities
as tested by the Sickness Impact Profile and objec-
tive performance of daily living skills as measured
by the Assessment of Motor and Process Skills.30
The tasks on the hospital version are compatible
with the environment in typical inpatient facilities.
Only two tasks must be adapted to the specific test-
ing location (the name and address on the posted
envelope and the ward to contact by phone).
Alderman and associates documented two pat-
terns of impairments that emerged for those who
performed poorly on the test, those who broke
rules and those who failed to achieve tasks.1 The
“rule breakers” also tended to demonstrate mem-
ory disturbances particularly those related to mem-
ory control such as confabulations, difficulties with
temporal sequencing, and perseveration. Those
who tended to fail tasks on the MET showed nega-
tive affective symptoms such as such as apathy, lack
of emotion, and poor motivation. These findings
suggest different patterns of dysexecutive symptoms
observed in everyday life and most likely requiring
differing intervention approaches (Figure 10-5).
262 cognitive and perceptual rehabilitation: Optimizing function

Bookshop
4

3 Supermarket

1 Greengrocers 1 Greengrocers
2
2 12 13 Record shop
7 News agent News agents
3 Chemist Chemist
Travel agent Travel agent 5 6
4
11 9
Bakery

10 Stationers
8
6

5
7
8

Post office Post office

Figure 10-5  Performance of the Multiple Errands Test: control vs. impaired person. (From Burgess PW, Alderman N, Forbes C, et al: The
case for the development and use of “ecologically valid” measures of executive function in experimental and clinical neuropsychology,
J Clin Exp Neuropsychol 12[2]:194-209, 2006.)

Profile of the Executive Control System
The Profile of the Executive Control System (PRO-
EX)15 assesses functioning in everyday situations. The
rating scale is completed by a person who is closely
associated with the person being tested such as a par-
ent, significant other, or therapist. The tool documents
functioning during daily activities such as cooking or
money management in the following areas:
• Goal selection or the ability to generate a goal
with a sense of intention
• Planning and sequencing; the organizational
skills to develop written or oral plans
• Initiation, or initiating an action independently
or with various prompts
• Execution or carrying out a multistep action
• Timesense or the ability to execute a behavior in
a specified time period as well as to judge and
monitor time and to follow a time schedule
• Awareness of deficits postinjury as well as the
need to use compensatory strategies
• Self-monitoring or the ability to evaluate and
implement modifications as needed
Normative data are available. Raw scores for
each component are summed for a total final score.
The tool has been used with adults and adolescents
living with closed head injuries74,95 and has recently
been suggested to use with older adults with late-
life mood and anxiety disorders.69
Cognitive Failures Questionnaire
Broadbent and coworkers16 developed the Cognitive
Failures Questionnaire (CFQ) as a self-report mea-
sure to assess the frequency of lapses of attention,
memory, and cognition in everyday life. The CFQ
consists of 25 items that are scored by the client or
significant other. Score is based on frequency of mis-
takes and ranges from 0 (never) to 4 (very often) (see
Figure 8-2). The CFQ is clearly valuable to use for
those with other (or a combination of) cognitive
impairments (see Chapter 8 for more information
on the CFQ).
Executive Function Route-Finding Task
The Executive Function Route-Finding Task (EFRT)14
uses Likert scales to rate executive aspects of route-
finding such as task formulation, strategy of
approach, detection and correction of errors, and
dependence on cueing. This naturalistic test con-
sists of having a person find an unfamiliar office
within the facility. Developing the strategy to do
 Chapter 10  Managing Executive Function Impairments to Optimize Function 263

this is up to the person being tested. Performance
is rated on understanding the task, information
seeking, retaining directions, error detection, error
correction, and on-task behaviors. It has been used
with those with impairments of executive functions
secondary to brain damage and older adults with
cognitive decline (Figure 10-6).91
Spikman and colleagues studied the presence
and nature of dysexecutive problems after closed
head injury using a series of unstructured tasks tap-
ping executive functioning.87 The measures were
administered to 51 participants with closed head
injury in the chronic stage and to 45 healthy con-
trols. In addition, commonly used structured tests

Name: Date of evaluation: / /

Examiner: Disability code:

Instructions
‘I am going to give you an exercise which involves your finding an unfamiliar office, .
How you do this is up to you. I will go with you, but cannot answer questions about how to find the office. I want you to do
this exercise as quickly and efficiently as possible. Before you begin I would like you to tell me what I have asked you to
do.’

I. Task understanding
1. Failure to grasp nature of task despite several elaborations.
2. Faulty understanding of important element(s) requiring specific or explanatory cueing and elaboration (e.g. ‘How am
I supposed to know where it is?’).
3. Distorts peripheral detail requiring slight clarification or a non-specific cue (e.g. ‘Can you tell me where it is?’).
4. Shows a clear grasp or asks for clarification appropriately (e.g. ‘Can I get someone to take me there?’). Initiates the
task spontaneously.

II. Information-seeking
1. Aimless wandering.
2. Follows a hunch without gathering information first (unless shows prior knowledge of destination) or exhaustive
door-to-door search.
3. Gathers information before commencing search, but without appraisal of information source.
4. Shows judgement in use of information sources (e.g. selects staff over patients; clarifies confusing directions; verifies
information with another person).

III. Retaining directions (functional memory)

1. Continual forgetting of directions or name of destination and failure to use suggested means of compensating (e.g.
note taking) unless cued repeatedly.
2. Needs repeated non-specific cueing or provision of concrete strategy to compensate for memory deficits.
3. Forgets detail(s) but compensates after non-specific cue (e.g. ‘How might you keep yourself from forgetting the
destination?’).
4. Paraphrasing or clarification sufficient for remembering, or spontaneous compensation (e.g. note taking).

IV. Error detection (self-monitoring)

1. Continued errors without self-detection even after repeated examiner cues.
2. Some spontaneous awareness of errors but more instances of cueing required.
3. Some cueing required but more instances of spontaneous error detection shown.
4. Verifies correctness independently when appropriate; may exploit incidental information (e.g. signs) to prevent errors.

V. Error correction (troubleshooting)

1. Helpless or perseverative behaviour.
2. Inefficient strategy (e.g. returns to original information source).
3. Seeks help immediately once aware of error.
4. Reasons efficiently (e.g. looks for signs; considers where may have erred in following directions to self-correct).

VI. On-task behaviour

1. Must be held to task in ongoing fashion (e.g. distractible, stimulus-bound).
2. Digression from task requiring cues to redirect attention to task.
3. Incidental behaviours (e.g. small talk) interfere with inefficiency.
4. Any incidental behaviours (e.g. waving to a friend) do not hinder performance observably.
Figure 10-6  Executive Function Route-Finding Task. (From Boyd TM, Sautter SW: Route-finding: a measure of everyday executive
functioning in the head-injured adult, Appl Cogn Psychol 7[2]:171-181, 1993.)
(Continued )
264 cognitive and perceptual rehabilitation: Optimizing function

Potential contributing problems

Emotional Interpersonal

Indifference, lack of effort Self-consciousness/shyness

Poor frustration tolerance Social skills
Self-criticism, depression Requesting information
Defensiveness Flirting
Thought disturbance Interrupting
Other Other

Communication Perceptual

Speech reception Visual acuity

Expressive speech Auditory acuity
Reading ability Right/left confusion
Other Other

Motor

Manual limitations
Ambulation difficulties
Other

Evaluation of overall independence

Patient’s rating Examiner’s rating Overall
Extensive cueing required
Appreciable cueing needed (specific cues or
several non-specific cues)
Occasional non-specific cueing required
Independent of cueing

Scoring summary
Tasking understanding 1 2 3 4
Information seeking 1 2 3 4
Retaining directions 1 2 3 4
Error detection 1 2 3 4
Error correction 1 2 3 4

Overall average

Rules for cueing

1. When to cue:
(a) A non-specific cue is given when the patient deviates from the path approaching the goal (not necessarily most
direct) and passes up a subsequent opportunity for correction (e.g. sign, staff person, office doorway which might
lead to information, path leading towards goal).
(b) A specific cue is given following a non-specific cue, after the patient fails to attempt correction or passes another
opportunity for correction in doing so.
2. Nature of cues:
(a) A non-specific cue alerts the patient to monitor performance (i.e. ‘Tell me what you need to do now’), which is
essentially a means to assist the patient to be aware of the process of executive functioning.
(b) A specific cue provides information on how to execute the task, by providing the patient directive guidance in
carrying out aspects of the task.
Figure 10-6—Cont’d  Executive Function Route-Finding Task.
 Chapter 10  Managing Executive Function Impairments to Optimize Function 265
of attention and planning were administered. Of the
executive tasks, only the EFRT showed a significant
difference between both groups. (See Table 10-4
for a summary of outcome measures.)
Interventions
Interventions for those presenting with functional
limitations secondary to impairments of the execu-
tive functions can be categorized based on the focus
of the intervention and the hypothesized outcome.
These distinctions are somewhat artificial because
of overlap between the categories. For example,
using a checklist system to complete a meal may be
considered both a compensatory strategy and an
environmental modification (Box 10-1).
Problem Solving and Planning Training
von Cramon and associates90 compared specially
formulated problem-solving training (PST) to
memory training (MT) as a means of effectively
rehabilitating those with brain damage. The PST
was focused on teaching participants to be more
Box 10-1 Categories of Interventions for
Those Living with Impairments
of the Executive Functions
Environmental modifications: Examples include using
antecedent control, manipulating the amount of distrac-
tions and structure in the environment, organizing work
and living spaces, and ensuring balance of work, play,
and rest, among others.
Compensatory strategies: Examples include the use of
external cueing devices such as checklists, electronic pag-
ers, use of reminder systems, organizers, etc.
Task-specific training: Training of specific functional
skills and routines including task modifications.
Training in metacognitive strategies to promote a func-
tional change by increasing self-awareness and control
over regulatory processes: These include self-instruction
strategies, teaching problem solving, and goal manage-
ment training.
Data from Cicerone KD, Giacino JT: Remediation of executive func-
tion deficits after traumatic brain injury, NeuroRehabilitation 2(3):12-22,
1992; Sohlberg MM, Mateer CA: Management of dysexecutive symptoms.
In Sohlberg MM, Mateer CA, editors: Cognitive rehabilitation: an integra-
tive ­ neuropsychological approach, New York, 2001, Guilford Press; and
Worthington A: Rehabilitation of executive deficits: the effect on disability. In
Halligan PW, Wade, DT, editors: Effectiveness of rehabilitation for ­cognitive
deficits, Oxford, 2005, Oxford University Press.
effective in breaking down problems, and using a
slower, more controlled, and step-wise problem-
solving approach as opposed to a usual impulsive
approach. Seventeen people with brain damage
received MT and 20 received PST. The aim was to
substitute a participant’s impulsive approach to
problem solving with a verbally mediated system-
atic analysis of the goal and the means by which
it may be achieved. The participants were encour-
aged to act in the manner attributed to an intact
executive system focused on five aspects of problem
solving:
1. Problem orientation or identifying and analyz-
ing: Focused on difficulty of general recognition
of a task or a situation as a problem. The par-
ticipant’s tendency to oversimplify problems and
neglect relevant information was addressed.
2. Problem definition and formulation: Participants
learned to survey information by reading and
rereading directions and formulated questions
to augment their understanding of the problem.
Main and relevant points were written down.
A focus was to teach participants to discriminate
between relevant and irrelevant information.
3. Generating alternatives and solutions: Partici­
pants were asked to generate as many solutions
as possible for a given problem. This was done
individually followed by participants sharing
solutions. The goal was to make participants
aware that there were more solutions available
than they had originally thought.
4. Decision making: Solutions were discussed and
pros and cons of the solutions were weighed.
Feasibility of the solutions was also considered.
5. Solution verification and evaluation: Participants
learned to recognize faulty solutions, self-correct
errors, and return to other hypotheses. The focus
here was on increased sensitivity to errors and
discrepancies.
Intervention was carried out in a group format
except for a few participants who had difficulty par-
ticipating in the group secondary to marked apa-
thy. Examples of tasks used in the problem-solving
training included formulating want ads, taking
notes during a lecture, comparing lists, working
with timetables and schedules, and short detective
stories.
Participants were evaluated before and after the
training by standard intelligence tests, a planning
test, the tower-of-Hanoi puzzle, and an everyday
problem-solving behavior rating. Although some
participants in both groups seemed to have worse
test results after treatment, there was considerable
266 cognitive and perceptual rehabilitation: Optimizing function
improvement in specific problem-solving tasks,
planning scores, and behavioral ratings (inter-
preted as generalization to everyday function)
after the PST. Very few who received MT bene-
fited from the training. Further evaluation of the
intervention related to generalization is needed.
The same authors published a case study focused
on using a similar problem-solving technique to
help a person secure employment after a TBI 9
years prior.89
Rath and coworkers76 examined 60 higher-level
outpatients with TBI at least 1 year postinjury. The
subjects were randomly assigned to either conven-
tional group neuropsychological rehabilitation or an
experimental group treatment focused on the treat-
ment of problem-solving deficits. The intervention
incorporated strategies for addressing underlying
emotional self-regulation and logical thinking or
reasoning deficits. The intervention paid particular
attention to motivational, attitudinal, and affective
processes and problem-solving skills in people with
TBI. Eight specific modules were utilized within
the group under the general headings of “problem
orientation” (modules 1 through 4) and “problem-
solving skills” (modules 5 through 8). Group top-
ics included introduction to worksheets used in
the group, sensitizing group members to the sig-
nals that a real-life problem exists or recognizing
a problem exists, improving awareness of “pitfalls”
and maladaptive responses and the interaction of
these behaviors with specific internal (e.g., fatigue)
and external (e.g., dealing with certain people) con-
texts, generating lists of problematic contexts, and
self-regulation strategies to use during real-life
­scenarios. Strategies included:
° “stop and think,”
° asking “clear thinking questions,”
° “thinking their way through” each step,
° defining the problem,
° use clear thinking questions to produce,
evaluate, and examine the utility of as many
alternative solutions as possible,
° emotional self-regulation strategies, and
° problem-solving skills reinforced via role
plays and practice of demanding real-life
examples.
Those in the experimental group improved
in problem solving as assessed by several mea-
sures (executive function, problem-solving
self-appraisal, self-appraised emotional self-
­regulation, and clear thinking). In addition, objec-
tive observer ratings of role-played ­ scenarios
improved. Improvements were maintained at
6-month follow-up. The authors concluded that
their findings were consistent with successful
compensatory strategy use.
Foxx and associates39 tested a program for teach-
ing a problem-solving strategy to six adults with
closed head injuries. The program addressed four
general areas for training including community
awareness and transportation, medication/alcohol/
drugs, stating one’s rights, and emergencies/inju-
ries/safety. Forty-eight problem-solving situations
were developed. An example is, “Your friend took
his medication and 30 minutes later had a severe
rash. How would you help?” Situations to work on
were chosen by relevance, importance to indepen-
dent living, and frequency of occurrence. Responses
to four criterion questions were used for scoring,
providing feedback, and as cues during training:
When will the problem be solved? Where would
you look for help? Who would you talk to? and
What would you say?
The problem-solving training program used cue
cards that included the four questions for solving
problems, response-specific feedback, prompts, and
coaching to solve the presented problems, model-
ing by the trainer who provided sample correct
responses, teaching of self-monitoring strategies,
positive reinforcement, response practice, cueing
for self-correction, and individualized performance
criterion levels.
The three experimental subjects received base-
line, training, probes, and pre- or post-training
generalization assessments. The contrast group
received only the pre- or post-training assessments.
At 6 months the post-training results revealed that
the experimental subject’s problem-solving skills
had not only improved, but, more important, gen-
eralized to similar and most dissimilar types of sit-
uations (even when not using cue cards), whereas
the contrast group showed little change. The exper-
imental group’s 6-month scores on the generaliza-
tion assessments were comparable with those of
three normal controls.
Hewitt and associates developed and tested as
intervention based on research that suggests that
one reason people with TBI are poor at everyday
planning is that they fail to spontaneously use spe-
cific autobiographic memories to support planning
in unstructured situations.50 The authors examined
whether a self-instructional technique involving
self-cueing to recall specific autobiographic expe-
riences would improve performance on a planning
task. Two groups of 15 participants living with a
closed TBI carried out the Everyday Descriptions
 Chapter 10  Managing Executive Function Impairments to Optimize Function 267
Task in which they were asked to describe how they
would plan eight common unstructured activities.
Examples included, “How would you organize a
move to a new place to live?” “How would you look
for a new car?” and “How would you look for a new
carpet?” (Box 10-2).
Group one was then asked to describe how
to plan a second set of eight unstructured activi-
ties without training. Before completing their sec-
ond set of eight activities, group two underwent a
30-minute training session aimed at prompting the
retrieval of specific memories to support planning.
The protocol consisted of:
• Informing participants that research has shown
that people can plan activities better if they are
able to think of specific examples from their
memory of when they did something similar in
the past.
• The trainer providing the example of answering
the question, “How would you plan a holiday?”
by recalling specific memories of when this had
been done in the past.
• Another example was then given until the par-
ticipant had demonstrated an understand-
ing of the value of trying to retrieve specific
memories.
• Participants were assumed to have an under-
standing when they were able to give examples
of retrieving specific memories from their own
personal experience.
• A cue card was then placed in front of the par-
ticipants for a reminder cue (“Try to think of a
specific time and place where you carried out a
similar activity in the past”) when planning the
follow-up set of activities.
The results suggested that the intervention was
effective at increasing the number of specific mem-
ories recalled, with a corresponding increase in the
Box 10-2 Planning Tasks in Everyday Descriptions Task
Set A
• How would you organize a move to a new place to live?
• How would you look for a new car?
• How would you organize a surprise party for someone?
• How would you plan a weekend away?
• How would you look for a new kitchen?
• How would you organize a school reunion?
• How would you look for a new wedding outfit?
• How would you plan a birthday party?
From Hewitt J, Evans JJ, Dritschel B: Theory driven rehabilitation of executive functioning: improving planning skills in people with traumatic brain injury
through the use of an autobiographical episodic memory cueing procedure, Neuropsychologia 44(8):1468-1474, 2006.
effectiveness of the plan and number of relevant
steps in the plan as determined by a blind rater.
Using a single case study design, Honda tested
the effectiveness of direct training on three people
after rupture of an anterior communication artery
aneurysm.52 The intervention consisted of self-
instructional training (verbalizing steps of the task
aloud followed by whispering each step), a staged
problem-solving training (analyze the problem,
critical evaluation, etc.), and physical-set changing
exercises (showing a movement video that changes
physical activity every 2 to 3 minutes) for 6 months.
Two subjects improved their scores on a neuro-
psychological test (Tinkertoy Test) after problem-
solving training. Clients revealed improvement in
all activities in their daily lives based on significant
others’ observations, including ADL, instrumental
ADL (IADL), and leisure activities.
Self-Instruction Training
Some examples of interventions that utilized self-
instruction training as related to improving plan-
ning and problem solving have been reviewed
earlier. Cicerone and Wood published a case study
focused on a young man who was presenting with
impaired planning ability and poor self-control
secondary to a closed head injury.27 The interven-
tion consisted of a self-instructional procedure
that required him to verbalize a plan of behavior
before and during execution of the training task
and gradually faded overt verbalization (overt
verbalization/verbalizing each step out loud →
whispering → covert verbalization/inner talk).
During the self-instruction training the partici-
pant was provided with instructions related to
various aspects of planning and problem solv-
ing such as problem formulation, goal definition,
Set B
• How would you plan a trip to a museum in London
• How would you organize buying some furniture?
• How would you look for a new carpet?
• How would you plan a trip to the Lake District?
• How would you plan a wedding?
• How would you plan your Christmas shopping?
• How would you organize an evening out?
• How would you organize a day trip to France?
268 cognitive and perceptual rehabilitation: Optimizing function

