CHAPTER 1

OVERVIEW OF NERO- ANATOMY

Neuroanatomy
The brain is divided into four main areas:
Forebrain
 Cerebrum divides into two hemispheres with four lobes
(frontal, parietal, temporal and occipital lobes)
 Internal capsule
 Basal ganglia (caudate nucleus, globus pallidus and
putamen)
 Diencephalon (thalamus and hypothalamus)
Midbrain (brainstem)
 Mesencephalon (midbrain).
 Pons.
 Medulla oblongata.
Hindbrain
 Cerebellum
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  Spinal medulla
Midbrain (brainstem)
 Mesencephalon (midbrain).
 Pons.
 Medulla oblongata.
Hindbrain
 Cerebellum
 Spinal medulla (spinal cord).
Cerebrum
 Conscious thought processes, intellectual functions
 Memory storage and processing
 Conscious and subconscious regulation of skeletal muscle
contractions.
Thalamus
 Relay and processing centres for sensory and motor
information.
Hypothalamus
 Centres controlling emotions, autonomic functions and
hormone production.
 Mesencephalo
 Processing of visual and auditory data
 Generation of reflexive somatic motor responses
 Maintenance of consciousness.
Pons
 Relays sensory information to cerebellum and thalamus
 Subconscious somatic and visceral motor centres.

Medulla Oblongata
Relays sensory information to thalamus and to other portions of
the brain stem
 Autonomic centres for regulation of visceral function
(cardiovascular, respiratory and digestive system activities).

Cerebellum
 Coordinates complex somatic motor patterns
 Adjusts output of other somatic motor centres in brain and
spinal cord.

The arterial supply to the brain is from: The anterior circulation

comprising two internal carotid arteries which divide into two
major arteries:
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  Anterior cerebral artery.
 Middle cerebral artery.
The posterior circulation comprising two vertebral arteries which
lead to:
 Posterior inferior cerebellar artery.
 Basilar artery.
 Posterior cerebral artery.
The anterior circulation can also be divided into right and left
circulations, as there is a carotid artery on each side. Because
the vertebral arteries join quite low down the brainstem, most of
the posterior circulation is supplied by a single basilar artery. If
each of these circulations existed in isolation, then blockage of
either carotid or the basilar artery would result in extensive, life-
threatening infarction. This does not occur, however, because of
anterior and posterior communicating arteries which connect the
brain arteries into an anatomical circle, known as the circle of
Willis. Thus when one vessel is blocked, an alternative (or
collateral) blood supply is available. There is considerable
variation between individuals with regard to how effective their
communicating arteries are, and thus collateral circulation, is.
Thus carotid, or basilar, occlusion can result in life-threatening
stroke for some individuals and will pass unnoticed by others. In
reality, most patients exist on a spectrum somewhere between
these extremes. This explains why a given vascular abnormality,
for example, carotid occlusion, will result in different severities of
stroke in different patients.

Damage That Can Occur In Different Areas of The Brain

Each hemisphere has specialized functions known as
hemispheric lateralization. For ex-ample, the left hemisphere
senses and controls movement on the right side of the body and
specialises in language-based skills such as reading, writing and
speaking, and performs analytical tasks such as mathematics
and logical reasoning. Oppositely, the right hemisphere senses
and controls movements on the left side of the body and is
specialised in more creative, spatial and interpretive skills
Testani-Dufour and Morrison (1997) summarised the arterial
supply of the brain and the results of occlusion to those arteries.
They also summarised the functions of the different areas of the
brain and the impairments that can occur as a result of damage
(occlusion) to those areas.
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4
 CHAPTER 2
ACUTE NEURO/NEUROSURGICAL CARE
An accurate description of the patient’s neurological symptoms is
an important aid in establishing the diagnosis; but this must be
taken in conjunction with information from other systems,
previous medical history, family and social history and current
medication. Often the patient’s history requires confirmation
from a relative or friend. The following outline indicates the
relevant information to obtain for each symptom, although some
may require further clarification. Onset (sudden, gradual)
Precipitating factors (stooping, coughing) Relieving factors
(analgesics)
Site
Severity
Character (aching, throbbing)
Neurological disease may produce systemic signs and systemic
disease may affect the nervous system. A complete general
examination must therefore accompany that of the central
nervous system. In particular, note the following
Temperature Evidence of weight loss Septic source, e.g. teeth,
ears. Blood pressure Breast lumps Skin marks, e.g. rashes
Neck stiffness Lymphadenopathy café-au-lait spots
Pulse irregularity Hepatic and splenic angiomata
Carotid bruit enlargement, Anterior fontanelle in baby Cardiac
murmurs, Prostatic irregularity Head circumference
Cyanosis/respiratory insufficiency.

EXAMINATION – CONSCIOUS LEVEL ASSESSMENT

GENERAL APPROACH TO HISTORY AND EXAMINATION
A wide variety of systemic and intracranial problems produce
depression of conscious level. Accurate assessment and recording
are essential to determine deterioration or improvement in a
patient’s condition. In 1974 Teasdale and Jennett, in Glasgow,
developed a system for conscious level assessment. They
discarded vague terms such as stupor, semicoma and deep coma,
and described conscious level in terms of EYE opening, VERBAL
response and MOTOR response. The Glasgow coma scale is now
used widely throughout the world. Results are reproducible
irrespective of the status of the observer and can be carried out
just as reliably by paramedics
EYE OPENING – 4 categories
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VERBAL RESPONSE – 5 categories
Orientated – Knows place, e.g. Southern General Hospital and
time, e.g. day, month and year
Confused – Talking in sentences but disorientated in time and
place
Words – Utters occasional words rather than sentences
Sounds – Groans or grunts, but no words
None
Supraorbital nerve or finger nails pressure
Spontaneous
To speech,
To pain and None

MOTOR RESPONSE – 5 categories

Obeys commands
Localising to pain
Apply a painful stimulus to the supraorbital nerve, e.g. rub
thumb nail in the supraorbital groove, increasing pressure until a
response is obtained. If the patient responds by bringing the
hand up beyond the chin = ‘localising to pain’. (Pressure to nail
beds or sternum at this stage may not differentiate ‘localising’
from ‘flexing’.)
Flexing to pain
Extending to pain
If in response to the same stimulus elbow extension occurs,
record as ‘extending to pain’. This is always accompanied by
spastic flexion of the wrist. None. Before recording a patient at
this level, ensure that the painful stimulus is adequate. During
examination the motor response may vary. Supraorbital pain
may produce an extension response, whereas fingernail pressure
produces flexion. Alternatively one arm may localise to pain; the
other may flex. When this occurs record the best response during
the period of examination (this correlates best with final
outcome). For the purpose of conscious level assessment uses
only the arm response. Leg response to pain gives less consistent
results, often producing movements arising from spinal rather
than cerebral origin.

MEMORY TEST

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Testing requires alertness and is not possible in a confused or
dysphasic patient.
IMMEDIATE memory – Digit span – ask patient to repeat a
sequence of 5, 6, or 7 random numbers.
RECENT memory – Ask patient to describe present illness,
duration of hospital stay or recent events in the news.
REMOTE memory – Ask about events and circumstances
occurring more than 5 years previously.
VERBAL memory – Ask patient to remember a sentence or a
short story and test after 15 minutes.
VISUAL memory – Ask patient to remember objects on a tray and
test after 15 minutes.
Note: Retrograde amnesia – loss of memory of events leading up
to a brain injury or insult.
Post-traumatic amnesia – permanent loss of memory of events for
a period following a brain injury.

REASONING AND PROBLEM SOLVING

Test patient with two-step calculations, e.g. ‘I wish to buy 12
articles at 7 pence each. How much change will I receive from
£1?’
Ask patient to reverse 3 or 4 random numbers.
Ask patient to explain proverbs.
Ask patient to sort playing cards into suits.
The examiner must compare patient’s present reasoning ability
with expected abilities base

Cranial Nerve Examination

OLFACTORY NERVE (I)
Test both perception and identification using aromatic non-
irritant materials that avoid stimulation of trigeminal nerve fibres
in the nasal mucosa, e.g. soap, tobacco. One nostril is closed
while the patient.

OPTIC NERVE (II)

Light? Severe deficit – Can patient see movement? Visual acuity
Can patient count fingers? Mild deficit – Record reading acuity
with wall or hand chart.
N.B. Refractive error (i.e. inadequate focusing on the retina, e.g.
hyper-metropia, myopia) can be overcome

7
by testing reading acuity through a pinhole. This concentrates a
thin beam of vision on the macula.

Visual fields
Gross testing by CONFRONTATION. Compare the patient’s fields
of vision by advancing a moving finger or, more accurately, a red
5 mm pin from the extreme periphery towards the fixation point.
These maps out ‘cone’ vision. A 2 mm pin will define central field
defects which may only manifest as a loss of colour perception.
In the temporal portion of the visual field the physiological blind
spot may be detected. A 2 mm object should disappear here.
The patient must fixate on the examiner’s pupil. OCULOMOTOR
(III), TROCHLEAR (IV) AND ABDUCENS (VI) NERVES A lesion of
the III nerve produces impairment of eye and lid movement as
well as disturbance of pupillary response. Pupil: The pupil dilates
and becomes ‘fixed’ to light. Shine torch in affected eye –
contralateral pupil constricts (its III nerve intact). Absent or
impaired response in illuminated eye.

TRIGEMINAL NERVE (V)

Test pain (pin prick) sensation temperature (cold object or
hot/cold tubes) light touch Compare each side. Map out the
sensory deficit, testing from the abnormal to the normal region.
Corneal reflex Test corneal sensation by touching with wisp of
wet cotton wool. A blink response should occur bilaterally.
Afferent route – ophthalmic division V (light touch – main sensory
nucleus) Efferent route – facial nerve VII. This test is the most
sensitive indicator of trigeminal nerve damage Motor
examination. Observe for wasting and thinning of temporalis
muscle ‘hollowing out’ the temporalis fossa. Ask the patient to
clamp jaws together. Feel temporalis and masseter muscles.
Attempt to open patient’s jaws by applying pressure to chin. Ask
patient to open mouth. If pterygoid muscles are weak the jaw will
deviate to the weak side, being pushed over by the unopposed

TRIGEMINAL NERVE (V) (cont’d)

Jaw jerk
Ask patient to open mouth and relax jaw. Place finger on the chin
and tap with hammer: Slight jerk – normal
Increased jerk – bilateral upper neuron lesion.
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FACIAL NERVE (VII)
Observe patient as he talks and smiles, watching for:
 eye closure
 asymmetrical elevation of one corner of mouth
 Flattening of nasolabial fold.
Patient is then instructed to: wrinkle forehead (frontalis) (by
looking upwards)
 close eyes while examiner attempts to open them
(orbicularis oculi)
 purse lips while examiner presses cheeks (buccinator)
 Show teeth (orbicularis oris).

AUDITORY NERVE (VIII)

Cochlear component
Test by whispering numbers into one ear while masking hearing
in the other ear by occluding and rubbing the external meatus. If
hearing is impaired, examine external meatus and the tympanic
membrane with auroscope to exclude wax or infection.
Differentiate conductive (middle ear) deafness from perceptive
(nerve) deafness by:
1. Weber’s test: Hold base of tuning fork (512 Hz) against the
vertex.

GLOSSOPHARYNGEAL NERVE (IX): VAGUS NERVE (X)

These nerves are considered jointly since they are examined
together and their actions are seldom individually impaired.
Note patient’s voice – if there is vocal cord paresis (X nerve palsy),
voice may be high pitched. (Vocal cord examination is best left to
an ENT specialist.) Note any swallowing difficulty or nasal
regurgitation of fluids. Ask patient to open mouth and say ‘Ah’.
Note any asymmetry of palatal movements (X nerve palsy).
Uvula swings due to unopposed muscle action on one side. Gag
reflex Depress patient’s tongue and touch palate, pharynx or
tonsil on one side until the patient ‘gags’. Compare sensitivity on
each side (afferent route – IX nerve) and observe symmetry of
palatal contraction (efferent route– X nerve).

ACCESSORY NERVE (XI)

Sternomastoid

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Ask patient to rotate head against resistance. Compare power
and muscle bulk on each side. Also compare each side with the
patient pulling head forward against resistance. N.B. The left
sternomastoid turns the head to the right and vice versa.
Trapezius
Ask patient to ‘shrug’ shoulders and to hold them in this position
against resistance. Compare power on each side. Patient should
manage to resist any effort to depress

HYPOGLOSSAL NERVE (XII)

Ask patient to open mouth; inspect tongue. Look for – evidence of
atrophy (increased folds, wasting) fibrillation (small wriggling
movements). Ask patient to protrude tongue. Note any difficulty
or deviation. (N.B. apparent deviation may occur with facial
weakness if present; assess tongue in relation to teeth.)
Protruded tongue deviates towards side of weakness. Non
protruded tongue cannot move to the opposite side. Dysarthria
and dysphagia are minimal.

EXAMINATION – UPPER LIMBS MOTOR SYSTEM

Appearance
Note: – any asymmetry or deformity
 muscle wasting If in doubt, measure circumference at fixed
distance
 Muscle hypertrophy above/below joint. Note muscle group
involved.
 Muscle fasciculation irregular, non-rhythmical contraction
of muscle fascicules, increased after exercise and on tapping
muscle surface.
 muscle myokimia a rapid flickering of muscle fibres,
particularly in orbicularis oculi but occasionally in large
muscles, after exercise or with fatigue ‘Benign Fasciculation
Tone
Ensure that the patient is relaxed, and assess tone by alternately
flexing and extending the elbow or wrist.
Note: – decrease in tone ‘Clasp-knife’: the initial resistance to the
movement.

Power
Muscle weakness. The degree of weakness is ‘scored’ using the
MRC (Medical Research Council) scale.
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Score 0 – No contraction
Score 1 – Flicker
Score 2 – Active movement/gravity eliminated
Score 3 – Active movement against gravity
Score 4 – Active movement against gravity and resistance
Score 5 – Normal power

SENSATION
Pain
Pin prick with a sterile pin provides a simple method of testing
this important modality. Firstly, check that the patient detects
the pin as ‘sharp’, i.e. painful, then rapidly test each dermatome
in turn. Memorising the dermatome distribution is simplified by
noting that ‘C7’ extends down the middle finger.
If pin prick is impaired, then more carefully map out the extent of
the abnormality, moving from the abnormal to the normal areas.

Light touch
This is tested in a similar manner, using a wisp of cotton wool.

Temperature
Temperature testing
Joint position sense
Hold the sides of the patient’s finger or thumb and demonstrate
‘up and down’ movements. Repeat with the patient’s eyes closed.
Ask patient to specify the direction of movement. Ask the patient,
with eyes closed, to touch his nose with his forefinger or to bring
forefingers together

Vibration
Place a vibrating tuning fork (usually 128 c/s) on a bony
prominence, e.g. radius. Ask the patient to indicate when the
vibration, if felt, ceases. If impaired, move more proximally and
repeat. Vibration testing is of value in the early detection of
demyelinating disease and peripheral neuropathy, but otherwise
is of limited benefit. If the above sensory functions are normal
and a cortical lesion is suspected, it is useful to test for the
following:
 Two point discrimination: the ability to discrimination.

11
  Two point discrimination: the ability to discriminate two
blunt points when simultaneously applied to the finger, 5
mm apart (cf, 4 cm in the legs).
 Sensory inattention (perceptual rivalry): the ability to detect
stimuli (pin prick or touch) in both limbs, when applied to
both limbs simultaneously.
 Stereognosis: the ability to recognise objects placed in the
hand.
 Graphaesthesia: the ability to recognise numbers or letters
traced out on the patient.

REFLEXES
Biceps jerk C5, C6 roots. Musculocutaneous nerve

EXAMINATION – UPPER LIMBS

GENERAL APPROACH TO HISTORY AND EXAMINATION 22
Joint position sense
Hold the sides of the patient’s finger or thumb and demonstrate
‘up and down’ movements. Repeat with the patient’s eyes closed.
Ask patient to specify the direction of movement. Ask the patient,
with eyes closed, to touch his nose with his forefinger or to bring
forefingers together with the arms outstretched. Supinator jerks
C6, C7 roots. Radial nerve

CO-ORDINATION
Inco-ordination (ataxia) is often a prominent feature of cerebellar
disease prior to testing; ensure that power and proprioception are
normal.

CO-ORDINATION
Ask patient to repeatedly run the heel from the opposite knee
down the shin to the big toe. Look for ATAXIA (in co-ordination).
Ask patient to repeatedly tap the floor with the foot. Note: any
DYSDIADOCHOKINESIA (difficulty with rapidly alternating.

GAIT
Note:
 Length of step and width of base Normal
 Abnormal leg movements (e.g. excessively high step)
 Instability (gait ataxia)
 Associated postural movements (e.g. pelvic swinging.
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13
 CHAPTER 3
LESIONS OF PYRAMIDAL SYSTEM.
NEUROANATOMY, PYRAMIDAL TRACT LESIONS
Introduction
The central nervous system (CNS) is a complex network of
components that allow an organism to interact with its
environment. It is made up of multiple different parts, each of
which plays a different role. Primarily, the CNS is formed by the
upper motor neurons (UMN) which carry signals for movement
down to the lower motor neurons (LMN) which signal the muscles
to either contract or relax. The UMN further subdivides into
multiple tracts, each of which has specific functions within the
body. Specifically, the pyramidal tract is the main pathway that
carries signals for voluntary movement. Lesions to the pyramidal
tract can lead to devastating consequences such as spasticity,
hyperactive reflexes, weakness, and a Babinski sign (stroking the
sole of the foot causes the big toe to move upward). These
symptoms are all characteristic of an upper motor neuron lesion.
However, certain symptoms are specific to a pyramidal tract
lesion.

Structure and Function

The pyramidal tracts are part of the UMN system and are a
system of efferent nerve fibers that carry signals from the
cerebral cortex to either the brainstem or the spinal cord. It
divides into two tracts: the corticospinal tract and the
corticobulbar tract. The corticospinal tract consists of neurons
that synapse on the spinal cord controlling movements in the
limbs and trunk. It originates in multiple areas of the brain,
mainly in the primary motor cortex (Brodmann area 4) and in
premotor areas (Brodmann area 6). However, it can also originate
from the somatosensory cortex, cingulate gyrus, and the parietal
lobe. From here, it will descend through the corona radiata,
internal capsule, cerebral peduncles, pons, and upper medulla.
Once it reaches the lower medulla, about 85 to 90% of the fibers
will cross over or “decussate” at the pyramidal decussation to
form the lateral corticospinal tract (LCST). They continue their
descent in the lateral funiculus and terminate at all levels of the
spinal cord. A few of these fibers that are responsible for fine
motor function such as controlling finger and hand movement
will synapse directly on lower motor neurons. However, most will
14
terminate in lower motor neuron “pools” (groups of interneurons
that process and integrate the information before passing it on to
the lower motor neurons). At the pyramidal decussation, the 10
to 15% of fibers that did not decussate will continue down
uncrossed as the anterior corticospinal tract (ACST). These fibers
are involved in controlling proximal muscles such as those in the
trunk. Typically lesions of the ACST tend to have a minimal
clinical effect. The pyramidal decussation is a critical concept to
understand. Because of the crossing over of the fibers, the
location of the lesion will determine which side the symptoms will
arise. Lesions above the decussation will cause symptoms on the
contralateral side of the body, whereas lesions below the
decussation (typically the spinal cord) will cause symptoms on
the ipsilateral side. The corticobulbar tract synapses on the
cranial nerves controlling muscles of the face, head, and neck. It
originates in the frontal lobe’s primary motor cortex and follows a
similar path to the corticospinal tract. It descends through the
corona radiata and the internal capsule. They will then exit and
synapse directly on the lower motor neurons of cranial nerves.
The fibers of the corticobulbar tract bilaterally innervate almost
every cranial nerve except for cranial nerves VII and XII, which
are innervated by the contralateral cortex. What this means is
that a corticobulbar tract lesion on the left side of the face will
cause weakness of the right side. However, since every other
cranial nerve except for VII and XII are innervated bilaterally
(both the left and right hemispheres), lesions to both sides of the
corticobulbar tract will need to occur for symptoms to appear.

Blood Supply and Lymphatics

The pyramidal tract, specifically the corticospinal tract, spans an
incredibly long distance along the body. Damage to specific
vasculature structures can lead to damage to the tract. The
pyramidal tract originates in the primary motor cortex. The
primary motor cortex for the face and upper extremities receive
blood from the middle cerebral artery (MCA) while the primary
motor cortex for the lower extremities receives blood from the
anterior cerebral artery (ACA). An occlusion of either of these
arteries can lead to weakness in the associated extremities. As
the corticospinal tract passes down, it will go through the corona
radiata and internal capsule, which are innervated by the
lenticulostriate arteries (branches of the MCA). The occlusion of
15
these arteries will lead to the contralateral weakness of both
upper and lower extremities. As the corticospinal tract passes
down into the brainstem, it gets supplied by the basilar artery.
The blockage of blood here can result in a variety of symptoms
ranging from isolated nerve palsies to tetraplegia or death.

Surgical Considerations
Pyramidal tract lesions can have devastating consequences if not
discovered quickly. The most important aspect of surgery focuses
on determining the location and cause of the lesion, which will
help dictate the procedure. A detailed history and physical exam
will aid in guiding this process. Pyramidal tract lesions will
present very similarly to upper motor lesions with symptoms
such as hyperreflexia, weakness, spasticity, and a Babinski sign.
Damage to the corticobulbar tract can present with additional
symptoms of lower facial weakness and changes to speech. Initial
treatment for these lesions is typically intensive rehabilitation
and exercise. They can also be managed with medical
interventions such as botulinum toxin, benzodiazepines, and
baclofen, which can all help to decrease the spasticity and
contractures to improve functionality and quality of life in
patients. It is only when these measures fail, and in the cases of
a severe and life-threatening emergency, that surgery becomes a
consideration.

Clinical Significance
Pyramidal tract lesions can occur from any type of damage to the
brain or spinal cord. They can result from a variety of injuries
and diseases such as strokes, abscesses, tumors, hemorrhage,
meningitis, multiple sclerosis, or trauma. Damage to the
corticospinal tract will present similarly to upper motor lesion
syndrome and will present with symptoms such as spasticity,
clonus, hyperreflexia, and Babinski sign. Damage to the
corticobulbar tract can present with pseudobulbar palsy or
damage to cranial nerves VII or X.

Pseudo-bulbar Palsy
The corticobulbar tract bilaterally innervates most of the cranial
nerves, except VII and XII, which means that for symptoms to
arise from damage to these nerves, both sides of the
corticobulbar tract must be injured as is the case in pseudo-
16
bulbar palsy. Symptoms in this condition may include slow
speech, dysphagia (difficulty swallowing), dysarthria (difficulty
speaking), spastic tongue, and pseudobulbar affect
(uncontrollable episodes of laughing or crying).

Cranial Nerve VII or X Lesion

Unilateral lesions to either of these nerves will cause
contralateral symptoms. Since cranial nerve VII innervates
muscles of the lower face, damage to this nerve will cause
deviation of angle of mouth towards the opposite side of the
lesion due to the over action of the muscles of the opposite side.
Similarly, damage to cranial nerve X will lead to the deviation of
the uvula to the opposite side of the lesion.

Other Issues
There are a wide variety of pathologies associated with pyramidal
tract lesions. They can be the result of many diseases including
stroke, amyotrophic lateral sclerosis, multiple sclerosis, and
central pontine myelinolysis.

Stroke
Cerebrovascular accidents, or strokes, are caused by occlusion of
blood flow to a particular area of the brain. They divide into
either an ischemic stroke or hemorrhagic stroke. Ischemic
strokes are the sudden interruption of blood supply to a
structure due to occlusion or obstruction by a thrombus or
embolus. Hemorrhagic strokes result from the rupture of a blood
vessel leading to bleeding into the brain. Because the pyramidal
tract is such a large structure and receives blood supply from so
many different arteries, any occlusion to these supporting
arteries can lead to a wide variety of symptoms.

Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis (ALS) is a progressive
neurodegenerative disease that leads to progressive damage of
nerve cells within the spinal cord and brain. It causes symptoms
of both upper and lower motor neuron syndrome. Upper motor
neuron symptoms include spastic gait, dysphagia, dysarthria,
and clonus. Lower motor neuron symptoms include muscle
atrophy, weakness, and flaccidity. As it progresses upwards, it
causes such severe dysphagia and dyspnea that the patient is
17
unable to breathe and generally dies from respiratory failure. It
most commonly afflicts adults between the ages of 40 and 70 and
at this time is incurable. The only pharmaceutical treatment
available that has been shown to extend the lifespan of patients
is riluzole, a glutamate blocker.

Multiple Sclerosis
Multiple sclerosis is a demyelinating autoimmune disease of the
nervous system. Its manifestations show a wide range of
symptoms such as double vision, muscle weakness, coordination
trouble, or cognitive disturbance. It is the most common CNS
autoimmune disorder, and there currently is no cure.
Management centers on improving function after an attack, and
preventing recurrent attacks.

Central Pontine Myelinolysis

Central pontine myelinolysis (CPM) is a condition that involves
damage to nerve cells in the pons. It can be devastating leading
to paralysis, dysphagia, dysarthria, pseudobulbar palsy, and
locked-in syndrome (loss of all muscle movement except for eye
movements). Its most common cause is the rapid correction of
low blood sodium levels (hyponatremia). If the sodium levels are
corrected too quickly, water gets driven out of the brain cells
which cause widespread damage throughout the entire brain.
Once CPM has begun, it cannot be corrected. Therefore, the best
treatment of CPM is prevention by correcting hyponatremia at a
consistent rate.

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 CHAPTER 4
CEREBROVASCULAR ACCIDENT CVA

Stroke, or cerebrovascular accident (CVA), describes a variety of

disorders characterized by the sudden onset of neurological
deficits caused by vascular injury to the brain. Vascular damage
in the brain disrupts blood flow, limits oxygen supply to
surrounding cells, and leads to brain tissue death or infarction.
The mechanism, location, and extent of the lesion determine the
symptoms and prognosis for the patient. This chapter focuses on
patients with stroke, but nonvascular brain trauma or disease,
such as gunshot wounds or tumors, may manifest many of the
same neurological deficits and may be treated similarly.

