LEARNING OBJECTIVES
At the end of this chapter readers will be able to:
1 Understand various classification systems that can be used to guide the evaluation and intervention process for those living with functional limitations secondary to cognitive and perceptual impairments.
2 Apply the principles of client-centered practice to this population.
3 Understand which outcome measures are appropriate for this population.
4 Understand patterns of cognitive and perceptual impairments that interfere with everyday function.
āBest 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.ā38
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 impairment. It was assumed that the remediation of an identified impairment or impairments would generalize into the ability to perform meaningful, functional activities. In general, this assumption has not been supported by empirical research.
An early example is the elegant work of Neistadt.47 The researcher had previously identified a relationship 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 conducted to examine the effects of interventions focused on retraining meal preparation skills versus 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 rehabilitation programs. Results showed task-specific learning in both groups and suggested that training in functional activities may be the better way to improve performance in such activities in this population. In other words, those trained in construction tasks performed better on novel tabletop construction tasks but did not improve on meal preparation measures, whereas those trained in the meal preparation 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 academic settings and those that were commonly used in the clinic at the time it was published.
In general, interventions at that time were provided 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 target stimulus on paper, pegboard designs, memory drills, and so on. As technology became more readily available, specialized cognitive-retraining computerized 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 nonfunctional test items such as copying words and designs, picture matching, block building, sequencing 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 meaningful functional changes (e.g., improved ability to read, manage medications, play board games, manage money, etc.) cannot be documented.
As rehabilitation professions began to understand the importance of evidence-based practice and have refocused on āreal-worldā functional outcomes, 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, outcome 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 perceptual impairments has been notoriously difficult. It is expected that as the research literature focused on testin...