subgoal identification, consideration of alter- of improvement in level of recall on both paired-

natives, and self-evaluation of results. Explicit associate and free recall tests following the executive
training regarding generalization of the use of strategy training.
these strategies applied to real-life problems.
This required an extended period of training that
Goal Management Training
included self-monitoring, multiple examples, and
feedback on the application of training in real-life Levine and colleagues published two studies exam-
situations. The authors documented a systematic ining the effects of a training procedure, Goal
reduction of off-task behaviors and problem- Management Training (GMT), aimed at decreasing
solving errors over the training period. Pre- and the disorganized behavior observed following TBI
post-­measures documented significant changes and improving one’s ability to maintain intentions
consistent with increased planning ability. Self- in goal-directed behavior (goal management).61
control ratings of everyday behaviors improved This disorganization results in one neglecting daily
with explicit training to promote generalization. goals, such as never cleaning the house, forgetting
They concluded that training of plan-ahead and to pack a lunch, or never getting around to making
self-verbalization strategies appears effective for a shopping list, all of which compromise functional
remediation of executive functioning after TBI. independence.
Generalization to real-life situations was observed In study one, clients with TBI were randomly
with extended training. assigned to brief trials of GMT or motor skills
Cicerone and Giacino published a follow-up to training. GMT entails five stages that corre-
the study, examining the effects of the self-instruc- spond to key aspects of goal-directed behavior 78
tion strategy on six clients.25 All participants pre- (Figure 10-7):
sented with impaired planning and self-monitoring.
Five of the six participants had a marked reduction
in task-related errors and perseverative behaviors.
Two of the clients who were given extra direction Stage 1 STOP! What am I doing?
related to the application of self-instruction train-
ing demonstrated increased spontaneous use in
untrained situations. Stage 2 DEFINE The MAIN TASK
Lawson and Rice also used a verbal self-instruc-
tion method to improve the reading comprehen-
sion of an adolescent male by working on executive Stage 3 LIST The STEPS
processes.58 He presented with a very limited range A.....
of ways of processing both spoken and written B.....
information and showed significant recall prob- C.....
lems. Executive strategy training was provided to
improve his ability to identify a memory problem
and to initiate a general plan for dealing with that Stage 4 LEARN The STEPS
problem. This training involved consideration of (Do I know the steps?)
task analysis, strategy selection and initiation, and NO
monitoring of strategy use. The strategy used was YES
WSTC.
DO IT
W: What are you going to do?
S: Select a strategy for the task.
T: Try out the strategy.
C: Check how the strategy is working. Stage 5 CHECK
This strategy is also reviewed related to those with (Am I doing what I planned to do?)
specific memory impairments in Chapter 9. The YES
steps were presented on cue cards and were even- NO
tually faded. The participant was taught to use this Figure 10-7  Goal management training. (From Levine B, Robertson
strategy while completing homework assignments IH, Clare L, et al: Rehabilitation of executive functioning: an
involving memorization (e.g., English and geogra- experimental-clinical validation of goal management training,
phy). The authors reported long-term maintenance J Clin Exp Neuropsychol 6[3]:299-312, 2000.)
 Chapter 10  Managing Executive Function Impairments to Optimize Function 269
• Stage 1: Orienting and assessing current state.
Stopping current activity and direct awareness
toward the task.
• Stage 2: Select the main goal.
• Stage 3: Partition the goals and make subgoals.
• Stage 4: Rehearse the steps necessary to complete
the task. Encode, rehearse, and retain goals and
sub-goals.
• Stage 5: Monitor the outcome. Compare out-
come of action with the stated goal.
These steps were taught using errorless tech-
niques—the cues for each stage were gradually
faded to make sure the person maintained near
perfect performance. Errorless learning techniques
also have been successful to manage impairments
such as apraxia and memory loss (see Chapters 5
and 9). The authors found that GMT, but not motor
skills training, was associated with significant gains
on everyday paper-and-pencil tasks designed to
mimic tasks (proofreading, a grouping task, and a
room layout task) that are problematic for clients
with goal neglect.
In study two contained in the same paper, GMT
was applied to a person who was postencephalitic
and seeking to improve her meal-preparation abili-
ties (Figure 10-8). Both naturalistic observation
and self-report measures revealed improved meal
preparation performance following GMT. The
authors concluded that these studies provide both
experimental and clinical support for the efficacy of
GMT toward the treatment of executive function-
ing deficits that compromise independence after
brain damage.
Time Pressure Management
Fasotti and coworkers noted that following severe
closed head injury, deficits in speed of informa-
tion processing are common, resulting in a feeling
of “information overload” while performing daily
tasks.34 The authors tested an approach to manag-
ing slow information processing, Time Pressure
Management (TPM). TPM uses alternative cognitive
strategies to support participation in real-life tasks
(e.g., cooking, conversation, etc.) while compensat-
ing for delayed processing. The overall focus is to
teach people to give themselves enough time to deal
with situations. Specific strategies used to prevent or
manage time pressure include the following:
• Enhancing awareness of errors and deficient
performance
• Self-instruction training
• Optimizing planning and organization
• Rehearsing task requirements
• Modifying the task environment
• Using an overall strategy of “Let me give myself
enough time”
The specific interventions are based on memory,
attention, executive functioning, and environmen-
tal modification to either prevent or manage time
pressure (see Chapters 8 and 9).
The authors tested TPM via a randomized trial
(pretraining vs. post-training vs. follow-up), exam-
ining those with severe closed head injury. TPM
training was compared with concentration training
in which verbal instruction was the key element.
Specific concentration strategies included trying to
focus, not getting distracted by outside sounds and
other information, not getting distracted by irrel-
evant thoughts, and trying to imagine things that
are being said. The authors found that although
both treatments improved task performance, TPM
resulted in greater gains than concentration train-
ing and seemed to generalize to other measures of
speed and memory function.
External Cueing Devices
Evans and coworkers described the rehabilitation of
executive problems in a 50-year-old woman follow-
ing a stroke 7 years earlier.33 The client presented
with intact general intellectual and memory func-
tioning, but had specific executive impairments
of attention, planning, realizing intended actions,
and exhibited behavioral routines similar in form
to obsessive-compulsive rituals (this was particu-
larly evident in bathing routines that could require
up to 90 minutes to complete secondary to a rit-
ual of washing 31 body parts, each for a particu-
lar amount of time). Overall she had a significant
impairment related to carrying out tasks that she
intended to perform. The intervention consisted of
an external cueing system, NeuroPage, which has
also been used for people living with memory loss
(see Chapter 9). The use of a pen-and-paper check-
list system also was tested. Using a series of single-
case experimental designs, the efficacy of the two
external cueing systems in prompting appropriately
timed action was documented.
When using the NeuroPage device, specific tasks
were chosen that the client failed to perform regu-
larly and without prompting. These included taking
medications, watering plants, washing undergar-
ments, attending a volunteer job, and preparing
dinner. The NeuroPage was programmed to pro-
vide reminders to perform the targeted tasks. The
270 cognitive and perceptual rehabilitation: Optimizing function

Figure 10-8  Application of goal management training to improve meal preparation. (From Levine B, Robertson IH, Clare L, et
al: Rehabilitation of executive functioning: an experimental-clinical validation of goal management training, J Clin Exp Neuropsychol
6[3]:299-312, 2000.)