CAUSATION
Strokes are usually classified by the mechanism and location of
the vascular damage. The two broad causes are ischemia and
hemorrhage. Ischemic strokes result from a blockage of a
cerebral vessel and can further be categorized as caused by
thrombosis or embolism. Thrombosis is the stenosis or occlusion
of a vessel, usually as a result of atherosclerosis. This occlusion
is typically a gradual process, often with preceding warning
signs, such as transient ischemic attack (TIA). An embolism is
dislodged platelets, cholesterol, or other material that forms at
another location, travels in the bloodstream, and blocks a
cerebral vessel. Ischemic strokes are the most common type,
accounting for about 87% of strokes (American Stroke
Association, 2011). Hemorrhagic strokes result from a rupture of
a weakened cerebral blood vessel. In such strokes, blood
accumulates outside of the vascular space and compresses
surrounding brain tissue. Hemorrhagic strokes are either
intracerebral (bleeding into the brain itself) or subarachnoid
(bleeding into an area surrounding the brain). Aneurysms and
arteriovenous malformations are the most common types of
weakened blood vessels causing hemorrhagic strokes (American
Stroke Association, 2011). Hemorrhagic strokes are less common
(an estimated 13% of strokes), but they result in a higher
mortality rate than ischemic strokes (Roger et al., 2011).

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Location of Involvement
Most lesions are either anterior circulation strokes, which
present signs and symptoms of hemispheric dysfunction, or
posterior circulation strokes, which display signs and symptoms
of brainstem involvement (Simon, Greenberg, & Aminoff, 2009).
Another distinction related to location of CVA is whether the
lesion results from large-vessel or small-vessel disease.
Thrombosis occurs most often in the large cerebral blood vessels.
Small-vessel, or lacunar, strokes are very small infarctions that
occur only where small arterioles branch off the larger vessels
(National Institutes of Health, 2011).

INCIDENCE
Stroke is the third leading cause of death in the United States
and a leading cause of chronic disability among adults. Of the
estimated 795,000 persons who have first or recurrent CVAs in
the United States each year, approximately two-thirds survive,
bringing the number of stroke survivors in the U.S. population at
any one time to over nine million (American Stroke Association,
2011). Stroke is the most common neurological diagnostic
category among patients seen by occupational therapists
(National Board for Certification in Occupational Therapy, 2008).
The projected aging of the U.S. population is expected to raise the
incidence of stroke, because about two-thirds of all strokes occur
in those older than age 65 years (National Institutes of Health,
2011).

MEDICAL MANAGEMENT
Acute stroke care focuses on determining the cause and site of
the stroke, preventing progression of the lesion, reducing cerebral
edema, preventing secondary medical complications, and treating
acute neurological symptoms (Bartels, 2011). Techniques of
diagnostic imaging, including computed tomography (CT) and
magnetic resonance imaging (MRI), can distinguish ischemic from
hemorrhagic lesions and define their location, size, and vascular
territory (National Institutes of Health, 2011). In acute ischemic
stroke, treatment concerns include restoration of blood flow and
limitation of neuronal damage. Medications, including
antithrombotics and thrombolytics, are the most common
medical intervention for stroke (National Institutes of Health,
2011). Antithrombotics include antiplatelet drugs (such as
20
aspirin) and anticoagulation drugs (such as heparin) and are
used to prevent further clotting or thrombosis. After stroke,
physicians mainly prescribe antithrombotics for prevention,
because first time stroke survivors are at a high risk for recurrent
strokes (National Institutes of Health, 2011). Thrombolytic drugs,
such as tissue plasmino-gen activator (tPA), help reestablish
blood flow to the brain by dissolving clots in cerebral vessels. A 5-
year trial conducted by the National Institute of Neurological
Disorders and Stroke found that appropriately selected subjects
treated with TPA within 3 hours of onset of stroke symptoms
were at least 33% more likely than patients given a placebo to
recover from their stroke with little or no disability (National
Stroke Association, 2011). The use of thrombolytics is limited,
however, by the associated increased risk of hemorrhage and the
fact that they must be administered within a 3-hour window after
stroke onset for effectiveness. It is estimated that only 3%–5% of
per-sons suffering a stroke will seek medical attention in time for
possible TPA treatment (American Stroke Association, 2011).
With hemorrhagic stroke, acute treatment includes control of
intracranial pressure, prevention of rebleeding, maintenance of
cerebral perfusion, and control of vasospasm. Surgery or
endovascular procedures are often recommended to limit damage
(National Stroke Association, 2011).

RECOVERY FROM STROKE

The specific abilities lost or affected by stroke and the degree and
time course of recovery from stroke vary with the location, type,
and extent of the initial injury, and treatment provided (National
Stroke Association, 2011). Early initial improvement or
spontaneous recovery occurs because pathologic processes in the
brain resolve, and neurotransmission resumes near and remote
from an infarct or hemorrhage (Dobkin, 2005). Later, ongoing
improvement occurs with structural and functional
reorganization within the brain, or neuroplasticity; the term
neuroplasticity refers to transiently achieved functional changes
in the context of learning and recovery, as well as structural
changes on the cellular level. Neuroplasticity includes greater
excitability and recruitment of intact neurons in both
hemispheres of the brain as a response to stimulation,
participation, training, and experience (Albert & Kesselring,
2011). Langton Hewer (1990) de-scribed a model of stroke
21
recovery that includes both intrinsic neurological and
compensatory adaptive recovery.
Neurological Impairment
Neurological impairments following stroke and describe the
possible effects of each on occupational functioning. The most
typical manifestation of CVA is hemiparesis or hemiplegia,
ranging from mild weakness to complete paralysis on the side of
the body opposite the site of the CVA. About 80% of people who
have had a stroke have some degree of hemiparesis (National
Stroke Association, 2011), although the rate of physical
impairment usually decreases after the first 3–6 months post
stroke (Roger et al., 2011). Certain impairments are associated
with lesions in a particular hemisphere. For example, left CVA
may cause right hemiparesis, aphasia or other communication
deficits, and/or apraxia or motor planning deficits. Right CVA
may result in left hemiparesis, visual field deficits (VFDs) or
spatial neglect, poor insight and judgment, and/or impulsive
behavior (American Stroke Association, 2011). Many patients do
not regain full movement or function of the upper extremity.
Studies report that 65% of individuals after stroke are unable to
incorporate their hemiparetic upper extremity into daily function
(Lum et al., 2009). Historically, motor recovery in the patient with
hemiparesis was described as progressing from proximal to distal
movement and from mass, patterned, undifferentiated movement
to selective, coordinated movement (Brunnstrom, 1970; Fugl-
Meyer et al., 1975). Therapists now rarely see such a distinct
progression of motor recovery in patients, partly because
thrombolytic agents limit brain damage and partly because
insurance restrictions limit long-term rehabilitation services.

ASSESSMENT
Numerous evaluations exist to identify stroke impairments and
disability. Assessment practices vary greatly among therapists
caring for individuals post stroke, and no single test is
universally accepted (Gresham et al., 1995). To help in the
selection and ordering of assessment tools, therapists are guided
by models of practice and evidence-based practice guidelines. The
OT assessment of a patient post stroke includes both
determination of the occupational profile (the roles, tasks, and
activities important to that individual) and analysis of the
individual’s occupational performance (his or her competence in
22
performing these valued roles, tasks, and activities). Therapists
consider each individual and the individual’s stage of recovery
when determining whether to follow a bottom-up or a top-down
approach to client evaluation. During the acute stage,
assessments of client factors and performance skills are most
critical in deter-mining immediate post hospital placement.
During the rehabilitation and community-reentry stages,
therapists must also consider activity demands, contexts,
patterns of performance, and integration of skills in order to help
clients reach goals for quality of life and participation in
meaningful roles (Sabari & Lieberman, 2008). Therapists can use
available practice guidelines to assist in the selection of
assessment tools. Recommended guide-lines are the American
Occupational Therapy Association’s Occupational Therapy
Practice Guidelines for Adults with Stroke (Sabari & Lieberman,
2008) and Appendix D of the American Heart
Association/American Stroke Association’s (AHA/ASA)

Management of Adult Stroke Rehabilitation

Care: A Clinical Practice Guideline (Duncan et al., 2005). The
AOTA guideline lists both standardized assessments and
observationally based assessments commonly used by
occupational therapists with stroke survivors. The AHA/ASA
guideline lists recommended well-validated standardized
measures for all disciplines and stages of stroke care. The use of
standardized evaluation tools helps ensure reliable
documentation, achieve consistency of treatment decisions,
facilitate team communication, and monitor progress for each
survivor (Duncan et al., 2005). Often, multiple assessment
instruments must be used because of the wide variation in
individual stroke manifestations and the patient’s changing
needs over the course of recovery. Therapists should be familiar
with commonly used standardized stroke deficit scales because
they are frequently used as an interdisciplinary summary of
baseline function and as indicators of recovery or treatment
outcomes. The National Institutes of Health Stroke Scale (NIHSS)
(Brott et al., 1989) is a brief, well-validated tool that can be
administered by physicians, nurses, or therapists. Items scored
include consciousness, vision, extraocular movements, facial
palsy, limb strength, ataxia, sensation, speech, and language.
Although no single measure can fully describe or predict the
23
diverse picture of stroke disability and recovery, the NIHSS is
widely used as an initial assessment tool and for planning
discharge disposition (Kasner, 2006).

Assessment of Areas of Occupation

The patient’s ability to perform the self-care, leisure, vocational,
home, and community tasks that he or she hopes to continue is
evaluated by observation rather than report be-cause there can
be a difference between what a patient can do and actually does.
Evaluation to determine a patient’s level of occupational
functioning is administered early to predict answers to the
following questions (Wade, 1992): (1) Where will the patient live,
and what physical adaptations will be necessary? (2) How much
and what type of assistance will the patient need? (3) What roles
will the patient be able to fulfill, and how will he or she spend his
or her time? A patient’s ADL performance in a structured clinical
setting may not indicate performance at home. For example,
patients who can put on and remove clothing during therapy
sessions may not be able to fi nd and retrieve their clothes in a
cluttered closet, select clothing appropriate for the weather, or
initiate the dressing routine without prompting (Campbell et al.,
1991). Conversely, a patient may be unable to master simple
meal preparation in the unfamiliar environment of a clinic
kitchen but may re-adapt easily to this task upon returning
home. A home evaluation can help determine what resources and
means a patient has to achieve independence in areas of
occupation as well as assessing safety and accessibility (see

24
 CHAPTER 5
INTRODUCTION AND APPLICATION OF APPROACHES/FORS
USED IN NEUROLOGICAL REHABILITATION SENSORIMOTOR
TREATMENT APPROACHES

INTRODUCTION
Sensory integration (SI) theory is a dynamic and ecological theory
that specifies the critical influence of sensory processing on
human development and function. This theory emphasizes a
person’s ability to appropriately process sensory information from
the body and integrate it with information about what is going on
around the person so that he or she can effectively acton the
environment. It contributes to our understanding of how
sensation affects learning, social-emotional development, and
neurophysiological processes such as motor performance,
attention, and arousal. Occupational therapists commonly use
sensory integration theory in practice as a frame of reference that
can be used to both assess and intervene with people who have
sensory integrative or sensory processing dysfunction that
adversely affects function (Parham & Mailloux, 2005). It is
important to be clear what one is referring to when using the
term sensory integration, as this singular term has been used to
refer to a theory, a neurological process, a disorder, and an
intervention approach (Bundy, 2002; Mulligan, 2003). The
theoretical principles that support the use of this frame of
reference draw on evidence from neuroscience as Dr. Ayres
recognized that behavior and emotions are regulated by brain
mechanisms. Advances in neuroscience continue to expand and
support Dr. Ayres’ original hypotheses, contributing to evidence-
based practice (Bauman, 2005; Schneider, 2005). Dynamic
systems theories have emerged that provide an under- standing
of the complexity of development (Thelen & Smith, 1994) and
help to explain the complexity of the way in which this
intervention effects change in children (Spitzer, 1999). SI is now
commonly applied in educational settings with children who have
learning and behavior disorders (American Occupational Therapy
Association, 2003), as well as in private settings. While education
in sensory integration theory and intervention principles is part
of the entry-level curricula for occupational therapists and
occupational therapy assistants, postgraduate training is
recommended for those specializing in the use of SI intervention
25
in clinical practice. Occupational therapists with sensory
integration certification and mentorship with a master clinician
are best prepared to evaluate and provide SI intervention.
Occupational therapy assistants may provide intervention using
SI principles with appropriate supervision by an occupational
therapist.

26
 CHAPTER 6
SENSORY INTEGRATION THEORY

Dr. Ayres developed a theory of sensory integration to explain the

link between the nervous system and behavior. Five basic
assumptions formed the theoretical basis for Dr. Ayres’ thinking:
1. The remarkable potential for change of the developing brain,
or neuroplasticity, which has recently been found to be true
of the adult brain as well (for reviews, see Buonomano &
Merzenich, 1998; Cruikshank & Weinberger, 1996; Gross,
2000)
2. Interactions between the “higher-order” (cortical) areas of
the brain and those in the “lower” subcortical areas as
fundamental to adequate sensory integration
3. Neurophysiological development of sensory integrative
functions that occur in a natural order and following basic
sequence
4. An adaptive response, which is “the ability to adjust one’s
action upon environmental demand” and promotes a higher
level of integration as a consequence of the feedback to the
central nervous system
5. Presence of an inner drive to meet and master a challenge,
which fosters the development of sensory integration

Neuroplasticity
Dr. Ayres’ appreciation of the importance of experience as a
major determinant of cortical organization and resulting function
remains a bedrock principle in the field of neuroscience today.
This “experience-dependent plasticity in the cerebral cortex
reflects the importance of learning in our mental life and
behaviors” (E. K. Miller, 2000, p. 1067). During the period when
Dr. Ayres studied neuroplasticity, researchers thought that the
brain’s ability to be modified was robust during childhood but,
after a critical period of development, became quite limited. It is
now known that the brain has the capacity to be modified
throughout the life course (Bear, Connors, & Paradiso, 2006;
Gilbert & Wiesel, 1992).

Organization of the Brain

Although our nervous systems are almost constantly being
bombarded by sensation, not all of this sensation reaches the
27
cortex. If the cortex had to process every sensation a person
experienced, it would not be able to perform higher- level tasks,
such as thought and action. Neuroscientists have long explored
the hierarchical organization of the brain. Dr. Ayres understood
that higher brain levels, as they develop, remain dependent on
lower brain levels (Ayres, 1972, 2004, 2005). Before many of the
incoming sensory messages ascend or somewhere along their
ascent toward the thalamus and then the cortex, other neurons
are acting on them to either dampen their activity (inhibition) or,
in some cases, enhance their activity (facilitation). Dr. Ayres
described this process of inhibition and facilitation as a central
nervous system process of self-organization (2005). In this way,
the subcortical structures are important drivers of the
information that higher cortical levels might have to act on. On
the basis of her understanding that perception of any sensory
input requires facilitation of some input and inhibition of other
input, Dr. Ayres designed intervention that would incorporate
these mechanisms and would therefore promote more integrated
functioning of the brain as a whole. Using stimuli that have an
inhibitory effect and using a task on which the child can focus
that elicits an adaptive response were proposed by Dr. Ayres as
early therapeutic principles to advance central nervous system
organization. These principles remain today as core elements of
occupational therapy using a sensory integration approach. To
date, there has been no change in our appreciation of the role of
the subcortical structures to provide the foundation for efficient
functioning. However, there is currently a greater focus on the
reciprocal interdependence between 794 UNIT 11: OT Evaluation
and Intervention: Personal Factors higher and lower brain levels
(Middleton & Strick, 2000; Wall, Xu, & Wang, 2002). This
interplay of activity between the higher-level cortex and
subcortical structures (in particular, the thalamus) further
contributes to the self- organizing processes of the brain. In this
way, the brain is able to develop representations that impart
deeper meaning than is provided by the multisensory information
alone. For example, suppose we have an object that is orange and
round (vision), has a citrus scent (olfaction), and has a slight
bumpiness along its surface (tactile); the interplay in the brain
contributes to our associating these qualities with an orange. Dr.
Ayres believed that the therapeutic use of appropriate
multisensory activities might be the most effective way to
28
promote sensory integration. The research that guided her
thinking suggested that there were common integrating sites
within the central nervous system where information from
separate sensory sources converged onto neurons that had the
potential to respond to inputs from multiple sensory sources.
These were referred to as “convergent” or “polysensory” neurons
and were considered important sites for the coordination of
several different types of information (Ayres, 1972). Over the past
25 years, there has been extensive research into cross-modality
or multisensory convergence, and findings demonstrate that this
process takes place at sites in the midbrain, thalamus, and
cortex (for a review, see Stein and Meredith, 1993). At every such
site, there is the opportunity for cross-modality or multisensory
integration. One of the best-studied groups of multisensory
neurons is in the superior colliculus (SC) (Sparks & Groh, 1995;
Stein, 1984; Wallace, Meredith, & Stein, 1993). This midbrain
structure is classically divided into superficial layers
predominantly containing visual neurons and deep layers
containing multisensory (visual, somatosensory, and/or auditory)
and premotor neurons. Investigation into the SC has
demonstrated how signals from the different senses are combined
and used to guide adaptive motor responses, such as hearing a
sound and turning to visually locate the source (King & Palmer,
1985; Meredith & Stein, 1986; Stein, Meredith, Huneycutt, &
McDade, 1989; Stein, Huneycutt, & Meredith, 1988; Wallace et
al., 1993). In this example of the orienting response, when the
auditory and visual stimuli occur close together in space and
time, their combination enhances the ability to detect and
identify the external stimuli. Conversely, cross-modality cues that
are significantly discordant (e.g., spatially disparate) can have the
opposite effect and depress responses (Stein et al., 1989).
Whether the response is enhanced or depressed, an important
behavioral consequence of the synthesis (or discordance) of the
sensory information is closely related to changes in attention
(Stein et al., 1989).Recent studies by Stein (2005) exploring
multisensory integration demonstrate that the cortex plays an
important role in mediating convergence of sensory inputs at the
level of the superior colliculus. By temporarily deactivating the
information flow from the cortex to SC neurons, response
enhancement is compromised. As a consequence, the ability to
use cross-modal stimuli to enhance SC-mediated behavioral
29
performance is also compromised. As Dr. Ayres suspected and
the ongoing research has confirmed, the process of multisensory
integration is highly adaptive, “knit- ting together information
from different sensory channels to better detect, identify and
react to environmental events. . . . Sensory integration is critical
to perception and behavior” We have come to recognize that
primary sensory pathways, rather than merely transmitting
sensation in an inflexible manner, are sending impulses that are
constantly being adjusted in relation to attention, arousal, and
anticipation as well as thought and planning. Eide notes that
“when the sensory system is working effectively, cross modality
improves our responsiveness and interaction with our
environment. However, when sensory systems are underactive or
overactive (sensory defensiveness), attention becomes
inappropriately directed or diverted” Eide proposes that
therapeutic interventions focused on environmental adaptations
and appropriate sensory strategies “are often children’s best hope
of reducing bodily “distractions” so that they can focus on
learning and socialization” Over the past two decades, findings
from neuroscience research indicate that sensory information
(such as that which allows us to perceive an object as an orange)
is distributed as serial and parallel streams of information
(Felleman & Van Essen, 1991; Pons et al., 1987; for a review, see
Mesulam, 1998). Even though this distributed processing model
of brain structure and function was not specified at the time, in
1972, Dr. Ayres wrote, “Organization must and does occur
vertically among the levels of the brain as well as horizontally
between two structures at the same level” demonstrating an
understanding of the integrative and reciprocal complexity of the
brain. Bundy and Murray (2002) comment that a systems
approach to nervous system organization, in which “systems
interact, and both cortical and subcortical structures contribute
to sensory integration” is consistent with Dr. Ayres’ theory.

Developmental Progression
Viewing development as a process that the brain undergoes, Dr.
Ayres noted that “each child’s brain is designed to follow an
orderly, predictable, interrelated sequence of development that
results in the capacity for learning” Given an enriched,
supportive environment, children will grow and develop sensory
and motor memories that help the children adapt to their own
30
growth and interests in the context of an ever-changing
environment. Whereas Dr. Ayres focused on the first seven years
of life as the time frame in which this occurred, we now know
that the brain continues to develop throughout the life course
(Bear et al., 2006; Gilbert & Wiesel, 1992). A critical aspect of
this process is that the child experience sensations, which places
a demand on the brain to organize the incoming stimuli into
percepts. Depending on the context in which the stimuli are
experienced, the child might focus on and attend to the input
(sensory detection as a central nervous system process; sensory
registration as inferred from the child’s behavior), or if they are
not relevant, the stimuli might be ignored (inhibition centrally,
sensory modulation behaviorally) (Lane, Miller, & Hanft, 2000;
Miller & Lane, 2000). For example, a child who is riding a bicycle
typically attends to visual and auditory inputs along the ride
(sensory registration) while ignoring the feel of the shirt as it is
blown by the wind (inhibition). If the child’s brain is unable to
organize incoming sensation efficiently, these “filtering out” and
“attending to” processes might be inadequate. In this example,
the child who is unable to tolerate the tactile input from the
shirt’s movement against the body will have difficulty attending
to the important visual and auditory information in the
environment that are necessary for both safety and skill. Until
the tactile sensation is discriminated as “safe,” the child is
considered to remain in a more primitive “fight- or-flight” mode.
In general, this primitive state under- mines both the
development of skills and emotions as it is through the ability of
the brain to organize sensations that “the child gains control over
his emotions” (Ayres,

Adaptive Response
Our ability to make adaptive responses to ever-changing
environmental demands and challenges allows us to learn
something new and, in turn, change the environment (Ayres,
1972, 1979, 2005). Spitzer (1999) discusses the congruence
between the concepts of self-organization in dynamic systems
theory with Dr. Ayres’ concept of the adaptive response in
sensory integration theory. In both theories, feedback from the
individual’s spontaneous, active adjustments contributes to self-
organization of the brain (Smith & Thelen, 1993; Ayres, 1979,
2005). Dr. Ayres stressed the importance of “organizing adaptive
31
responses to increasing complexity” as a key component of
intervention. She was guided by neuroscience research
suggesting that inefficiency in synaptic activity along anatomical
pathways might be contributing to poor integration of sensory
information and proposed that focusing on eliciting a response
that was not yet well developed might enhance synaptic function
(Ayres, 1972; Katz & Shatz, 1996; Schlaug, 2001). While an
adaptive response occurs most typically during a motor task, it is
also apparent with demands arising in other domains (e.g.,
emotional regulation, cognitive, and social interaction). “Therapy
using a sensory integration approach is a natural process”

The Frenchay Activities Assessment of Performance Skills

and Client Factors
Observation of a patient’s occupational performance suggests to
the therapist specific performance skills and client factors that
can enhance or impair the client’s desired functional outcome.
Assessment of performance skills helps to determine motor and
cognitive abilities available to an individual in order to resume
valued tasks and roles. Assessment of client factors, including
primary and secondary impairments associated with stroke helps
determine potential for improvement in skills and occupational
performance (Sabari & Lieberman, 2008). These skills and factors
can be measured directly by administration of selected tests.
Areas to be evaluated include postural adaptation, specific
components of upper extremity function, and motor learning
ability.

Postural Adaptation
Postural adaptation, or postural control, refers to the individual’s
ongoing ability to achieve, maintain, or restore an upright
position against gravity (balance) for stability during activities or
changes in body position (Pollock et al., 2000). The recognition
and treatment of deficits in postural adaptation constitute an
important aspect of therapy for stroke patients because so many
daily living tasks (e.g., putting on socks, getting in and out of a
bathtub, housework, and participating in sports) depend on this
skill. Evaluation and treatment limited to a patient securely
supported in bed or in a wheelchair fail to address most usual
daily tasks that require dealing with gravity. A person with
hemiplegia typically has decreased motor control, poor bilateral
32
and sensory integration, and impaired automatic postural
responses (Oliveira et al., 2008). As a result, the patient must
devote increased effort to remaining upright, with decreased
ability to focus on purposeful tasks. When engaging in a
challenging activity, the hemiplegic patient often resorts to
compensatory strategies to help maintain stability, such as using
upper extremities for support (Oliveira et al., 2008). Postural
adaptation factors and skills can best be observed during the
performance of meaningful functional activities, although the
Berg Balance Scale.

Upper Extremity Function

Occupational therapists are the clinicians most often involved
with the evaluation and treatment of motor deficits in the
hemiplegic or hemiparetic upper extremity. Achievement of
skilled arm and hand function is a complex, often difficult
process following stroke and involves interaction of several body
functions and structures. Evaluation of the involved upper
extremity should address sensation; the mechanical and
physiological deterrents to movement; the presence and degree of
active or voluntary movement; the quality of this movement,
including strength, endurance, and coordination; and the extent
of function resulting from movement.

Somatosensory Assessment
During evaluation of sensory deficits in the person with stroke, it
is important to remember that sensation is a component of
function that is only a focus for treatment when it relates to the
ability to perform usual daily living tasks. When somatosensory
disturbances are present, they usually accompany motor
impairment in the same anatomic distribution (Stein &
Brandstater, 2010). Most tests of sensation require attention,
recognition, and response to multiple stimuli; therefore, sensory
testing is difficult in patients with aphasia, confusion, and other
cognitive deficits. It is often necessary to determine the patient’s
level of comprehension and communication, including yes/no
reliability. An expressively aphasic patient can nod, gesture,
point to written or pictured cues, or select a stimulus object from
an array of objects. When testing with standard procedures is not
possible, information may still be gained from observing a
patient’s reactions to the testing. The presence of gross protective
33
sensation (flinching when pricked with a sharp pin) can be
documented even if discriminatory perception cannot be
determined. Patients who have had mild CVAs and who have
intact primary sensory awareness may need to be tested for more
subtle discriminatory problems using two-point discrimination
testing or the Moberg Pick-up Test (Dellon, 1981). Such testing is
indicated when motor return is good, but hand dexterity remains
impaired. Chapter 9 provides de-tails of sensory assessment.

