Cognitive and Perceptual Rehabilitation

Optimizing Function

Glen Gillen

• Publisher: Mosby
• Year: 2008
• ISBN:
  9780323074704
• Topic: Medicina
• Subtopic: Terapia occupazionale

Reflecting current practice with a renewed focus on function-based assessments and evidence-based interventions, Cognitive and Perceptual Rehabilitation: Optimizing Function includes all of the tools you need to make a positive impact on your patients' lives. This clinical resource summarizes, highlights, and constructively critiques the state of cognitive and perceptual rehabilitation. This text helps you enhance your patients' quality of life by promoting improved performance of necessary and meaningful activities, and decreasing participation restrictions.

• Evidence-based intervention tables focus on improving daily function through proven methods.
• Summary tables highlight each assessment's clinical utility and pyschometric properties to provide you with the tools you need to choose the best assessment for each patient.
• An entire chapter on Application of Concepts features five case studies, each discussing background data and medical record review, evaluation findings, assessments, long-term goals, short-term goals, and interventions/functional activities to help you apply the theories and principles from the book to real-world situations.
• Handy learning aids including Key Terms, Learning Objectives, and Review Questions help you remember important information.

Chapter 1 Overview of Cognitive and Perceptual Rehabilitation

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.

“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

KEY TERMS

Activity Demands

Activity Limitation

Areas of Occupation

Client-centered Practice

Client Factors

Context

Environmental Factors

Impairment

Participation Restriction

Performance Patterns

Performance Skills

Quality of Life

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 “real-world” 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...