pager had a marked effect on the probability of the
client’s carrying out her intended actions at the
appropriate time.
The intervention used to decrease the amount of
time spent on ritualistic behavior in the bath was
that of a checklist. Further investigation revealed
that bathing took so long because the client would
lose track of where she was in her bathing sequence
and go back to wash areas she had already washed.
A checklist was provided that cut the number of
 Chapter 10  Managing Executive Function Impairments to Optimize Function 271
body areas down to nine (eight body areas plus her
glasses). The client was to check off the body part
washed and move on to the next. Using the check-
list system, bath time decreased to a more appropri-
ate 40 minutes.
The authors argued that the combination of
external control and increased sustained attention to
action were critical to the success of NeuroPage with
this client. Furthermore, they hypothesized that the
checklist was effective in facilitating the client’s abil-
ity to foresee and recognize the consequences of her
actions, which in turn had an effect on the probabil-
ity of her changing those same actions.
The successful use of external cueing systems was
also documented by Schwartz.83 She documents the
case of a 30-year-old male with a brain injury who
presented with impaired daily living skills secondary
to decreased problem solving, memory, error detec-
tion, initiation, and attention. External cueing was
provided by a tape recorder with a personalized mes-
sage that created a behavioral chain for a morning
routine. A timer was used on the tape recorder that
played on a high volume at the time of the client’s
awakening. An example of the taped message is “It’s
time to do the three S’s: shower, shave, and sham-
poo.” Overall the tape recording addressed show-
ering, shaving, hair washing, brushing teeth, and
taking medications. Additional tapes focused on eat-
ing breakfast and checking an appointment sched-
ule. In addition written reminders and checklists that
reinforced the tape recordings were taped on the wall
(e.g., “Go to the bathroom, not the living room”).
Manly and associates tested an intervention
based on previous reports of everyday difficulties,
and performance on complex lifelike tasks, hypoth-
Sorting conference labels
into alphabetical order
Proof-reading
the hotel
leaflet
Sorting the
charity
collection
Figure 10-9  The hotel task (From Manly T, Hawkins K, Evans J, Woldt K, et al: Rehabilitation of executive function: facilitation of effective
goal management on complex tasks using periodic auditory alerts, Neuropsychologia 40[3]:271-81, 2002.)
esizing that an adequately represented goal may
become neglected as clients become overly engaged
in current activity.66 The researchers modified the
environment by providing a brief auditory stim-
ulus used to interrupt current activity and to cue
clients to consider their overall goal in an attempt
to improve performance in a complex task. The
auditory cues were delivered by a tape recorder
to serve as brief interruptions to current activ-
ity with the hope that the participants would use
them as a reminder to consider their current behav-
ior and goals. Ten people with brain injury com-
pleted a modification of the Six Element Test called
the Hotel Test. In the Hotel Test, the participants
were asked to try to do some of each of five sub-
tasks within 15 minutes. Simulated tasks related to
running a hotel included compiling individual bills,
sorting the charity collection, looking up telephone
numbers, sorting conference labels, proofreading
the hotel leaflet, and opening and closing the garage
doors by pressing buttons. Because the total time
to complete all of the tasks would exceed an hour,
the measure focused on the participants’ ability to
monitor the time, switch between the tasks, and
keep track of their intentions (Figure 10-9).
The Hotel Test was given in two conditions (with
and without auditory cues). When the alerting
tones were used, participants were informed that
the tape recorder would periodically “beep” and
were told, “You might find this useful in remind-
ing you to think about what you are currently doing
and your overall aims during the session.” Without
the external auditory cues, the participants per-
formed significantly more poorly than age- and
IQ-matched control volunteers. A common error
Looking-up
telephone
numbers
Opening and
closing the garage
doors at set times
Compiling
individual
customer bills
272 cognitive and perceptual rehabilitation: Optimizing function
was to continue performing one task to the detri-
ment of beginning or allocating sufficient time to
others. When exposed to the periodic, nonpredic-
tive, interrupting tones, their performance was sig-
nificantly improved and was no longer significantly
different from the control group on key variables
(number of tasks attempted and the time alloca-
tion to those tasks). The authors felt that the results
attribute poor performance to goal neglect rather
than other deficits such as poor memory or com-
prehension. They suggest that providing environ-
mental support to one aspect of executive function
may facilitate monitoring and behavioral flexibility
and improve performance.
Successful use of external cues such as checklist
has improved performance of specific skills. Burke
and colleagues published a series of case studies
focused on retraining of work and vocational skills
that were impaired secondary to impaired execu-
tive functions after traumatic brain injury.22 One
case study that focused on planning and prob-
lem solving concerned J., who was having dif-
ficulty in his rehabilitation process, specifically
vocational skills. J. was performing woodworking
tasks incorrectly secondary to sequencing and mem-
ory impairments, which resulted in his becoming
angry and frustrated. Specific woodworking skills
were trained via verbal prompting to encourage
task performance, training in the use of a check-
list with the steps of the task written out along with
boxes for checkmarks to indicate completion, and
practice without the checklists. J. improved on all
four woodworking tasks. When the checklist was
introduced, performance increased to 100%, which
was maintained at follow-up when the checklist
was withdrawn. A generalization task that consisted
of altered equipment and hidden tools gradually
increased to 100% without intervention indicating
a level of generalization.
A second study by the same authors focused on
three adults with brain injuries who had difficulty
with work/vocational tasks secondary to an inabil-
ity to carry out plans and self-initiate. Specifically
trained tasks included a series of kitchen tasks (pre-
paring salads on dinner trays, bagging garbage,
stacking dishes, cleaning counters, and sweeping),
wood shop tasks (sweeping, cutting timber, planing
wood), and work tasks (taking inventory, clocking
in and out, setting up workstations, cleaning up).
Interventions consisted of the following:
• Use of self-initiation checklists. The checklist
ordered the tasks sequentially to be checked off
on completion.
• Modeling prompts of how to perform the task,
check it off on the checklist, and determine
which task is next.
• Breaking the tasks into components.
• Verbal prompts and cues regarding which tasks
occurred next.
• Withdrawal of the checklists after training.
Positive results included a significant reduction
in cues or prompts needed to complete the tasks
and an increased number of components of the
tasks completed correctly.
Metacognitive and Strategy Training
Birnboim and Miller12 tested the effectiveness of a
metacognitive therapeutic approach11on 10 people
with multiple sclerosis and executive dysfunction.
Metacognition has been described as “cognition
about your cognition” or “knowing about knowing.”
The approach focuses on the metacognitive aspects
of behavior (see Chapter 4) and assumes that meta-
cognitive aspects can and should be learned explic-
itly using a structured process. Phases of the process
include the following:
1. Understanding: The person must recognize his
or her specific metacognitive deficits such as not
planning. This was achieved via confronting var-
ious tasks in the clinic to increase awareness.
2. Practice: Efficient and specific strategies that the
participant and therapist identify together (e.g.,
set priorities) are learned and practiced.
3. Transfer: Participants and their therapist con-
sider when and where these strategies can be
applied in real-life situations.
Computer strategy games (e.g., “Mastermind)
and tabletop exercises were used during the first two
phases of the training. Individualized daily activi-
ties were the focus of the generalization phase (e.g.,
specific work tasks). Positive results were noted on a
strategy application test, tests of attention, memory
tests, tests of executive function, and, most impor-
tant, improved occupational role as measured by
the Occupational Therapy Functional Assessment
Compilation Tool (OT FACT).
Manipulating Environmental Variables
Hayden and coworkers described a treatment model
focused on improving function and productivity
as well as decreasing burden of care for individu-
als with TBI.49 The model addressed the interaction
between critical environmental variables and areas
of deficit. A specific focus is placed on two primary
 Chapter 10  Managing Executive Function Impairments to Optimize Function 273
environmental variables: (1) degree of distraction
tolerated and (2) degree of structure required by
each individual to function optimally. These vari-
ables are systematically addressed in treatment
through environmental simulations within the
clinic. Key principles of the program include the
following:
1. The only treatment that counts is treatment that
generalizes to natural environments.
2. Areas of deficit that affect function and partici-
pation are assessed and treated in a systematic
way.
3. Responsibility for treatment of all deficits is
shared across disciplines; therefore, ways of gen-
eralizing treatment throughout the day are cre-
atively sought and used.
4. Treatment modalities are embedded in tasks or
situations in which the client would be expected
to engage outside the clinic, and tasks that have
no direct relevance or face validity to a client are
avoided, if at all possible.
5. Although treatment uses both restorative and
compensatory techniques, a heavy focus is placed
on compensation.
6. A client will not use compensatory strategies that
do not appear “natural,” and client participation
in choice of strategies is critical.
7. Outcome is highly dependent on each client’s
becoming an expert on his or her own situation
and clinical presentation; therefore, emphasis is
placed on the importance of accurate self-evalu-
ation, and the ability to assess his or her own sta-
tus accurately on a day-to-day basis.
Specific tasks used in treatment are selected and
include independent living tasks (e.g., brushing
teeth, completing bathing routine, doing laundry,
preparing a simple sandwich, calling for infor-
mation about times for movies, maintaining a
checkbook), community mobility (e.g., structured
topographical orientation exercises, trips, read-
ing maps, arranging transportation), and volun-
teer or vocational activities. Clients are assigned
to the appropriate environment, and as treat-
ment progresses (i.e., clients master skills in the
initial treatment environment) they are gradually
moved to more distracting and complex environ-
ments. Environmental structuring is focused on
level of tolerated distractions and necessary struc-
ture. The amount of distractions that can be tol-
erated in the environment without overwhelming
brain resources ranges from very low (an environ-
ment with essentially no auditory or visual stim-
uli that are extraneous to the treatment) to high
(an environment with constantly changing visual
and auditory stimuli, including frequent interrup-
tions). The amount of structure ranges from very
high (the person is guided through tasks by sim-
ple one-step commands, and/or greater than 50%
of the structure is imposed from sources exter-
nal to the client and no abstraction or interpreta-
tion is demanded) to low (demands less than 5%
external structure for successful task completion).
Functional outcome is considered an interplay
between deficit and environment. The outcome
data presented indicate the participants in this
treatment model made significant gains with
regard to improved daily function.
Using Antecedent Control
Fluharty and Glassman published a case study of
K.M., a 23-year-old male, after a severe TBI sus-
tained during a motor vehicle accident.37 K.M. pre-
sented with disorientation, aggressive behavior,
a lack of awareness of deficits, decreased divided
attention, perseveration, decreased sequencing,
and profound deficits in memory, reasoning, and
insight. Overall his presentation was consistent
with dorsolateral frontal involvement. In addition
to his cognitive deficits he presented with hypersen-
sitivity to stimuli. Overall he was unmanageable in
a subacute rehabilitation setting requiring restraint
to complete ADL, threatening and hitting staff and
clients, and so on. Barriers to transition to a group
home included aggression and inability to perform
ADL. The staff focused on identifying character-
istic mannerisms that preceded aggression (e.g.,
swearing, baring teeth) and documented them.
Hypersensitivity to loud noise and poor tolerance
for people approaching K.M.’s personal space was
also documented.
The staff then focused on preempting the aggres-
sive behavior including the following:
• Reframing agitating stimuli as benign (“A
person touching you is being friendly”).
• Use of distraction with jokes or comments
related to topics that K.M. was interested in.
This technique redirected K.M. from becoming
aggressive or noticing irritating stimuli.
• Modification of ADL to be less irritating and
noxious (e.g., elastic laces to make shoes easier
to don; because showering was interpreted as
a noxious stimulus, bathing was used instead).
Only one staff member at a time was present for
bathing to make it less stimulating. Step-by-step
directions for ADL sequencing were provided.
274 cognitive and perceptual rehabilitation: Optimizing function
• The Premack principle (a commonly occur-
ring and more desirable action is used as a
reinforcer for a less commonly occurring and
less desirable one) was used. High- and low-
frequency behaviors were paired to increase
cooperation with ADL. Tasks that were read-
ily engaged in and found reinforcing by K.M.
such as walking and snacking were engaged
in after he completed activities that he found
less reinforcing such as nail care and dressing.
For example, he could go for a walk after he
brushed his teeth.
Minimizing sources of agitation reduced the
client’s outbursts and facilitated the completion
of functional tasks, such as bathing and dress-
ing. These modifications of the environment also
increased K.M.’s participation in social and leisure
activities. The changes improved the outcome of
K.M.’s rehabilitation and he transitioned success-
fully to a group home.
Box 10-3 Further Strategies to Manage Functional Deficits Secondary to
Dysexecutive Symptoms*
1. Organize living and work spaces such as:
• Labeling and organizing drawers, cabinets.
• Organizing shelves in kitchen cabinets and the
refrigerator based on categories (e.g., by meal, food
category, products that are used together).
• Use paper-based organization systems such as
organizers, calendars, appointment books.
• Color code or use in/out tray systems for work and
home tasks (e.g., blue dots indicate priority work
such as bills to be paid or files in the bottom tray can
be reviewed next week).
• Use organizing technology such as personal data
assistants, alarm watches, handheld organizers,
personal information manager software (these may
include e-mail applications, a calendar, task and
contact management, note taking, and a journal.
• Post lists of usual and typical sequenced tasks in
appropriate locations (e.g., a morning ADL routine
posted on the bathroom mirror, night tasks such
as lock the door and make lunch posted on the
nightstand, arrive-at-work tasks such as check e-mail
and phone messages posted on the computer screen).
• Use timer functions while cooking.
*See related chapters that discuss memory, attention, and awareness.
Data from Cicerone KD, Giacino JT: Remediation of executive function deficits after traumatic brain injury, NeuroRehabilitation 2(3):12-22, 1992; Sohlberg
MM, Mateer CA: Management of dysexecutive symptoms. In Sohlberg MM, Mateer CA, editors: Cognitive rehabilitation: an integrative neuropsychological
approach, New York, 2001, Guilford Press; and Worthington A: Rehabilitation of executive deficits: the effect on disability. In Halligan PW, Wade, DT, editors:
Effectiveness of rehabilitation for cognitive deficits, Oxford, 2005, Oxford University Press.
Self-Regulatory Training
Liu and coworkers published a case series focused on
counteracting the loss of previous learned behaviors
that affect an individual’s daily functioning.64 Self-
regulatory training was used to improve individually
selected daily living tasks. The authors designed the
intervention on the premise that the use of self-reg-
ulation helps the individual to relearn lost behaviors
by bringing problems and solutions to the self-con-
scious level through independent and reflective
learning derived using a social cognitive perspec-
tive. The linking of problems and solutions makes
information processing possible. Client-chosen
daily tasks such as doing laundry, making tea, wash-
ing dishes, handling money, taking medications, and
using the phone were used to assess the relearning
ability of the subjects pre- and postprogram. The
1-week self-regulatory training on five selected daily
tasks consisted of the following:
2. Decrease environmental distractions
• Keep office door closed.
• Use “do not disturb” signs when appropriate.
• Turn off background radio and television.
• Shut window blinds.
• Keep workspaces (desks, kitchen counters, coffee
tables) clear of clutter.
• Use phone-answering systems.
• Post office hours.
3. Plan and organize the day
• Avoid multitasking.
• Families should establish structured routines (e.g.,
dinner at 7 pm each day, laundry is done on Saturday
mornings).
• Avoid situations in which multiple people are
speaking at once.
• Use clear and concise instructions.
• Integrate relaxation breaks throughout the day.
• Establish several “check your work and progress”
points throughout the day (time to tick off checklists
for completed tasks, check organizer for tasks that
still need to be completed).
 Chapter 10  Managing Executive Function Impairments to Optimize Function 275
1. The participants watched a videotape of a healthy
volunteer perform the task.
2. The participant then performed the task, and it
was videotaped.
3. The video was played back, and participants
were encouraged to identify problems encoun-
tered during the task. The whole performance
was shown to them and they reviewed problems
as a whole.
4. This was followed by replaying the video with
pauses and using slow motion when problems
were identified.
5. If there were problems that the participants were
not aware of, slow-motion playback was used to
guide problem identification.
6. Possible solutions were identified by the
participants.
7. Solutions were practiced and videotaped to
review the effectiveness of the solutions.
8. The process of finding and evaluating solutions
continued until an effective solution was found.
The authors concluded that their observations
suggest that with specific guidance for people with
different needs, such as with impaired cognitive
function and depression, self-regulation is effec-
tive in enhancing the relearning of lost functions.
Box 10-3 lists further potential strategies to manage
dysexecutive syndrome. See Appendix 10-1 for a
review of evidence-based interventions.
Review Questions
1. Describe how an impairment of the executive
functions would affect (1) meal planning, (2)
vacationing in a city you have never been to, and
(3) working as a receptionist.
2. Describe two models of frontal lobe function.
3. Develop a treatment program for a person with
planning deficits who is preparing to return to
high school after a brain injury.
4. Describe components of goal management train-
ing and time pressure management interventions.
References
1. Alderman N, Burgess PW, Knight C, et al: Ecological
validity of a simplified version of the Multiple Errands
Shopping Test, J Clin Exp Neuropsychol 9(1):31-44,
2003.
2. Árnadóttir G: The brain and behavior: assessing
­cortical dysfunction through activities of daily living,
St Louis, 1990, Mosby.
3. 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/Mosby.
4. Austin MP, Mitchell P, Goodwin GM: Cognitive defi-
cits in depression: possible implications for functional
neuropathology, Br J Psychiatry 178:200-206, 2001.
5. Baddeley AD: Working memory, New York, 1986,
Oxford University Press.
6. Baddeley AD, Hitch G: Working memory. In Bower
GH, editor: The psychology of learning and motiva-
tion: advances in research and theory, Vol. 8, New
York, 1974, Academic Press.
7. Ballard C, Stephens S, McLaren A, et al: Neuro­
psychological deficits in older stroke patients, Ann N Y
Acad Sci 77:179-182, 2002.
8. Baum CM, Edwards D: Cognitive performance in
senile dementia of the Alzheimer’s type: the kitchen
task assessment, Am J Occup Ther 47:431-436, 1993.
9. Baum CM, Edwards DF, Morrison T, et al: The reli-
ability, validity, and clinical utility of the Executive
Function Performance Test: a measure of executive
function in a sample of persons with stroke, Am J
Occup Ther, in press.
10. Bennett PC, Ong B, Ponsford J: Measuring executive
dysfunction in an acute rehabilitation setting: using
the dysexecutive questionnaire (DEX), J Clin Exp
Neuropsychol 11(4):376-385, 2005.
11. Birnboim SA: Metacognitive approach to cognitive
rehabilitation, Br J Occup Ther; 58:61-64, 1995.
12. Birnboim S, Miller A: Cognitive rehabilitation for
multiple sclerosis patients with executive ­dysfunction,
J Cogn Rehabil, 22:11-18, 2004.
13. Bogod NM, Mateer CA, Macdonald SWS: Self-
awareness after traumatic brain injury: a comparison
of measures and their relationship to executive func-
tions, J Clin Exp Neuropsychol 9(3):450-458, 2003.
14. Boyd TM, Sautter SW: Route-finding: a measure of
everyday executive functioning in the head-injured
adult, Appl Cogn Psychol 7(2):171-181, 1993.
15. Braswell D, Hartry A, Hoornbeek S, et al: Profile of the
executive control system, Wake Forest, NC, 1993, Lash
& Associates.
16. Broadbent DE, Cooper PF, FitzGerald P, et al:
The Cognitive Failures Questionnaire (CFQ) and its
correlates, Br J Clin Psychol 21:1-16, 1982.
17. Burgess PW, Alderman N, Emslie H, et al: The dys-
executive questionnaire. In Wilson BA, Alderman N,
Burgess PW, et al, editors: Behavioural assessment of
the dysexecutive syndrome, Bury St. Edmunds, UK,
1996, Thames Valley Test Company.
18. Burgess PW, Alderman N, Evans J, et al: The ecologi-
cal validity of tests of executive function, J Clin Exp
Neuropsychol 4:547-558, 1998.
19. Burgess PW, Alderman N, Forbes C, et al: The case
for the development and use of “ecologically valid”
measures of executive function in experimental and
clinical neuropsychology, J Clin Exp Neuropsychol
12(2):194-209, 2006.
276 cognitive and perceptual rehabilitation: Optimizing function
20. Burgess PW, Simons JS: Theories of the frontal lobe
executive function: clinical applications. In Halligan
PW, Wade DT, editors: Effectiveness of rehabilitation
for cognitive deficits, Oxford, 2005, Oxford University
Press.
21. Burgess PW, Veitch E, de Lacy Costello A, et al: The
cognitive and neuroanatomical correlates of multi-
tasking, Neuropsychologia 38(6):848-863, 2000.
22. Burke WH, Zencius AH, Wesolowski MD, et al:
Improving executive function disorders in brain-
injured clients, Brain Inj 5(3):241-252, 1991.
23. Busch RM, McBride A, Curtiss G, et al: The compo-
nents of executive functioning in traumatic brain
injury, J Clin Exper Neuropsychol 27(8):1022-1032,
2005.
24. Chan RC: Dysexecutive symptoms among a non-
clinical sample: a study with the use of the dysexecutive
questionnaire, Br J Psychol 92(Pt 3):551-565, 2001.
25. Cicerone KD, Giacino JT: Remediation of execu-
tive function deficits after traumatic brain injury,
NeuroRehabilitation 2(3):12-22, 1992.
26. Cicerone K, Levin H, Malec J, et al: Cognitive reha-
bilitation interventions for executive function: mov-
ing from bench to bedside in patients with traumatic
brain injury. J Cogn Neurosci 18(7):1212-1222, 2006.
27. Cicerone KD, Wood JC: Planning disorder after
closed head injury: a case study, Arch Phys Med
Rehabil 68(2):111-115, 1987.
28. Costa A, Peppe A, Carlesimo GA, et al: Major and
minor depression in Parkinson’s disease: a neuropsy-
chological investigation, Eur J Neurol 13(9):972-980,
2006
29. Cummings JL: Vascular subcortical dementias: clini-
cal aspects, Dementia 5:177-180, 1994.
30. Dawson DR, Anderson N, Burgess PW, et al: The eco-
logical validity of the Multiple Errands Test-Hospital
Version: preliminary findings, J Int Neuropsychol Soc
11(S1):99, 2005.
31. Elliott R: Executive functions and their disorders,
Br Med Bull 65:49-59, 2003.
32. Emslie H, Wilson FC, Burden V, et al: The behav-
ioural assessment of the dysexecutive syndrome test
for children (BADS-C), Bury St Edmunds, UK, 2003,
Thames Valley Test Company.
33. Evans JJ, Emslie H, Wilson BA: External cueing sys-
tems in the rehabilitation of executive impairments
of action, J Int Neuropsychol Soc 4(4):399-408, 1998
34. Fasotti L, Kovacs F, Eling PATM, et al: Time pres-
sure management as a compensatory strategy train-
ing after closed head injury, Neuropsychol Rehabil
10(1):47-65, 2000.
35. Fisher AG: Assessment of motor and process skills.  vol. 1:  in people with traumatic brain injury through the use
development, standardization, and administration man-
ual, ed 5, Fort Collins, Colo, 2003, Three Star Press.
36. Fisher AG: Assessment of motor and process skills. vol.
2: user manual, ed 5, Fort Collins, Colo, 2003, Three
Star Press.
37. Fluharty G, Glassman N: Use of antecedent control
to improve the outcome of rehabilitation for a client
with frontal lobe injury and intolerance for auditory
and tactile stimuli, Brain Inj 15(11):995-1002, 2001.
38. Fortin S, Godbout L, Braun CM: Cognitive struc-
ture of executive deficits in frontally lesioned head
trauma patients performing activities of daily living,
Cortex 39(2):273-291, 2003.
39. Foxx RM, Martella RC, Marchand-Martella NE:
The acquisition, maintenance, and generalization of
problem-solving skills by closed head-injured adults,
Behav Ther 20(1):61-76, 1989.
40. Funahashi S: Neuronal mechanisms of executive
control by the prefrontal cortex, Neurosci Res 39:
147-165, 2001.
41. Gioia GA, Isquith PK: Ecological assessment of
executive function in traumatic brain injury, Dev
Neuropsychol 25(1-2):135-158, 2004.
42. Gioia GA, Isquith PK, Guy SC, et al: Behavior rating
inventory of executive function. Child Neuropsychol
6(3):235-238, 2000.
43. Gioia GA, Isquith PK, Retzlaff PD, et al: Confirmatory
factor analysis of the Behavior Rating Inventory of
Executive Function (BRIEF) in a clinical sample,
Child Neuropsychol 8(4):249-257, 2002.
44. Godbout L, Grenier MC, Braun CM, et al: Cognitive
structure of executive deficits in patients with frontal
lesions performing activities of daily living, Brain Inj
19(5):337-348, 2005.
45. Goverover Y, Hinojosa J: Categorization and deductive
reasoning: Can they serve as predictors of instrumen-
tal activities of daily living performance in adults with
brain injury? Am J Occup Ther 56:509-516, 2002.
46. Goverover Y, Kalmar J, Gaudino-Goering E, et al: The
relation between subjective and objective measures of
everyday life activities in persons with multiple sclero-
sis, Arch Phys Med Rehabil 86(12):2303-2308, 2005.
47. Hanks RA, Rapport LJ, Millis SR, et al: Measures of
executive functioning as predictors of functional
ability and social integration in a rehabilitation sam-
ple, Arch Phys Med Rehabil 80(9):1030-1037, 1999.
48. Hart T, Whyte J, Kim J, et al: Executive function and
self-awareness of “real-world” behavior and atten-
tion deficits following traumatic brain injury, J Head
Trauma Rehabil 20(4):333-347, 2005.
49. Hayden ME, Moreault AM, LeBlanc J, et al: Reducing
level of handicap in traumatic brain injury: an
environmentally based model of treatment, J Head
Trauma Rehabil 15(4):1000-1021, 2000.
50. Hewitt J, Evans JJ, Dritschel B: Theory driven rehabilita-
tion of executive functioning: improving planning skills
of an autobiographical episodic memory cueing proce-
dure, Neuropsychologia 44(8):1468-1474, 2006.
51. Ho AK, Robbins AO, Barker RA: Huntington’s dis-
ease patients have selective problems with insight,
Mov Disord 21(3):385-389, 2006.
 Chapter 10  Managing Executive Function Impairments to Optimize Function 277
52. Honda T: Rehabilitation of executive function impair-
ments after stroke, Top Stroke Rehabil 6(1):15-22, 1999.
53. Jorge RE, Robinson RG, Moser D, et al: Major depres-
sion following traumatic brain injury, Arch Gen
Psychiatry 61(1):42-50, 2004.
54. Katz N, Hartman-Maeir A: Occupational per-
formance and metacognition, Can J Occup Ther
64(2):53-62, 1997
55. Katz N, Tadmor I, Felzen B, et al: Validity of the exec-
utive function performance test (EFPT) in persons
with schizophrenia: An occupational performance
test, Occup Ther J Res, in press.
56. Knight C, Alderman N, Burgess PW: Development
of a simplified version of the multiple errands test
for use in hospital settings, Neuropsychol Rehabil
12(3):231-256, 2002.
57. Lawrence AD, Sahakian BJ, Hodges JR, et al:
Executive and mnemonic functions in early
Huntington’s disease, Brain 119:1633-1645, 1996.
58. Lawson MJ, Rice DN: Effects of training in use
of executive strategies on a verbal memory prob-
lem resulting from closed head injury, J Clin Exp
Neuropsychol 11(6):842-854, 1989.
59. Leeds L, Meara RJ, Woods R, Hobson JP: A compari-
son of the new executive functioning domains of the
CAMCOG-R with existing tests of executive function
in elderly stroke survivors, Age Ageing 30(3):251-254,
2001.
60. Levin HS, Hanten G: Executive functions after
traumatic brain injury in children, Pediatr Neurol
33(2):79-93, 2005.
61. Levine B, Robertson IH, Clare L, et al: Rehabilitation
of executive functioning: an experimental-clinical
validation of goal management training, J Clin Exp
Neuropsychol 6(3):299-312, 2000.
62. Lezak MD: Newer contributions to the neuropsy-
chological assessment of executive functions, J Head
Trauma Rehabil 8(1):24-31, 1993.
63. Lezak MD: Executive function and motor perfor-
mance. In Lezak MD, Howieson DB, Loring DW,
editors: Neurological assessment, New York, 2004,
Oxford University Press.
64. Liu KP, Chan CC, Lee TM, et al: Self-regulatory
learning and generalization for people with brain
injury, Brain Inj 16(9):817-824, 2002.
65. Manchester D, Priestley N, Jackson H: The assess-
ment of executive functions: coming out of the office,
Brain Inj 18(11):1067-1081, 2004.
66. Manly T, Hawkins K, Evans J, et al: Rehabilitation of
executive function: facilitation of effective goal man-
agement on complex tasks using periodic auditory
alerts, Neuropsychologia 40(3):271-281, 2002.
67. Mathias JL: Neurobehavioral functioning of per-
sons with Parkinson’s disease. Appl Neuropsychol
10(2):57-68, 2003.
68. Miyake A, Friedman NP, Emerson MJ, et al: The unity
and diversity of executive functions and their contri-
butions to complex “frontal lobe” tasks: a latent vari-
able analysis, Cogn Psychol 41:49-100, 2000.
69. Mohlman J: Does executive dysfunction affect treat-
ment outcome in late-life mood and anxiety disor-
ders? J Geriatr Psychiatry Neurol 18(2):97-108, 2005.
70. Mooney B, Walmsley C, McFarland K: Factor analy-
sis of the self-report dysexecutive (DEX-S) question-
naire, Appl Neuropsychol 13(1):12-18, 2006.
71. Norman DA, Shallice T: Attention to action: willed
and automatic control of behaviour. In Davidson RJ,
Schwartz GE, Shapiro D, editors: Consciousness and
self-regulation, Vol 4, New York, 1986, Plenum.
72. Norris G, Tate RL: The Behavioural assessment of
the dysexecutive syndrome (BADS): ecological, con-
current and construct validity, Neuropsychol Rehabil
10(1):33-45, 2000.
73. Ownsworth T, McKenna K: Investigation of factors
related to employment outcome following traumatic
brain injury: a critical review and conceptual model,
Disabil Rehabil 26(13):765-783, 2004.
74. Proctor A, Wilson B, Sanchez C, et al: Executive func-
tion and verbal working memory in adolescents with
closed head injury (CHI), Brain Inj 14(7):633-647,
2000.
75. Rapoport MJ, McCullagh S, Shammi P, et al:
Cognitive impairment associated with major depression
following mild and moderate traumatic brain injury,
J Neuropsychiatr Clin Neurosci 17(1):61-65, 2005.
76. Rath JF, Simon D, Langenbahn DM, et al: Group
treatment of problem-solving deficits in outpatients
with traumatic brain injury: a randomised outcome
study, Neuropsychol Rehabil 13(4):461-488, 2003.
77. Robbins TW, James M, Owen AM, et al: Cognitive
deficits in progressive supranuclear palsy, Parkinson’s
disease and multiple systems atrophy in tests sensi-
tive to frontal lobe dysfunction, J Neurol Neurosurg
Psychiatry 57:79-88, 1994.
78. Robertson IH: Goal management training: a clinical
manual, Cambridge, UK, 1996, PsyConsult.
79. Roth RM, Isquith PK, Gioia GA: BRIEF-A: Behavior
rating inventory of executive function — adult version,
Lutz, Fla, 2005, Psychological Assessment Resources.
80. Royall DR, Chiodo LK, Polk MJ: Correlates of dis-
ability among elderly retirees with “subclinical”
cognitive impairment, J Gerontol A Biol Sci Med Sci
55(9):M541-M546, 2000.
81. Royall DR, Lauterbach EC, Cummings JL, et al:
Executive control function: a review of its prom-
ise and challenges for clinical research. A report
from the Committee on Research of the American
Neuropsychiatric Association, J Neuropsychiatry Clin
Neurosci 14(4):377-405, 2002.
82. Salmon E, Collette F: Functional imaging of executive
functions, Acta Neurol Belg 105(4):187-196, 2005.
83. Schwartz SM: Adults with traumatic brain injury:
three case studies of cognitive rehabilitation in the
home setting, Am J Occup Ther 49(7):655-667, 1995.
278 cognitive and perceptual rehabilitation: Optimizing function
84. Serino A, Ciaramelli E, Di Santantonio A, et al:
Central executive system impairment in traumatic
brain injury, Brain Inj 20(1):23-32, 2006.
85. Shallice T: From neuropsychology to mental structure,
New York, 1988, Cambridge University Press.
86. Shallice T, Burgess PW: Deficits in strategy applica-
tion following frontal lobe damage in man, Brain
114(Pt 2):727-741, 1991.
87. Spikman JM, Deelman BG, van Zomeren AH:
Executive functioning, attention and frontal lesions
in patients with chronic CHI, J Clin Exp Neuropsychol
22(3):325-338, 2000.
88. Van Spaendonck KP, Berger HJ, Horstink MW, et al:
Executive functions and disease characteristics in
Parkinson’s disease, Neuropsychologia 34(7):617-626,
1996.
89. von Cramon DY, Matthes-von Cramon G: Back
to work with a chronic dysexecutive syndrome?
Neuropsychol Rehabil 4(4):399-417, 1994.
90. von Cramon DY, Matthes-von Cramon G, Mai N:
Problem-solving deficits in brain-injured patients:
a therapeutic approach, Neuropsychol Rehabil
1(1):45-64, 1991.
91. Webber LS, Charlton JL: Wayfinding in older adults,
Clin Gerontol 23(1/2):168-172, 2001.
92. Weinberger DR, Gallhofer B: Cognitive function
in schizophrenia, Int Clin Psychopharmacol 12(Suppl 4):
S29-S36, 1997.
93. Wilson BA, Alderman N, Burgess PW, et al:
Behavioural assessment of the dysexecutive syndrome,
Flempton UK, 1996, Thames Valley Test Company.
94. Wilson BA, Evans JJ, Emslie H, et al: The devel-
opment of an ecologically valid test for assessing
patients with dysexecutive syndrome, Neuropsychol
Rehabil 8(3):213-228, 1998.
95. Wilson BM, Proctor A: Oral and written discourse
in adolescents with closed head injury, Brain Cogn
43(1-3):425-429, 2000.
 Appendix 10-1
Evidence-Based Interventions for Impairments of Executive
Functions Focused on Improving Daily Function
Table 1 Summary of Research
Study Intervention Description
von Cramon et al, Problem-solving training (group
199190 and individual)
Rath et al, 200376 Group treatment of problem-
solving deficits.
Foxx et al, 198939 Program for teaching a problem-
solving strategy
Hewitt et al, 200650 Self-instructional technique
involving self-cueing to recall
specific autobiographic
experiences
Honda, 199952 Direct training approach
including self-instruction,
problem-solving training, and
physical set training
Cicerone and Wood, Self-instruction training
198727
Levine et al, 200061 Goal management training
Levine et al, 200061 Goal management training
Fasotti et al, 200034 Time pressure management
Evans et al, 199833 External cueing strategies
(NeuroPage and written
checklists)
Schwartz, 199583 External cueing strategies (tape-
recorded messages and
written checklists/reminders)
Manly et al, 200266 External cueing strategies using
periodic auditory alerts
Burke et al, 199122 Training planning and problem
solving in the context of
learning vocational skills
Participant Characteristics n Age
Adults with various types of brain 37 M = 44
injuries (traumatic brain injury, Range: 18-60
stroke, etc.)
Adults with stable brain injury at 60 M = 43.6 (SD = 11.2)
least 1 year postinjury
Adults with closed head injury  6 Range: 24-31
Adults with chronic traumatic 30 Group 1: M = 33.13 (SD
brain injury (TBI) = 8.25)
Group 2: M = 38.47
(SD = 14.72)
Adults status post aneurysm  3 Ages 65, 72, and 73
rupture approximately 1 year
post
Adult male with a closed head  1 20
injury
Adults with chronic TBI 30 Goal management
group: M = 29
(SD = 13)
Motor skills group:
M = 30.8 (SD = 9.2)
An adult 5 years after an episode   1 35
of meningoencephalitis
Adults with severe head injury 22 M = 26.1 (SD = 8.1)
(chronic and subacute) and
slowed information processing
as measured by 3 tests of
attention
An adult female 7 years  1 50
poststroke
A 30-year-old male with a brain  1 30
injury (right occipital and
bifrontal hematomas)
Adults with brain injury 10 M = 32.1 (SD = 11.1)
Range: 23-53
Adult male with a TBI  1 38
(Continued)
279
280 cognitive and perceptual rehabilitation: Optimizing function