Mechanical and Physiological Components

Factors that can interfere with movement and function of the
hemiplegic upper extremity include limitations in PROM, joint
mal alignment, abnormal muscle tone, and pain. Interview and
medical records can help determine whether these conditions
resulted from the stroke or were pre-sent prior to onset. Passive
movement restrictions in the joints and soft tissues of the
extremity may result from an individual’s anatomy and lifestyle
or from premorbid conditions such as arthritis or injury.
Limitations may result more directly from the stroke, with
sudden and prolonged immobilization of joints caused by
weakness or spasticity in muscles. Persistent stereotyped
positioning of joints without counteracting movement results in
the shortening and eventual contracture of muscles, tendons,
and ligaments. Edema secondary to reduced circulation and loss
of muscle action can further limit passive joint motion,
particularly in the hand. Goniometric measurement of passive
range of motion (PROM) is usually not indicated unless treatment
is specifically aimed at increasing passive motion, such as when
trying to eliminate an elbow flexion contracture. More useful in
assessing patients with stroke is a comparison of the involved to
the uninvolved arm to determine probable baseline joint motion.
Shoulder subluxation, or mal alignment of the glenohumeral
joint, occurs in approximately 50% of stroke patients (Yu, 2009).
This condition is probably caused by the weight of the arm
pulling down the humerus when the supraspinatus and deltoid
muscles are weak and by weakness of scapular muscles that
allows the glenoid cavity to rotate downward (Stein &
Brandstater, 2010). Shoulder subluxation can be identified by
palpation: the seated patient’s arm hangs freely with trunk
stabilized while the examiner palpates the sub acromial space for
the separation between the acromion and the head of the
34
humerus. The distance separating the two is measured in finger
widths, that is, the number of fingers that can be inserted in the
space (Yu, 2009).The role of subluxation in the painful shoulder
is controversial; in the shoulder, adhesive capsulitis, tendonitis,
bursitis, rotator cuff tear, traction/compression neuropathy, and
complex regional pain syndrome (CRPS) are common
complications of hemiparesis, and all can result in pain and
limited range of motion (ROM) (Duncan et al., 2005). Spasticity,
defined as velocity-dependent hyperactivity of tonic stretch
reflexes, can result in ROM limitations and pain, often leading to
contractures and functional impairments. The Ashworth
Scale/Modified Ashworth Scale (Bohannon & Smith, 1987) is
included in the AOTA practice guideline as a recommended
assessment of spasticity (see Chapter 8; see Chapter 3 for
descriptions of pain evaluation).

Voluntary Movement
Determining the amount and quality of voluntary movement a
patient can produce is one of the first steps in assessing
movement potential (Warren, 1991). The patterns of motion
available are different for each stroke patient. Movement can
change dramatically or subtly with time; hence, it requires
careful reassessment throughout recovery. Factors to consider
when evaluating motor control of the involved upper extremity
include the following:
 Can the patient perform reflexive but not voluntary
movement? Example: Patient demonstrates active el-bow
extension in the involved arm when balance is disturbed
(equilibrium reaction) or flexes the hemi paretic elbow while
yawning (associated reaction) but can perform these
movement on request Do proximal segments (neck, trunk,
shoulder, hip) stabilize as needed to provide firm support for
movement of the distal parts, or do they substitute for distal
movement? Example: A patient can raise his hemi paretic
arm only with pronounced lateral bending of the trunk and
excessive elevation of the shoulder girdle.
 Can voluntary movement be performed unassisted against
gravity, or is it possible only with assistance in the form of
positioning, support, or facilitation? Example: A patient can
bring her hand to her mouth only by flexing her elbow in a
horizontal plane with gravity eliminated.
35
  Can voluntary movement be performed in an isolated
fashion or only in a synergistic pattern? Example: A patient
can reach for an object on a table only with a pat-tern of
shoulder abduction, elbow flexion, and trunk flexion rather
than with the more efficient pattern of shoulder flexion and
elbow extension.
 Can reciprocal movement (the ability to perform
agonist/antagonist motion in succession in an individual
joint) be performed with practical speed and precision?
Examples: A patient cannot produce a smooth pattern of
elbow extension-flexion-extension needed to grasp a glass,
take a drink, and set it back on the table but can perform
each movement separately. A patient cannot perform the
rapid alternating movements necessary to brush teeth.
One of the major movement difficulties following stroke is
attaining the capacity and ability to isolate and control single
muscle actions and combine them in a pat-tern appropriate for
the task at hand. In motor patterns typical in hemiplegia,
movement initiated in one joint results in automatic contraction
of other muscles linked in synergy with that movement. This
results in limited, stereotyped movement patterns rather than
adaptive, selective motions. In Brunnstrom’s theory of hemiplegic
limb synergies (Brunnstrom, 1970), typical stereotyped patterns
are described as flexor or extensor synergy patterns according to
the motion at the elbow. The flexor synergy presents with
scapular retraction and/or elevation, shoulder abduction and
external rotation, elbow flexion, and forearm pronation. The
extensor synergy presents with scapular protraction, shoulder
horizontal adduction and internal rotation, elbow extension, and
forearm pronation. Wrist and hand position varies (Brunnstrom,
1970). There is considerable variation in synergistic patterning,
and other causes of abnormal stereotyped patterns include
compensatory movements, unnecessary movement, muscle
tension resulting from exertion or stress, and movement in
response to gravity (e.g., pronation). According to Brunnstrom
(1970), movement recovery after stroke is determined by an
individual’s ability to move independently of synergies. More
contemporary clinical studies suggest that in addition to
pathological limb synergies, loss of strength or centrally mediated
impaired interjoint coordination can contribute to movement
disturbances and impaired function (Welmer, Holmqvist, &
36
Sommerfeld, 2006). A study designed to look at the extent
abnormal limb synergies influence voluntary movements of hemi
paretic patients with first-time stroke found that 3 months after
stroke, 13% of all subjects moved within synergies (Welmer,
Holmqvist, & Sommerfeld, 2006). Several methods for evaluating
voluntary movement post stroke are described in Chapter 8 and
online Chapters A, B, and C. Valid and reliable tools for
evaluating voluntary movement post stroke recommended by
both the AHA/ASA clinical guideline and the AOTA practice
guideline are the Fugl-Meyer Assessment of Motor Function
(Fugl-Meyer et al., 1975) and the Motor Assessment Scale (Carr
et al.,1985). The Fugl-Meyer Assessment is an adaptation of
Brunnstrom’s original Hemiplegia Classification and Progress
Record (Brunnstrom, 1970) and incorporates Brunnstrom’s six
stages of motor recovery with an underlying predicted sequence
of recovery. The Fugl-Meyer Assessment of the Upper Extremity
(FMA-UE) is the most commonly used research assessment to
describe upper extremity motor impairment and evaluate the
success of new interventions, but its focus on synergy patterns
no longer forms the basis for newer function-oriented treatments
(Woodbury et al., 2007). After investigating the dimensionality
and construct validity of the FMA-UE, researchers suggest that
assessment of reflexes in the FMA-UE gives little information
about volitional movement. They also challenge the stepwise
orderly sequence of motor recovery described by Brunnstrom and
Fugl-Meyer and suggest instead that “UE motor behavior during
recovery may be a dynamic interaction of neural factors with the
task-specific difficulty of a movement” (Woodbury et al., 2007, p.
720).

Strength and Endurance

Muscle weakness ranging from slightly less than normal strength
to total inability to activate muscles has been recognized as a
limiting factor in the occupation and participation of patients
with hemiplegia (Harris & Eng, 2007). The measurement of
muscle strength to monitor recovery after stroke has been
controversial because traditional neurological rehabilitation
frameworks link muscle resistance to increased upper extremity
tone and pain (Bobath, 1990). A meta-analysis of randomized
controlled trials examining the evidence for strength training of
the paretic upper extremity found evidence that strengthening
37
can improve upper limb strength and function without increasing
tone or pain in individuals with stroke (Harris & Eng, 2010).
Methods used to quantify muscle strength after stroke include
assessments of motor performance (e.g., Fugl-Meyer), manual
muscle testing, dynamometry to measure grip strength, and
measurements of active range of motion.

TREATMENT
A careful interpretation of evaluation results helps determine a
patient’s assets and deficits in areas of occupational functioning.
General goals of OT intervention with stroke survivors are to
prevent secondary impairments, restore performance skills,
modify activity demands and contexts as necessary, promote a
healthy and satisfying lifestyle, and maintain available
performance and health (Sabari & Lieberman, 2008). Intervention
is always a collaborative process between therapist and
client/family or caregiver. Possible goals for individuals
recovering from stroke include the following:
 The patient will gain competence in valued and necessary
BADL and IADL in order to perform at the highest level of
independence possible in the desired post discharge setting.
 The patient will improve postural control in order to perform
daily living tasks requiring balance and changes in body
position.
 The patient will gain increased somatosensory perception
and/or will employ compensatory strategies in order to
perform ADL safely.
 The patient and/or caregiver will demonstrate appropriate
management techniques for the hemiparetic upper
extremity to prevent pain and other secondary mechanical
or physiological movement restrictions.
 The patient will gain the necessary strength, endurance,
and control of movement of the involved upper extremity in
order to use the involved upper extremity spontaneously
during the performance of ADL.
 The patient will gain visual function or will employ
compensatory strategies in order to safely resume previously
performed ADL.
 The patient will improve motor planning ability in order to
relearn old methods or learn new methods of performing
ADL.
38
  The patient and/or caregiver will demonstrate appropriate
strategies for improving or compensating for cognitive
deficits during the performance of ADL.
 The patient and/or caregiver will be able to verbalize the
reality and impact of emotional reactions to stroke and
identify coping strategies or resources to help ad-just to
living with a stroke.
 The caregiver will demonstrate appropriate methods and
problem-solving strategies for assisting the patient with ADL
and with home activities to improve/pre-serve performance
skills.
 The patient will gain competence in tasks and activities
necessary to resume valued roles or to assume new
meaningful roles in the community.
Intervention will vary with the patient’s stage of recovery,
intervention setting, living environment, extent of impairment,
and personal goals and preferences (Sabari & Lieberman, 2008).

Acute Phase
Stroke rehabilitation begins “as soon as the diagnosis of stroke is
established and life-threatening problems are under control”
(Duncan et al., 2005, p. e104). Length of stay in acute hospital
beds is typically just long enough for necessary diagnostic tests,
for initiation of appropriate some control over the environment
and begin to improve occupational functioning and component
abilities and capacities (Gresham et al., 1995). Even at this early
stage, the occupational therapist’s assessment of a patient can
help determine the most appropriate setting for re-habilitation
and discharge. The goals of discharge planning during the acute
phase are to determine the need for postacute rehabilitation,
arrange the best possible living environment, and ensure
continuity of care after discharge (Gresham et al., 1995).

Lowering Risk for Secondary Complications

As part of the stroke care team, the occupational therapist
should practice methods to prevent or lessen complications
resulting from stroke.

Skin Care
It is estimated that up to 21% of patients with stroke develop
pressure sores (Langhorne et al., 2000). Those who are comatose,
39
malnourished, or incontinent or who have diabetes, peripheral
vascular disease, abnormal sensation, severe paralysis, or muscle
spasticity are at greatest risk (Duncan et al., 2005). The
occupational therapist helps patients maintain skin integrity by
doing the following:
 Using proper transfer and mobility techniques to avoid
undue skin friction
 Recommending appropriate bed and seated positioning and
participating in scheduled position changes as needed
 Assisting with wheelchair and seating selection and
adaptation
 Teaching patient and caregiver precautions to avoid injury
to insensitive skin and involved side of body
 Watching for signs of skin pressure or breakdown on a
patient (bruising, redness, blisters, abrasions, ulceration),
especially over bony areas, and alerting nursing or medical
staff as appropriate

Maintaining Soft-Tissue Length

Contractures, or shortening of skin, tendons, ligaments, muscles,
and/or joint capsules, may result from the immobilization
following stroke. Risk factors include muscle paralysis, spasticity,
and imbalance between agonist and antagonist muscle groups.
Contractures restrict movement, may be painful, and may limit
functional recovery (Gillen, 2011b). The appropriate management
is therefore a preventive program of proper positioning and soft
tissue and joint mobilization. Suggested bed positioning for
patients with stroke, based on a literature review (Carr & Kenney,
1992), is summarized in Procedures for Practice 33-1. However,
bed positioning, like any treatment, must be adapted to meet the
individual needs of the patient. Care must be taken to protect the
weak upper extremity during treatment because improper
handling, positioning, and transferring techniques can exert
great stress on the vulnerable shoulder early after stroke (Walsh,
2001). Specific techniques for supporting the hemiparetic
shoulder are discussed later in this chapter. Resting hand splints
are often applied to prevent soft tissue shortening, but their use
has not been found to significantly prevent or reverse contracture
of wrist and finger flexor muscles (Lannin et al., 2007). Controlled
and frequent soft tissue and joint mobilization is the preferred
method to prevent contractures (Gillen, 2011b). When a patient
40
cannot use the involved side to engage in meaningful activities,
therapists should initiate supervised active or active-assistive
movement activities. When active movement is not possible,
therapist should see that immobile body parts go through PROM
at least once daily. If performing PROM on the involved arm,
ensure mobility of the scapula on the thoracic wall before
elevation of the arm and manually assist upward rotation of the
scapula if needed. Safety Message: Do not attempt overhead
ranges unless the scapula glides freely in upward rotation. The
humerus should be externally rotated during abduction to
prevent impingement of the supraspinatus between the greater
tubercle of the humerus and the acromion process (Gillen,
2011b). As soon as possible, patients should learn strategies for
safe ROM activities they can perform independently or
with assistance of caregivers. Fall Prevention. For patients
hospitalized with stroke, falls are the most common cause of
injury (Gresham et al., 1995). Factors that increase the risk of
falls include advanced age, confusion, comorbidity, impulsive
behavior, mobility deficits, poor balance or coordination, visual
impairments or neglect, and communication deficits that
interfere with a patient’s ability to request assistance in a timely
manner. Treatment that helps to prevent falls includes detecting
and removing environmental hazards, scheduled routine
toileting, optimizing motor control, recommending appropriate
adaptive devices, and teaching safety measures to the patient
and family.

Patient and Family Education

Early in recovery, support for patients who have had strokes and
their families may best be provided in the form of education to
promote a realistic understanding of the causes and
consequences of stroke and the process, goals, and prognosis of
rehabilitation (Duncan et al., 2005). In a systematic review,
Forster et al. (2001) found evidence that passive education alone,
such as providing written handouts, is not as effective as a
combination of passive and interactive education, such as classes
or training sessions. All aspects of OT assessment and treatment
for survivors of stroke should be considered opportunities for
education: to engage cooperation and participation in the
identification of meaningful treatment goals, to highlight residual
abilities as well as disabilities, and to promote carryover of
41
treatment gains. Because the period after stroke is stressful,
emotional, and tiring for both the patient and family, education
sessions pro-vided during the acute phase should be brief,
simple, and reinforced as needed with repetition or appropriate
learning aids (see Chapter 13).

Rehabilitation Phase
Part of discharge planning during the acute phase of stroke is
screening for rehabilitation services. The AHA/ASA guideline
recommends that “patients who have sustained an acute stroke
should receive rehabilitation services if their poststroke
functional status is below their prestroke status, and if there is a
potential for improvement” (Duncan et al., 2005, p. e118).
Rehabilitation choices depend on a patient’s condition, the social
support system, and the re-sources available in a community. To
qualify for further treatment in an inpatient rehabilitation facility,
a patient must require active and ongoing intervention of multiple
therapy disciplines, require an intensive rehabilitation therapy
program (generally consisting of at least 3 hours of therapy per
day at least 5 days per week), and reasonably be expected to
actively participate in and significantly benefit from the
rehabilitation program (U.S. Department of Health and Human
Services, 2011). Patients who do not qualify for this level of
rehabilitation may receive multidisciplinary rehabilitation
services at a skilled nursing facility or long-term care facility or
treatment by one or more disciplines in home care or in an
outpatient clinic. During this phase of recovery, the patient and
family are focused on getting better and are usually more
concerned with recovering lost function than on adapting to a life
of chronic disability (Sabari, 1998). Successful OT intervention
coordinates a patient’s striving for restoration of function with
the potential for compensation and alternative occupational roles.

Treatment to Improve Performance of Occupational Tasks

The occupational therapist’s primary role in stroke rehabilitation
is to enhance clients’ participation and quality of life through
occupation. Interventions to improve performance of BADL is a
major component of therapy for people who have had a stroke.
Indeed, levels of independence in BADL are used to measure the
success of rehabilitation (Stroke Unit Trialists’ Collaboration,
2001), serve as out-comes in stroke research trials (Sulter, Steen,
42
& De Keyser, 1999), and, in current U.S. trends, determine
reimbursement for services (Sabari & Lieberman, 2008). A
systematic review of nine randomized controlled trials (Legg et al.,
2007) found that OT focused on improving BADL after stroke can
improve performance and reduce the risk of deterioration of these
skills. It is accepted practice to teach patients with significant
performance skills deficits compensatory methods for performing
important tasks and activities, using the affected limb when
possible and, when not, the unaffected limb (Gresham et al.,
1995). Many consider that early ADL training focusing on
modifying activity demands, contexts, and performance patterns
(compensatory techniques) results in faster success and is
therefore more cost effective and more satisfying to the patient,
who again feels competent (Nakayama et al., 1994). Others
contend that, when ADL training focuses on one-handed
techniques and use of devices or modifications without working
to restore performance skills, the patient fails to relearn bilateral
movements and instead develops unilateral habits (Bobath, 1990;
Roberts et al., 2005). Skilled OT intervention considers each
individual’s needs, goals, and motivations and combines both
compensatory and remedial treatment strategies and attempts to
improve both areas of occupation and performance skills by en-
gaging the patient in meaningful activities. Putting on a front-
buttoning shirt, for example, besides helping a patient gain
independence in the task of dressing, addresses the following
component abilities, capacities, and conditions:
 Joint and soft-tissue integrity (self-stretching or relaxation
techniques for involved arm in preparation for dressing,
positioning of arm on a surface to prevent stretching of
weak shoulder structures)
 Voluntary movement and function of involved upper
extremity (abducting shoulder to put on a sleeve, extending
elbow to push the hand through the sleeve, pinching one
side of the shirt to stabilize while buttoning)
 Somatosensory perception (the texture of the shirt, the
position of the affected arm)
 Postural adaptations (anterior pelvic tilt, trunk rotation,
sitting/standing balance, weight shifting)
 Visual-perceptual skills (finding the shirt in the visual field,
distinguishing top from bottom, finding the sleeve opening)

43
  Cognitive skills and emotional reactions (sequencing,
attention span, frustration tolerance, motivation) ADL
training with stroke patients begins with simple tasks and
gradually increases in difficulty as a patient gains
competency (Gresham et al., 1995). Several studies
discerned a hierarchy of achievement of self-care skills.
Results of one study showed that bathing, dressing, and
climbing stairs were the activities for which stroke survivors
most often required assistance, with 32% of patients
needing help with bathing, 25.5% needing help with
dressing, and 32% requiring assistance with stairs
12 months poststroke (Carod-Artal et al., 2002). Aspects of
dressing that are particularly difficult for stroke patients are
putting a sock and shoe on the affected foot, lacing shoes,
and pulling up trousers or pants (Walker & Lincoln, 1990).
A study that investigated the relationship between dressing
abilities and cognitive, perceptual, and physical deficits
found that, in general, lower extremity dressing correlates
more with motor performance, and upper extremity dressing
correlates more with cognitive or perceptual performance
(Walker & Lincoln, 1991). Adaptive devices should be
considered if they increase simplicity, independence, and
safety for the patient or caregiver.
As the patient progresses, occupational performance tasks other
than basic self-care should be addressed, particularly if the
patient expects to return to independent community living
(Duncan et al., 2005). IADL tasks such as homemaking, home
management, and community. Mobility involves greater
interaction with the physical and social environment and require
higher level problem-solving and social skills than BADL tasks
(Carod-Artal et al., 2002). Chapter 25 discusses specific
techniques for regaining independence in BADL/IADL for those
with loss of the use of one side of the body. Vocational interests,
including adapted methods of continuing familiar hobbies, are an
important area of treatment. Many stroke survivors are faced
with increases in leisure time because of the inability to go back
to work; however, a reduction in social and leisure participation
commonly occurs after stroke (Lai et al., 2002).

Treatment to Improve Performance Skills and Client Factors

44
Performance-component goals are based on the impairments
associated with an individual’s stroke and are directly linked to
occupational performance goals. The goals and modalities used to
address these component deficits must be purposeful and
meaningful from the patient’s point of view (Trombly,
1995/2011). Therapists use occupation-based interventions,
purposeful activity, and preparatory methods to help patients
achieve long-term occupational goals (AOTA, 2008). Thus, in
addition to direct practice of dressing and grooming activities, a
patient may be engaged in a floor game to improve sitting balance
needed to don socks, or use therapy putty for resistive grasp
activities to strengthen muscles needed to squeeze a tube of
toothpaste. Treatments for stroke deficits are described
individually in the following sections, but most patients in
rehabilitation programs have multiple interacting problems
requiring efficient, integrated intervention plans that
simultaneously address several deficit areas.

Postural Adaptation
The ability to make automatic postural adjustments, including
trunk control and the maintenance of balance, is a prerequisite
for successful performance of occupational tasks. A systematic
review of recent evidence related to the effect of balance training
on balance performance among individuals poststroke supports
the use of balance training for individuals with moderately severe
stroke (Lubetzky-Vilnai & Kartin, 2010). Part of the occupational
therapist’s role in training a patient with stroke in ADL
independence poststroke is in understanding each patient’s
particular strengths and weaknesses regarding stability and
mobility. For ex-ample, some clients may be challenged in
maintaining sitting balance on the side of a bed for the duration
of eating an entire meal, whereas others may be ready to im-
prove dynamic standing balance in order to cast a fishing line or
play golf. Therapists should teach patients the safest, most
effective and efficient “ready” position for engaging in activities.

45
 CHAPTER 7
BRUNNSTROM APPROACH
BRUNNSTROM’S MOVEMENT THERAPY

In 1951, Dr. Thomas Twitchell, a neurologist, published a

seminal paper in which he described the longitudinal progression
of motor recovery in 121 patients. Twitchell observed that, early
in recovery, these people tended to demonstrate stereotypical
movement patterns. In addition, he observed that they tended to
progress in their motor recovery through a consistent series of
stages. Twitchell did not hypothesize why some patients
recovered further than others and did not present any
recommendations for therapeutic interventions that might
influence motor recovery. Signe Brunnstrom, a physical
therapist, combined Twitchell’s findings with her own clinical
observations to develop a treatment approach that was designed
to facilitate the progression through the stages of recovery that
Twitchell had reported. Brunnstrom’s major contributions were
 her detailed description of reflexes and associated reactions
exhibited by patients with post-stroke hemiplegia
 the concept of flexor and extensor synergy patterns in the
paretic arm and leg
 a postulated sequence of treatment, designed to move
patients through seven stages of recovery for the arm and
hand. Please see online Chapter B about Brunnstrom’s
Movement Therapy approach. For more information about
these concepts and techniques.
Many of Brunnstrom’s contributions remain influential today.
The associated reactions and reflexes she described are still
recognized as characteristic features of motor behavior in stroke
survivors with limited recovery. A major difference is that
Brunnstrom advised therapists to use techniques to elicit these
pathological responses in an effort to stimulate movement. Today,
however, rehabilitation professionals seek to prevent eliciting
these responses. The current understanding is that refl exive
movements are not precursors to active, functional motor
performance. Many members of the rehabilitation community
continue to consider the upper limb synergies as hallmarks of
motor performance in stroke survivors. In fact, the
FuglMeyerMotor Assessment (FMA) (Fugl-Meyer et al., 1975),
sometimes called the Brunnstrom-Fugl-Meyer Motor Function
46
Assessment, is a widely used adaptation of Brunnstrom’s
Hemiplegia Classifi cation and Progress Record. This assessment,
often considered to be the “gold standard” for evaluating
movement ability, is used by researchers as well as clinicians,
even when Brunnstrom’s approach to therapy is not used. For
details about the FMA, see Chapter 8. Even though there is no
research sup-port for the premise that stroke survivors pass
through the predictable stages of motor recovery that
Brunnstrom described, these seven stages are still used today to
facilitate communication between rehabilitation professionals.
Therefore, it is valuable for occupational therapists to be familiar
with these stages and comfortable in grossly categorizing a
patient’s general arm function as “stage I,” “stage II,” etc. (see
Definition 21-1). Currently, rehabilitation professionals
disagree on whether to consider the limb synergies as primary
sequelae of the neurological damage (as Brunnstrom and
Twitchell postulated) or examples of maladaptive strategies that
patients develop when they attempt to move, in spite of
underlying mechanical obstacles, such as immobility at the pelvis
or scapula. This may be an important distinction. Those who
view the flexor and extensor synergies of the upper limb as
maladaptive strategies organize therapeutic.

Brunnstrom Stages of Recovery for the affected Arm

Stage I Flaccidity: no voluntary movement, muscle tone, or
reflexive responses
Stage II Synergies can be elicited reflexively; spasticity is
developing
Stage III Beginning voluntary movement but only in synergy;
spasticity may be significant
Stage IV Spasticity begins to decrease; ability to voluntarily
perform movements that deviate slightly from synergy patterns
Stage V Increased control of isolated voluntary movements,
independent of synergy patterns
Stage VI Isolated motor control; spasticity is minimal
Stage VII Normal speed and coordination of motor function.
interventions to prevent or remove specified “obstacles to
movement” that may lead the person to develop inefficient motor
strategies. Those who view the synergies as unavoidable motor
deficits that precede full recovery of motor function are not
concerned when patients move in these stereotypical patterns of
47
movement. There is no controversy, however, about the efficacy of
following a therapeutic sequence in which the therapist guides
the patient in moving through the six postulated stages of
recovery. This paradigm for structuring motor therapy is not
supported by current understanding of neural plasticity and
recovery of motor function after stroke.

48
 CHAPTER 8
ROOD AND PROPRIOCEPTIVE NEUROMUSCULAR
FACILITATION APPROACHES

The Rood and proprioceptive neuromuscular facilitation (PNF)

approaches, advanced during the mid-20th century, shared
Brunnstrom’s reliance on the predominant paradigms for
understanding motor performance at the time. Reflecting the view
that motor development and motor recovery from stroke followed
a hierarchical sequence, these approaches advocated that
patients “recapitulate” the movement sequence exhibited by
typically developing infants during the first year of life. Hence,
therapy techniques included exercises that required the person to
first learn how to maintain stability and then to move, in the
prone position on elbows, quadruped positions, and kneeling
positions. Subsequent understanding of motor recovery in adults
with acquired brain injuries has negated the value of using a
developmental model. In fact, today, the emphasis is on providing
movement practice to patients in natural contexts. Therefore,
motor activities are performed in supine, sitting, or standing
postures. Decisions about which posture is most effective at a
given session with a particular patient are based on mechanical
factors (such as the influence of gravity) and the patient’s
functional goals (such as the desire to kneel during
housecleaning or gardening activities) rather than on
developmental considerations. Another hierarchical concept, also
influenced by knowledge of infant development, was that stroke
survivors recovered motor function in a proximal to distal
sequence. Hence, therapeutic interventions always began at the
pelvic and shoulder girdles. When working to improve upper limb
motor function, proximal control over scapular and glenohumeral
motions was considered to be a prerequisite for implementing
treatment that focused on forearm and hand function. Today, it
is understood that survivors of stroke or TBI may demonstrate
distal voluntary movements (e.g., some capacity to fl ex the
thumb joints) before they have achieved a particular level of
proximal control of scapular and glenohumeral motions (Beebe &
Lang, 2008, 2009). In addition, research about reach and grasp
has revealed that, during functional performance, the neural plan
begins with attention to the object that is going to be lifted or
moved. Neural signals to proximal muscle groups are based on
49
orienting the shoulder, elbow, and forearm so that the hand is in
the optimal position for interacting with the goal object
(Paulignan et al., 1997). Therefore, current motor intervention for
patients recovering from stroke or brain injury does not follow a
proximal to distal sequence. Instead, each patient’s constellation
of motor abilities guides the therapist in setting treatment goals.
At the same time, however, therapists must be mindful of the
kinesiological interactions between proximal and distal limb
segments. Proximal alignment and stability at the scapula, trunk,
and pelvis affect functional use of the arm and hand. For the
purpose of minimizing mechanical constraints to pain-free
movement, several interventions (described later in this chapter)
focus on improving proximal function. Like Brunnstrom’s model,
both the Rood and PNF approaches advocated the use of specific
sensory stimuli for facilitation or inhibition of motor “fi ring”
within selected muscles. Stimuli that facilitate the spinal level
myotatic reflex, like quick stretch, or vibration over a muscle
belly, were used to stimulate the stretch reflex and thus elicit a
momentary increase of muscle fiber contraction. The
physiological principle of reciprocal inhibition (that stimulation to
a muscle will simultaneously elicit inhibitory neural signals to its
antagonist) was used to relax spastic muscles. For example, a
quick stretch to the triceps would elicit a momentary increase of
neural signals to elicit con-traction of muscle fibers in the elbow
extensor muscle and also elicit a momentary decrease of neural“
firing” to the muscle fibers of the biceps. The observed result was
a temporary decrease in hypertonicity in the biceps and greater
ease in passively or actively moving the elbow into extension.
Generalized inhibitory stimuli included slow, rhythmic vestibular
input (as in slow rolling) and various types of relaxing
somatosensory stimuli. Although these techniques are no longer
used in neuro-rehabilitation as initially prescribed by the Rood
and PNF approaches, there are certainly modern correlates to
these ideas. Functional electrical stimulation (FES) has replaced
the facilitation techniques. Medical interventions such as
botulinum toxin injections and GABA ergic medications
(Denham, 2008; Ivanhoe et al., 2006) and generalized relaxation
strategies, as applied through yoga poses, controlled breathing,
guided imagery, and meditation, have replaced the reflex-based
inhibitory techniques advanced by the Rood and PNF
approaches. A major contribution by the PNF approach is the use
50
of diagonal patterns of limb movement (see figures C-5 through
C-8 in online Chapter C), which are consistent with well-
supported kinematic and kinetic linkages (Surburg, 1997). Before
PNF, rehabilitation professionals tended to view movement as
occurring only through the three cardinal planes (sagittal,
coronal, and transverse). Passive movement through diagonal
patterns ensures safe and efficient stretch to all muscles, at all
joints of the upper limb. Active and resisted movements through
diagonal patterns provide exercise to groups of muscles in the
limbs and trunk that are recruited synergistically by the CNS.
PNF diagonals and ancillary techniques continue to be used
effectively in orthopedic rehabilitation and athletic training. Their
effectiveness as an intervention to improve motor function after
brain injury has never been supported by research. Most likely,
this is related to the fact that PNF interventions are directed
toward improving motor execution, without providing task-related
practice to improve motor control. Even so, occupational
therapists apply a core concept of PNF, which is that functional
movements comprise integrated interaction between multiple
joints and muscles through an infinite number of diagonal
planes. Please see online Chapter C about the Rood and PNF
approaches for more information about these concepts and
techniques.

51
 CHAPTER 9
NEURODEVELOPMENTAL THERAPY (THE BOBATH
APPROACH)

Berta Bobath, a physical therapist, and her husband, Karel

Bobath, a psychiatrist and neurophysiologist, began advancing a
different set of ideas for enhancing motor recovery in children
and adults as early as the 1940s. Their first major publication
about stroke rehabilitation (Bobath, 1970) was, in several ways, a
direct challenge to primary tenets espoused by Brunnstrom.
Where Brunnstrom’s approach capitalized on spasticity and
hyperactive reflexes as opportunities to elicit early movement, the
Bobaths viewed hypertonicity as an obstacle to a person’s ability
to move freely. In addition, they recognized that once a person
begins to move his paretic limbs in abnormal patterns, it is
extremely difficult to break away from these obligatory patterns
for flexible movement sequences that meet the contextual
demands of activity performance. Finally, the Bobath approach
conceptualized the underlying cause of limb synergies quite
differently than Twitchell and Brunnstrom. Instead of viewing the
synergies as primary impairments that are directly associated
with cerebral damage, they conceptualized these abnormal
movement patterns as secondary maladaptive strategies. Carr
and Shepherd (2003) later coined the term “adaptive features” to
describe disorders of movement that develop in response to a
person’s attempt to move within the constraints of limited
mobility, specific weakness, or hypertonicity in specific muscles.
For example, Figures 21-1A and 21-1B illustrate the marked
difference in scapular mobility in two people. Notice the extent to
which the scapula pro-tracts and upwardly rotates when the
young man on the left flexes his shoulder. As demonstrated by
the photo on the right, many stroke survivors experience limited
scapula mobility (also described as impaired dissociation between
the scapula and the thorax). This is a secondary impairment,
usually caused by loss of muscle length in the middle trapezius
muscle. As the man in the photo tries to raise his arm into
flexion, his lack of scapulohumeral rhythm interferes with
efficient kinematics. To achieve the movement, he uses what
motor capacities are available to him. He laterally flexes his
trunk, elevates his scapula, abducts his arm away from the body,
and ultimately, to achieve greater active range of motion (AROM),
52
externally rotates at the glenohumeral joint. Compare this photo
to Figure A-1 in online Chapter A, which illustrates a flexor
synergy pattern. Neurodevelopmental therapy (NDT) introduced
the concept that therapy could “prevent” the development of
abnormal limb synergy patterns by removing mechanical
obstacles to movement. NDT training, which continues today,
prepares therapists to have keen observational skills and to
employ kinesiological concepts when determining motor
interventions. In particular, NDT provides specific guidelines for
observing a patient’s postural alignment, predicting how
misalignment might impact the kinematics of limb movement,
and improving the patient’s postural symmetry and balance. The
Bobaths were the first to articulate that motor performance
problems in stroke survivors are due to factors beyond the
activation of individual muscles. They stressed that many stroke
survivors have “lost the feeling of normal movement” (Bobath,
1970). In today’s lexicon, this concept of “normal movement” is
described as motor programs or flexible attractor states (to be
discussed later in this chapter). In addition, they recognized that
postural alignment and postural control provide a critical
foundation for functional movement. Thanks to the foresight of
Berta and Karel Bobath, the NDT approach has continued to
evolve over time, in response to newer ideas about motor control
and relearning. Numerous textbooks by the Bobaths and others
who have studied with them provide helpful guidelines for
structuring motor interventions with stroke survivors (Davies,
2000; Howle, 2002; Ryerson & Levit, 1997). However, outcome
studies have not supported the efficacy of the total package of
NDT intervention, as compared with other approaches to
improving motor control in stroke survivors (Kollen et al., 2009).
In addition, some have suggested that NDT therapists put too
much emphasis on monitoring the kinematics of movement and
using hands-on techniques in an attempt to prevent the person
from developing “abnormal movement patterns.” Be-cause of this,
NDT interventions may fail to provide patients with sufficient
opportunities to actually practice using their emerging motor
skills (French et al., 2010). Influences from
NeuroscienceEvidence about Brain Plasticity. There has been an
explosion of evidence in the past 30 years that confirms the
human brain’s capacity to reorganize after injury has occurred.
The American Occupational Therapy Association (AOTA) Practice
53
Guidelines for Adults with Stroke present an extensive review of
research findings that support the importance of activity-based
environmental challenges and repetitive practice opportunities in
facilitating this neural reorganization (Sabari, 2008). Combined
with advances in medical treatment of acute cerebrovascular
accident (Wardlaw et al., 2003) and stroke rehabilitation (Stroke
Unit Trialists’ Collaboration, 2007), emerging concepts related to
neuroplasticity have contributed to a heightened sense of
optimism that stroke survivors have the potential to recover
motor function (Gauthier et al., 2008). Depending on the extent
of neuropathology, all stroke survivors have varying potential for
spontaneous recovery and reorganization of neural mechanisms.
Studies of humans and other mammals have provided significant
evidence that recovery of function after brain lesions is associated
with recruitment of brain regions not typically activated for a
specific function (Butefish, 2004; Murphy & Corbett, 2009).
These studies consistently find that brain plasticity is a dynamic
process that is influenced by the individual’s active efforts to
meet environmental and task demands (Hoffman et al., 2008).
This finding has contributed significantly to changing views
about neurorehabilitation. The philosophy, long held within the
OT profession, that engagement in specially designed therapeutic
activities can improve motor function is now supported by the
scientific community. In addition, neurorehabilitation goals have
been reframed from a focus on motor execution to an emphasis
on helping patients improve motor control and, with regard to
paretic limbs, amount of use. Several streams of research, in a
variety of disciplines, have added support to incorporate these
ideas into rehabilitation interventions to improve motor
performance in survivors of stroke and brain injury.

Evolution from Impairment-Focused Interventions Designed

to Help Patients Develop Effective Movement Strategies
Although kinesiology has long been a core subject of study in OT
and physical therapy curricula, it was not until the 1970s and
1980s those rehabilitation professionals began to seriously
consider how principles from the academic disciplines of
movement science and motor learning could be applicable to
therapeutic interventions. Many of these principles related to
stages of learning, types of feedback, and therapeutic use of
practice are described in Chapter 13, “Learning.” We recommend
54
that you review this chapter, with particular emphasis on
Definition 13-2 (implicit learning and explicit learning) and
Procedures for Practice 13-2 (Therapeutic Use of Context,
Feedback, and Practice to Promote Transfer and Generalization).
At the same time, a major paradigm shift was occurring in
neuroscience. Previously, neural control of movement was
explained by tracking the descent of neural signals through
corticospinal pathways, delineating the direct influences from
brainstem nuclei on motor neurons in the spinal cord, and
describing communication between alpha motoneurons and
muscle fibers (the “final common pathway”). In essence, motor
performance was viewed as the collection of neural stimuli to
individual muscles. Furthermore, regions of the CNS were viewed
as relatively static structures, with assigned functions that did
not change in response to experience or injury. A proliferation of
neuroscience research provides significant evidence that neural
control of movement can best be conceptualized as a fl uid,
dynamic system. Through repetitive but varied practice, people
develop motor pro-grams that govern the production of
generalized categories of movement. These motor programs are
then adapted to suit particular features of task performance.
Therefore, a unique pattern of activity with core foundational
characteristics emerges whenever the motor program is executed.
For example, a tennis player develops an underlying motor
program that structures her posture and sequence of muscle
recruitment for producing a forehand swing. This set of
kinesiological relationships forms a core foundation, but the
athlete alters the force characteristics, timing, and spatial details
each time she returns the ball. The tennis player chooses these
alterations (or variant characteristics of the motor program)
based on the speed, force, and direction of the tennis ball, as well
as the player’s intentions regarding how to return the ball to her
opponent. The confluence between empirical findings in
movement science and neuroscience research has led to
increasing overlap between these two fields of study. These
findings have had significant influence on rehabilitation
interventions to improve motor performance in survivors of stroke
and TBI. Schmidt and Lee (2011) provide useful background
information about core concepts and research evidence related to
human motor control and motor learning. Shumway-Cook and
Woollacott (2012) provide more specifi c applications to OT and
55
physical therapy practice. Winstein and Knecht (1990), Carr and
Shepherd (1998, 2003), and Mathiowetz and Bass- Haugen
(1994) developed practical guidelines for therapeutic intervention
based on dynamic systems, ecological systems, and motor
program theories.

Influences from Dynamical Systems, Ecological Systems, and

Motor Program Theory
Dynamical systems theory, also known as nonlinear dynamics,
provides a mathematical paradigm for conceptualizing
phenomena that are subject to unpredictable changes over time
(Hirsch, Smale, & Devaney, 2004). True dynamical systems
theorists are mathematicians and philosophers, but in the 1980s
scholars in the movement and neural sciences began to apply
these ideas to explanations of motor learning, skill development,
and recovery of motor function after brain injury (Schmidt & Lee,
2011). Ecological systems theory began as an exploration of how
multiple factors interact to influence child development
(Bronfenbrenner, 1979). Several OT scholars have synthesized
these concepts into broad-based models for OT intervention
(Dunn, Brown, & McGuigan, 1994; Law et al., 1996). Dynamical
systems and ecological systems theories have significantly
impacted our current understanding of how people develop motor
skill and recover motor function after brain injury. The following
principles guide the way rehabilitation professionals
conceptualize our role in helping patients reach their maximum
functional potential.
 Dynamic systems are self-organizing. When a system is in a
state of equilibrium, all influences are in perfect balance,
and the system perpetuates itself without any need for
change. As occupational therapists, we are most interested
in understanding systems in states of disequilibrium. The
human CNS can be conceptualized as a dynamic system.
The hypothetical “system” that plans and organizes
movement can also be conceptualized as a dynamic system.
Dynamic systems continuously seek to “solve problems”
that are presented by internal or external challenges.
Furthermore, dynamic systems have the capacity to self-
organize for the purpose of meeting these challenges. For
illustration purposes, when learning to water ski, a person
develops a strategy that will enable him or her to rise from a
56
 crouched position to standing, and then maintain his or her
balance all while wearing skis, on the surface of a lake, and
being pulled by a motor boat that will vary its speed and
direction. Similarly, when recovering from brain injury, a
person relearns motor strategies for skills as basic as
maintaining sitting balance, rising to a standing position,
and coordinating arm and hand movements to reach and
grasp objects. In dynamic systems theory (DST), external
challenges are described as “perturbations.” Without
perturbations, a system will have no reason to use its self-
organizing capabilities. Just as a person learns to water ski
by “solving the problems” that are presented when
participating in this sport, a person recovering from brain
injury needs task-based challenges to begin the active
process of “figuring out” how to move, using his or her
current motor capabilities.
 Influences on dynamic systems are heterarchical rather
than hierarchical. By that we mean that responsibilities for
motor control are distributed among a number of structures
within and external to the CNS. Spinal level structures are
not completely dependent on higher centers for direct
movement commands. Instead, the role of hemispheric
structures is to tune and prepare the motor system to
respond most efficiently to changing.

57
 CHAPTER 10
MANAGEMENT OF COGNITIVE AND PERCEPTUAL
DEFICITS

Cognition refers to the integrated functions of the human mind

that together result in thought and goal-directed action.
Cognition underlies being and doing and is evidenced in how
people interact with others and perform both simple and complex
activities of daily life. Perhaps the central role of cognition in
occupational performance is best illustrated as one imagines
what it must be like to suddenly lose the ability to concentrate,
remember, and problem solve. Survivors of traumatic brain
injury (TBI) describe how their once-familiar routines and
environments become chaotic, confusing, and frightening, which
devastates their sense of identity and competence (Erikson et al.,
2007). Occupational therapists assess cognition because many
people seeking occupational therapy services are likely to have
some degree of cognitive impairment that influences their ability
to participate in rehabilitation and achieve rehabilitation
outcomes (Skidmore et al., 2010). Cognitive changes can be
temporary, relatively static, or progressive. As above, many
survivors of TBI experience deficits in information processing
speed, attention, memory, and executive functions that persist
for months or years postinjury (Skandsen et al., 2010). A
significant number of persons who sustain a spinal cord injury
also have a concurrent TBI with similar implications for cognition
(Macciocchi et al., 2008). Individuals with chronic conditions may
also experience cognitive changes including those with multiple
sclerosis (Rogers & Panegyres, 2007), Parkinson’s disease
(Caviness et al., 2007), cancer (Boykoff, Moieni, & Subramanian,
2009), epilepsy ( Helmstaedter et al., 2003), systemic lupus
erythematosus (McLaurin et al., 2005), and human
immunodeficiency virus/acquired immunodeficiency syndrome
(Heaton et al., 2004). Even individuals with mild stroke who are
independent in activities of daily living (ADL) may have executive
dysfunction that impacts their ability to work, drive, and engage
in recreational activities (Edwards et al., 2006; Wolf, Barbee, &
White, 2011). This chapter begins with descriptions of specific
cognitive domains and processes. We then review clinical
reasoning considerations pertinent to cognitive assessment and
describe specific methods and tools based on three
58
complementary approaches to cognitive assessment. We conclude
with considerations for interpreting the results of cognitive
assessment.

DEFINING COGNITIVE CAPACITIES AND ABILITIES

The term cognition generally refers to the product of many
integrated processes carried out by the brain that allow humans
to be aware, think, learn, judge, plan, and execute behavior
(National Institutes of Health [NIH], n.d.). These domains and
processes include orientation, perception, attention , memory
and learning, judgment, reasoning, language, and executive
functions (NIH, n.d.). How these processes and domains precisely
interact to enable being, thinking, and doing is unclear, but it
appears that executive functions may control and coordinate the
other cognitive operations in the service of goal-directed action
(Salthouse, 2005). Consider the working definitions that follow
and how dysfunction might be observed in every-day activities
(see Table 6-1).

Primary Cognitive Operations

Primary cognitive operations such as orientation, attention, and
memory are thought to be prerequisite to higher level thinking
abilities such as executive functions and metacognition. That is,
people must have a sense of place or time and some ability to
focus their attention and remember information in order to
reason, problem solve, plan, and execute complex activities.

Orientation
Orientation refers to the awareness of self in relation to person,
place, time, and circumstance (Sohlberg & Mateer, 1989).
Orientation deficits are typically symptoms of brain dysfunction,
with disorientation to time and place being most common (Lezak,
1995).

Attention
The term attention was famously defined by William James as
“the taking possession by the mind, in a clear and vivid form, of
one out of what seem several simultaneously present objects or
trains of thought” (James, 1890, pp. 403–404). Attentional
abilities are dependent on multiple brain regions including the
cingulate cortex, limbic system, prefrontal cortices, and
59
sensorimotor regions (Posner, 1980). Each person is thought to
have a limited capacity for consciously attending to information a
hard-wired upper limit that dictates how many inputs can be
simultaneously processed (Lezak, 1995). Deficits in attention are
common following brain injury as numerous and diffuse neural
regions work to support the individual’s attentional abilities.
Deficits can also be experienced because of a lack of sleep or
decreased nutrition (Groeger et al., 2011). Learning is dependent
on attention as individuals can-not encode into memory stimuli
or content they do not attend to. Definition 6-1 describes five
components of attention (Sohlberg & Mateer, 2001) and their
implications for task performance.

Memory
Memory broadly refers to information storage and retrieval
(Lezak, 1995). Rather than a unitary process or construct, there
are many types of neural processes that support an individual’s
memory capacity (Sohlberg & Turkstra, 2011). Experts still
debate about what transpires during the process of remembering
(Cowan, 2008). Atkinson and Shiffrin’s (1971) Information-
Processing Model, which highlights stages of acquiring and
employing new knowledge and skills, is one of many conceptions
as to how this process occurs. We use this model to introduce
memory-related concepts, acknowledging the continued debate
regarding precise terms and their meanings in this realm. (Also
see Dubuc [2011] and Levy [2011] for more in-depth information
on the following discussion.)

Sensory Registers
Information from the environment is briefly (milliseconds) held in
registers (or stores) specific to the human senses (Lezak, 1995).
This registration stage has been called the intake valve for
determining what data from the environment are ultimately
stored. This phase is influenced by acuity of the senses (such as
hearing and vision), affective set, and perception.

Short-Term Memory/Working Memory

The short-term phase of information processing reflects “faculties
of the human mind that can hold a limited amount of information
in a very accessible state temporarily” (Cowan, 2008, p. 324). It
has many labels: primary memory, immediate memory, short-
60
term memory, and working memory. The term primary memory
pertains to a pattern of neural fi ring associated with a given
idea, about which the person may or may not be aware (Cowan,
2008). This includes data just transferred from the sensory
registers related to one’s focus of attention (Levy, 2011). The term
working memory pertains to the attention-related processes that
are involved in managing incoming information and manipulating
stored information for planning and problem solving (Cowan,
2008). It can be thought of as the seat of conscious thought; it
connotes the effortful deployment of cognitive resources during
this stage as well as the manipulation of information involved in
active thinking (Sohlberg & Turkstra, 2011). Many experts believe
that for input from sensory registers to proceed to storage in
long-term memory, the input must be the subject of deliberate
concentration in working memory for approximately 30 seconds
(Lezak, 1995). Without this focused attention, the memory trace
decays, and the memory is not retained (Lezak, 1995). Unlike
long-term memory, which is thought to have an infinite capacity,
working memory has a restricted holding capacity of seven plusor
minus two chunks of information (Miller, 1956). In addition to its
role in information processing, working memory is the foundation
of concentration and problem solving (Baddeley, 1990). Based
onelectrochemical activity in the brain, working memory reflects
the contribution of attention to the memory process (Lezak,
1995).

Long-Term Memory
Whereas data in working memory have a short shelf life,
information in long-term memory can be stored for minutes to a
lifetime (Lezak, 1995). When we remember information (an event
that occurred an hour ago or a year ago), we have located and
retrieved data from long-term memory and are holding it for
conscious attention and thought in limited-capacity working
memory. Storage in long-term memory is based on relatively
permanent changes in brain cell structure (Glover, Ronning, &
Bruning, 1990), although there does not appear to be a single
local storage site for stored memories (Lezak, 1995). Long-term
memory is thought to consist of two subsystems, explicit (or
declarative) memory and implicit (or non declarative) memory
(Fig. 6-2). Declarative memory pertains to factual information and
includes episodic memory (knowledge of personal information
61
and events such as what you ate for breakfast) and semantic
memory (knowledge of facts about the world such as that horses
are big and ants are small) (Eysenck & Keane, 1990). Prospective
memory is another form of declarativememory, having to do with
remembering to do tasks that one intends (Fish, Wilson, &
Manly, 2010). Implicit or nondeclarative memory differs from
explicit memory because it does not involve conscious awareness
of learning (Sohlberg & Turkstra, 2011). This includes procedural
memory, which pertains to knowing how to do things; it allows us
to learn and perform skilled motor actions (Eysenck & Keane,
1990). Memory impairments are typically characterized as mild,
moderate, or severe based on the results of cognitive assessment.
The term neurologic amnesia is reserved to de-scribe losses of
broad categories or segments of memory resulting from brain
trauma, stroke, or tumor

Measures of Functional Cognitive Performance

Occupational therapists’ education and expertise lend themselves
especially well to this aspect of cognitive assessment. There are
three themes in the realm of assessing cognitive functional
performance: dynamic assessment, informal observations of
function, and performance-based assessments.

Dynamic Assessment
Unlike static assessments, which identify and quantify
impairment at a specific point in time, dynamic assessment
refers to an approach in which the clinician uses cues and
feedback to understand how to elicit the patient’s best
performance (Toglia & Cermak, 2009). Dynamic Interactional
Assessment (DIA) (Toglia, 1998) is an example of a dynamic
assessment approach. DIA consists of awareness questioning,
cueing and task grading, and strategy investigation (Toglia,
1998). Patients predict their performance before beginning the
assessment task. Graded verbal cues are offered as needed once
the patient begins work, and parameters of the task are changed,
if necessary, to buoy the patient’s performance. The therapist
also asks questions about what strategies or approaches the
patient uses. Toglia (1993) incorpo-rated DIA into a number of
the standardized assessment tools she developed, including the
Contextual Memory Test. In addition to these specific measures,
therapists can convert any task (such as organizing the messy
62
cupboard in Fig. 6-3) into a dynamic assessment by deliberately
manipulating task and environment variables and offering
strategies and cues to determine in what conditions the patient
performs at his or her best (Dougherty & Radomski, 1993).