Table 1 Summary of Research—Cont’d

Study Intervention Description Participant Characteristics n Age

Burke et al, 1991 22

Training self-initiation in the Adult males with traumatic brain 3 Ages 28, 32, and 40
context of learning vocational injuries
skills
Birnboim and Miller, Metacognitive and strategy Adults with multiple sclerosis 10 M = 45.5 (SD = 9.25)
200412 training
Fluharty and Use of antecedent control to Adult male with brain injury 1 23
Glassman, 200137 improve behavior and function
Liu et al, 200264 Self-regulatory training to Adults living with a stroke 3 Ages 62, 68, and 78
improve daily function

M, Median; SD, standard deviation.

Table 2 Summary of Outcomes

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

von Cramon et al, Quasi-experimental Intelligence measure + p < 0.01 Impairment

199190 with pretest- (for 3/5 subtests)
posttest of two Planning measures + p < 0.01 Impairment
comparable Behavioral ratings + p < 0.05 Impairment observed
groups of everyday during daily
problem solving function
Rath et al, 200376 Randomized control Executive functions + p < 0.05 Impairment
trial Memory + p < 0.01 Impairment
Self-esteem + p < 0.05 Impairment
Self-appraised + p < 0.05 Impairment
problem solving
Self-appraised clear + p < 0.01 Impairment
thinking
Self-appraised + p < 0.01 Impairment
emotional
self-regulation
Objective + p < 0.005 Simulated activity
observation of limitations
role plays
Community — N/A Participation
integration restrictions
Foxx et al, 198939 Nonrandomized Daily problem- + N/A Simulated activity
pretest-posttest solving criterion limitations
control group questions
design (% correct)
Generalization to + N/A Simulated activity
other situations limitations
Hewitt et al, 200650 Randomized trial Effectiveness + p < 0.01 Simulated activity
of everyday limitations
problem-solving
abilities
Number of relative + p = 0.03 Simulated activity
steps in everyday limitations
planning
 Chapter 10  Managing Executive Function Impairments to Optimize Function 281

Table 2 Summary of Outcomes—Cont’d

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

Honda, 199952 Single case study Behavioral Rating + N/A Activity limitations
design Scale
Wisconsin Card No change N/A Impairment
Sorting Test
Tinkertoy Test + N/A Impairment
(2/3 subjects)
Reports of activities + N/A Activity limitations
of daily living
(ADL) and
instrumental ADL
performance
Cicerone and Case study Improved planning + N/A Impairment
Wood, 198727 and problem
solving during a
contrived task
Transfer of training + p < 0.05 Impairment
to other contrived
tasks
Generalization + p < 0.001 Impairment observed
to everyday during daily
problem solving function
and situations
(self-control
rating scale)
Levine et al, 200061 Randomized trial Performance on + p < 0.05 Simulated activity
pen-and-paper limitations
tasks that
were chosen
to correspond
with everyday
situations
Levine et al, 200061 Single subject Performance on + N/A Simulated activity
pen-and-paper (2/3 tasks) limitations
tasks that were
chosen to
correspond with
everyday situations
Improved efficiency + p < 0.05 Activity limitations
in meal
preparation
Self-report of meal + N/A Activity limitations
preparation
Fasotti et al, 200034 Randomized Use of self- + p < 0.05 Activity limitations
controlled trial management
strategies to
support task
performance
Measures of memory + p < 0.05 Impairment
Measures of + p < 0.05 Impairment
attention

(Continued)
282 cognitive and perceptual rehabilitation: Optimizing function

Table 2 Summary of Outcomes—Cont’d

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

Evans et al, 199833 Single case Taking medications + N/A Activity limitations
experimental Watering plants
design Washing
undergarments + N/A Activity limitations
Decreasing time + N/A Activity limitations
spent bathing + N/A Activity limitations
Preparing dinner + N/A Activity limitations
Attending volunteer + N/A Participation
job restrictions
Schwartz, 199583 Case study Morning ADL + N/A Activity limitations
routine including
multiple tasks
Manly et al, 200266 Crossover design Performance on
a modified Six
Element Test, the
Hotel Test:
Number of tasks + p < 0.05 Simulated Activity
attempted limitations
Time allocated to + p < 0.01 Simulated Activity
tasks limitations
Burke et al, 199122 Case study with Percentage of
multiple baselines steps completed
across four
woodworking
tasks:
Task 1 + 50% to 100% Activity limitations
Task 2 + 43% to 100% Activity limitations
Task 3 + 59% to 100% Activity limitations
Task 4 + 33% to 100% Activity limitations
(generalization
task)
Burke et al, 199122 Case series with Number of cues + Decreased from Activity limitations
multiple baselines required to 3.2 to zero
complete work-
related kitchen
tasks
Number of correctly + Increased from Activity limitations
completed 25% to 38%
components of to 100%
vocational tasks
Number of prompts + Reduced from Activity limitations
required to 10 to a mean
complete 10 work of 0.6
tasks
 Chapter 10  Managing Executive Function Impairments to Optimize Function 283

Table 2 Summary of Outcomes—Cont’d

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

Birnboim and Pretest-posttest Measure of strategy + p < 0.005 Impairment

Miller, 200412 design application
Measures of + p < 0.014 Impairment
memory
Measures of + p < 0.019 Impairment
attention
Measures of + p < 0.011 Impairment
executive function
ADL: self-care + NS Activity limitations
ADL: occupational + p < 0.007 Participation
role restrictions
Fluharty and Case study Controlling + N/A Impairment
Glassman, 200137 aggressive
behavior
Participating in basic + N/A Activity limitations
ADL
Liu et al, 200264 Case series Level of + N/A Activity limitations
independence
performing self-
selected IADL