Informal Observation
Informal observation of task performance enables the therapist to
make hypotheses about cognitive strengths and weaknesses and
identify domains warranting further evaluation. For example,
during an ADL or homemaking evaluation, occupational
therapists observe attention to task by counting episodes of
distraction in a specific. Learning is a primary therapeutic
mechanism underlying many, if not all, occupational therapy
interventions. Occupational therapists teach patients to perform
activities of daily living (ADL), teach family members home
programs, teach other therapists new techniques, and teach the
public in community education courses. Each teaching
opportunity requires preparation: the physical environment
needs to be prepared; any needed materials, props, or equipment
needs to be gathered; and most importantly, the learner must be
pre-pared for the session. Teaching strategies need to be
consciously designed to maximize learning, using methods
designed to support different learning styles (e.g., visual, aural,
read/write, or kinesthetic learners) (Lofl and, 2009). Any
handouts should address health literacy concerns and are
developed with an understanding of the cultural, social, and
cognitive issues that might affect the teaching session (DeWalt et
al., 2010). All of these concerns need to be addressed in order for
effective teaching to take place. Finally as teachers, therapists
must determine whether learning has taken place. For example,
after a 30-minute dressing session, a patient who has had total
knee replacement surgery is able to don his pants, socks, and
shoes. From a traditional learning perspective, the patient’s
performance at the end of the session reflects the extent to which
he has learned the desired skill or strategy. However, what if a
nurse later reports that the patient is unable to carry out the
activities he demonstrated proficiency with the day before? One
can easily see that although within-session performance was
buoyed by cues and practice, true learning did not occur.
Schmidt and Lee’s (2011) contemporary definition of motor
learning allows us to differentiate learning from within-session
63
performance: “. . . motor learning is a set of processes associated
with practice or experience leading to relatively permanent
changes in the capability for responding” (p. 327). Based on this
definition of learning, we would expect the patient with knee
replacement to demonstrate similar levels of proficiency after the
occupational therapy session as during. The term performance is
used to describe what is seen during training, that is, short-term
capabilities resulting from instruction, cues, or assistance. For
occupational therapy to help patients resume occupational roles
therapists must understand the process of transforming
performance into learning and use teaching methods that help
the patient learn new skills. This chapter discusses the role of
information processing in learning and then summarizes the
array of variables that affect the patient-specific teaching plan.
Key influences on learning are detailed, and the chapter
concludes with specific applications to occupational therapy
practice. Regarding issues of learning, there has been a
traditional division in the research between motor and cognitive
tasks. In clinical practice, however, it is unusual to find motor
tasks that do not have a cognitive component or the reverse.
Because this distinction does not translate into practice and
because principles in the two areas are similar, the principles are
combined in this chapter.

64
 CHAPTER 11
MOTOR LEARNING

Learning is inextricably linked to memory, specifically the

encoding and retrieval of information. As explained in Chapter 6,
people hold environmental stimuli very briefly in a series of short-
term sensory stores before transferring it to limited-capacity
working memory (Atkinson & Shiffrin, 1971). In working memory,
sometimes called short-term memory, people may use control
processes to encode information for storage in long-term memory
(Schneider & Shiffrin, 1977). These control processes include
techniques such as rehearsal, coding, and imaging (Atkinson &
Shiffrin, 1971). Rehearsal is rote repetition of information,
whereas coding entails linking the new information to something
meaningful. Imaging transforms verbal information to visual
images that are stored in memory. Craik and Tulving (1975)
found that the durability of the memory trace is a function of
depth of processing. That is, deep processing, as in the time-
consuming process of linking new information to personally
relevant old knowledge, results in better retention than shallow
processing, such as rote rehearsal. If the learner does not use
some form of conscious control, the memory trace quickly fades
from working memory and cannot be recovered (Atkinson &
Shiffrin, 1971). From the standpoint of human information
processing, learning is the transfer of information from short-
term or working memory to long-term memory (Shiffrin &
Schneider, 1977).

Controlled versus Automatic Information Processing

Consider the attentional resources required of you the first time
you drove a car compared with the attention required for the
same task now. After years of experience, the car seems to drive
itself, freeing the driver to concentrate on plans for the day or
talk to a passenger. This example typifies the difference between
controlled and automatic processing.

Controlled Processing
Controlled processing is technically a temporary activation of a
series or sequence of elements in long-term memory under the
attention and control of the thinker (Schneider & Shiffrin, 1977).
For example, the new driver must actively recall specific rules
65
and instructions and direct his attention to each motor sequence
of the task. Con-trolled processing is limited by the capacity of
working memory and is therefore effortful but flexible in handling
novel situations. When learning a new task.

Processing
Thus, patients learning new skills or behaviors can process only
a limited number of inputs (instructions, cues, and
environmental distractions) at a time.

Automatic Processing
With enough controlled processing, a task requires less and less
concentration to carry out (Shiffrin & Schneider, 1977). That is,
the task becomes increasingly automatic, as in the example of
the proficient driver. Automatic processing occurs when specific
contextual stimuli internal or external to the person trigger the
activation of a specific learned sequence in long-term memory
(Schneider & Shiffrin, 1977). Given enough repetition, the
individual performs the skill or task in a consistent manner with
little or no attention. Sternberg (1986) suggested that
development of a full level of automatization requires at least 200
trials of a task but that automatization begins in as few as 10
trials, so long as those trials are consistent. With fully automatic
skills, people cannot stop themselves from per-forming the
overlearned sequence unless control processes are employed to
override it. Definition 13-1 discusses implications related to
helping patients with memory impairment to reacquire skills.
According to Giles (2005), overlearning is practice of a skill or
strategy well beyond demonstration of learning or proficiency; it
increases the likelihood that the skill or strategy will become
automatic. These automatic skills and strategies become the
easiest behaviors to initiate from an array of possible behaviors
(Giles, 2005), minimizing demands on attention and decision
making. Habits and routines are examples of automatic motor
sequences that, according to Kielhofner, Barris, and Watts
(1982), organize a person’s tasks, space and time. Characteristic
of automatic skills and strategies, habits and routines are
responsive to the environmental conditions under which they are
learned and develop with repetition (Kielhofner, Barris, & Watts,
1982; Wood, Quinn, & Kashy, 2002). Habit learning is a form of
implicit learning, which is described in Definition 13-2.
66
Occupational therapists often help patients resume or relearn
self-maintenance tasks so that they are once again automatic.
Learner Characteristics
A client’s learning potential is determined by many factors.
Variables affecting cognitive status (reviewed in Chapter 6) are
critical contributors to learning potential. Remember, these
considerations apply to family caregivers as well as patients (see
Procedures for Practice 13-1). Literacy is one important
dimension of the experiential sociocultural influence on learning,
with many implications regarding teaching methods (see Chapter
3). Neistadt (1995) suggested that occupational therapists
attempt to answer four questions regarding patients’ learning
capacities during the course of their traditional evaluation. These
questions include the following:
1. What modes of input (e.g., visual, auditory, and tactile) can
this patient process most easily?
2. What approaches to tasks (outputs or behaviors) are still
available to this patient?
3. What tasks remain meaningful or are most likely to facilitate
learning for this patient?
4. How well is this patient able to transfer learning, that is,
apply specific skills to a variety of tasks under

Anticipated Length of Treatment

Occupational therapists also consider how many teaching
sessions are likely to be available, as dictated by expected length
of stay at the hospital, rehabilitation center, Motor Skills/ Motor.

Learning and Occupational Performance: Assessments and

Interventions.
Occupational therapy practitioners assess and treat patients with
a variety of neuromotor impairments that interfere with
movement control and organization. These deficits are displayed
by both children and adults with specific difficulties such as tone
irregularities, loss of postural and or limb control, motor
planning problems, and motor coordination deficits as well as by
children and adults with delayed sensory motor development.
From an occupational therapy perspective, movement problems
can interfere with the individual’s performance of every- day
tasks and the organization of purposeful and meaningful
activities into daily occupations. This chapter focuses on
67
identifying common elements of movement control and
organization that are essential to an individual’s motor
development and attainment of fundamental motor skills as well
as life skills.

THE EMERGENCE OF MOTOR SKILLS

Conceptually, the development of motor skills, regardless of one’s
age, is essential for success in any type of occupation that
requires a motor component. This statement hints at the
foundation on which much occupational therapy treatment is
based. Numerous factors contribute to success in motor skills,
not the least of which is an intact central nervous system (CNS).
As the CNS develops from infancy through early adulthood, there
are associated increases in motor skill ability. Although motor
skills per se are not automatically developed, their age-
appropriate emergence is limited to the maturational level of the
various systems of the body, including the CNS. The integrity of
the CNS is the ultimate rate-limiting factor in determining any
potential success in acquiring motor skills. It has been proposed
that motor skills are not actually developed at all; rather, they
are acquired. For example, a child who is beginning to learn how
to walk will make many attempts at taking his or her first step
before actually being successful. In the process of these attempts,
the child is learning consciously and sub- consciously about the
limits of his or her stability, postural control, and balance. Once
these (and several other factors) have been at least marginally
accounted for, the child will be successful in acquiring the ability
to actually take that first step. The development of motor
abilities, however, is based on more than just CNS maturation.
Many systems develop and change simultaneously along with the
CNS, including, but not limited to, the muscular, skeletal, and
endocrine systems. Each system within the body develops at its
own rate and experiences periods of varying degrees of change
across time. For any given motor skill, success with acquiring
that skill rests on the critical maturation of any number of
underlying systems (e.g., skeletal size, muscle strength, and
postural stability). When each of the systems has reached a level
of development that supports the acquisition of the new skill, the
child then has the capability to acquire that new skill (Thelen,
1995). A large part of learning requires that the child learn what
his or her body can and cannot do, given the constraints of the
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environment and the task at hand. Once the child’s systems have
the developmental maturity to allow the child to have the
capability to learn a new skill and the child experiences the
environmental constraints (physical constraints, social
constraints, and task constraints), then all of the ingredients for
successful learning are in place. Stated another way, once
experimentation occurs, the child will learn how to succeed,
given his or her developmental maturation and environmental
constraints.

Reflexes, Myelination, and Maturational Processes in Motor

Development
Interestingly, when a child is newly born, the number of neurons
within the CNS is approximately 100 billion (Nolte, 2002). After
birth, these neurons are believed to be unable to divide and
reproduce themselves. Additionally, as a person traverses the
decades of his or her life starting in the second decade, the CNS
tends to lose neurons. This is considered to be a part of the
normal aging process associated with the CNS. The point here,
though, is that when a baby is born, it essentially has all of its
neurons at the first day of its life. The question then becomes: If
the infant has all of its neurons, then why does the child need to
learn? Clearly, there are many processes involved in the
development of the child. This is particularly true in the child’s
motor development. Some of the earliest patterns of movement or
positioning are in the form of primary reflexes. These primary
reflexes are often conspicuous when one views the positioning of
a child younger than six months of age. Two common primitive
reflexes are known as the asymmetrical tonic neck reflex and the
symmetrical tonic neck reflex. These two reflexes affect the
position of the upper and lower extremities and are elicited or
determined by the position of the head. Although these reflexes
remain with us throughout life, their influence on the positioning
of the body is not as apparent after the age of approximately six
months. Sometimes these reflexes can emerge in older children
or adults after an injury to the brain occurs. There are several
theories as to why these primitive reflexes become integrated.
One of the most prevalent theories has to do with the rapid
myelination of the brain within the first few years of life. The
average mass of a human brain at birth is about 400 grams, and
by the end of the third year, the mass has increased to
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approximately 1,200 grams (Nolte, 2002). Much of this increase
is thought to come from the myelination of the CNS neurons.
Myelination is thought to continue at least into the second
decade of life. Further, it is believed that as the individual ages,
the rapidity of myelination decreases. Why is myelination so
important? Once myelin is established, the ease of neuronal
depolarization and the rate of the neuronal propagation increase
dramatically. This results in the ability of the neurons to
communicate with each other more efficiently. Simultaneously
the establishment and proliferation of neuronal dendrites occur
at a relatively intense rate during the early years of life. The more
dendrites there are, the more connections there are to other
neurons. Whereas the myelin facilitates the speed at which
depolarization travels down the neuronal axon, the dendrites act
as connections between other neurons. The increase in myelin
and dendrites results in more efficient communication to many
more neurons, which in turn means that the brain can process
much more information much more efficiently. Pragmatically
speaking, this results in being able to process more information,
allows for greater coordination of movement, and facilitates the
ability to learn new skills at a quicker rate. As these neuronal
changes are rapidly developing in typically developing children,
growth charts provide some insight into the physical development
in terms of height and weight. From birth to approximately age
20, there are two large growth spurts, which can be readily seen

How Body Systems Change with Motor Development

Once the person has successfully navigated puberty and enters
the twenties, many of the body’s systems (i.e., muscle mass,
skeletal size, CNS myelination) remain relatively stable for the
next several decades. However, detrimental changes in muscle
mass can been seen as early as age thirty, when loss of muscle
fibers begins, continuing to decrease at least through age 75
years (Abrams, Beers, Berkow, Fletcher, & Besdine, 1995). Bone
mass is another area that changes, especially for menopausal
women, but both sexes normally experience slow progressive loss
of bone mass beginning at about age 50 years. Brain mass tends
to decline by approximately 10% between the ages of 25 and 90
years (Abrams et al., 1995). This reduction in brain mass is not
necessarily associated with decreased cognitive function, though
some cognitive changes do occur with the normal aging process.
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As an example, people with large ventricles can still function
normally, while those with “normal” sized ventricles have been
known to have severe dementia. Therefore, normal age-related
loss of brain mass does not necessarily mean loss of cognitive
function. Although we just touched on three systems that change
across the life course (bone mass, muscle mass, and brain mass),
changes occur in every organ and system through- out the life
course, including, but not limited to, the cardio- vascular system,
the kidneys, the gastrointestinal system, the skin, and the
immune system. Just as when the development of the child’s
subsystems provides the potential to acquire skills, the opposite
can be true as the person traverses the fifth and sixth decades
(and beyond). For instance, as the individual ages and
experiences age-related organ and system changes, the potential
for either learning new skills or maintaining the ability to perform
skills learned earlier in life may decline. Having discussed some
developmental, growth, and maturational issues that occur
throughout life, we turn in the following section to motor control
concepts that are specific to functional movement and skills.

THE INTERACTION OF MOTOR TASKS WITH THE

ENVIRONMENT AND THE PERSON
Movement, with all its exquisite manifestations, is essential to
the performance of everyday activity and skills. Occupational
activities, such as writing and typing, require developing and
organizing movements or actions that adapt to the task demands.
For example, writing on a piece of paper requires organizing
several actions: (1) reaching for a pen, (2) orienting, (3) grasping
and (4) holding a pen to write on the surface of a piece of paper,
(5) generating thoughts to write with the pen on the paper, (6)
forming and initiating the plan to write, (7) executing the action
plan for writing, (8) completing and stopping writing. In current
scientific thought, movement emerges from the interaction of the
individual with the task and the environment (Shumway-Cook &
Woollacott, 1995). How we write will depend on the tool we grasp,
the surface we write on, the message we want to convey, and
what we know about the act of writing. The organization of each
movement we make varies depending on the person and the task
and reflects the multiple influences of the physical, social, and
cultural environment on the person and the task. Movements are
task specific, context dependent, and constrained by factors
71
inherent to the situation. For example, the act of reaching
depends on the posture, position, location, and size of the person
reaching, as well as the size and placement of the object being
reached for and its location relative to the person reaching. If a
person has a disability that interferes with or disrupts the ability
to move, then that person’s initiation and/or task performance is
affected. All individuals generate movements in line with task
demands, and each person’s ability to adapt to changing task
demands on a daily basis reflects his or her functional
capabilities and limitations. Current thinking highlights the
expression of movement as a function of the integrity of the
individual, the task, and the environment and not solely as the
expression of neuromotor and musculoskeletal processes within
the person. The scientific thinking that guided therapeutic
practice from the 1950s through the 1980s relied heavily on the
understanding of movement as both neuromotor and
musculoskeletal derived. However, contemporary thinking
highlights a multidimensional systems approach to motor
development and motor control. Figure 55.3 illustrates this
fundamental thought about a systems and multifactorial
approach to the organization of movement and factors con-
trolling movement.

Motor Control and Individual Constraints on Movement

Motor control involves both the study and understanding of the
nature and regulation of movement. Motor control is seen as the
end product of a dynamic interaction between the person’s
cognitive-perception-action systems, the task at hand, and the
environment (Heriza, 1991; Shumway-Cook & Woollacott, 2001).
An overview of the different body systems within the individual
that contribute to movement follows.

Movement and Sensation/Perception

Most motor control theories propose several roles for sensory
input and feedback in movement regulation. The sensory
channels provide information from the environment and the body
that is useful in initiating and maintaining movement. Sensory
input not only has a role in initiating movement, but also has a
role as sensory feedback in con- trolling the movement as the
movement occurs. Perception is the integration of sensory
impressions from the different sensory sources into
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psychologically meaningful information. Both the perceptual and
sensory systems provide information about the state of the body
and features of the environment that influence movement
control. Sensation and perceptual information are important to
action just as action is essential to perceptual information
(Rosenbaum, 1991). We act on what we perceive, and we perceive
and act on our perceptions. Therefore, understanding movement
requires an understanding of the systems that control sensation
and perception and how these systems influence and form action.

Movement and Action

Movements are housed within actions, and for the occupational
therapy practitioner, the focus on movement control is to
understand how the individual organizes movements into
meaningful and purposeful actions, activities, and routines
within different occupations. Also, movements are described and
best understood within the context of accomplishing goal-
directed actions. Movement control is studied within the context
of an action, such as reaching, with the assumption that the
control processes that are involved in this function will provide
insight into principles related to how similar movements are
controlled. Understanding the control of action implies under-
standing how the motor output is based on musculoskeletal and
neuromuscular components, including movement synergies and
the motor programming systems. The musculoskeletal system
includes joint and muscle properties, such as joint and muscle
lengthening flexibility, contributing to the organization of the
movement. There are numerous joints and muscles in the body,
and these must be controlled during the execution of
coordinated, functional movement. The problem of coordinating
many muscles and joints into a coordinative structure, called the
degrees of freedom problem, is a major research issue for motor
control researchers. Another movement structure that is relevant
to action are synergies, which are categories of movement that
require the action of more than one muscle. As defined by
Shumway-Cook and Woollacott (2007), synergies are functional
couplings of groups of muscles constrained to act as a unit and
reflect preferred strategies for moving. Examples include grasping
an object and throwing a ball. Synergies are characterized by
spatial and temporal characteristics that allow for both stability
and flexibility in movement. Flexibility in synergistic patterns
73
allows the coordinated structure to adapt to the environmental
demands, while stability is evidenced by the reliability of the
spatial and temporal ordering of the specific movement. In the
standing position, lower extremity stability is provided by the
distal-to-proximal muscle sequence activation, while flexibility
allows for walking on an uneven surface (Shumway-Cook &
Woollacott, 2007). In occupational therapy literature, atypical
synergies associated with impaired movement control have
frequently been described, particularly in populations with stroke
and cerebral palsy. These atypical flexion- and extension-
dominated synergies are groups of muscles acting as mass
movement patterns that reflect the individual’s response to
reorganization of movement control subsequent to brain injury.
Such synergies are marked by lack of flexibility and stability and
can result in muscle shortening and musculoskeletal deformity
as set postures emerge and normal reciprocal movements and
sequences do not occur as part of movement control.

Motor Program and Plans

Motor programs and plans are also part of the action sys- tem
that is hypothesized to influence movement control. Several
definitions of motor programs have been offered in the literature.
According to Brooks (1986), motor programs have been defined
as “communications within the central nervous system that are
based on past experiences and can generate planned postural
adjustments and movements”. Motor programs are defined as
abstract representations that when initiated result in the
production of a coordinated movement sequence (Keele, Cohen, &
Ivry, 1990; Schmidt & Lee, 2005). Much of motor control
research has focused on examining the hypothesized invariant
characteristics of motor programs and their role in movement
planning and control. Invariant characteristics of motor programs
include the relative timing, the order, and the relative force of an
action. Such elements characterize categories of movements,
such as throwing. Throwing is the motor programming action,
and this action is generalized so that “throwing” can include
throwing a football, throwing laundry into a hamper, or throwing
a snowball at a friend. Several motor control theorists question
the usefulness of the programming construct or the abstract
representations of movements. However, the concept of a motor
program or a stored representation of movement is central in
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cognitive approaches to movement planning and control. It is
thought that the individual uses existing motor programs to
organize motor behavior when faced with novel actions and tasks
in the environment. Although there is neurobehavioral evidence
to support the notion of motor programs in the individual, how
motor programs develop and where they are stored in the
individual remain controversial (Shea & Wulf, 2005). Along with
movement plans and programs, an understanding of posture,
stability, and postural control informs our understanding of
movement. Postural control involves controlling the body’s
position in space to maintain stability and orientation. Horak and
Macpherson (1996) have defined postural orientation as the
ability to maintain an appropriate relationship between body
segments and between the body and the environment for a task.
Postural stability or balance is the ability to maintain the body in
equilibrium. Maintaining postural control requires two separate
sensory motor processes: the sensory organization process and
the motor adjustment process. The sensory organization process
involves the interplay of one or more of the orientation senses
(vision, somatosensory, and vestibular), their integration within
the CNS, and their contributions to postural control. The motor
adjustment process involves the ability to execute coordinated
and properly scaled musculoskeletal responses. The motor
responses are automatic processes that develop early in
childhood, while the sensory processes develop over time in
children and are not fully developed until a child is about 14 or
15 years of age. Both sensory and motor processes are essential
to developing and maintaining postural control. Disruptions in
these sensory or motor systems due to injury, disease or delay
will result in in- adequate postural control strategies. The term
posture is most often used to describe both the biomechanical
alignment of the body and the orientation of the body to the
environment. For example, the occupational therapy practitioner
might describe the client’s posture as sitting, standing, or lying
down. When working with a client, the occupational therapy
practitioner might focus on developing postural control and
coordinative movements as part of the person’s needed to develop
motor programs and plans. The practitioner considers the
process of posture, action, and movement organization in relation
to an individual’s performance of a task and does not focus on
the execution of a single movement or posture. What is essential
75
is the therapist’s supporting the organization of the client’s
movement relative to the task and the activity demands
associated with different tasks.

Cognition and Action

Actions can occur as a result of external prompts, such as seeing
a toothbrush and reaching for it, or reflexively in response to an
external stimulus, or as a result of an internal intent or
motivation, such as wanting to brush one’s teeth in the morning
and looking for and reaching for a toothbrush. Cognitive
processes that are important to action include attention,
memory, motivation, and the emotional aspects of motor control
underlying the establishment of the person’s intent or goals
(Shumway-Cook & Woollacott, 2001). Also, the ability to attend to
the relevant cues of a task and the performance environment and
the ability to make task comparisons, to evaluate one’s own
performance, and to identify errors in movement planning are
cognitive strategies that are useful in skill learning and
relearning.

Reaction Time
One example of cognition and action that has been relatively well
researched as a measure of cognitive processing is reaction time.
Reaction time is considered to be a measure of how efficiently the
CNS is working. Reaction time is defined as the time from when a
stimulus is given to the time when a movement begins in reaction
to the stimulus. There are different types of reaction time. For
instance, simple reaction time is the reaction time when there is
a single stimulus associated with a solitary specific response. For
example, suppose that when a person sees a light turn on, he or
she is required to reach forward; in this case, there is a one-to-
one relationship between the stimulus and the response. Choice
reaction time is somewhat more complex, occurring when a
number of potential stimuli are present and the motor response
is unique for each of the different stimuli. For example, there
might be three potential stimuli involving a red light, a green
light, and a blue light. The directions might be that when he or
she sees the red light, the participant is required to lift his or her
arm straight up; when he or she sees the green light, the
participant is supposed to move his or her arm to the left; and
when he or she sees the blue light, the participant is supposed to
76
move his or her hand to the right. It has been shown that a
person’s choice reaction time performance is typically longer than
his or her simple reaction time performance. It has also been
shown that the best reaction times occur during the late teens
and early twenties and that the reaction time increases each
decade thereafter. Men tend to have faster reaction times than
women. It also appears that the more education a person has,
the better is his or her reaction time (Fozard, Vercryssen,
Reynolds, Hancock, & Quilter, 1994; Houx & Jolles 1993) Within
the individual movement is the product of many systems that
need to be examined as they interact and contribute to movement
organization and control. Deficits in one system affect the
function of other systems. To understand motor control and
organization, the perceptual, cognitive, and action components of
motor control must be considered and synthesized as part of the
full picture of motor control. In addition to individual body
factors affecting control, different tasks as well as the
environment impose constraints on motor control. The Person,
the Task, and the Environment Skill acquisition is dependent on
several factors. Practitioners help patients to learn skills, and
these skills have multiple dimensions that influence
reacquisition. Understanding the types and requirements of tasks
as well as the regulatory features of the environment that affect
task performance allows the practitioner to plan with the patient
the optimal environment for skill learning. Also, under- standing
how movement control is affected in the client with a neurological
disorder and what body systems have been affected helps the
practitioner to plan effective multi systems interventions for skill
learning. Along with using task analysis, a task taxonomy can be
useful for retraining functional movements in the patient with a
neurological disorder. Using the three continuums of closed to
open skills, stability to mobility, and no manipulation versus
manipulation, the practitioner could assess a client’s capability
and skill level across many basic and instrumental activities of
daily living. By systematically varying the regulatory features of
the task and the environment, the practitioner, can help the
patient to develop the motor program and plans that are
necessary for rebuilding task routines. Now that we have
reviewed some fundamental aspects of motor learning and
control and its development from a theoretical perspective, the

77
next section focuses on defining and assessing motor skills and
motor performance.