+, Improvement in the outcome measure that was beneficial to the participants; —, worsening or no change in status based on the outcome measure;
N/A, not applicable.
*Dimension based on World Health Organization’s (WHO) International Classification of Function (ICF). Impairments are problems in body function
(physiologic functions of body systems) or structure (anatomic parts of the body such as organs, limbs, and their components) such as a significant devia­
tion 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.
 Chapter 11
Application of Concepts: Case Studies
Case 1: Miguel
Miguel, 65 years old, presents with activity limitations
and participation restrictions secondary to a stroke
damaging his occipital lobe and presenting with visual
agnosia as a primary impairment (see Chapter 7).
Setting: inpatient rehabilitation
Background Data and Medical Record Review
Miguel was in his usual state of health (type 2 dia-
betes mellitus and asthma) until last week, when
he experienced dizziness, vomiting, and transient
confusion. He was brought in by ambulance to the
local medical center. A computed tomography (CT)
scan on day 3 revealed an infarction around the cal-
carine fissure (the visual association area). He was
­admitted to inpatient rehabilitation after 5 days of
monitoring on the acute service.
Evaluation Findings
Participation (now restricted)/roles:
• Retiree: Retired plumber
• Husband: Lives with wife who works the day
shift at a store
• Father of two adult children
• Grandfather (two grandchildren)
• Friend
Daily activities (now limited)
• Self-care
• Manages bills
• Makes breakfast and lunch for himself each day
• Watches television
• Grocery shops
• Walks to the local men’s social club in the after-
noon to play cards and dominoes
• Spends the evenings with his wife (dinner and
television)
284
Assessments
• Assessment of Motor and Process Skills (AMPS):
Motor skills are adequate to support daily living
skills, although his process skills are inadequate
and/or markedly deficient. Specific performance
skills that are inadequate or markedly deficient
include searching and locating, inquiring, nav-
igating, paceing, accommodating, adjusting, noti­
cing and responding, benefiting, gathering, and
organizing. Assessed making a lunchmeat sand-
wich and setting a table for four (see Chapter 1).
• Árnadóttir Occupational Therapy-ADL Neuro­
behavioral Evaluation (A-ONE): Physical and or
verbal assistance required for grooming, dressing,
bathing, and mobility (ambulation) secondary
to visual agnosia and topographical disorienta-
tion (see Chapter 1).
• Functional Independence Measure: Minimal
assistance for the majority of basic activities of
daily living and mobility (see Chapter 1).
• Awareness: Poor. Predicted perfect performance
on the basic and instrumental activities of daily
living assessments. Activity processing after the
assessments revealed that Miguel still was not
aware of the number and amount of cues or
support necessary to complete the tasks (see
Chapter 4).
• Sensory (proprioception, light touch, pain, tem-
perature) and motor function (strength, coordi-
nation, control) intact.
• Balance during sitting and standing activities:
Intact.
• Observations during meal preparation and
grooming at the sink: Haphazard search pat-
terns, not able to find necessary objects, relies on
touch and tactile feedback to recognize objects,
and requires verbal and minimal physical assis-
tance to locate objects (e.g., ham and cheese to
 Chapter 11  Application of Concepts: case studies 285
make a sandwich, toothpaste and toothbrush to
groom). Touching objects facilitated recogni-
tion, and once objects were located and gathered
Miguel had no difficulty completing the task.
Marked difficulty with wayfinding and route
finding (i.e., easily lost and is not aware of this
deficit).
Long-Term Goals
1. Independent with basic activities of daily living
using compensatory strategies.
2. Independent with cold meal preparation using
compensatory strategies.
3. Supervision for community activities (i.e., shop-
ping, attending social club).
Short-Term Goals
1. Client will make a sandwich with minimal
­physical assistance.
2. Client will retrieve clothing and dress with
­minimal (general) verbal cues.
3. Client will navigate cafeteria to purchase lunch
with close supervision and minimal (general)
verbal cues.
Interventions and Functional Activities
• Awareness training: Comparison of predicted
and actual performance of functional activities
based on the number of therapist’s cues required
to complete the task. Miguel’s wife observed
kitchen activities and provided him with feed-
back based on his difficulties as well. “Safe fail-
ures” also were used to develop awareness. For
example, Miguel was brought to the gift shop in
the lobby and was asked to return to his hospital
room without asking for assistance. The therapist
shadowed Miguel to ensure safety and to point
out (in a supportive and constructive manner)
why he was so easily lost (see Chapter 4).
• Teaching systematic search strategies: Miguel
presented with haphazard methods of scanning
the environment to collect visual information.
Systematic scanning behaviors (right to left, up
and down, circular) were taught in small envi-
ronments (i.e., Miguel’s hospital room), then
larger environments (e.g., gift shop and out-
doors) (see Chapter 3).
• Teaching focus on relevant features: Through
structured observation it became clear that Miguel
could recognize components and features of objects,
but this information was not enough to facilitate
object recognition. For example, when looking at
an apple he would describe it as red and round
and name it as a child’s ball. Time was spent figur-
ing out which components of objects were recog-
nized the most consistently. These included color,
shape, and size. When trying to locate an object
Miguel was taught to imagine what the object
looks like so that he could narrow down his search.
For example, when looking for American cheese
he would only focus and search for objects that
were both square and orange hued. This technique
made him substantially more ­efficient during task
­performance (see Chapter 7).
• Use other senses to facilitate recognition:
Typically people living with agnosia identify
objects via other senses. Miguel was taught pri-
marily to use tactile feedback (i.e., object manip-
ulation) to assist in object recognition. This
technique combined with systematic search
strategies and focusing on key perceptual fea-
tures of objects helped Miguel compensate for
his visual processing deficit (see Chapter 7).
• Environmental modifications: Miguel’s wife was
encouraged to simply the home environment to
ensure safety and decrease the demands of every-
day living. Examples include the following:
• Placing all of Miguel’s food and beverages
required for breakfast, lunch, and snacks on
one shelf in the refrigerator.
• Organizing clothing in his dresser. Socks
and underwear in the top drawer, pants in
the second, and shirts in the bottom drawer.
Clothing was folded in order so that Miguel’s
garments matched if he took the top garment
in each drawer each day of the week.
• The home was “de-cluttered” and throw rugs
were removed.
• Emergency objects such as aspirin and adhe-
sive bandages were placed on one shelf in the
medicine cabinet and identified via a red strip
of tape.
• The home phone was programmed with key
numbers via one-touch dialing (e.g., his wife’s
work phone number was number 1, emer-
gency “911” number was number 2, etc.). The
touch pad was color-coded with tape. Colors
were decided with Miguel’s input based on
memory strategies. Miguel decided that the
emergency number should be red, his wife’s
number should be black (to match her black
hair), his son’s number should be blue, and
his daughter’s ­number should be pink.
286 cognitive and perceptual rehabilitation: Optimizing function
Case 2: Ann
Ann, a 24-year-old, presents with activity limita-
tions and participation restrictions secondary to a
moderate/severe closed brain injury (coup-contre-
coup injury) from a car accident. Ann is presenting
with confusion, poor attention and memory, disor-
ganization, poor direction following, and decreased
arousal (see Chapters 8, 9, 10).
Setting: acute care
Background Data and Medical Record Review
Ann was in her usual state of health (no comor-
bidities) until 2 weeks ago when she was in a
head-on motor vehicle collision. She lost con-
sciousness and was brought in by ambulance
to the medical center and admitted to the neu-
rologic intensive care unit. Upon admission her
Glasgow Coma Scale score was 11 (see Appendix
A). Diagnosed with a coup-contrecoup injury
(contusions that are at the site of the impact as
well as on the opposite side of the brain). As she
regained consciousness she was admitted to acute
neurology from the neurologic intensive care unit
for further observation.
Evaluation Findings
Participation (now restricted)/roles:
• Single and lives alone
• Elementary schoolteacher
• Daughter (involved parents live 5 miles away)
• Sister (brother lives in Europe)
• Friend
Daily activities (now limited)
• Self-care
• Work tasks
• Manages bills
• Meal preparation
• Housekeeping
• Swims three times per week
• Maintains a large garden
• Avid mystery novel reader
• Grocery shops
• “Computer addict” as per family
Assessments
• Rancho Level of Cognitive Function (see
Appendix 2): Level V—confused, inappropriate,
nonagitated: Maximal assistance.
• A-ONE: Maximal physical assistance to depen-
dent for grooming, dressing, feeding, bathing,
and mobility (ambulation) secondary to orga-
nizing and sequencing impairments, periods of
decreased alertness, confusion, memory loss,
and decreased attention (see Chapter 1).
• Functional Independence Measure: Maximal or
total assistance for the majority of basic activi-
ties of daily living and mobility (see Chapter 1).
• Sensory: Not able to test formally.
• Motor: Moving all limbs except her left non-
dominant upper extremity. Moderate spastic-
ity in the left upper extremity based on quick
stretch examination.
• Balance during sitting is poor: Requires guard-
ing for static sitting and minimal assistance to
control the trunk during reaching. Standing has
not been attempted secondary to hypotensive
episodes.
• Observations during initial evaluation (in addi-
tion to Ann’s parents’ report): Not oriented,
slightly agitated when challenged by task per-
formance, severe memory loss, confabulations
noted when Ann is describing the day’s events,
confusion (confusing past and present events),
able to converse on a social, automatic level for
brief periods of time when provided external
structure and cues, requires step-by-step cues
and hand-over-hand guidance to participate in
simple daily activities. Ann is unaware that she
has sustained a head injury and seems to be
unaware of her limitations, commonly stating,
“I need to get to work.”
Long-Term Goals
1. Ann will perform basic activities of daily living
with moderate assistance.
2. Ann will recognize family members with moder-
ate verbal cueing.
3. Ann will propel her wheelchair on the unit with
minimal assistance.
Short-Term Goals
1. Client will wash her hands (three-step task) with
moderate assistance and step-by-step verbal
cues.
2. Client will transition from supine to sitting
with minimal physical assistance and one ­verbal
cue.
3. Client will eat a bowl of oatmeal with hand-
over-hand guiding.
 Chapter 11  Application of Concepts: case studies 287
Interventions or Functional Activities
• Orienting or attending: Each session was con-
ducted bedside. The door was closed and the
television was turned off to reduce distractions.
Basic orientation information was posted next
to Ann’s bed including a calendar, and this infor-
mation was reviewed prior to each session. Ann
was then asked to immediately recall the infor-
mation followed by recall 7 to 10 minutes after.
Recognition cues were used when necessary
(e.g., “Is it March, July, or October?”).
• Backward chaining: A simple breakfast of oat-
meal, a banana, and orange juice was preset on the
table. A simple general cue of “Let’s eat” started
the feeding session. Ann’s poor initiation made it
necessary to use backward chaining techniques.
For each component of the meal, the therapist
performed all of the steps except for the last (i.e.,
bring food to the mouth), which Ann performed
with guiding and a one-step command of “to
mouth.” As the session progressed, chaining con-
tinued but Ann was required to perform the last
two steps (i.e., scoop oatmeal and bring it to her
mouth), followed by the last three steps, and so
on (see Chapter 9).
• Attention processes: The next activity was
oral care performed while sitting at the sink.
Techniques were continued but perhaps because
of fatigue Ann’s attention began to wane and she
was becoming highly distractible by irrelevant
stimuli. Guiding was continued and performed
in conjunction with the therapist periodically
and systematically stating, “Let’s focus!” Ann was
encouraged to begin to self-monitor her atten-
tion by periodically stating “focus” out loud as
well (see Chapter 8).
• Memory: Ann’s family brought in her photo
album to help work on recognition of family
members and events. They labeled the back of
each picture based on who was in the picture and
where and when it took place (see Chapter 9).
Mnemonic strategies were used to facilitate
name/face recognition.
• Repetition, habits, and routines: Ann’s family
was asked to bring in her own clothing, groom-
ing equipment, and favorite home-cooked
meals so they could be integrated into treat-
ment. Each functional activity was performed
the same way each time and cues were vanished
as able.
• Family training (see Appendix B): Ann’s family
was taught the same cueing strategies that were
being used in therapy when they were assisting
her with self-care or helping her participate in lei-
sure activities such as using her CD player. They
were asked to control the number of visitors, use
simple language during conversation, and use
recognition strategies as opposed to recall strat-
egies during memory-based conversations.
Case 3: Paula
Paula, a 40-year-old, presents with activity limi-
tations and participation restrictions secondary
to multiple sclerosis, which is now affecting her
short-term memory and executive functions such
as planning (see Chapters 9 and 10).
Setting: outpatient rehabilitation
Background Data and Medical Record Review
Paula has been living with multiple sclerosis for
the past 10 years. She was diagnosed when she
was 30. She reports that she feels that she has
responded well to disease-modifying medications
because she has been maintaining her function
until recently. At baseline, she has poor endurance,
is “forgetful,” has poor visual acuity, and gets over-
whelmed (both emotionally and cognitively) in
busy environments such as grocery stores or large
family events. Lately she feels her everyday mem-
ory is worse, particularly remembering to carry
out daily activities (i.e., lock the door at night,
remembering to go to appointments, taking medi-
cations, etc.). In addition she feels her days are best
described as “disorganized.”
Evaluation Findings
Participation (now restricted)/roles:
• Homemaker
• Volunteers as a peer counselor at the local
­multiple sclerosis society
• Wife: Her husband works full time and travels
frequently
• Writer: Is writing “the next great American
screenplay”
Daily activities (now limited)
• Self-care
• Loves going to the movies
• Manages family finances
• Prepares all meals
• Grocery shops
• Plays Scrabble with friends
• Enjoys crosswords
288 cognitive and perceptual rehabilitation: Optimizing function

Assessments In addition demanding tasks were scheduled to

occur across the course of the week and not all in
• Canadian Occupational Performance Measure:
one day. A master weekly schedule was decided
Identified shopping, managing family finances,
on. Time pressure management strategies were
meal preparation, volunteering as the most
taught (see Chapter 10).
important activities to focus on. Reports per-
• Assistive technology: The weekly schedule was
formance deficits with these activities and is
transposed into a yearly planner as well as into a
not satisfied with her level of performance (see
personal data assistant. Paula’s planner was orga-
Chapter 1).
nized to allow her to check off completed tasks as
• Contextual Memory Test: Paula is quite aware of
well as provide her with a “to-do” section. Paula’s
her memory impairments. She performed poorly
husband was asked to place strategic reminder
on this screening and did not report using strat-
notes that said “check your planner.” These were
egies to remember the test items. She benefited
placed on the bathroom mirror, the refrigerator,
(i.e., improved score) on the second part of the
the nightstand, and next to the television. When
assessment after the therapist provided a mem-
out in the community Paula used an alarm
ory strategy by letting Paula know the test items
watch that chimed every 30 minutes to remind
were part of an overall theme of being in a res-
her to check her planner or personal data assis-
taurant (see Chapter 9).
tant. This allowed her to keep the planner up-to-
• Rivermead Behavioural Memory Test: Scored
date. The watch was also used as a medication
12 (moderately impaired memory). Paula had
reminder (see Chapter 9).
particular difficulties with prospective memory
• Environmental modifications: In addition to
tasks (see Chapter 9).
the reminder notes, Paula was encouraged to
• Cognitive Failures Questionnaire: Items that
decrease distractions in her environment such
Paula reported particularly difficult included,
as keeping the radio turned off and drawing the
Do you find you forget why you went from one
curtains when she was working on challenging
part of the house to the other? Do you find you
tasks (see Chapter 10).
forget whether you’ve turned off a light or locked
• Task adaptations: Paula was encouraged to per-
the door? Do you find you forget appointments?
form community tasks such as shopping during
Do you forget where you put something like a
off hours to minimize distraction and to allow
newspaper or a book? (see Chapter 8).
her to maintain focus. She also made therapy
and doctor’s appointments so that she was the
Long-Term Goals first client of the day. Monthly bills were orga-
nized into a labeled accordion file. This file sys-
1. Client will manage all home management skills tem was kept next to the counter where Paula
independently with the use of compensatory opened her mail. Using this system, she immedi-
strategies. ately threw out junk mail and organized her bills
based on due dates (see Chapter 10).
Short-Term Goals
1. Client will independently complete all daily Case 4: Carol
household chores using a checklist system. Carol, 70 years old, has activity limitations and
2. Client will grocery shop with supervision. participation restrictions secondary to a left mid-
3. Client will balance her checkbook and pay dle cerebral artery stroke and presents with global
monthly bills with supervision. aphasia, ideational and motor apraxia, right hemi-
plegia, and impaired postural control (for standing
as well as seated activities) (see Chapter 5).
Interventions or Functional Activities
Setting: acute care
• Daily scheduling: Initial discussions with Paula
focused on identifying the most cognitively
Background Data and Medical Record Review
challenging activities for her. It was decided
that those activities such as financial manage- Carol was in her usual state of health (hypertension
ment would take place in the mornings because and atrial fibrillation) until 2 days ago, when she col-
she felt she was “at her best” in the mornings. lapsed at the home she shares with her daughter and
 Chapter 11  Application of Concepts: case studies 289
grandson. She was brought in by ambulance to the
medical center. Clinical presentation is consistent
with a left middle cerebral artery occlusion (both
upper and lower trunks). She is being treated on the
acute neurology unit.
Evaluation Findings
Participation (now restricted)/roles:
• Retiree: Retired nurse
• Widowed 8 years ago after a 40-year marriage
• Mother of one adult child
• Grandmother (one grandchild)
• Family cook (lives with her daughter and
grandchild)
• Volunteers at the local church teaching religion
classes to young children
• Avid gardener
Daily activities (now limited)
• Self-care
• Cooking
• Telephone use
• Grocery shopping
• Teaching classes
• Driving
• Planting and tending flower garden
Assessments
• Structured observation of four activities: wash-
ing face and upper body, putting on a shirt or
blouse, preparing food, and oral care. Difficulties
noted in initiation, execution, and control (see
Chapter 5).
• A-ONE: Moderate to maximal physical assis-
tance required for grooming, dressing, feed-
ing, and bed mobility secondary to ideational
apraxia, motor apraxia, expressive and receptive
language impairments, impaired organization
and sequencing, and severe right-sided motor
impairment (flaccid limbs) (see Chapter 1).
• Sensory: Not able to assess formally secondary
to global aphasia but withdraws to pain.
• Balance during seated activities: Requires mini-
mal physical assistance to maintain static sitting
as well as during dynamic reaching.
• Observations during feeding and grooming at
the sink: Does not initiate tasks until provided
with hand-over-hand guiding, uses objects
incorrectly (e.g., eating toothpaste, hairbrush
used as toothbrush), not using utensils (e.g., eat-
ing eggs with hands), leaves out critical activity
steps (e.g., begins to brush teeth without water),
performance latency, clumsy movements noted
on the nondominant and motor/sensory-spared
left limbs, responds best to gestural and tactile
(i.e., guided movements) cues.
Long-Term Goals
1. Moderate assistance with basic activities of daily
living.
2. Close supervision for bed mobility.
3. Minimal assistance for transfers to the wheel-
chair, and bedside commode.
4. Will respond to basic personal questions (e.g.,
“Is your name Carol?”) with 75% accuracy.
Short-Term Goal
1. Client will feed self with moderate physical assis-
tance after setup.
2. Client will perform oral care with moderate
assistance after setup.
3. Client will roll and sit at the edge of the bed with
contact guard.
Interventions or Functional Activities
• Emphasis was placed on demonstration and ges-
tural cues and tactile kinesthetic cues via guid-
ing the limbs through various activities (see
Chapter 5). For example, when teaching bed
mobility skills, the therapist demonstrated roll-
ing while simultaneously saying the word “roll.”
This was followed by guiding Carol’s limbs
through the activity followed by weaning of the
guidance to encourage independent practice.
• A strategy training approach was used to train
basic mobility and activities of daily living (see
Box 5-3). Grooming activities were an initial
focus of treatment. Difficulties related to initia-
tion were treated via gesturing, pointing, hand-
ing objects, and starting the activity together.
Assistance was the intervention provided when
problems related to execution of the activity
occurred. Assistance consisted of physical assis-
tance such as guiding movements.
• Graded functional activities. Meaningful activi-
ties were graded based on the number of objects
required to complete the task, the number of
steps required, and the number of activities that
were completed in sequence (see Chapter 5). For
example, feeding activities were graded (in con-
junction with strategy training) as follows:
• Finger feeding sliced banana.
290 cognitive and perceptual rehabilitation: Optimizing function