DEFINING AND ASSESSING MOTOR SKILLS AND MOTOR

PERFORMANCE PROBLEMS
This section presents concepts from the International
Classification of Function (ICF) to provide a framework for
understanding motor skills and how neuro- motor impairments
that affect motor skills are defined and assessed. The ICF
integrates medical and social models of disability by specifying
the nature and parallels between functional ability and disability,
as well as the impact of social and environmental factors on
performance. According to the ICF, function reflects the
composite of one’s body functions, activity and participation,
whereas disability reflects impairments, limitations of activity
and function, and activity restrictions (Figure 55.5). Within the
ICF classification, the person’s achievement of a level of function
that affords independence and quality of life is the determinant of
a successful rehabilitation outcome. The ICF’s focus on health
and quality of life resonates with the focus of the occupational
therapy profession on health and wellness, as well as its focus on
the multifaceted aspects of function and occupational
performance. In assessing, treating, and determining client out-
comes, the practitioner focuses on understanding the client
factors, the client’s occupational activity demands, the client’s
occupational performance contexts, the client’s occupational
performance patterns, the client’s occupational performance
skills, and the client’s actual performance of and participation in
personal tasks and meaningful occupations. Also, in assessing
and treating the client, the practitioner observes what the client
can and cannot do and what enables or interferes with the
client’s performances of his or her occupations. In under-
standing motor control and organization, this means that the
practitioner integrates his or her understanding of the individual,
the task, and the environment as it relates to movement control
and motor skill to address the client’s motor issues that interfere
with the ability for participation in occupation. It is this
integration that uniquely defines the art of occupational therapy
as a profession. This section lists the primary motor terms that
are used to explain motor skills additionally, client factors,
including body structures, functions, and impairments that
78
interfere with motor skill acquisition and performance, are
defined. This is so that the reader has an understanding of both
typical motor skill and the impairments that interfere with motor
performance and result in inefficient movements. From the
practitioner’s perspective, motor skills are clients’ skills in
moving and interacting with task, objects, and environment
specific to their engagement in the occupations that are
meaningful and necessary to their life roles and participation and
satisfaction with their life. Also, clients’ skilled performance in
their occupations will depend on the integrity of their different
body systems (client factors), the composite of activity demands
of their occupations, and the influence of and the contexts in
which they function. Motor skill is defined as a goal-related
volitional movement that requires both motor and sensory input
for success. Motor skills are learned and can wax and wane
depending on practice and experience. There can be multiple
client factors that interfere with the performance of motor skills,
as motor control and organization are integrally involved with the
body systems and mental functions contributing to task
performance. Not the least of these are neuromotor factors or
impairments at the neuromuscular and postural levels that can
interfere with motor skill. For instance, in addition to problems
with motor planning (e.g., problems with praxis), the disruption
of skilled performance can result from postural instability and
mal alignment, limited functional trunk and limb mobility,
dyscoordination of the upper extremities, problems with in-hand
manipulation, limb and body weakness, the inability to grade and
sustain muscle coactivation and force, and the inability to
sequence muscle activity. The following discussion defines terms
and impairments that help the practitioner to understand the
components of posture, movement, and skill, as well as what
neuromuscular impairments can interfere with efficient and
skilled movement. The typical components of postural control
include posture, alignment, and adaptation. Posture is a
composite of the positions of all the joints of the body at any
given time. It is the static position that is assumed by any body
part at any time. Therapists must evaluate spinal alignment and
curves, pelvis, trunk, head, neck, and upper extremity posture
alone and in relation to each other in positions of standing,
sitting, and lying down and in the context of occupational
performance. Good body and postural alignment occurs when the
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center of gravity of each body segment is over the supporting
base of the body. In the case of a child with cerebral palsy,
postural alignment can be limited by the presence of interfering
reflexes, such as an asymmetrical tonic neck reflex, which results
in the child’s body being dominated by more extensor tone on the
side of the body to which the head is turned and more flexion
tone on the other side of the body (Preston, 2006). Similarly, in a
person who has sustained a stroke, atypical muscle synergies
can result in an atypical and sustained increase of flexion and or
extension tone in different groupings of muscles, leading to
postural asymmetries as the client is sitting or standing. Postural
adaptation refers to the ability of the body to maintain balance
automatically and remain upright during alterations in positions
and challenges to stability. Nor- mal control and adaptation
involve the ability to produce movements through adequate
ranges and to control movements throughout the ranges. Also,
they involve the ability to differentiate and selectively control
different body parts; to initiate, stop, and hold a limb in action;
and to have normal tone in the body to stabilize the body and
support limb movements while the body is stationary or moving.
As defined by Howle (2002), postural control consists of (1)
proactive reactions or postural orientation, which helps to
anticipate the appropriate relationship between body segments
that is task specific; (2) postural stability, which is the ability to
maintain the center of mass within the limits of the base of
stability; and (3) reactive postural adjustments, which are flexible
and varied responses to perturbations from the environment,
self-initiated movements or a moving surface. When evaluating a
client, the practitioner needs to observe the client’s posture in the
context of his or her everyday actions, such as sitting at a
computer, standing pushing a grocery cart, or lying in bed.
During these observations, the practitioner observes what is
occurring in the client’s body and whether the client is able to
move efficiently and easily while also having a goal such as get-
ting out of bed or typing while sitting. In this context,
observations are made of the client’s postural alignment,
initiation of movement, selective and independent control of his
or her limbs, and ability to terminate actions. Practitioners
should look at the client’s posture, alignment, and balance while
the client is on stable, hard surfaces and when the client is on an
unstable surface or a slippery surface. A difficulty in determining
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balance deficits is that balance has both sensory and motor
components. Appropriate postural control depends on inputs
from visual and somatosensory receptors and the vestibular
system and on the ability of the CNS to interpret the relative
importance of each. To fully assess balance, the practitioner
needs to evaluate all contributions to balance, including
perturbations to balance and both sensory and motor influences
on postural control. The client’s ability to bend and tie shoes and
to get into and out of the bathtub should also be assessed as part
of the observation of the dynamic nature of postural control.
Table 55.1 describes several clinical assessment tools that
evaluate postural control. Tone can be defined in several ways;
varies from per- son to person; and can depend on age, gender,
and occupation. Muscle tone is characterized by the stiffness or
tension with which a muscle resists being lengthened. Both
neural and nonneural mechanisms contribute to muscle tone
(Lin, Brown, & Brotherstone, 1994). Normal tone is characterized
by ability to move against gravity, shift between stability and
mobility, use muscles in groups or selectively, and balance
between agonist and antagonist tone (Preston, 2006). Tone in a
muscle can be affected by damage to the nervous system and can
increase and decrease as well as vary under different task and
environmental conditions (Figure 55.6). Hypotonia reflected in
low-tone clients is a decrease in the sensation of a muscle’s
resistance to stretch as the joint is moved through the range of
motion and the client’s inability to recruit adequate force to move
against gravity. Clinically, muscles appear soft, joints are lax as
contraction around the joints is less than optimal because of
inadequate force generation, and deep tendon reflexes are absent
or diminished. Hypotonia is observed in lesions of the cerebellar
pathways, primary muscle dis- eases, lower motor neuron
disorders, and the acute phases of stroke and spinal cord injury.
Hypotonia can also be observed as a transient phase in infants
with cerebral palsy. Hypertonia in contrast to hypotonia, is
characterized by increased resistance to stretch, a feeling of
stiffness, and limits to the range and variety of movements.
Spasticity is a motor disorder that is characterized by a velocity
dependent increase in tonic stretch reflexes with exaggerated ten-
don jerks resulting from a hyperexcitability of the stretch reflex.
Clinically, spasticity is characterized by hypertonic muscles,
hyperactive deep tendon reflexes, clonus, abnormal spinal
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reflexes, increased resistance to passive movement, and
decreased coordination. Spasticity is influenced by the client’s
postural status and by extrinsic factors such as anxiety, pain,
and temperature extremes. It can be mild, moderate and severe.
Rigidity is defined as the simultaneous increase of muscle tone in
the agonist and antagonist muscles that result in increased
resistance to passive motion in any direction. Rigidity occurs in
extrapyramidal system lesions such as Parkinson’s disease,
encephalitis, and tumors. Rigidity that is characterized by a
feeling of constant stiffness throughout the range is called lead
pipe rigidity, whereas rigidity that is characterized by alternating
contraction and relaxation is called cogwheel rigidity. There are
many challenges to assessing muscle tone, as tone can vary and
depends on intrinsic and extrinsic factors. Observation of tone
can be evaluated directly by using the Ashworth Scale of
Spasticity (Ashworth, 1964) and the Modified Ashworth Scale of
Spasticity (Bohannon & Smith, 1987). These scales provide a way
to loosely quantify the level of spasticity in muscle. The Modified
Ashworth Scale of Spasticity is fairly commonly cited in the
literature and is fairly straightforward in its application and
interpretation. Another scale for assessing spasticity is the
Tardieu scale (Tardieu, Shentoub, & Delarue, 1954), later
adapted by Held and Pierrot-Deseilligney (1969). This scale
involves testing spasticity using three separate velocities (V1: as
slow as possible, V2: velocity of limb as if it were falling under
gravity, and V3: velocity of the limb as fast as possible, that is,
faster than the effects of gravity). Under these various velocities,
both the quality of muscle reaction (“X”) and the angle of the
muscle reaction (“Y”) are recorded. The quality of muscle reaction
uses a five-point scale from zero to four. Zero refers to “no
resistance throughout the course of the passive movement.” One
refers to “slight resistance through the course of the passive
movement, with no clear catch at a precise angle.” Two refers to a
“clear catch at a precise angle, interrupting the passive
movement, followed by release.” Three refers to “fatigable clonus
(<10 seconds when maintaining pressure) occurring at a precise
angle.” Four refers to “infatigable clonuses (>10 seconds when
maintaining pressure) occurring at a precise angle” (Gracies et
al., 2000, p. 1555). The angle of muscle reaction is “measured
relative to the position of minimal stretch of the muscle
(corresponding to angle 0) for all joints except hip, where it is
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relative to the resting anatomic position” (Gracies et al., 2000, p.
1555.). Gross coordination is the combined activity of many
muscles into smooth patterns and sequences of motion and is
described as smooth, directed, and fluid actions supporting
everyday activities. Also, coordinated movement is characterized
by rhythm, appropriate muscle tension, appropriate postural
tone, and refinement to the minimal number of muscle groups
necessary to produce the desired movements and equilibrium.
Coordination is an automatic response that is monitored
primarily through proprioceptive sensory feedback. Visual and
tactile sensory feedback, body scheme, and ability to judge and
move the body through space also affect overall coordination.
Incoordination is a broad term that is used for extraneous,
uneven, or inaccurate movements. Neurological disorders and
trauma such as muscle or peripheral nerve disease and lesions of
the cerebellum, spinal cord, and frontal or post central cortex can
cause unique disturbances Fine coordination is defined as the
smooth and harmonious action of groups of muscles working
together to produce a desired motion, whereas dexterity is
defined as a type of fine coordination that is mostly demonstrated
in the use of the upper extremity. Coordination problems can be
manifested in irregularity in rate of movement, excessive force,
incorrect sequencing, and sudden corrective movements.
Practitioners use several standardized tests to assess speed of
object manipulation, grasp and release, accuracy of movement,
prehension patterns, writing skills, and hand posture, Besides
standardized tests that are performance based, it is important to
observe the client using the upper extremities in self-help tasks
such as buttoning, keyboarding, manipulating change, and
writing. The Assessment of Motor and Process Skills, a
standardized test based on the client’s preferred task to perform,
is a tool that was developed by an occupational therapist, Dr.
Anne Fisher. The therapist grades the client’s performance across
tasks according to process, motor, and communication skills.
This partitions task performance across the dimensions of
posture, mobility coordination, strength, and energy. However, to
administer this test, special training is required, which limits the
applicability of this tool across population

83
INTELLECTUAL HERITAGE AND OCCUPATIONAL THERAPY
THEORETICAL FRAMES OF REFERENCE GUIDING
NEUROMOTOR INTERVENTIONS
The field of motor control draws from a wide range of disciplines
and reflects the scholarly and research activities of scientists who
are interested in motor behavior. Research findings and theories
about motor control and recovery of function have had an
ongoing influence on the practice of occupational therapy focused
on adults and children with motor control disorders. In the years
following World War II, the dominant therapeutic approach that
was used in the field of physical disabilities was muscle
reeducation. This approach, although useful for polio, was not
appropriate for treating people with disorders of the CNS with
resultant paresis. Because of the inadequacies of applying
muscle reeducation principles to CNS disorders, a few
occupational and physical therapy practitioners (e.g., Ayers,
1972; Bobath, 1965; Brunnstrom, 1970; Knott, 1956; Rood,
1952; Voss, Ionata, & Myers, 1965) began to study and
hypothesize about how the nervous system controls movement
and applied these principles to clinical practice. As a result of
their efforts, the development of organized approaches and
techniques to restore CNS function emerged in the therapy fields.
The period from the mid-1950s through the 1980s was marked
by the development and teaching of specialized neurotherapeutic
approaches such as proprioceptive neuromuscular facilitation,
neurodevelopmental therapy, and Brunnstrom’s movement
therapy. These approaches were situated in the knowledge of the
time focused on specific sensorimotor techniques and
assumptions about the CNS and the organization of motor
behavior. More recently, these approaches have been less
favored, as there are more current theoretical approaches that
have better research evidence supporting their use. The field of
motor control and learning tries to explain both the regulation
and control of normal movements, as well as the factors and
processes that are involved in nor- mal motor learning. Motor
learning is commonly defined as the processes associated with
permanent changes in motor behavior resulting from practice
and experience. The reader is referred to texts that provide in-
depth explanations of the motor learning process and the
research that supports learning using different practice
conditions and the salient factors such as feedback that affects
84
motor learning (e.g., Brooks, 1986: Schmidt & Lee, 2005). The
motor control approaches that are used in occupational therapy
reflect an integration of ideas that explain the nature and
regulation of movement. There is no one singular motor control
theory of occupational therapy; rather, there are several applied
motor learning and control approaches and models. These
approaches are supported by motor learning and control research
drawn from the movement and therapeutic sciences and provide
evidence supporting different occupational therapy interventions.
Understanding motor control implies knowledge about what is
controlled and how the controlling processes are organized
(Horak, 1991). Motor control involves the ability to regulate or
direct the mechanisms that are essential to movement.
Rosenbaum (1991) has proposed that the central issues in motor
control revolve around the multiple factors that determine
movement selection, movement sequencing, and the coordination
of perception and action in goal-directed activities. For instance,
a fundamental question for motor control theorists is how
stability is maintained and controlled while the individual acts in
and on the environment. In the context of occupational
performance, this question becomes “How are postural stability
and movement regulated and controlled for in an individual
engaged in an everyday daily life activity such as dressing while
sitting on a stable or unstable surface such as a chair or soft
mattress?” Motor learning is directed more toward understanding
how movements are acquired and modified with practice.
Schmidt (1988) has defined motor learning as a set of processes
associated with practice or experience leading to permanent
changes in the capability for skilled acts. Shumway-Cook and
Woollacott (2001) have proposed that motor learning develops
from a complex set of perceptual, cognitive, and action that are
processes developed in response to individual-task-environment
interactions. The field of motor control and learning continues to
provide occupational therapy with new ideas for under- standing
the nature, cause, acquisition, and modification of movement
supporting optimal occupational performance. The following
section provides a synopsis of the prevailing motor learning and
control theories and their implications for occupational therapy
treatment. Theories are organized according to whether the
control is centralized within the CNS or dispersed throughout the
CNS and or other systems.Motor development is the culmination
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of a number of underlying subsystems. These underlying
subsystems all develop and mature at their own rates relative to
other sub- systems. Examples of these subsystems include, but
are not limited to, the skeletal system, the muscular system, the
central and peripheral nervous systems, the endocrine sys- tem,
and the sensory systems (visual, auditory, gustatory, olfactory,
haptic, proprioceptive, and vestibular systems). Historically,
motor development was thought to occur through specific and
prescribed stages. Gessell (1928) and others (Gessell & Ames,
1947; McGraw, 1935) developed. ontogenetic stages that depict
developmental milestones for children from approximately 6
months to 6 years of age. These developmental milestones
include postural and motor abilities that are believed to be
stereotypical of various stages of development. The typical
development follows certain directions, specifically cephalocaudal
(head to tail) and proximodistal (axial to extremities). In other
words, developmentally, a child gains control of the head before
gaining control of the lower parts of the body (e.g. the ability to
walk). In a similar vein, developmental milestones show that
proximal stability is required before the affordance of distal
mobility. If the trunk is not stable, the ability to successfully
reach for an object will be diminished. These directionally
dependent constructs require that the CNS organization is largely
hierarchical in nature. That is, higher, more complex parts of the
brain control or have some dominion over lower centers of the
brain. Most primitive reflexes have their neuroanatomical origin
in the midbrain, cerebellum, and medulla. As was stated earlier,
if damage occurs to a higher area of the brain (e.g., the cerebral
cortex), then the reemergence of primitive reflexes is not
uncommon. This gave empirical evidence that reaching
developmental milestones within the “normal” stereotypical time
periods was a good indication of the child’s overall development.
Further, the evaluation and assessment of primitive reflexes and
developmental milestones was believed to be a reliable method for
evaluating the potential for success in age appropriate
occupations (Capute et al., 1982). Recently, however, there has
been some question as to the veracity of this assumption
(Bartlett, 1997). Bartlett evaluated 156 infants who were believed
to be developing normally on the Primitive Reflex Profile and the
Alberta Infant Motor Scale. Assessments were at 6 weeks and at
3 and 5 months. Bartlett found no statistical correlation between
86
the developmental scale scores and the primitive reflex scores.
Thus, Bartlett concluded that there was no relationship between
motor development and the presence of primitive reflexes. Along
the same lines, Thelen (1986) found that when a 6- to 7-month-
old infant was supported over a treadmill, the infant
demonstrated a relatively mature bipedal stepping motion. This is
particularly interesting because the traditionally held ontogeny of
developmental milestones asserted that the stepping motion
normally appears as a newborn but then dis- appears at
approximately 2 months only to reappear at approximately 12
months of age (Strauss, 1982). What Thelen has shown was that
when the environment was manipulated (e.g., by supporting the
child’s body weight, thereby reducing the effects of gravity), the
child spontaneously demonstrated a precocious bipedal stepping
motion. Because it is illogical to think that the CNS matured only
while the child was supported, it is clear that the assumed
hierarchical organization of the CNS is not the exclusive factor or
control mechanism in motor development. Another line of
evidence regarding grip configuration questions the traditionally
held belief that there is a stereotypical sequence of hand grasp
configurations (J. S. Connolly & Elliott, 1972; K. J. Connolly,
1973; Gessell, 1928). This sequence involves the initial use of a
gross grasp/ clawlike configuration and ending up with a mature
finger thumb opposition configuration. One group of researchers
(Newell, Scully, Tenenbaum, & Hardiman, 1989) developed an
interesting experiment in which the participants were asked to
grasp blocks of varying sizes from 0.8 cm to 24.2 cm in width.
Participants included 26 preschoolers aged 3 years 3 months to 5
years 4 months and 22 adults aged 18 to 46 years. These
researchers found that when the ratio of the width of the block to
the size of the hand was the same, similar types of grip
configurations were elicited regardless of the age of the
participant. These results demonstrated that if the child’s
environmental constraints are manipulated to match the
constraints that an adult would face, the child will demonstrate
grip configurations similar to those that the adult employed.
Subsequent studies have shown similar results (Cesari & Newell,
2000; Newell, McDonald, & Baillargeon, 1993; Newell, Scully,
McDonald, & Baillargeon, 1989). Conceptually, these studies by
Thelen, Newell, and others offer a departure from the belief that
development is based on hierarchical organization of the CNS. On
87
the basis of theoretical work by Bernstein (1967), these more
contemporary theorists believe that the “system” (meaning the
various organ, tissue, and bodily systems) is organized in a
heterarchical fashion. This means that the method by which a
person successfully plans and executes a motion requires the
input of many subsystems (e.g., muscle groups, nervous
systems), each of which contributes to the movement solution as
the task requires. The subsystems are not necessarily under the
direct control of the cerebral cortex; that is, the cerebral cortex or
consciousness regarding the motor plan does not prescribe the
specific details of what each subsystem must do for a successful
motor action. Bernstein (1967) argued that although the
“executive function” knows the general goal of the task at hand, it
does not have the capability of knowing the precise myriad of
details required by each of the subsystems. The executive
function knows the goal of the task and can direct in a very
general manner, but the subsystem is what handles the small
details, such as how much range of motion is required at each
joint, how much force is required with each muscle, and how
many motor neurons to recruit, the sequential timing of the
agonist and antagonist muscles. Bernstein (1967) further argued
that the subsystems tend to work together in synergistic
patterns. For example, suppose that a person is sitting on a sofa
and reaches for a television remote control that is two feet in
front of the person on top of a coffee table. Certain muscle groups
are recruited, such as the anterior deltoids and the triceps, as
the primary muscles to fling the arm forward to the remote. Now
suppose that the person is lying on his or her side on the sofa
instead of sitting. The person reaches for the remote as in the
previous example, but because the position of the arm in relation
to the remote and to gravity is different, a different set of primary
muscles is recruited (namely, the medial deltoid to counteract the
direct pull of gravity, along with the anterior deltoid and the
triceps) to move the arm in the direction of the remote. If one
were to compare the electrical activity of the anterior deltoid and
triceps between the two conditions, the electromyography would
be completely different. An important thing to remember in this
example is that although the goal was the same in both
situations (i.e., grab the remote), different subsystems were
recruited depending on what the situation required. The following

88
section provides more information about some specific models of
motor control that take these concepts into account.

DISTRIBUTED AND SYSTEM MODELS OF MOTOR CONTROL

General Description of Distributed Models of Motor Control In
this model, control of movement is not peripheral or central. As
scientists examined different motor behaviors along with task
and environmental constraints, a concept of distributed control
of movement emerged; that is, the internal and external forces
acting on this system were considered (Keshner, 1991).
Distributed models of motor control are not unidirectional.
Rather, they allow for communication within the nervous system
to take place in ascending, descending, and lateral arrangements.
The control hierarchy is perceived not as a descending chain of
command but as an overlapping circular network in which each
level influences those above and below it. Various sites within
and throughout the system are part of the process underlying
and controlling movement. Some models of distributed control,
however, minimize the relevance of the nervous system. Others,
such as neural network models, continue to rely heavily on
processing units that consist of neurons and their extensive
system of linked dendrites (Bate, 1997). Control of movement in
these models is seen as being distributed throughout many
working systems, which can include mechanical and
environmental factors as well as nervous system factors. The
following subsections contain a brief description of a few of many
theories involving distributed control of movement.

General Description of Systems Theory

Bernstein, a Russian scientist, was among the first to look at
internal and external forces acting on the body to under- stand
the characteristics of the system being moved. The body was
regarded as a mechanical system with mass and subject to
external forces, such as gravity, as well as inertial and
movement-dependent forces. Bernstein asked questions related
to (1) the function of the system in a continually changing
environment, (2) the properties of the initial conditions affecting
movement, and (3) the body as a mechanical system influencing
the control process (Shumway-Cook & Woollacott, 2001).
Bernstein (1967) was also responsible for identifying what is
known as the degrees of freedom problem. In describing the
89
mechanics of the system, Bernstein noted that many degrees of
freedom need to be controlled for coordinated movement to occur.
For example, there are many joints that can flex, extend, and/or
rotate, and these multiple options complicate the control of
movement. Control therefore involves converting the body into a
“controllable” system (Schmidt, 1988). Bernstein’s solution to
this problem was proposing that hierarchical control exists to
simplify the body’s multiple degrees of freedom. He proposed that
1. groups of muscle are constrained to act together as a unit,
and
2. These units are activated at lower levels in the system.

Description of Dynamic Pattern Theory

This is an operational approach to the study of coordinated
movement (Keshner, 1991) as used in the movement sciences.
The impact of this theory is seen in a variety of research areas,
including development (Thelen & Smith, 1994), aging (L. S.
Greene & Williams, 1996), rehabilitation (Scholz, 1990), and
coordination research (Lee, 1998; Sternad, 1998; Walter, 1998).
Dynamic pattern theory incorporates aspects of Bernstein’s
systems theory and the study of dynamics and synergistics. It is
an attempt to define terms and provide behavioral and
mathematical predictions for coordinated movement patterns.
The following basic concepts are fundamental to many dynamical
systems approaches and motor control research.
1. The human system exhibits self-organizing behavior.
2. The human system is a many element system that can be
described by a few elements, which are referred to as
collective variables. Collective variables are the fewest
number of variables that completely describe the behavior.
For example, Heriza (1991) proposes that for humans,
walking is a highly complex behavior that is characterized
by a specific movement pat- tern. The new walker
compresses the many degrees of freedom available from the
muscles, bones, joints, tendons, neurons, and motor units
into a relatively few degrees of freedom that can be observed
in walking. In this example, a complex behavior—walking—
becomes characterized by a description of the behavior: the
specific movement pattern.
3. Collective variables characterize movement patterns and
capture the systems that cooperate to produce the
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 movement, as movement is more than just muscles and
motor neurons. For example, kicking, stepping, and
throwing a ball are examples of coordinated movement
patterns. Again, an example by Heriza (1991). Helps to
clarify this. In intralimb coordination, as seen within one
limb in kicking or stepping, the identified collective variables
are the timing of the individual movement phases, such as
flexion and extension; phase lags, defined as the time
between the onset of movement of one joint and that of
another joint; and the relationship of individual joints to
each other.
4. The identification of phase transitions is basic to
understanding behavior. Control parameters are variables
that shift the movement from one form to another
movement form. Control parameters act to reorganize the
system. In the example of intralimb coordination as well as
in interlimb coordination, behavioral states can drive the
system. For instance, when an infant is asleep or drowsy,
little kicking is noted. If the infant is aroused, the spatial
and temporal pattern of kicking is observed. If the infant is
in a crying state, a new pattern emerges that is described as
a rigid coactivation of all the muscles into stiff mobility.
Therefore, control parameters can be defined as components
that are essential but nonspecific to the movement behavior.
In this example, the control parameters can reside in the
individual, such as behavioral state; in the environment,
such as gravity; in the social environment, such as the
caretaker; or in the goal or in the task. New coordinated
patterns emerge because old patterns become unstable and
the system is driven to a new state. Changes in the control
parameters push the system to a new state. During these
shifts in phase or phase transitions, the prevailing
movement pattern becomes less stable and more easily
perturbed by the control parameter (Heriza, 1991).
5. The study of the stability or instability of behavior during
transition periods is essential to understanding Npattern
change in complex systems. In this approach, movement
behavior and control can be aptly de- scribed by a set of
collective variables and control variables associated with
phase transition.

91
MOTOR CONTROL APPROACHES PROPOSED FOR
THERAPEUTIC INTERACTION
New approaches to intervening with motor performance deficits
that affect occupational performances have evolved. These
therapeutic approaches are based on both motor learning
principles and on more contemporaneous models and research
about the control of movements in both typical populations and
populations with movement disorders. Task-Oriented Model The
task-oriented model (Gordon, 1987; Horak, 1991; Shumway Cook
& Woollacott, 2001) targets both peripheral and central control
systems. In line with system models of motor control, the task-
oriented model assumes that control of movement is organized
around goal- directed functional tasks. Clients are taught to
accomplish goals for functional tasks. By practicing a wide
variety of movements, the client solves different types of motor
problems. The assumptions seen in Table 55.6 guide treatment.
Along with these assumptions and guidelines, Horak (1991)
suggests organizing questions around several areas in treating
clients with motor performance deficits. These areas are the
client’s behavioral goals, movement strategies, musculoskeletal
constraints, compensatory strategies, and need for adaptations.
Examples of questions about these areas are as follows:
1. Behavioral goals: Are the therapist’s and client’s goals the
same? This might entail the practitioner incorporating the
use of the Canadian Occupational Performance Measure
(COPM) and the Assessment of Motor and Process Skills.
Using both would allow the practitioner to determine what
is important to the client and what are the strengths and
weaknesses in the client’s motor and process skills.
2. Movement strategy: What are the organizing principles of a
normal movement strategy?
3. Musculoskeletal constraints: How much of the motor
deficit in a patient with neurological deficits is due to a
deficit in the musculoskeletal system rather the neural
components?
4. Compensatory strategies: Has the patient found the most
effective strategy?
5. Adaptation: How must a movement strategy be adapted to
accomplish a task in a new environmental context?

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 CHAPTER 12
CARR AND SHEPHERD
MOTOR RE-LEARNING PROGRAM

The Motor Re-Learning Program (Carr & Shepherd, 1987) is a

synthesis of the prevalent contemporary models of motor control
and the motor learning process (Sabari, 1995). It is specific to the
rehabilitation of patients following stroke. The program is based
on four factors that are thought to be essential for the learning of
motor skill and assumed to be essential for the relearning of
motor control:
1. Elimination of unnecessary muscle activity
2. feed- back
3. practice,
4. The interrelationship of postural adjustment and movement.
In this program, treatment is directed toward relearning of
control rather than to activities incorporating exercise or to
facilitation or inhibition techniques.
Treatment is directed toward enhancing motor performance, and
the emphasis is on the practice of specific tasks, the training of
controllable muscle action, and control over the movement
components of these tasks. The major assumptions about motor
control underlying this approach are listed in Box 55.1. To
provide this program, a four-step sequence is followed for skill
acquisition.
Step 1 is an analysis of the task, including observation.
Step 2 is practice of missing components, including goal
identification, instruction, practice, and feedback with
some manual guidance.
Step 3 is practice of the task with the addition of reevaluation
and encouraging of task flexibility.
Step 4 targets transfer of training (Carr & Shepherd, 1987).

Contemporary Task-Oriented Approach Description

Haugen and Mathiowetz (1995) have proposed a task-oriented
approach based on a systems model of motor control and
influenced by contemporary developmental and motor learning
theories. This model takes into account the interaction between
the personal characteristics or systems of the person such as the
sensorimotor system and the performance context. Occupational

93
performance emerges from the interaction between personal
characteristics and performance contexts.

ASSUMPTIONS UNDERLYING THE MOTOR RE-LEARNING

APPROACH WITH GUIDELINES FOR EXERCISE AND
TRAINING TO OPTIMIZE MOTOR SKILL
 In regaining motor control, learning is required. This
learning follows the same principles and factors as those
incurred in normal learning. Therefore, practice, receiving
feedback, and understanding the goal are essential for
treatment.
 Motor control is exercised in both anticipatory and ongoing
modes.
 Sensory input is related to motor output and helps to
modulate action.
 Control of a specific task can be effectively regained by
practice of that specific motor task in various contexts.
 Conscious practice of tasks builds up awareness of the
ability to elicit motor control activity.
 Progression of practice is from conscious awareness to
practice at a more automatic level in order to ensure that a
skill is learned.
 Cognitive function is emphasized. If the client is to learn,
then the environment must encourage the learning process.
 When clients can perform a task effectively and efficiently
without thinking about it in a variety of contexts, learning
has occurred.
 Contemporary theories of motor control emphasize
distributed control rather than a top-down or bottom-up
approach. Therefore, in the Motor Re-Learning Program,
recovery is directed to relearning control through many
systems.
 The client is defined as an active participant in the
treatment process. The major goal in rehabilitation is to
relearn effective strategies for performing functional
activities.
 The role of the therapist is to prevent the use of inefficient
strategies by the client.
 The program addresses seven categories of functional daily
activities: upper limb function, or facial function, sitting up

94
 over the side of the bed, balanced sitting, and standing up
and sitting down, balanced standing, and walking.
The Task-Oriented Approach (Mathiowetz, 2004) considers the
person’s role performance as well as the performance in areas of
occupation. In addition, this model espouses that a task analysis
be performed to determine the factors (from the person, the
environmental context, and the task itself, the same three factors
as in the perceptual motor workspace) that either facilitate or
restrict performance. The treatment focus of this approach
involves any individual or combination of the following:
 Environmental modification
 Manipulating or grading the task
 Remediating skills/abilities that are particularly limiting
within the person

Implications
Specific strategies are espoused for the remediation of limiting
factors within the person. Many of these strategies are founded in
the motor learning body of knowledge. Some of these strategies
involve how feedback is given. For instance, it has been shown
(particularly with nondisabled populations) that reduced
feedback actually results in better retention and transfer of the
motor skill being learned (Rice, 2003; Rice & Hernandez, 2006;
Winstein & Schmidt, 1990; Wulf, Schmidt, & Deubel, 1993). See
Shea and Wulf (2005) for a review. Another motor learning
strategy involves presenting tasks to be learned or practiced in a
random fashion (e.g., moving from task to task without providing
repeated trials on any given task) rather than giving multiple
trials of the same task before moving on to another task.
Limitations Much of the motor learning research has been
performed on healthy college students, and the tasks have
usually involved simple rote motor skills that do not represent
normal occupationally oriented activities. Therefore, the
generalization of these strategies to special populations should be
done with caution until a greater body of evidence supports their
use with special populations.

ASSUMPTIONS GUIDING A CONTEMPORARY TASK-

ORIENTED APPROACH
Assumptions Treatment Principles

95
 Functional tasks help to organize behavior. Recent research
suggests that parameters of motor behavior are not
performance components but in fact functional goals
(Burton & Davis, 1992; Gentile, 1992; Heriza, 1991; Thelen,
1989).
 Occupational performance emerges from the interaction of
multiple systems that represent the unique characteristics
of the person and the performance context.
 After CNS damage or other changes in personal or
environmental systems, clients’ behavioral changes reflect
their attempts to compensate and achieve functional goals.
 Personal and environmental systems are hierarchically
organized. There is no inherent ordering of the personal and
environmental systems in terms of their influence on motor
behavior. There is also no inherent ordering within the
system, even within the CNS.
 A person must practice and experiment with varied
strategies to find optimal solutions for motor problems and
develop skill in performance.
 Because the primary purpose of motor behavior is to
achieve functional goals, therapists begin and end therapy
by focusing on occupational performance. The emphasis on
task performance and evaluation is primarily at the
disability level, using the World Health (1980) Organization
Model of Disablement.
 The therapist assesses all systems that are contributing to
problems in functional performance or supporting optimal
performance, keeping in mind the tasks the person
currently does or will be doing in the future. Because the
client brings to the situation a unique constellation of
characteristics, the therapist makes the client’s perspective
the focus of assessment. The client determines the
important goals and roles necessary for occupational
performance.
 Movement patterns that are used for compensation and
achievement of functional goals must be understood fully.
The evaluation of occupational performance must include
an examination of the process (actual movement patterns),
the outcome, and the stability or instability of observed
motor behavior.

96
  Evaluation strategies consider all personal and
environmental systems. The ones that interfere the most
with performance are evaluated first.
 As part of treatment, clients practice, experiment, and
problem-solve in order to achieve functional goals.
Treatment planning is to develop and implement learning
opportunities for clients with problem-solving abilities.
When clients are unable to problem solve, the therapist
might need to train them to use given routines.

Evaluation and Intervention /Management Of Cognitive

Perceptual Impairments
Thinking, remembering, reasoning, and making sense of the
world around us are fundamental to carrying out everyday living
activities” (Unsworth, 1999, p. 3). Cognition consists of
interrelated processes including the ability to perceive, organize,
assimilate, and manipulate information to enable the person to
process information, learn, and generalize (Abreu & Toglia, 1987).
Because so much of rehabilitation in general requires learning
and generalization, the principles of intervention that are
discussed in this chapter are important to consider with a wide
spectrum of clients and are not limited to those who are typically
identified with cognitive impairments. Cognitive impairments may
be seen as a result of developmental or learning problems, brain
injury or disease, psychiatric dysfunction, or sociocultural
conditions (American Occupational Therapy Association, 1999).
Cognitive impairments can result in significant activity
limitations and participation restrictions in all aspects of the
client’s life, potentially compromising safety, health, and well-
being. For example, decreased abilities to recognize potential
hazards, anticipate consequences of actions and behaviors, follow
safety precautions, and respond to emergencies are often major
factors that interfere with independence. Cognitive limitations
can also diminish one’s sense of competence, self-efficacy, and
self–esteem, further compounding difficulties in adapting to the
demands of everyday living. The influence of cognitive symptoms
can be observed across all aspects of the domain of occupational
therapy practice. The aim of occupational therapy intervention
for people with cognitive-perceptual impairments is to decrease
activity limitations, enhance participation in everyday activities,
and assist individuals to gain the abilities they need to take
97
control over their lives and develop healthy and satisfying ways of
living. Although the ultimate goal of intervention with this
population is clear, there are different perspectives and
rehabilitation approaches to accomplish the goal.

98
 CHAPTER 13
COGNITIVE IMPAIRMENTS: DEFINITIONS,
EVALUATIONS, AND INTERVENTIONS

In this section, the main constructs involved in cognition will be

discussed in terms of their definitions, evaluation, and treatment.
Self-awareness will be discussed first because lack of awareness
can affect the motivation, effort, and sustained participation that
are needed for intervention. Following discussion of self-
awareness, the areas of orientation, attention, memory, executive
functions, motor planning, unilateral neglect, and visual
processing will be reviewed. Evidence-based reviews in cognitive
rehabilitation have found that training in strategies, and self-
monitoring or self-regulatory skills are key characteristics of
studies demonstrating the effectiveness of cognitive rehabilitation
(Cicerone et al., 2000, 2005). These interventions will therefore be
emphasized. It should be kept in mind that the context of the
person’s life needs to be considered in planning and choosing
intervention activities (Johnston, Goverover, & Dijkers, 2005).
This includes the person’s occupations, personality, interests,
and premorbid level of functioning, culture, values, external
supports, and resources. Interventions that address cognitive
impairments need to be blended with those that address
interpersonal skills, social participation, and everyday activities,
routines, and roles (Abreu & Peloquin, 2005).

Self-Awareness
Impaired self-awareness associated with neurological dysfunction
includes lack of knowledge about one own physical or cognitive-
perceptual impairments and/or their functional implications as
well as inability to anticipate difficulties, recognize errors, or
monitor performance within the context of an activity (Toglia &
Kirk, 2000). Impaired self-awareness presents obstacles to
adjustment, collaborative goal setting, and active participation in
intervention. Decreased awareness results in poor motivation and
compliance, lack of sustained effort, unrealistic expectations,
incongruence between goals of the client and family, impaired
judgment and safety, and inability to adopt use of compensatory
strategies (Hartman-Maeir, Soroker, Oman, & Katz, 2003; Sherer,
Oden, Bergloff, Levin, & High, 1998; Toglia & Kirk, 2000). A
number of studies support the association between awareness
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and functional outcome (Fischer, Gauggel, & Trexler, 2004;
Goverover, 2004; Hoofien, Gilboa, Vakil, & Barak, 2004; Noe et
al., 2005; Tham, Ginsberg, Fisher, & Tegner, 2001). Unawareness
may be related to psychological or neurological sources. Denial is
a psychological defense mechanism that is related to premorbid
personality traits and is characterized by over rationalization,
hostility, resistance to feedback, and an unwillingness to
confront problems (Prigatano, 1999). A person who has a history
of denying inadequacies and resisting help from others and a
strong desire to be “in control” is more likely to use denial as a
coping strategy. Impaired self-awareness resulting from neuro-
logical lesions, represents a lack of access to information
regarding one’s cognitive state, and is characterized by surprise,
indifference, or perplexity in response to feedback (Prigatano,
1999). In many cases, the neurological and psychological sources
of unawareness coexist and cannot be easily differentiated. If
denial is the predominant source of unawareness, methods of
awareness training might not be effective (Lucas & Fleming,
2005).

Orientation
Orientation is the ability to understand the self and the
relationship between the self and the past and present
environment. Orientation depends on the integration of several
mental activities that are represented in different areas of the
brain. Disorientation is indicative of significant impairments in
attention and memory (Lezak, Howieson, & Loring, 2004). For
example, disoriented clients might think they are home rather
than in a hospital, might confuse the hospital staff with relatives,
or might believe it that is a new day each time they wake up from
a short nap.

Evaluation
Evaluation of orientation traditionally includes the client’s
orientation to person, place, and time. Orientation to person
involves both the self and others. Is the client able to report
personal facts and events and describe his or her previous
lifestyle? Does the client recognize people and associate them
with their role and name? Orientation to place is demonstrated
by the client’s ability to understand the type of place he or she is
in (e.g., a hospital), to report the name and location of the place,
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and to appreciate distance and direction. Orientation to time
requires an ability to report the current point in time (e.g., day,
month, and year), to show understanding of the continuity and
sequence of time (i.e., estimation), and to associate events with
time. Topographical orientation, often considered a component of
orientation to place, is the ability to follow a familiar route or a
new route once given an opportunity to become familiar with it.
Functionally, the person might not be able to find his or her way
from the therapy area to his or her room or describe and draw
the layout of a familiar room or route (Unsworth, 2007).
Difficulties with the visual-spatial and memory aspects of
topographical orientation need to be distinguished during
evaluation (Brunsdon, Nickels, & Coltheart, 2007; Unsworth,
2007). Orientation assessments are traditionally covered in
mental status examinations. occupational therapists frequently
use non-standardized measures of orientation, such as
interviews with open ended questions asked in a conversational
or informal manner. Most practitioners use cues to determine the
severity of the disorientation. If the client is unable to answer the
questions independently, the practitioner might offer a multiple-
choice array or verbal cues. Cues usually move from general or
abstract to more concrete, as deter- mined by the severity of
disorientation (e.g., “Today is the beginning of the work week”
versus “Today is the day after Sunday”). The number and type of
cues offer a method for scoring and monitoring progress.
Fluctuations in orientation during the day should be noted, as
clients might experience sundowning, in which they become
confused in the evening because of fatigue.

INTERVENTION
STRATEGY TRAINING AND/OR ADAPTATIONS OF TASK OR
ENVIRONMENT
Strategy training for disorientation involves teaching the person
to look for external cues when he or she is feeling confused or is
having difficulty recalling orientation information. For example,
an information poster that contains orientation facts can be
placed on a wall, in a closet, or eventually inside a notebook.
When the client is asked orientation information, he or she is
expected to locate the information poster to verify responses or to
find the correct answers. A memory book, containing pictures
and names of familiar people or important life events, can also be
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placed in a key location within the room. As an alternative, an
audiotape or videotape can be created by a family member to
review orientation information at set times during the day or
used whenever the person feels confused. An alarm that is
preprogrammed to ring several times a day can be used to cue
the person to read his or her orientation fact book or listen to the
audiotape. Orientation questions with use of cueing strategies
can also be incorporated into a bean bag toss game, a board
game, or a “Family Feud” style game within a group format
(Toglia & Golisz, 1990). A calendar posted on the wall or closet
may be helpful in orienting the person to time. If the client has
poor selective attention, a single piece of paper with the day and
date written daily, rather than a monthly calendar, might be
needed. To assist the client in finding his or her room, directional
arrows can be placed in the hallway, and tape indicating the
route to his or her room can be placed on the floor. Key
landmarks can be pointed out and made more salient with
arrows or colored tape. The therapist needs to immediately
reinforce initiation or use of any of these external cues by
praising the client (or rewarding points), and each time the client
initiates the use of an external cue, the therapist should keep
track of it by recording it on a chart or visual graph. The use of
external cues should be gradually faded until the orientation
information is internalized. In addition, the person should be
trained to look for orientation cues (e.g., clocks, calendars) in
different environments. Spaced retrieval techniques can be used
to train use of strategies and external aids, such as using a daily
calendar. Spaced retrieval involves systematically lengthening the
period of retention and recall. There is evidence that this
technique is more effective than cueing hierarchies in treating
people with dementia (Bourgeois et al., 2003).

Attention
Attention is a multidimensional capacity that involves several
components:

1. Detect/react: the ability to detect and react to gross changes

in the environment, such as a telephone ringing, a name
being called, or a ball that is thrown.
2. Sustained attention: the ability to consistently engage in an
activity over time, such as reading for 15 minutes without
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 losing concentration. Repetitive and predictable activities,
such as stuffing envelopes or folding letters, place less
demands on sustained attention.
3. Selective attention: the ability to attend to relevant stimuli
while inhibiting distractions or irrelevant information.
Examples include selecting specific locations on a map,
finding items within a certain price range on a menu,
choosing all the red or even playing cards, and finding
specific ingredients in a closet. Selective attention demands
are increased as the number of items presented
simultaneously is increased and as the saliency of the target
stimuli is decreased.
4. Shifting of attention: the ability to shift or alternate
attention between tasks with different cognitive and/or
provide a cue to assist the client in attending to the different
items.

Unilateral Neglect
Unilateral neglect is a failure to orient to, respond to, or report
stimuli that are presented on the side contralateral to the
cerebral lesion in clients who do not have primary sensory or
motor impairments (Heilman, Watson, & Valenstein, 2003). The
term neglect connotes a volitional component to the disorder, but
this is a misnomer. The client with unilateral neglect is unaware
of the incompleteness of his or her perception of, and responses
to, the environment. He or she often behaves as though one half
of the world does not exist (Corben & Unsworth, 1999). For
example, following right-hemisphere strokes, clients often begin
scanning on the right side and miss or fail to explore most of the
stimuli on the left. Asymmetry may be observed in functional
activities, drawing tasks, reading, or writing. In severe cases,
clients may eat food on one side of their plate, shave half their
face, or dress half of their body without recognizing that anything
is wrong. In milder cases, they may misread the first letter of a
particular word or fail to attend to information while crossing a
street, shopping, or driving (see the Ethical Dilemma). Many
clients with unilateral neglect also exhibit anxiety or flattened
affect. Unilateral neglect has been identified as a major factor
impeding functional recovery in clients who have sustained
strokes (Chen Sea, Henderson, & Cermack, 1993; Cherney,
Halper, Kwasnica, Harvey, & Zhang, 2001). Those with unilateral
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neglect have more difficulty resuming activities of daily living,
have longer hospital stays (Gillen, Tennen, & McGee, 2005; Katz
et al., 1999), and are at increased risk for accidents (Webster et
al., 1995). Unilateral neglect has been described as a
heterogeneous disorder that includes different clinical subtypes
and behavioral components (Mesulam, 1994; Pierce & Buxbaum,
2002; Stone, Halligan, Marshall, & Greenwood, 1998). Unilateral
neglect can involve one or more modalities, may vary with the
nature of the stimuli (e.g., verbal versus nonverbal), and can
encompass single objects or different spatial frames of space:
extra personal or large space, peri personal or space within
reach, and personal or body space (Mesulam, 2000; Plummer,
Morris, & Dunai, 2003). For example, some clients demonstrate
neglect symptoms in large spaces, such as a room (extrapersonal
neglect), but do not have reduced awareness of their body
(personal neglect) or difficulty on paper-and-pencil tasks
(peripersonal neglect). Neglect subtypes have also been proposed
that involve internal mental images (representational neglect),
decreased movement into or toward the contralesional space
(motor neglect), or decreased ability to perceive sensory stimuli in
contralesional space (sensory neglect) (Mesulam, 1994).

Evaluation
Occupational therapists evaluating clients with unilateral neglect
must first distinguish between hemianopsia and unilateral
neglect. Visual field cuts (hemianopsia) are hemiretinal, while
neglect is hemispatial. Clients with visual field cuts typically have
awareness of their visual field loss and make compensatory head
movements and turns. Unilateral neglect may exist with or
without hemianopsia, and one syndrome does not cause the
other. Assessment of unilateral neglect typically involves
cancellation tasks that require detection of target stimuli,
distributed on both sides of space (see Table 57.1). Typically, the
majority of targets on the contralesional side of space are missed.
The complexity of unilateral neglect symptoms is not fully
captured by traditional tests of neglect. Therefore, it is important
not to rely completely on test instruments in identifying
unilateral neglect. The different behavioral manifestations and
subtypes of neglect need to be kept in mind during observation of
performance (Appelros, Nydevik, Karlsson, Thorwalls, & Seiger,
2003; Plummer et al., 2003). Dynamic assessment of unilateral
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neglect provides information about task conditions that increase
or decrease the symptoms of unilateral neglect as well as the
person’s ability to respond to different types of cues or implement
and carryover learned strategies to different situations. Toglia
(2005) has described a dynamic object search task that analyzes
the ability to learn and apply a strategy across a series of search
tasks in people with unilateral neglect.

Intervention
Specific skill training is emphasized in this section because
evidence exists to support the use of visual scanning training to
remediate disorders of unilateral neglect. In unilateral neglect,
clients demonstrate decreased eye movements to the affected
side. This decrease in eye movements reflects a decrease in
attention to one side of the environment (Antonucci et al., 1995;
Toglia, 1991b). A scientific literature review by Cicerone and
colleagues (2000, 2005) concluded that there is level 1 evidence
to support use of visuospatial interventions that include practice
in visual scanning because it improves compensation for
unilateral neglect and generalizes to everyday activities.
Therefore, they recommended visuospatial rehabilitation with
visual scanning as a practice standard for clients with visual
neglect after right-hemisphere stroke. The combination of forced
limb activation or movements of the left arm or hand on the left
side of space in conjunction with visual scanning also shows
positive results (Cicerone et al., 2005; Robertson, Hogg, &
McMillan, 1998). Intervention appears to be most effective when
a wide combination of intervention activities, including everyday
tasks, is used (Antonucci et al., 1995; Pizzamiglio et al., 1992).
Programs with greater levels of intensity have generally produced
more positive outcomes. However, even with intensive training, it
has been demonstrated that people with unilateral neglect have
poorer functional outcome than do other people with stroke
(Paolucci, Antonucci, Grasso, & Pizzamiglio, 2001). Weinberg and
colleagues (1977) designed systematic training techniques that
incorporated a combination of remedial worksheets and strategy
training techniques during reading and scanning tasks. For
example, they used graded anchoring, pacing the speed of
scanning, feedback, and decreasing the density of the stimulus.
Anchoring, or teaching the person to use a spatial reference
point, such as a colored line on the left side, is a common
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strategy in visual scanning training. Gross motor activities
involving vestibular input and whole body movement in space
increase general arousal and alertness and have been used in
combination with visual scanning activities to increase gaze and
attention to the affected side (Cappa, Sterzi, Vallar, & Bisiach,
1987). Activities such as balloon volleyball, with the client hitting
the balloon with his or her hands clasped together, is an example
of such an activity. Other intervention techniques that have been
recommended for clients with unilateral neglect include use of
prisms and visual occlusion techniques (Pierce & Buxbaum,
2002). Prisms cause an optical deviation of the visual field to the
right so that objects appear to be moved farther to the right than
they actually are (Redding & Wallace, 2006). Partial visual
occlusion methods attempt to force the person to use the
neglected visual field by patching the eye ipsilateral to the lesion,
patching the non-neglected half field of eyeglasses (Beis, Andre,
Baumgarten, & Challier, 1999), or darkening the nonneglected
half field of eyeglasses (hemispatial sunglasses) (Arai, Ohi,
Sasaki, Nobuto, & Tanaka, 1997). Recently, computer-assisted
training programs for street crossing and wheelchair navigation
have been described. Trained subjects with unilateral neglect
performed better on real-life tasks after virtual reality training
than control subjects did. The use of virtual reality–based
technology appears to show potential for clients with unilateral
neglect (Katz et al., 2005; Webster et al., 2001).