• Eating apple sauce with a spoon. Assessments

• Eating soup with a spoon and precut meat-
• Canadian Occupational Performance Measure
loaf with a fork.
(COPM): Based on the results of this measure
• Eating eggs, toast, and cereal, requiring choos-
it was decided that work-related computer use,
ing and using a spoon, fork, and/or knife
balancing accounting ledgers, meal preparation,
appropriately after setup.
and reading would be the focus of treatment (see
• Eating eggs, toast, and cereal, requiring
Chapter 1).
choosing and using a spoon, fork, and/or
• Barthel Index: Scored 85, interpreted as minimal
knife appropriately and requiring Carol to set
assistance or supervision for some basic activi-
up her own tray.
ties of daily living. Note: Greg has decided that
• Setting and eating a full dinner with all neces-
at this point his level of performance on these
sary utensils in addition to foils (e.g., a comb
activities is satisfactory and does not care to
and toothbrush) placed at the table setting.
focus on them. He prefers to focus on activities
he considers “more important” as identified by
Case 5: Greg the COPM (see Chapter 1).
• Catherine Bergego Scale: Scored 20/30, inter-
Greg, a 50-year-old, has activity limitations and par-
preted as unilateral neglect having a moderate
ticipation restrictions secondary to a right middle
effect on daily activities (see Chapter 6).
cerebral artery stroke and presents with left neglect
• Awareness: Greg filled out a self-assessment
and spatial impairments as primary impairments
version of the Catherine Bergego Scale, and
(see Chapters 3 and 6).
it was compared with the clinician’s rating on
Setting: home care
the same scale. Greg was aware of difficulties
in certain activities but was not aware of errors
Background Data and Medical Record Review being consistently related to missing stimuli on
his left side. In general he tended to overesti-
Greg was in his usual state of health (osteoarthritis in
mate his performance abilities. This discrep-
his spine and hips) until 4 weeks ago, when he com-
ancy was causing marital discord, and his wife
plained of numb left hand and drooling from the left
was concerned about safety issues as well (see
side of his mouth. Magnetic resonance imaging (MRI)
Chapter 4).
revealed a right middle cerebral artery occlusion. He
• Sensory findings: All sense modalities were
was admitted to inpatient rehabilitation after 7 days
detected, but Greg demonstrated left-sided tac-
of monitoring on the acute service. After 3 weeks on
tile extinction when simultaneously tested on
the rehabilitation he was discharged home.
both sides of his body (see Chapter 6).
• Motor function: When encouraged and cued,
Evaluation Findings Greg was able to use his left upper extremity
as a gross assistance (partial proximal control
Participation (now restricted)/roles:
and gross hand function) but did not inte-
• Owns and manages a home improvement
grate this movement into functional activities
contracting business with 24 employees
­independently secondary to motor neglect.
• Husband: Lives with wife who works as a college
• Balance during sitting and standing activi-
professor
ties: Intact except required supervision for stair
• Member of a bowling team
climbing.
• Avid golfer
Daily activities (now limited)
• Reading (for work and leisure)
Long-Term Goals
• Driving
• Managing household and work bills 1. Distant supervision for the following work tasks:
• Computer work (word processing and account- ­computer use, phone use, and filing.
ing programs for work) 2. Distant supervision provided by office assis-
• Sports activities (as above) tant for money management and accounting
• Household chores such as making meals, yard tasks.
work, and house cleaning 3. Independent for homemaking tasks such as meal
• Playing rummy with his wife preparation.
 Chapter 11  Application of Concepts: case studies 291
Short-Term Goals
1. Client will make a sandwich with general verbal
cues.
2. Client will read five emails with 80% accuracy
from his computer screen.
3. Client will input weekly figures into a computer-
ized spreadsheet with close supervision.
Interventions or Functional Activities
• Awareness training: An emotionally neutral task
(cancellation task) was used to improve Greg’s
awareness of the effect of his left-sided neglect
during the day. His performance was video-
taped and shown to him on his home TV. This
technique reverses the visual image so that the
neglected space is now on the right side. This
was followed by videotaping Greg trying to
locate items needed to make a sandwich in his
refrigerator. Again he watched this videotape
and the therapist pointed out trends in the left-
sided errors he made in both videos. In addition,
discrepancies in the self-rated and clinician-
rated Catherine Bergego Scale were discussed
(see Chapter 4).
• Teaching compensatory strategies: The Light­
house Strategy (an intervention protocol that
combines scanning training with visual imag-
ery; see Chapter 6) was used to improve Greg’s
ability to gather information from his left visual
field. This strategy was used during a variety of
functional activities and in the various envi-
ronments that Greg functioned in, including
locating items in kitchen cabinets, on grocery
shelves, and in the bathroom medicine cabi-
net; walking, performing desk work, and so on.
The same strategy to perform various functional
activities in multiple environments was used
to promote generalization of the strategy (see
Chapter 2).
• Left limb activation techniques: Because Greg
had partial control in left limb, he was encour-
aged to move his left limbs as much as pos-
sible before and during functional activities.
For example, he was taught to open and close
his hand and flex and extend his elbow before
working at the computer, and occasionally pause
to do the same movements. Multiple bilateral
activities (e.g., opening containers, wiping a
table hand-over-hand, bilateral golf putting,
etc.) encouraged use of the left limb. While per-
forming seated and standing activities, Greg was
taught to place his left arm on the work surface
(e.g., sink, counter, desk, etc.) and to use it as
a spatiomotor cue. Greg was always encouraged
to hold a tote bag in his left hand during ambu-
lation activities. Constraint-induced move-
ment therapy was considered for future use (see
Chapter 6).
• Environmental modifications: Anchoring tech-
niques were also used to improve performance of
various activities. Red strips of tape were placed
on the left side of Greg’s computer monitor and
on the left side of the refrigerator. Greg was
encouraged to scan to the left until he “found”
the anchor. These techniques were used in con-
junction with the Lighthouse Strategy.
 Appendix A
The Glasgow Coma Scale
T he Glasgow Coma Scale is a neurologic scale
that gives a reliable, objective way of recording
the conscious state of a person, for initial as well as
continuing assessment. A person is assessed against
the criteria of the scale, and the resulting points give
the Glasgow Coma score (or GCS). It has value in
predicting ultimate outcome and is used to assess
level of consciousness after head injury.
The scale comprises three tests: eye, verbal, and
motor responses. The three values separately as well
as their sum are considered. The lowest possible
GCS (the sum) is 3 (deep coma or death), and the
highest is 15 (fully awake person).
Best eye response (E)
4: Eyes opening spontaneously.
3: Eyes opening to speech.
2: Eyes opening in response to pain.
1: No eye opening.
Best verbal response (V)
5: Oriented. (Patient responds coherently and
appropriately to questions such as the patient’s
name and age, where he or she is and why, the
year, month, etc.)
4: Confused. (The patient responds to questions
coherently but there is some disorientation and
confusion.)
292
3: Inappropriate words. (Random or exclama-
tory articulated speech, but no conversational
exchange.)
2: Incomprehensible sounds. (Moaning but no
words.)
1: None.
Best motor response (M)
6: Obeys commands. (The person does simple
things as asked.)
5: Localizes to pain. (Purposeful movements toward
changing painful stimuli.)
4: Withdraws from pain. (Pulls part of body away
when pinched.)
3: Flexion in response to pain. (Decorticate
response.)
2: Extension to pain. (Decerebrate response.)
1: No motor response.
Individual elements as well as the sum of the
score are documented. For example, the score may
be documented as: GCS 10 = E3 V4 M3 at 9:30 am.
The coma score is interpreted as Severe, with
GCS ≤ 8, Moderate, GCS 9-12, Minor, GCS ≥13.
From Teasdale G, Jennett B: Assessment of coma and
impaired consciousness. A practical scale, Lancet
2:81-84, 1974.
 Appendix B
Rancho Levels of Cognitive Functioning–Revised and the Family
Guide to the Rancho Levels of Cognitive Functioning–Revised

Rancho Levels of Cognitive Functioning Revised

Patient name: Diagnosis:

MR#: Date of onset:

Level Examiners
of Behavioral Characteristics
Function Assessment Dates
Level I • Complete absence of observable change in
No response behavior when presented visual, auditory, tactile,
Total Assistance proprioceptive, vestibular or painful stimuli.

Level 2 • Demonstrates generalized reflex response to

Generalized painful stimuli.
Response
• Responds to repeated auditory stimuli with
increased or decreased activity.

• Responds to external stimuli with physiological

Total Assistance changes generalized, gross body movement
and/or not purposeful vocalization.

• Responses noted above may be same regard-

less of type and location of stimulation.

• Responses may be significantly delayed.

Level 3 • Demonstrates withdrawal or vocalization to

Localized painful stimuli.
Response
• Turns toward or away from auditory stimuli.

• Blinks when strong light crosses visual field.

• Follows moving object passed within visual field.

Total Assistance
• Responds to discomfort by pulling tubes or
restraints.

• Responds inconsistently to simple commands.

• Responses directly related to type of stimulus.

• May respond to some persons (especially family

and friends) but not to others.

© Chris Hagen, PhD, CCC-SLP, 1998, Rancho Los Amigos National Rehabilitation Center.

293
294 cognitive and perceptual rehabilitation: Optimizing function

Level Examiners
of Behavioral Characteristics
Function Assessment Dates
Level 4 • Alert and in heightened state of activity.
Confused-
Agitated • Purposeful attempts to remove restraints or tubes
or crawl out of bed.

• May perform motor activities such as sitting,

reaching and walking but without any apparent
purpose or upon another’s request.

Maximal • Very brief and usually non-purposeful moments

Assistance of sustained alternatives and divided attention.

• Absent short-term memory.

• Absent goal-directed, problem-solving, self-

monitoring behavior.

• May cry out or scream out of proportion to

stimulus even after its removal.

• May exhibit aggressive or flight behavior.

• Mood may swing from euphoric to hostile with no

apparent relationship to environmental events.

• Unable to cooperate with treatment efforts.

• Verbalizations are frequently incoherent and/or

inappropriate to activity or environment.

Level 5 • Alert, not agitated but may wander randomly or

Confused- with a vague intention of going home.
Inappropriate-
Non-Agitated • May become agitated in response to external
stimulation and/or lack of environmental
structure.

• Not oriented to person, place or time.

• Frequent brief periods, non-purposeful sustained

attention.

• Severely impaired recent memory, with

confusion of past and present in reaction to
ongoing activity.

• Absent goal-directed, problem-solving, self-

monitoring behavior.

Maximal • Often demonstrates inappropriate use of objects

Assistance without external direction.

• May be able to perform previously learned tasks

when structure and cues provided.

• Unable to learn new information.

• Able to respond appropriately to simple

commands fairly consistently with external
structures and cues.

• Responses to simple commands without

external structure are random and non-
purposeful in relation to the command.
 Appendix B  Rancho Levels of Cognitive Functioning–Revised 295

Level Examiners
of Behavioral Characteristics
Function Assessment Dates
Level 5 • Able to converse on a social, automatic level for
Continued brief periods of time when provided external
structure and cues.

• Verbalizations about present events become

inappropriate and confabulatory when external
structure and cues are not provided.

Level 6 • Inconsistently oriented to person and place.

Confused-
Appropriate • Able to attend to highly familiar tasks in non-
distracting environment for 30 minutes with
moderate redirection.

Moderate • Remote memory has more depth and detail than

Assistance recent memory.

• Vague recognition of some staff.

• Able to use assistive memory aid with maximal

assistance.

• Emerging awareness of appropriate response to

self, family and basic needs.

• Emerging goal-directed behavior related to

meeting basic personal needs.

• Moderate assist to problem solve barriers to task

completion.

• Supervised for old learning (e.g. self care).

• Shows carry over for relearned familiar tasks

(e.g. self care).

• Maximal assistance for new learning with little or

no carry over.

• Unaware of impairments, disabilities and safety

risks.

• Consistently follows simple directions.

• Verbal expressions are appropriate in highly

familiar and structured situations.

Level 7 • Consistently oriented to person and place, within

Automatic- highly familiar environments. Moderate
Appropriate assistance for orientation to time.

• Able to attend to highly familiar tasks in a

non-distraction environment for at least 30
minutes with minimal assist to complete tasks.

• Able to use assistive memory devices with

minimal assistance.

• Minimal supervision for new learning.

• Demonstrates carry over of new learning.

296 cognitive and perceptual rehabilitation: Optimizing function

Level Examiners
of Behavioral Characteristics
Function Assessment Dates
Level 7 • Initiates and carries out steps to complete
Continued familiar personal and household routine but has
shallow recall of what he/she has been doing.
Minimal
Assistance • Able to monitor accuracy and completeness of
For Routine each step in routine personal and household ADL
Daily Living and modify plan with minimum assistance.
Skills
• Superficial awareness of his/her condition but
unaware of specific impairments and disabilities
and the limits they place on his/her ability to
safely, accurately and completely carry out
his/her household, community, work and leisure
ADL.

• Minimal supervision for safety in routine home

and community activities.

• Unrealistic planning for the future.

• Unable to think about consequences of a

decision or action.

• Overestimate abilities.

• Unaware of others’ needs and feelings.

• Oppositional/uncooperative.

• Unable to recognize inappropriate social

interaction behavior.

Level 8 • Consistently oriented to person, place and time.

Purposeful
and • Independently attends to and completes familiar
Appropriate tasks for 1 hour in a distracting environment.

• Able to recall and integrate past and recent

events.

• Uses assistive memory devices to recall daily

schedule, “to do” lists and record critical
information for later use with stand-by
assistance.

• Initiates and carries out steps to complete

familiar personal, household, community, work
and leisure routines with stand-by assistance
and can modify the plan when needed with
minimal assistance.

• Requires no assistance once new

tasks/activities are learned.

• Aware of and acknowledges impairments and

Stand-by disabilities when they interfere with task
Assistance completion but requires stand-by assistance to
take appropriate corrective action.

• Thinks about consequences of a decision or

action with minimal assistance.

• Overestimates or underestimates abilities.

 Appendix B  Rancho Levels of Cognitive Functioning–ReviseD 297

Level Examiners
of Behavioral Characteristics
Function Assessment Dates
Level 8 • Acknowledges others’ needs and feelings and
Continued responds appropriately with minimal assistance.

• Depressed.

• Irritable.

• Low frustration tolerance/easily angered.

• Argumentative.

• Self centered.

• Uncharacteristically dependent/independent.

• Able to recognize and acknowledge inappropriate

social interaction behavior while it is occurring and
takes corrective action with minimal assistance.

Level 9 • Independently shifts back and forth between tasks

Purposeful and completes them accurately for at least two
and consecutive hours.
Appropriate
• Uses assistive memory devices to recall daily
schedule, “to do” lists and record critical informa-
tion for later use with assistance when requested.

• Initiates and carries out steps to complete familiar

personal, household, work and leisure tasks
independently and unfamiliar personal, household,
work and leisure tasks with assistance when
requested.

• Aware of and acknowledges impairments and

disabilities when they interfere with task comple-
Stand-by tion and takes appropriate corrective action but
Assistance requires stand-by assistance to anticipate a
on Request problem before it occurs and take action to
avoid it.

• Able to think about consequences of decisions or

actions with assistance when requested.

• Accurately estimates abilities but requires stand-by

assistance to adjust to task demands.

• Acknowledges others’ needs and feelings and

responds appropriately with stand-by assistance.

• Depression may continue.

• May be easily irritable.

• May have low frustration tolerance.

• Able to self-monitor appropriateness of social

interaction with stand-by assistance.
Level 10 • Able to handle multiple tasks simultaneously in all
Purposeful environments but may require periodic breaks.
and
Appropriate • Able to independently procure, create and maintain
own assistive memory devices.
298 cognitive and perceptual rehabilitation: Optimizing function

Level Examiners
of Behavioral Characteristics
Function Assessment Dates
Level 10 • Independently initiates and carries out steps to
Continued complete familiar and unfamiliar personal,
household, community, work and leisure tasks but
may require more than the usual amount of time
and/or compensatory strategies to complete them.

Modified • Anticipates impact of impairments and disabilities

Independent on ability to complete daily living tasks and takes
action to avoid problems before they occur but
may require more than the usual amount of time
and/or compensatory strategies.

• Able to independently think about consequences

of decisions or action but may require more than
the usual amount of time and/or compensatory
strategies to select the appropriate decision or
action.

• Accurately estimates abilities and independently

adjusts to task demands.

• Able to recognize the needs and feelings of others

and automatically respond in appropriate manner.

• Periodic periods of depression may occur.

• Irritability and low frustration tolerance when sick,

fatigued and/or under emotional stress.

• Social interaction behavior is consistently

appropriate.
 Appendix B  Rancho Levels of Cognitive Functioning–ReviseD 299

Family Guide to the Rancho Levels of Cognitive Functioning–Revised

Courtesy Rancho Los Amigos National Rehabilitation Center, Downey, CA.

300 cognitive and perceptual rehabilitation: Optimizing function
 Appendix B  Rancho Levels of Cognitive Functioning–ReviseD 301
302 cognitive and perceptual rehabilitation: Optimizing function

Note: Page numbers followed by f for figures, t for tables and b for boxes.
A Anosognosia
ABAB control phase, 226
ABA control phase, 231
Accommodation, 50, 51
Acquisition, 225t, 229t
Action Program, 257
Activation regulating function, 248
Activities of daily living (ADL), basic, 8
Árnadottir OT-ADL Neurobehavioral
Evaluation (A-ONE), 146
compensatory visual field training, 54
direct training versus exploration training,
128–129
errorless learning for, 128
executive deficits of, 245–247
executive function intervention for, 267
limb activation/sustained attention
training, 154
memory importance in, 216
memory intervention for, 235
memory notebook/diary for, 221
mental imagery as intervention for, 156
observation and scoring of, 122
retraining specific skills of, 197–199
single-task versus double-task
performance, 36
Structured Observational Test of Function
(SOTOF), 21
sustained attention/errorless learning, 160
unilateral neglect effect on, 142–143
visual impairments and, 45
visual neglect limitations on, 142
visuospatial impairment affecting, 58–62
Activity Card Sort (ACS), 9
Activity limitations, case study, 284, 286,
287, 288
Adaptation
as intervention approach, 38–39, 38t
as notebook training stage, 225t, 229t
Adaptive Behavior Scale, 235–236
Agnosia
alternate cues for, 180
alternate modalities for, 180
assessment of, 171–176, 177t
effect on daily life, 170–171
evidence-based interventions,
outcomes, 183
evidence-based interventions,
research, 182
functioning difficulties with, 171
intervention for, 176–180
language impairment versus, 176
organizational strategies for, 180
overview of, 169–170
recovery from, 175t
safety concerns, 180
subtypes of, 171, 172t
verbal strategies for, 180
visual impairment versus, 176
Alarm, 232
Alerting attention system, 187
Alexia. See Pure alexia
Alternate Cover Test, 56
Alternating attention, 186t
Alzheimer’s disease, 231
Ambulation, neglect and, 146
American Congress of Rehabilitation
Medicine, 127
American Occupational Therapy Association
(AOTA)
framework for guiding practice, 4, 5t
relationship with ICF, 5f
Amnesia, types of, 212t
Amusia, 171, 172t
Index
definition of, 67
for hemiplegia, 69
management of, 99–101
neglect rehabilitation, affect on, 142–143
stroke and, 69–70
Anosognosia Questionnaire, 89
Antecedent control, 273–274
Anterograde amnesia, 212t
Anticipation, 229t
Anticipatory awareness, 74–75
Anticipatory compensation, 75
Anxiety, 250–251
Aphasia
agnosia versus, 176
considerations relating to, 42
intervention for, 129
visual acuity, measurement of, 51–52
Apperceptive agnosia, 170, 171
Application, 225t, 229t
Apraxia
assessment and evaluation of, 120–122
daily life and rehabilitation, 119–120
definition of, 109, 110–116
differentiating types of, 114–116
distorted joint relationships, 114f
evidence-based interventions for, 122–131
function-based assessment for, 124t
ideational, 110–112
ideomotor, 112
impairment, relationship with other,
118–119
potential errors with, 119f
prevalence and recovery from, 116–118
recovery from, 123
standardized impairment tests for, 120
strategy training for, 123–127
task-specific training for, 129
treatment effectiveness, 129–130
Apraxic errors
during functional task performance,
121t, 123t
strategy training for, 123–127
Árnadottir OT-ADL Neurobehavioral
Evaluation (A-ONE)
agnosia, functioning difficulties of, 171
apraxia and ADL, relationship
between, 122
for attention deficits, 188t
for awareness measurement, 77–78
example of, 14f
for executive function, 252, 253t
items included in, 13
for memory deficits, 222t
neglect, as test for, 146, 149t
as outcome measure of awareness, 91t
purpose of, 13–15
Arousal, 186t
Assessment
of activity/participation and impairment,
13–21
of apraxia, 120–122
categories of, 42
client-centered, 9
Craig Handicap Assessment and Reporting
Technique (CHART), 8–9
environment influencing outcome, 37–38
of memory deficits, 216–221
performance-based versus pen-and-paper/
tabletop, 34–37
quality of life measures, 7–8
Reintegration to Normal Living (RNL), 8
role of individual, 33
of visuomotor abilities, 51
303
Assessment of Awareness of Disability (AAD),
86–88, 89, 91t
Assessment of Motor and Process Skills
(AMPS)
ADL, as test for, 146
Assessment of Awareness of Disability
(AAD), 86–88
for attention deficits, 188t
for awareness measurement, 76–77
example of, 17f
for executive function, 252, 253t
home versus clinical setting for, 37
for memory deficits, 222t
for neglect, 149t
as outcome measure of awareness, 91t
overview of, 15–20
Assistance
for functional deficit, 126
as intervention approach, 123–126
Assistive technology, memory aids, 231–233
Associative agnosia, 170
Astereognosis, 171, 172t
assessment procedures for, 177t
intervention for, 179
Attention
function-based assessment for, 188t
importance of, 184
neurologic background, 185–187
as stage of memory, 211t
Attentional control subsystem, 185
Attentional switching, 186t
Attention-based impairment, 136, 146
Attention deficit, 186t
assessment and evaluation of, 187–195
Behavioural Assessment of the
Dysexecutive Syndrome for Children
(BADS-C), 257
clinician and caretaker strategies for, 203
evidence-based interventions,
outcomes, 208
evidence-based interventions, research, 207
intervention for, 195–203, 202f
N-back procedure for, 202, 202f
retraining underlying, 196–197
self-management strategies for, 203, 204f
Attention process, 248f
Attention Process Training (APT)
changes experienced after, 197
overview of, 196
Attention Rating and Monitoring Scale
for attention deficits, 188t
details of, 195
Auditory agnosia, 171, 172t
Auditory elevator with reversal, 191
Auditory sound agnosia, 171
Auditory stimulation, 141
Automatic process, 200–201
Awareness
Dysexecutive Questionnaire (DEX),
91t, 251
executive function and, 251
factors contributing to deficits in, 100t
improvement of, 99
measurement of, 76–90
of memory deficits, 97–98
model for, 76f
neglect rehabilitation, affect on, 143
occupation to improve, 90–95
outcome measures of, 91t
video feedback to improve, 95
Awareness Intervention Program, 97, 100t
Awareness Interview, 87, 91t
Awareness Questionnaire (AQ), 79–81, 87t, 91t
Awareness training, 147–148, 161, 161t
304 Index
B Chunk, 211–213
Backward chaining, 230
Baking Tray Task, 147f, 149t, 159
Baking Tray Test, 152
Barthel Index (BI), 9, 58–62
Beck Depression Inventory, 251
Bedside care, 161t
Behavior
in motor neglect, 139
observation during activity, 136–137
Behavioral Inattention Test, 142
Behavioral Inattention Test (BIT), 142–143,
146, 149t
Behavioral intervention, 98
Behavioral self-regulatory function, 248
Behavioral skills assessment, 21
Behavior Rating Inventory of Executive
Function (BRIEF)
overview of, 258
sample items, 258–262
Behavior Rating Inventory of Executive
Function-Adult Version (BRIEF-A),
253t, 258
Behavioural Assessment of the Dysexecutive
Syndrome (BADS), 253t, 257
Behavioural Assessment of the Dysexecutive
Syndrome for Children (BADS-C),
257–258
Bergego Scale. See Catherine Bergego Scale
Bilateral stimulation detection, 141
Binocular diplopia, 55
Biomechanical theory, 23
Board game format, 95–96
Body neglect, 138t
Bon Saint Come’s device, 148–152
Bottom-up approach, 32
Brain
hemisphere damage, 29t
memory deficit, 97–98
patterns of cognitive-perceptual
impairments, 23–28. See also
Traumatic brain injury (TBI)
Brain injury
attention deficits due to, 186t
clinician rating scale for, 69f
memory deficit due to, 210
palm-held computer for, 232
rehabilitation after, 200
task-specific training for, 129
Brain Injury Visual Assessment Battery for
Adults (biVABA), 51
C Content-dependent memory, 211
Cambridge Apraxia Battery, 120
Cambridge Behaviour Prospective Memory
Test/Cambridge Prospective
Memory Test (CAMPROMPT),
218–219, 222t
Canadian Occupational Performance Measure
(COPM), 5, 9, 10f
Cancellation test, 153
Case study, 284, 286, 287, 288
Catherine Bergego Scale (CBS), 90
as functional neglect test, 145–146,
145f, 149t
as outcome measure of awareness, 91t
unilateral neglect, as test for, 146
Central achromatopsia, 172t, 177t
Central executive memory, 213
Central executive system (CES), 247
Cerebral artery dysfunction, 25t
Cerebral artery stroke, left middle, 288
Cerebral artery stroke, right middle, 288
Cerebrovascular dysfunction, 27t
Checklist, self-initiation, 272
Children
Behavior Rating Inventory of Executive
Function (BRIEF), 258
Behavioural Assessment of the
Dysexecutive Syndrome for Children
(BADS-C), 257–258
hands-on occupation, 236
memory deficit in, 215
Test of Everyday Attention for Children
(TEA-ch), 188t, 191
Classical conditioning, 214
Client-centered practice
goal setting, importance of, 5
strategies for, 4–6
Clinical setting for IADL, 37
Clinician’s Ratings Scale for Evaluating
Impaired Self-Awareness and Denial of
Disability after Brain Injury, 69f
Closed head injury (CHI)
case study, 286
executive deficits of, 245–247
Code Transmission, 192
Cognitive Failures Questionnaire, 253t
Cognitive Failures Questionnaire (CFQ)
for attention deficits, 188t
example of, 194f
executive function and, 251
as outcome measure of awareness, 91t
overview of, 193, 262
Cognitive function assessment, 36
Cognitive impairment, 6–21
Cognitive-perceptual impairment, 23–28
Cognitive process, controlled, 200–201
Cognitive rehabilitation
enhancing generalization of, 39
focus of, 1
International Classification of Function
(ICF), 2–4, 3t
Cognitive-Retraining Model, 23
Color agnosia, 171, 172t, 177t
Comb Test
as functional neglect test, 149t
personal neglect, as test for, 146
Community Integration Questionnaire
(CIQ), 8
Compensatory visual field training, 54
Complex passive movement, 155–156
Comprehensive Assessment of Prospective
Memory, 222t
components of, 219
overview of, 218
Computer-assisted training (CAT),
159, 232
Computer strategy game, 272
Computerized training, 159–160
Concurrent validity, 34
Confrontation test, 50, 53
Constraint-induced movement therapy
(CIMT), 155
Constructional ability, 1–2
Construct validity, 34
Content validity, 34
Contextual Memory Test, 217–218, 222t
Contralesional limb activation training,
154, 155f
Contralesional stimuli, 139
Controlled cognitive process, 200–201
Convergence, near point of, 49b
Convergent validity, 34
Cortical blindness, 47
Cortical lobe, 29t
Cover-Uncover Test, 56
Craig Handicap Assessment and Reporting
Technique (CHART), 8–9
Cranial nerve, 56
Creature Counting, 191
Criterion validity, 34
Crowds, avoiding, 204f
Cueing
environmental, 231
Executive Function Performance Test
(EFPT) using, 252–257
external devices for, 269–272
for memory deficits, 234
mnemonics as, 234
D for memory deficits, 240
Daily life. See Life; Quality of life
Declarative memory, 212t, 213–214
Dementia
errorless learning for, 231
Executive Function Performance Test
(EFPT), 257
Denial
characteristics of, 68t
clinician rating scale for, 69f
definition of, 67–68
neglect rehabilitation, affect on, 143
Denial of Disability (DD) subscale, 68
Depression, major, 250–251
Depth perception, 59t
Diagnostic Test for Apraxia, 121
Diary. See Memory notebook/diary
Diary and self-instructional training, 226
Diary-only training, 226
Digital voice recorder, 232, 233
Diplopia
management of, 55–58
questionnaire for, 57f
visual occlusion techniques for, 57f
Direct Attention Training, 198t
Direct training, 128–129
Disability
awareness of, 147–148
neglect effect on, 143
Discriminant validity, 34
Disease, quality of life and, 7
Disorientation, 143
Distance visual acuity, 49
Distractibility, 186t, 204f
Divided attention, 186t
Dorsal stream, 47
Dressing
difficulties in, 41f, 60f
memory intervention for, 235
as strategy to improve visuospatial
impairment, 38t
Dual-task performance, 36
Dynamic Interactional Approach, 22
Dynamic Model of Awareness, 75–76
Dysexecutive Questionnaire (DEX), 90
awareness measurement, 91t, 251
for executive function, 253t
overview of, 258
Dysexecutive symptom, 245–247, 246t
Dysexecutive syndrome, 248–249
E
Ecologic validity, 33–34
Electronic memory aid, 231–233
Elevator counting, 191
Emergent awareness, 74
Encoding, as stage of memory, 211t
Environment, assessment outcome, 37–38
Environmental adaptation, 161
Environmental agnosia, 172t, 177t
Environmental cue, 231
Environmental strategies, 161t, 234
Environmental structuring, 273
Environmental variable, manipulation of,
272–273
Epilepsy, 201
Episodic buffer, 213, 247f
Episodic memory, 212t
Error awareness, 96–97, 96t
Errorless learning, 127
for ADL improvement, 160
for dementia/Alzheimer’s disease, 231
environmental cues for, 231
for memory deficits, 228–231
trial-and-error learning versus, 230
Evaluation procedure, 32–38
Everyday Descriptions Task
planning tasks in, 267
protocol for, 266–267
Everyday memory, 211
Everyday Memory Questionnaire (EMQ),
218, 222t
Evidence-based intervention
for apraxia, 122–131
for executive function, 279
for neglect, 146–161
Evidence-based intervention, outcomes
for agnosia, 183
for attention deficits, 208
for awareness intervention, 106t
for improving daily function, 166

Evidence-based intervention, research
for agnosia, 182
for attention deficits, 207
for awareness intervention, 105t
for improving daily function, 165
Evidence-based practice, 2, 41–42
Executive cognitive function, 248
Executive control system, 187, 249–250
Executive deficits
of ADL, 245–247
forms of, 248
neuropathology of, 249–250
Executive function
assessment and evaluation of, 252–265
awareness measurement and, 251
Behavior Rating Inventory of Executive
Function-Adult Version
(BRIEF), 258
Behavioural Assessment of the
Dysexecutive Syndrome
(BADS), 257
Behavioural Assessment of the
Dysexecutive Syndrome for Children
(BADS-C), 257–258
definition of, 245
evidence-based interventions for, 279
example of, 246t
impairment of, 248–249
intervention for, 265
manipulating environmental variables,
272–273
Time Pressure Management (TPM),
269
WSTC strategy, 268
Executive Function Performance Test (EFPT),
20–21, 252–257, 253t
Executive Function Route-Finding Task
(EFRT), 253t
example of, 263f
overview of, 262–265
Executive process, 248f
Executive strategy training, 268
Executive system of attention control, 187,
249–250
Exercise, 204f
Explicit memory, 212t, 213–214, 229–230
Exploration training, 128–129
Extended Rivermead Behavioral Memory Test
(ERBMT), 217
External compensation, 75
External cueing, 269–272
Extinction
cause of, 139
functional manifestations of, 139, 140f
screening techniques for, 141
Extrapersonal neglect, 138
ADL, effect on, 142
Catherine Bergego Scale as test for, 145f
Eye
movements of, 46
view of, 47f
vision field loss in, 52
Eye exercise, 57–58
Eye patching, 156–157
F Home setting for IADL, 37
Face validity, 34
Family Guide to The Rancho Levels of
Cognitive Functioning, 299
Far extrapersonal neglect
recovery from, 142
spacial aspects of, 138t
Far transfer, 40
Fatigue, management for attention deficit,
204f
Feedback
as apraxia intervention, 123–126
during Baking Tray Task, 159
as behavioral intervention, 98–99
for functional deficit, 126
Feeding, 161t
Field-dependent behavior, 186t
Figure-ground discrimination, 59t
Fixation, 51
Fixational eye movement, 56
Index 305
Florida Apraxia Screening Test-Revised, 120 Ideomotor Apraxia Test, 121
Fluff Test, 148f, 149t Imagined limb movement, 156
Forward chaining, 230 Impaired self-awareness
Four-factor solution, 193–195 areas affected by, 68
Fresnel prism, 157 assessments questions for, 77
Frontal eye field, 46–47 clinician rating scale for, 69f
Frontal lobe definition of, 67
anatomy of, 250f outcomes for, 73–90
areas of, 249t problems contributing to, 72t
function of, 29t Impairment
Full occlusion patch, 56–57 assessment of, 13–21
Function cerebral artery dysfunction causing, 25t
evidence-based interventions, outcomes, 166 cerebrovascular dysfunction causing, 27t
evidence-based interventions, research, 165 patterns of, 143
managing deficits, 274 visual acuity, management of, 51–52
mental imagery as intervention, 156 Implicit memory
retraining specific skills of, 197–201 as component of long-term memory,
Functional cognition, 33–34 213–214
Functional imaging, 178f definition of, 212t
Functional Independence Measure (FIM), explicit memory versus, 229–230
9, 14f Incomplete hemianopsia, 52
disability rehabilitation, 143 Inferior occipitotemporal pathway, 47
grooming impairments from stroke, 24t Information, types of stored, 170
home versus clinical setting, 37 Information-processing theory, 23
unilateral neglect rehabilitation outcome, Initiation, 246t
142–143 Instruction
Functional magnetic resonance imaging for functional deficit, 126
(fMRI), 249–250 types of, 123–126
Function-based apraxia assessment, 124t Instrumental Activities of Daily Living (IADL)
Function-based executive function effect of environment on performance,
assessment, 253t 37–38
Function-based memory assessment, 222t executive deficits of, 245–247
Function-based neglect assessment, 149t executive function intervention for, 267
home versus clinical setting, 37
G Lawton Instrumental Activities of Daily
Game format, 95 Living Scale, 11
Generalization, 39–41, 95–96 measures of, 8
executive function and, 267–268 memory notebook/diary for, 221
for memory deficits, 234–235 Revised Observed Tasks of Daily Living
Geriatric Depression Scale, 51–52 (OTDL-R), 9–11
Gesture-production exercise, 129 standardized assessments of, 11t
Glascow Coma Scale, 292 unilateral neglect effect on, 142–143
Glasses, 158f Integrated Biophysical Approach to
Gnosis, 169–170 Awareness, 100t
Goal, rehabilitation and, 5 Intellectual awareness, 74, 76f
Goal management training, 270f Intermediate transfer, 40
Goal management training (GMT), Internally Cued Scale, 219
268–269, 268f International Classification of Function
Greebles, 177, 178f (ICF), 2–4
Grocery-shelf scanning, 159 elements of, 3, 3t
Grooming, 24t interaction between components of, 4f
Group intervention, 99–101 outcomes for IADLs and QOL, 6
relationship with AOTA practice
framework, 5f
H Intervention, 265
Half-blindness, 52 for apraxia, 123
Health, quality of life and, 7 for attention deficits, 195–203
Hemianopsia awareness, improvement of, 90
management of, 52–65 behavioral, 98
neglect and, 143–144 choosing appropriate approach, 39
treatment for, 53 for diplopia, 56–57
Hemiplegia, 69 for direct training, 128
Hemisphere, 139 error awareness and self-correction, 96
Hemisphere damage, 29t, 137, 137f, 138f for executive function, 265
Home management, 161t for exploration training, 128
for functional deficit, 126
Homonymous hemianopsias for functional limitations, 130, 131
cause of, 52
for memory deficits, 221–236
prisms as intervention for, 157 mental imagery as, 156
recovery from, 53
partial visual occlusion as, 156–157
Homonymous quadrantanopsia, 52 remediation versus adaptation, 38–39, 38t
Homonymous visual field impairment, 52
for scanning impairments, 152
Hospitalization, awareness interview for, 87 for topographic disorientation, 178
Hotel Test, 271, 271f
for unawareness, 100t
Human memory. See Memory Intransitive-nonsymbolic gesture training, 129
Huntington’s disease, 24
Intransitive-symbolic gesture training, 129
Hypersensitivity to stimuli, 273 Ipsilesional movement, 139, 140f
Ipsilesional stimuli, 139
I
Ideational apraxia K
definition of, 110–112 Kaufman Hand Movement Test, 120–121
manifestations of, 111f Key ideas log, 203
Ideomotor apraxia Key Search, 257
definition of, 112 Kitchen Task Assessment (KTA), 20–21
manifestations of, 115f Kohlman Evaluation of Living Skills, 37–38
306 Index

L Memory deficit (continued) Neglect (continued)

Landmark agnosia, 171, 172t, 177t guidelines for therapists, 213 monocular patching/lateralized visual
Language impairment, 42, 176 intervention for, 232, 234 stimulation, 156–157
Lateralized attention deficit, 136 palm-held computer for, 232 partial visual occlusion as intervention,
Lateralized visual stimulation, 156–157 presentation and recovery patterns, 156–157
Lawton Instrumental Activities of Daily Living 215–216 presentation of, 138–140
Scale, 11 strategies for significant others, 236 recovery from, 141–143
Learned nonuse, 155 task-specific training for, 235–236 rehabilitation training for, 152
Learning Activities Packet (LAP), 229t therapy session content, 235t right hemispheric dominance relating to, 137f
Left discrimination, 59t types of, 212t scanning training for, 148–153
Left frontoparietal stroke, 24t Memory loss case, 6–21 secondary impairments, exhibition of, 143
Left hemianopsia, 53–54 Memory notebook/diary spacial aspects of, 138t
Left hemiplegia effectiveness of, 227 stroke effect on, 140, 142
mental imagery as intervention, 156 example of, 226f testing after right hemisphere stroke,
neglect and, 155–156 purpose of, 221–228, 230t 144–145
Left limb activation, 154–155 sections of, 225t, 230t tests for reducing, 152
Left middle cerebral artery stroke, 288 stages of, 229t visual field loss and, 144t
Left neglect, 136–137, 156 three-stage approach to, 225t Neurobehavioral Specific Impairment
Leisure activity Memory process, 248f Subscale, 14f
Canadian Occupational Performance Memory questionnaire, self-report, 227f Neurodevelopmental theory, 23
Measure (COPM), 10f Memory training (MT), 265 Neurodevelopment treatment (NDT), 155
Nottingham Leisure Questionnaire, 11–12 Mental imagery, 155–156 Neurofunctional Approach, 23
Leisure competence Measure, 12–13 Metacognition, 272 Neuroimaging, 249–250
Leisure Diagnostic Battery, 13 Metacognitive process, 248 NeuroPage system, 231, 269
Lesion Metamemory, 211, 212t Neuropathology, executive function deficit,
apraxia and, 117f Micro perspective, 22–23 249–250
causing neglect, 137 Mnemonics, 178, 233–234 Neuropsychological deficit, 21
lateral view of right hemisphere with, 138f Mobility, 161t Non-associative learning, 214–215
unawareness with, 70–73 Modified Six Elements, 257 Noncomitant strabismus, 55–56
vision, effects of, 48f Monocular patching, 156–157 Nondeclarative memory, 212t, 213–214
vision field loss due to, 52–53 Moss Attention Rating Scale (MARS), 188t Notebook. See Memory notebook/diary
Life items and factors on, 192t Nottingham Health Profile (NHP), 8
agnosia effect on, 170–171 purpose of, 192–193 Nottingham Leisure Questionnaire, 11–12
executive function examples, 246t Motor extinction Novel task, performance of, 35
memory deficit effect on, 216 activities impeded by, 139
unilateral neglect effect on, 142–143. See also functional manifestations of, 139 O
Quality of life screening techniques for, 141 Object agnosia, 171, 172t, 177t
Lighthouse Strategy (LHS), 153–154, 153f Motor Free Visual Perception Test (MVPT), 40 Object recognition, 176–177
Likert scale, 8, 262–263 Motor neglect Occipital lobe, 29t
Limb activation approach, 154–156, 155f behavior seen in, 139 Occupation
Limb apraxia, 129 functional manifestations of, 139 improving awareness using, 90–95
Limb Apraxia Test, 121 Motor praxis, 117f using hands-on, 236
Line bisection test, 152 Motor skills. See Assessment of Motor and Occupational performance, 21
Long-Term Episodic Scale, 219 Process Skills (AMPS) Occupational Therapy Functional Assessment
Long-term memory, 211 Movement imagery, 156 Compilation Tool (OT FACT), 272
components of, 213–214 Movement Imitation Test, 121 Ocular mobility, 49b
definition and behavior of, 212t Multicontext Treatment Approach, 22 Online awareness, 76f, 88
Lottery task, 191 Multiple Errands Test (MET), 253t Opposite Worlds, 192
instruction sheet for, 260f Optic aphasia, 172t
M overview of, 258–262 Optic radiation, 46–47
performance of, 262f Organization, 246t
Macro perspective, 22–23 Multiple sclerosis (MS)
Magnetic attraction, 139 Organizational strategies, 234
case study, 287 Orienting procedure, 203
Major depression, 250–251 Executive Function Performance Test
Map Mission, 191 Orienting system of attention control,
(EFPT), 257 185–187
Map search, 191 impaired self-awareness with, 73
Meal preparation Orthoptics, 57–58
memory deficit due to, 215–216 Overt verbalization, 267–268
assessment of skills, 1–2 patterns of cognitive-perceptual
goal management training application impairments, 23
for, 270f P
strategy training for, 272
as strategy to improve visuospatial unawareness with, 69 Pacing, 203
impairment, 38t Multitasking, 247–248 Paging system, 231
Measurement instrument, 33–34 Palm-held computer, 232
Medical Outcomes Study Short Form-36, 8 N Parietal lobe, 29t
Memory Parkinson’s disease (PD)
assessment and evaluation of, 216–221 Naturalistic Action Test (NAT), 21, 76–77 impaired self-awareness with, 73
Baddeley and Hitch Working Memory Near extrapersonal neglect, 138t patterns of cognitive-perceptual
Model, 247f Near point of convergence, 49b impairments, 23–24
components of, 213, 214f Near/reading visual acuity, 49 unawareness with, 69
composition and purpose of, 210–211 Near transfer, 40 Partial homonymous hemianopsia, 52
depression and, 250–251 Neglect Partial visual occlusion, 57, 156–157, 158f
executive model of, 247 assessment and evaluation of, 144–146 Participation, 8
guidelines for therapists, 213 awareness training for, 147–148 Participation restrictions, case study, 284, 286,
mnemonics as technique for, 233–234 Constraint-induced movement therapy 287, 288
Rivermead Behavioral Memory Test (CIMT), 155 Passive movement, complex, 155–156
(RBMT), 217 definition of, 136 Patch
stages of, 211, 211t disability rehabilitation, 143 for diplopia, 56–57
systems of, 214f environmental strategies for, 161t as neglect intervention, 156–157
Memory aid, 231–233 evidence-based interventions, types of, 158f
Memory compensation system, 225f outcomes, 166 Patient Competency Rating Scale (PCRS), 78,
Memory deficit, 97–98 evidence-based interventions, research, 165 81f, 91t
effect on daily life, 216 evidence-based interventions for, 146–161 Patient Competency Rating Scale for
errorless learning for, 228–231 frequency of, 140 Neurorehabilitation (PCRS-NR),
evidence-based interventions for, imagery training as intervention, 156 78–79, 86f
221–236, 240 left hemiplegia and, 155–156

Patient Distress Scale, 81, 91t Rancho Levels of Cognitive Functioning-
Pavlovian conditioning, 214 Revised, 293
Pen-and-paper assessment, 34–37, 35t Rating Scale of Attentional Behavior, 188t,
for attention deficits, 187–191 193, 193f
for executive function, 252 Razor/Compact Test
for neglect, 144 as functional neglect test, 149t
Perceptual anchor training, 154 personal neglect, as test for, 146
Perceptual impairment, 6–21 Reading
Perceptual learning, 214 Everyday Memory Questionnaire
Perceptual rehabilitation (EMQ), 219
enhancing generalization of, 39 verbal self-instruction, 268
focus of, 1 visual field requirement for, 53–54
International Classification of Function Reading ability, 158
(ICF), 2–4, 3t Real-world functional outcome, 2
Performance Assessment of Self-Care Skills Recognition compensation, 75
(PASS), 21 Recovery, 9
Performance-based assessment, 34–37, 35t Rehabilitation
Performance-based group, 99–101 after brain injury, 200
Perimetry, 53 goal setting, importance of, 5
Peripersonal neglect for impaired self-awareness, 73
Catherine Bergego Scale as test for, 145f International Classification of Function
recovery from, 142 (ICF), 2–4, 3t
spacial aspects of, 138t neglect incidence rate with stroke, 140
Personal neglect prisms as, 157
ADL, effect on, 142 quality of life and, 7–8
Catherine Bergego Scale as test for, 145f shifting focus of, 2
recovery from, 142 unilateral neglect effect on, 142–143
spacial aspects of, 138t Reintegration to Normal Living (RNL), 8
Phonological loop, 213, 247f Reliability
Phoria, 55–56 types of, 34
Picture chart, 51–52 validity versus, 33
Pirate patching, 56–57 Remediation
Positron-emission tomography (PET), 185, focus of, 1
249–250 as intervention approach, 38–39, 38t
Praxis system, 109 Retrieval, as stage of memory, 211t
Predictive validity, 34 Retrograde amnesia, 212t
Prefrontal area, 249 Revised Observed Tasks of Daily Living
Prefrontal cortex, 249t (OTDL-R), 9–10
Premack principle, 274 Right brain damage (RBD)
Priming, 214 neglect incidence rate, 141
Prism, 55 unawareness with, 69
for diplopia, 57f Right discrimination, 59t
for unilateral neglect/hemianopsia, Right frontoparietal stroke, 24t
157–158 Right hemianopsia, 53–54
Prism adaptation, 157 Right hemisphere stroke, 142, 144–145
Problem solving, 246t Right hemispheric damage, 156
Problem-solving training (PST), 265 Right hemispheric dominance, 137f
Procedural memory, 212t, 214 Right middle cerebral stroke, 288
Process skills. See Assessment of Motor and Right-sided bias, 143
Process Skills (AMPS) Right unilateral neglect, 136–137
Profile of Executive Control System, 253t Rivermead Behavioral Memory Test (RBMT),
Prosopagnosia, 171, 172t 217, 222t
assessment procedures for, 177t Role, 33
intervention for, 179 Role reversal technique, 97
Prospective and Retrospective Memory Rule Shift Cards, 257
Questionnaire (PRMQ), 222t
overview of, 218 S for functional deficits, 126
proxy-version of, 220t Saccades, 50, 51
Prospective memory, 211, 212t Satisfaction with Life Scale (SWLS), 8
overview of, 215 Scanning impairment, 152
steps of, 215 Scanning training
Prospective Memory Questionnaire (PMQ), 222t as intervention for neglect, 148–153
overview of, 218 Lighthouse Strategy, 153f
subscale and sample items, 219 Schizophrenia, 257
Pure alexia, 171, 172t Score!, 191
assessment procedures for, 177t Selective attention, 186t
intervention for, 179 Self-awareness
Pure word deafness, 171, 172t characteristics of, 68t
assessment procedures for, 177t clinical presentation of, 69
intervention for, 179 clinician rating scale for, 69f
Pursuit, 51 feedback as intervention, 98–99
Pusher syndrome, 144–145 of memory deficits, 234
neurological considerations for, 68–69
Q Patient Competency Rating Scale (PCRS),
Q-sort methodology, 9 78, 81f
Quadraphonic Approach, 22–23 problems contributing to deficits of, 72t
Quality of life pyramid model of, 74, 74f. See also
improvement of, 2 Impaired self-awareness
measures of, 7–8. See also Life Self-Awareness Deficits Interview (SADI)
example of, 78f
for executive function, 251
R visuospatial impairment after, 58–62
Rabideau Kitchen Evaluation-Revised, 1–2 as outcome measure of awareness, 91t
purpose of, 77
Radiation, 47–51
questions for, 80t
Index 307
Self-awareness group, 99–101
Self-care training, 160
Self-correction, 96–97
Self-evaluation, 72t, 76f
Self-initiation checklist, 272
Self-instruction, 201t
Self-instruction training, 267–268
Self-knowledge, 72t, 76f
Self-management, for attention
deficit, 203
Self-prediction, 95
Self-Regulation Skills Interview (SRSI),
77–78, 91t
Self-regulatory training, 274–275
Self-report memory questionnaire, 227f
Self-verbalization, 267–268
Semantic knowledge, 170
Semantic memory, 212t, 213–214
Sensitization, 214–215
Sensory memory, 211
Sequencing, 246t
Seven-point Likert scale, 8
Shaping technique, 155, 200–201
Shirt, putting on, 41f, 60f
Short-Term Habitual Scale, 219
Short-term memory, 211
definition and behavior of, 212t
unit of measurement for, 211–213
Sickness Impact Profile, 8, 261
Simple classical conditioning, 214
Simultanagnosia, 171, 172t, 177t
Single-task performance, 36
Situational awareness, 76f
Situational compensation, 75
Six Element Test, 271
Sky Search, 191
Snellen chart, 51–52
Somatosensory agnosia, 171, 172t
Spatial dysfunction, 40
Spatial neglect, 138t
Spatial relations, 59t
Spatial relations impairment, 47–49, 58–65
Spatio-motor cueing, 154–156
Speed-processing deficit, 247
Star cancellation test, 152
Stereopsis, 50, 59t
Stimulus, hypersensitivity to, 273
Storage, as stage of memory, 211t
Stored information, types of, 170
Stored structural knowledge, 170
Strabismus, 55–56
Strategy training
as apraxia treatment, 123–127
for attention deficits, 201–203
for executive dysfunction/multiple
sclerosis, 272
generalization of, 39–41
Stroke
Canadian Occupational Performance
Measure (COPM), 10f
case study, 284, 288
Executive Function Performance Test
(EFPT), 257
grooming impairments based on FIM, 24t
Lighthouse Strategy, 153–154
memory deficit due to, 215
mental imagery as intervention, 156
neglect incidence rate, 140
neglect severity from, 142
Nottingham Leisure Questionnaire, 11–12
partial visual occlusion as intervention,
156–157
patterns of cognitive-perceptual
impairments, 23
prisms as intervention for, 157
retraining specific skills of ADL, 197–199
somatosensory intervention, 178
unawareness with, 69–73
visual agnosia and, 170
visual function and, 49–51
Stroke Impact Scale (SIS), 8
Stroop Test, 252
308 Index

Structural knowledge, stored, 170 Traumatic brain injury (TBI) (continued) Visual field deficit
Structured Observational Test of Function presentation and recovery patterns, 215 interventions for, 53
(SOTOF), 21, 40 problem-solving skills, 266 management of, 52–65
Superior occipitoparietal pathway, 47 unawareness with, 69 neglect and, 143–144, 144t
Supervisory attentional system (SAS), 247 using mnemonics for, 234 Visual imagery
Sustained attention, 186t Treatment combining with movement imagery, 156
Sustained attention system, 187 quality of life and, 7 combining with scanning training, 153
Sustained attention training, 154 for unawareness, 100t Visual impairment
for ADL improvement, 160 Trial-and-error learning, 127, 230 agnosia versus, 176
functional improvements using, 155f Tropia, 55–56 types of, 45
for unilateral neglect, 160 Tumbling E chart, 51–52 Visual neglect
limitations of, 142
T U testing for, 157–158
Table game, 161t Unawareness Visual occlusion technique, 57f
Tabletop assessment, 34–37, 35t after stroke, 69–73 Visual pathway, 46f
Tabletop exercise, 272 bases for, 100t Visual processing
Tactile agnosia, 171, 172t determination of, 81–86 components of, 46f
assessment procedures for, 177t Unilateral body/personal neglect, 138 function of, 45–46
functioning difficulties with, 171 Unilateral neglect Visual spatial skills, 59t
intervention for, 179 definition of, 136 Visual stimulation, 141
Tactile stimulation, 141 effect on life and rehabilitation, 142–143 Visual stimulation, lateralized, 156–157
Task performance prisms as intervention for, 157 Visuoperceptual impairment, 170
apraxic errors during, 121t recovery from, 142 Visuospatial agnosia, 171, 172t
contributing to impaired self-awareness, 72t video feedback to decrease, 158–159 assessment procedures for, 177t
generalization of, 39–41 Unilateral sensory loss, 143 functioning difficulties with, 171
single-task versus double-task, 36 Unilateral spatial, 138 Visuospatial impairment
Task-specific training, 129–131, 235–236 Unilateral spatial neglect, 142–143 dressing, effect on, 60f
TBI-associated diffuse axonal injury, 215 Unilateral stimulation detection, 141 improving function, 40
Teaching-learning theory, 23 overview of, 58–65
Techniques to Remember Scale, 219 Visuospatial sketchpad, 213, 247f
V Visuospatial skills
Telephone search, 191 Validity
Temporal Judgment, 257 functional activities to challenge, 40
reliability versus, 33 function and, 59t
Temporal lobe, 29t types of, 34
Ten-point Likert scale, 9 Voice organizer, 233
Ventral stream, 47
Test, reliable versus valid, 33 Verbal feedback, 123–126
Test of Everyday Attention (TEA) W
Vergence, 51
for attention deficits, 188t Very far transfer, 40 Walk, Don’t Run, 191–192
subtests of, 191 Video feedback Washing, 235
Test of Everyday Attention for Children decreasing unilateral neglect, 158–159 Wechsler Adult Intelligence Scale-
(TEA-ch), 188t, 191 on grocery-shelf scanning, 159 Revised (WAIS-R) Block Design
Time-dependent memory, 211 improving awareness using, 95 Test, 1–2
Time Pressure Management (TPM) neglect, improving awareness of, 148 Wheelchair collision test, 149t
cognitive strategy for, 201t purpose of, 97 Wheelchair mobility
for executive function, 269 Vision, 49–51 computerized assisted training, 159
purpose of, 201 Vision screening, 47–51 neglect affect on, 146
Top-down approach, 32 Vision therapy, 57–58 Wisconsin Card Sorting Task, 252
Topographic disorientation, 178, 179 Visual acuity Word finding, 176
Topographic orientation, 59t deficits in, 47–49 Working memory, 211–213
Topographical disorientation, 143 distance versus near/reading, 49 Baddeley and Hitch Working Memory
Trail Making Test, 252 impairment management, 51–52 Model, 247f
Training approach intervention for deficits, 52 components of, 213
direct versus exploration, 128–129 Visual agnosia, 170, 172t definition and behavior of, 212t
task-specific, 129–131 assessment procedures for, 177t executive model of, 247
transfer of, 41–42 functioning difficulties with, 171 guidelines for therapists, 213
Transfer criteria, 40 intervention for, 179 World Health Organization (WHO)
Transitive gesture training, 129 Visual cortex International Classification of Function
Traumatic brain injury (TBI), 24 components of, 46f (ICF), 2–4, 3t
depression associated with, 250–251 damage to, 47 relationship with AOTA practice
error awareness and sustained Visual elevator, 191 framework, 5f
attention, 185 Visual field, 46, 46f Wristwatch alarm, 232
impaired self-awareness with, 73 confrontation test, 50 WSTC strategy, 226, 268
mental imagery as intervention, 156 lesions of, 48f
Patient Competency Rating Scale (PCRS), prisms for, 55 Z
78, 81f reading requirements, 53–54 Zoo Map, 257