STRATEGY TRAINING
Strategies for unilateral neglect can be practiced within everyday
tasks such as setting a table for several people, dealing a deck of
cards to six people, identifying appointments on a wall calendar,
reading a newspaper, addressing envelopes of different sizes, or
identifying all the pictures or chairs in the room. Because
unilateral neglect symptoms vary with the size of space,
arrangement of space, and amount and density of information
presented, these activity parameters need to be matched with the
neglect symptoms and systematically varied and graded in
treatment. In some cases, treatment activities should emphasize
large-space activities; in other situations, activities should focus
on tabletop tasks that involve visual detail. In general, activities
that are unpredictable or involve stimuli randomly scattered on a
table or page are more sensitive to the symptoms of unilateral
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neglect than are activities that are arranged in a predictable,
structured, or horizontal array (Ferber & Karnath, 2001).
Intervention should include practice in identifying situations in
which neglect symptoms are most likely to occur, such as filling
multiple bowls with salad, placing cookie dough on a baking
sheet, or arranging photographs in a picture album. Individuals
with unilateral neglect do not always know when they are
attending to the left side. Intervention needs to assist clients in
finding external cues that will provide feedback about when they
are indeed attending to the left. An emphasis in intervention
should be teaching the client to find the edges of a page or a table
or the periphery of stimuli before beginning a task and to mark it
with spatial point of reference, such as colored tape, a colored
highlighter, a bright object, or placement of his or her arm on the
left border. Auditory cueing, utilizing a beeper or alarm device,
can be combined with strategy training to remind the person to
use a strategy or visual cue. The alarm device can require the
client to scan space and attend to the left to turn off the sound
(Seron, Deloche, & Coyette 1989). Other intervention strategies
for unilateral neglect include tactile search, use of mental
imagery, and general alerting techniques. Tactile search includes
teaching the client to feel the left side of space with eyes closed or
to feel the left edges of objects before visual search. Visual
imagery teaches imagining and describing familiar scenes or
routes and using mental images during movement of limbs or
visual scanning (Niemeier, 1998; Smania, Bazoli, Piva, &
Guidetti, 1997). For example, reduction in neglect symptoms and
increased performance on functional tasks were reported after a
mental imagery program that involved teaching people with
neglect to imagine their eyes as sweeping beams of a lighthouse
from left to right across the visual field. Clients were cued to use
this mental image during functional and therapy training tasks
(Niemeier, 1998; Niemeier, Cifu, & Kishore, 2001). In addition to
strategies specifically aimed at facilitating attention to the left
side, strategies that focus on the general ability to sustain
attention have also been found to reduce unilateral neglect. For
example, Robertson, Tegner, Tham, Lo, and Smith (1995) taught
clients with chronic unilateral neglect to mentally tell themselves
to “pay attention” and to tap loudly on a table. It has been
observed that response to strategy training depends on whether
people with unilateral neglect show improvements in their
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awareness (Tham et al., 2001; Robertson & Halligan, 1999). This
underscores the importance of deeply embedding awareness
training techniques, such as those described earlier, into all
intervention activities.

ADAPTATIONS OF TASK OR ENVIRONMENT

To minimize the need to attend to the left, it has been suggested
that the environment be rearranged so that key items (e.g., the
telephone, the nurse call button) are on the unaffected side.
However, a study by Kelly and Ostreicher (1985) found no
significant difference in functional outcome in clients whose
hospital rooms were rearranged in this way. Lennon (1994)
described the successful use of large colored paper markings on
the edges of tables, corners, and elsewhere to prevent collision for
clients with unilateral neglect. The client was trained to look for
these markers. Markers were gradually faded. Performance
improved and was maintained with removal of markers; however,
effects did not generalize to other environments. Calvanio, Levine,
and Petrone (1993) described the use of an adapted plate to
increase feeding skills in a client with a severe case of left
inattention and a dense left hemianopsia. The plate was mounted
on a lazy Susan so that it could be rotated. As the client pushed
at the food with a fork, the plate rotated so that all the food
eventually came into view, thus eliminating the need for scanning
to the left. Other environmental adaptations include placing red
tape on the client’s wheelchair brakes or placing brightly colored
objects such as a napkin or cup on the left side (Golisz, 1998).

Visual Processing
Visual perception is viewed on an information-processing
continuum involving the reception, organization, and assimilation
of visual information. On one end of the continuum, simple
visual-processing tasks such as matching shapes or objects
occur quickly and automatically, with minimal effort. On the
opposite end of the continuum, complex visual tasks that include
unfamiliar stimuli or subtle discriminations within visually
crowded arrays require slower and effortful processing. In this
conceptualization, visual-processing dysfunction is defined as a
decrease in the amount that the visual system is able to
assimilate at any one time (Toglia, 1989). To understand the
client’s visual perceptual skills and the effects of impairments on
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functioning, we need to analyze the activity conditions
(complexity, amount, familiarity, and predictability) rather than
the type of activity (visual spatial, visual discrimination, visual
motor, or visual gestalt). Problems in simple visual processing
include difficulty in discriminating between objects, pictures of
objects, and basic shapes; difficulty in detecting gross differences
in size, position, direction, angles, and rotations; decreased
ability to visually locate single visual targets in space or judge
gross distance between two objects; and decreased ability to
detect simple part-whole relationships in objects or basic shapes.
The person may have difficulty in familiar and routine activities
and may easily misinterpret or misidentify objects. Failure to
recognize an object is labeled visual agnosia. Toglia (1989)
proposes that labels such as visual agnosia are too broad for the
purposes of intervention because there are many different
underlying reasons for object recognition difficulties. For
example, a person might fail to attend to the critical feature of an
object or the part of the object that tells what it is (e.g., prongs of
a fork). Attention might be captured by salient but irrelevant
aspects of the object (e.g., the utensil’s decorative handle). There
might be an inability to process the overall shape and the details
simultaneously, so the person might miss important details.
Complex visual processing skills are required in visually
confusing environments; when there is abstract, unfamiliar, or
detailed visual information; or in conditions under which the
distinctive visual features are partially obscured (e.g., the object
is rotated and partially hidden on a crowded desk). Dysfunction
of complex visual perceptual skills may include decreased ability
to detect subtle differences in abstract shapes and objects or
angles, size, distance, and position. A client might have difficulty
making sense out of ambiguous, incomplete, fragmented, or
distorted visual stimuli. The client might misinterpret an object
when it is in an unusual position or partially hidden. The person
might experience increased difficulty in visually confusing or
crowded environments. Functional tasks such as finding items in
a crowded closet, drawer, desk, or supermarket shelf and locating
key information on a bill, map, or schedule might present
difficulty. On these tasks, the person might misinterpret
information, Miss key visual details, or become sidetracked by
irrelevant visual stimuli.

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Visual Motor
Visual motor skills include drawing tasks (e.g., drawing a map,
copying a design) or construction of three- dimensional figures
(e.g., assembling a coffeepot). Clients may demonstrate difficulty
on visual motor tasks for many reasons. For example, a client
might have difficulty constructing a block design because of a
poor ability to scan the complete design, decreased planning and
organization, unilateral neglect, or impaired discrimination of
size, angles, and rotations. The term constructional apraxia is
used to refer to difficulty with drawing or assembly tasks that
cannot be attributed to primary motor or sensory impairment,
ideomotor apraxia, or general cognitive impairments (Farah,
2003). Constructional abilities are closely related to ADL
performance (Neistadt, 1992a; Warren, 1981). Clients may have
difficulty dressing (dressing apraxia), orienting clothes correctly
on a hanger, or assembling a sandwich or coffeepot. People with
left-hemisphere parietal lesions tend to omit individual pieces or
details in constructional tasks, whereas those with right-
hemisphere lesions demonstrate spatial disorganization of the
pieces and lose the overall gestalt (Kramer, Kaplan, & Blusewicz,
1991). Constructional apraxia is not a unitary syndrome.
Impairments in different types of perceptual processing or spatial
relations are thought to underlie constructional apraxia in both
right and left-hemisphere lesions (Laeng, 2006).

Evaluation
Evaluation for people with visual perceptual impairments should
examine visual foundations skills, visual abilities without a motor
response, and visual motor skills. Visual foundation skills,
including visual acuity, oculomotor skills, and visual fields,
should be evaluated prior to a visual processing evaluation to
screen out visual problems that will interfere with the accuracy of
perceptual testing (Cate & Richards, 2000). Several clinical
observations during functional tasks can alert occupational
therapists to the need for a formal visual assessment:
compensatory head movements and tilting, squinting, shutting of
one eye, or a tendency to lose one’s place while reading. A basic
screening can be performed by the occupational therapist (i.e.,
visual acuity, range of motion of the eyes, ocular alignment,
visual pursuits or smooth tracking of moving objects, saccades or
quick eye movements to place an object of interest in view, and
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visual-scanning functions). Any disruptions of these foundational
skills will affect interpretations of higher level visual-processing
assessments (Warren, 1993). Standardized nonmotor
assessments of visual perception (see Table 57.1) categorize
visual perception into specific skills such as figure-ground,
position in space, form constancy, spatial relations, and visual
recognition. Adults with neurological lesions may have difficulty
performing various types of visual processing tasks for similar
reasons (e.g., a tendency to over focus on parts, a tendency to
miss visual details, failure to simultaneously attend to the details
as well as the whole). Therefore, Toglia (1989) recommends an
approach that conceptualizes visual processing on a continuum
and evaluates both conventional and unconventional objects
under a variety of different activity conditions. In a dynamic
approach to visual perception, the therapist systematically
manipulates activity parameters and analyzes responses to cues
to understand why a client is having difficulty accurately
discriminating objects or visual stimuli (Kline, 2000; Toglia,
1989; Toglia & Finkelstein, 1991). Visual perceptual assessment
should examine responses to activities with and without a motor
response to examine differences in performance. Visual motor
skills are typically evaluated with block designs, puzzles, or
copying designs. The therapist needs to observe how the person
begins and how he or she proceeds. For example, does the client
begin by drawing the details rather than attending to the overall
shape of the figure? Informal observations in tasks such as
copying a map route, assembling a coffeepot or woodworking
project, wrapping a package, packing a lunchbox, or folding
clothes can provide additional information on visual motor
abilities. Symptoms may include angular deviations; improper
position, location, spacing, or alignment of parts; and spatial
distortions. The client’s ability to recognize and correct errors in
alignment or position should be investigated. For example, some
clients do not recognize visual spatial errors even when attention
is directed to the problem area, whereas other clients recognize
errors but are unable to correct them.

Intervention
Interventions may address visual foundations skills or visual
processing skills with or without a motor response.

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VISUAL FOUNDATION SKILLS
Treatment of visual foundation skills such as visual acuity and
contrast sensitivity, oculomotor skills, and visual fields generally
involves adaptations a such as large-print reading materials;
magnifiers; talking devices; increasing contrast of edges, borders,
or backgrounds; and changes in lighting. However, remedial
exercises may be recommended for individuals with oculomotor
or visual field deficits. For example, range-of-motion eye exercises
to the involved muscle have been advocated for individuals with
eye muscle pare- sis. Occlusion of the intact visual field with eye
patching has been used to force use of the impaired visual field
(Warren, 1993).

STRATEGY TRAINING
Strategies that maximize the client’s ability to process visual
information can be trained within everyday activities that involve
choosing among objects that are similar in shape and size (e.g.,
matching socks, sorting teaspoons and soupspoons); locating
information within supermarket circulars, calendars, maps, or
schedules; arranging information within grids or spread- sheets;
copying patterns in arts and craft activities; or finding
information in crowded draws, shelves, tables, or bulletin boards.
Strategies can include getting a sense of the whole before looking
at the parts; teaching the person to partition space before
localizing details; using one’s finger to scan, trace visual stimuli,
or focus on details; covering or blocking visual stimuli when too
much information is presented at once; verbalizing salient visual
features or subtle differences; and mentally visualizing a
particular item before looking for it (Toglia, 1989, 1998).
Intervention involves careful manipulation of activity parameters.
Activities that involve familiar items or contexts, high contrast
(e.g., red socks and white socks), distinctive features, little detail,
and solid colors or backgrounds require less attention, effort, and
visual analysis than do activities that involve choosing among
items that have low contrast (e.g., light beige and white socks),
are in unusual positions, are embedded within crowded or
distracting visual backgrounds, or are partially obscured.
Changes in the familiarity, number of items, and degree of detail
can place greater demands on visual processing. In addition,
verbal mediation, including repeating a list of step-by step
instructions during a functional activity such as dressing,
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capitalizes on strengths in verbal abilities and can be effective in
facilitating functional performance (Sunderland, Walker, &
Walker, 2006).

ADAPTATION OF TASK OR ENVIRONMENT

The key guideline in minimizing the effects of visual perceptual
difficulties is to make the distinctive features of objects more
salient with color cues. An example is placing colored tapenon
buttons to operate appliances or using salient color cues on
objects to make them easier to locate and discriminate (e.g.,
bright pink tape on a medication bottle). Cues such as colored
marks or tape at spatial landmarks (e.g., tape recorder,
wheelchair footrests, or label of a shirt) reduce spatial demands
and make it easier to orient and align parts of an item. Visual
stimuli such as items on a shelf or sentences on a page that are
large and arranged in an organized manner with large spaces
between items are easier to perceive. Consistent locations for
objects in the refrigerator, closet, or drawer or a countertop
increase predictability and provide contextual cues for
recognition. Significant others should be instructed to decrease
visual distractions in the room or within a task by limiting
designs and patterns and by using solid colors with high
contrast. Patterns, designs, and decorations make it harder to
select and recognize critical features of an object. Significant
others should also be trained to introduce only a small amount of
visual information at one time.

Motor Planning
Motor planning, or praxis, is the ability to execute learned and
purposeful activities. Apraxia is defined as a disorder of skilled
movement that cannot be adequately explained by primary motor
or sensory impairments, visual spatial problems, language
comprehension difficulties, or cognitive problems alone (Heilman
& Rothi, 2003). Damage to the association areas of the brain
(affecting the cognitive aspects of motor control) is thought to
cause apraxia (Kertesz, 1982). Apraxia may be seen after strokes
in either hemisphere, although it is more commonly seen in
clients who have sustained a left-hemisphere lesion. Aphasia is
often associated with apraxia, since the left hemisphere is also
dominant for language (Heilman & Rothi, 2003). People with
apraxia can improve performance of skilled movement over time
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(Basso, Burgio, Paulin, & Prandoni, 2000); however, they
frequently continue to have significant functional limitations in
both the learning of new motor tasks, such as one-handed shoe
tying (Poole, 1998), and in the performance of motor acts to
verbal command or demonstration Roy (1978) identifies two
major subsystems in apraxia: the conceptual and the production
subsystems. The symptoms of apraxia may reflect disorders in
one or both of these subsystems. The production aspect of motor
planning, traditionally called ideomotor apraxia, involves
generating the action plan, sequencing and organizing the
appropriate elements, and carrying out the plan (e.g., reaching
for a glass of water to take a drink). The greatest difficulty is
observed when the client is asked to pretend use of a tool or
object or to perform limb gestures. Some improvement may be
seen when the client is asked to imitate the motion or perform
the motion with the actual object, but the movement is still
imprecise. These clients know what they want to do, but actions
are carried out in an awkward, inefficient, or clumsy manner.
Errors of preservation, sequencing, or omissions may be
observed. The conceptual aspect of motor planning (Roy, 1978)
includes knowledge about the functional properties of an object,
the object action, and the sequence of action. Conceptual errors,
traditionally called ideational apraxia, involve object function,
action knowledge, and knowledge of sequence. Clients might be
able to accurately identify and match objects, but inappropriate
use of objects is frequently observed. For example, the client
might try to brush his or her hair with a toothbrush. Although
object recognition may be intact, the person might be unable to
associate the object with its correct action plan. Dressing apraxia
and constructional apraxia are additional subtypes of apraxia,
previously described in the section on visual processing.
Traditional labels of apraxia are narrow in scope and do not
account for the wide range of skills that underlie motor planning
and constructional abilities.

Evaluation
The classic definition of apraxia includes motor-planning
problems that cannot be accounted for by weakness, increased
tone, incoordination, sensory loss, or other cognitive-perceptual
impairments. The clinician is urged to analyze underlying
reasons for difficulties in performance rather than attempting to
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classify clients within traditional categories. In clinical practice,
most clients have associated difficulties that contribute to
difficulty in motor planning. Information on the client’s language
skills should be obtained from the speech-language pathologist
or be screened for by testing for “yes” or “no” comprehension and
ability to follow one-step commands, since apraxia and aphasia
often coexist. In evaluating apraxia, the clinician typically
observes the client’s performance of different types of movements,
noting the method of evocation (e.g., command, imitation, or
object use) and type of errors made (Haaland, 1993).
Assessments for apraxia are listed in Table 57.1. An
observational method for assessing apraxia in ADL activities,
adapted from the Arnadottir OT Neurobehavioral Evaluation (A-
ONE), has been validated for people with stroke (van Heugten et
al., 2000). A dynamic assessment approach attempts to identify
the activity conditions under which the limb apraxia symptoms
emerge, the client’s response to cueing, and the client’s
awareness of his or her activity performance (Toglia, 1998).

Intervention
Interventions to overcome motor-planning deficits may emphasize
either the production aspect or the conceptual aspect of motor
planning (Roy, 1985). Techniques that address the orientation of
an object or limb in space or the timing, sequence, and
organization of the motor elements aim to enhance the
production aspect of motor planning. For example, the
practitioner might provide physical con- tact (i.e., hand-over-
hand assistance or light touch) to limit inappropriate or
extraneous movements while simultaneously using guiding
methods to facilitate a smooth motor pattern or to guide the
manipulation of objects. Through repeated practice in different
tasks, the client begins to learn the movement patterns that feel
“right,” and the practitioner gradually withdraws assistance.
Deep proprioceptive input and contact have an inhibitory effect
on normal people, whereas light touch tends to have a more
facilitatory effect (Farber, 1993). Familiar tasks that are
performed in context are easier for people with motor-planning
disorders because the context provide cues that facilitate the
desired action (Ferguson & Trombly, 1997). Interventions can be
graded by gradually introducing activities and environments that
have less stability and predictability, such as negotiating around
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obstacles in a crowded store. Intervention addressing the
conceptual aspect of motor planning focuses on facilitating the
client’s understanding of how an object is used or how a gesture
is performed (Helm-Estabrooks, 1982; Pilgrim & Humphreys,
1994; Smania, Girardi, Domenicali, Lora, & Aglioti, 2000).

STRATEGY TRAINING
Clients may be taught to use verbal, visual, or tactile cues to
enhance movement. For example, before performing an activity,
the client might mentally practice or imagine the task
performance; or the client might imagine how an object should
look in his or her hand before picking it up. Incorrect patterns of
movement, such as holding an object the wrong way, can also be
visualized, with an emphasis on having the client mentally
practice correcting the movement. Talking a client through action
sequences or use of step-by-step written lists or illustrations can
be useful in facilitating functional performance in tasks such as
drinking from a cup (Butler, 1999). The person can be taught to
verbally rehearse an action sequence or associate the movement
with a rhyme, rhythm, or musical tune with a gradual fading of
the verbalization. Self-monitoring strategies can be used to teach
a client to monitor unnecessary cocontraction, incomplete
actions, or difficulty in switching direction of movements.
Preliminary studies indicate that strategy training is effective in
improving everyday function (Donkervoort, Dekker, Stehmann-
Saris, & Deelman, 2001; Geusgens et al., 2006). For example, in
a randomized study design, changes on nontrained ADL activities
were greater in a group of people with stroke who had received
strategy training as compared with those receiving usual
occupational therapy. This suggests that the strategies
generalized to everyday activities (Geusgens et al., 2006).

ADAPTATION OF TASK OR ENVIRONMENT

Simple adaptations to objects that draw attention to the critical
features of the object or activity can facilitate action and motor
planning (e.g., colored tape on the knife handle or toothbrush
handle). Patterns and designs on utensils or clothing might draw
attention to the wrong detail and result in an inappropriate motor
response. Tool use should be minimized (Poole, 2000), and
adaptive equipment should be selected with caution for the
apraxic client. For example, some adaptations, such as a button
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hook, one-handed shoe tying, or a one-arm drive wheelchair,
might be confusing for clients with apraxia and place greater
demands on motor-planning abilities. Other adaptations, such as
adaptive clothing closures, may simplify the task or motor
pattern required to manipulate or hold objects, reduce the
number of steps, and facilitate function in the client with
apraxia. Other adaptations include training the caregiver to
modify instructions so that the activity is broken into one
command at a time (Unsworth, 2007). Simple whole commands
(e.g., “Get up”) can put the activity on an automatic level and
effectively enhance motor planning (Zoltan, 1996).

Memory
Memory gives us the ability to draw on past experiences and
learn new information (Toglia, 1993a). This provides us with a
sense of continuity in the environment and frees us from
dependency in here-and-now situations. Memory is
conceptualized as a multistep process involving encoding (i.e.,
input of information), storage (i.e., hold- ing information), and
retrieval (i.e., getting information) (Levy, 2005b). There are
different types of memory. Working memory is the temporary
storage of information while one is working with it or attending to
it. It includes the ability to recall information immediately after
exposure. It allows one to focus conscious attention and keep
track of information as one is performing an activity. Declarative
memory is one aspect of long-term memory and includes
conscious memory for events, knowledge, or facts. Procedural
(nondeclarative) memory involves the ability to remember how to
perform an activity or procedure without conscious awareness.
Prospective memory involves the ability to remember intentions
or activities that will be required in the future (Levy, 2005b).

Evaluation
It is important to distinguish whether everyday memory problems
are due to failures to recall past events or conversations or
failures in carrying out future activities (e.g., prospective
memory). A comprehensive evaluation of memory, whether static
or dynamic, must address the different types of memory and
methods of retrieval (Table 57.1). Assessments must consider
factors such as the modality in which the information is
presented (auditory or visual), the type of instructions (general or
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specific), the amount of stimuli presented, the familiarity and
meaningfulness of the information, the presence of contextual
cues during recall phases, the type of information to be remem-
bered (factual or skill related), and the length of retention.
Dynamic assessment of memory, such as Toglia’s (1993b)
Contextual Memory Test, evaluates awareness of memory
capabilities and use of strategies.

Intervention
Memory impairments can be closely related to other cognitive
impairments, particularly attention. Some investigators have
suggested that an indirect approach that addresses other
cognitive skills, such as attention or organization, rather than
memory, may be effective. For example, Sohlberg and Mateer
(1989a) reported improvement in memory function after
attentional training. Interventions for memory impairments
include memory strategy training, external aids and devices, and
adaptations, as well as techniques of errorless learning,
vanishing cues, and spaced retrieval that were discussed earlier
in this chapter.

STRATEGY TRAINING
Training of internal memory strategies is most appropriate for
people with mild memory deficits or those in whom other areas of
cognition are intact (Cicerone et al., 2000, 2005). The client
practices one or two targeted memory strategies in a variety of
different tasks, such as remembering telephone numbers, news
headlines, a sequence of errands, items that need to be bought in
a store, or instructions to an activity. During practice on different
memory tasks, a variety of awareness training techniques may
also be used. Memory strategies may be directed primarily at
encoding operations (i.e.,getting information in) or the retrieval
phase of memory (i.e., getting information out). Encoding
strategies include the following:
 Chunking or grouping similar items
 The story method, or linking a series of facts or events into
a story
 Rehearsal, or repeating information over and over silently
 Rhymes, or recalling a fact by changing the fact into a
rhyme
 Visual imagery

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Retrieval strategies include the following:
 Alphabetical searching, or going through the alphabet to
find the first letter of a forgotten item
 Retracing one’s steps to find a missing object or to recall an
event
 Thinking of associated information to cue the recall of a new
fact or event
 Self-generating words, concepts, or items to improve
learning and memory (Chiaravalloti & DeLuca., 2002)
MEMORY EXTERNAL STRATEGIES AND AIDS. External aids
such as notebooks, tape recorders and computers store
information that the person might have difficulty remembering.
Other aids such as pagers or alarm signals serve to remind a
person to perform an action (prospective memory) (Toglia, 1993a).
The success of an intervention program that utilized a
combination of external aids and strategies with awareness
training to improve prospective memory was recently described
by Fleming, Shum, Strong, and Lightbody (2005). External
memory aids include the following: timers, tape recorders,
devices with preprogrammed alarms or alarm messages,
electronic devices such as pagers, mobile phones, palm pilots,
and cell phones, computers, pill box organizers, lists, daily plan-
ners, and notebooks (Figure 57.3). Case studies have
documented the effectiveness of external aids (McKerracher,
Powell, & Oyebode, 2005; Wade & Troy, 2001; Wilson, Emslie,
Quirk, & Evans, 2001). Intervention is most effective when the
client is motivated, involved in identifying the memory problem,
and fairly independent in daily function (Cicerone et al., 2000,
2005). Evidence obtained from case studies supports the use of
memory notebooks and other external aids in reducing everyday
memory failures for people with moderate to severe memory
impairments (Cicerone et al., 2000, 2005, McKerracher et al.,
2005; Wade & Troy, 2001; Wilson et al., 2001). However, the
successful use of an external memory aid may require extensive
training. The client may need to practice initiating and using the
aid in a variety of different situations. The use of external aids
might need to be graded. In the initial stages, the client might be
expected to use the aid only when it is initiated by another
person. Gradually, the client might be trained to initiate the use
of the aid independently. Errorless learning, spaced retrieval, and
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other task-specific training methods that capitalize on procedural
memory, may be used in training clients with moderate or severe
memory impairments to use an external aid. The most commonly
used external memory strategy is the memory notebook. The
memory notebook needs to be designed with the person’s needs
and lifestyle in mind (McKerracher et al., 2005). Sample sections
in a memory notebook are as follows: personal facts, names of
people to remember, calendar and schedule, things to do
important events (daily, within the next week), daily log of
important events, conversations, summary of readings (articles,
newspaper), medication schedule, and directions to frequently
traveled places. Initially, the notebook should begin with one or
two sections and gradually increase. Memory notebook training
needs to take place in the context of a variety of everyday
activities. Therapy sessions should include role-playing and
practice in use of the notebook. In addition, the client may be
asked questions that involve reviewing and rereading the memory
notebook. Specific memory notebook training protocols have been
described in the literature (Donaghy & Williams 1998; Sohlberg &
Mateer, 2001).

ADAPTATIONS OF TASK OR ENVIRONMENT

Tasks and environments can be rearranged so that they place
fewer demands on memory:
 Cue cards or signs in key places (e.g., a sign on door where
it will be seen before leaving: “Take keys and . . .”)
 Labeling the outside of drawers or closets to minimize the
need to recall the location of items
 Providing step-by-step directions to reduce memory
demands
 Providing checklists to assist in keeping track of task steps
Significant others can be trained to use methods that increase
the likelihood that the client will remember material, such as
asking the client to repeat any instructions or important
information in his or her own words; encour- aging the client to
ask questions; and presenting material in small groups, clusters,
or categories (Levy, 2005a.

Executive Functions, Organization, and Problem Solving

Executive functions are a broad band of performance skills that
allow a person to engage in independent, purposeful, and self-
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directed behavior. Higher-level cognitive skills, including
planning, cognitive flexibility, organization, problem-solving, and
self–regulation, are fundamental components of executive
function (Katz & Hartman-Maeir, 2005). Lezak and colleagues
(2004) identifies four primary components of executive functions:
volition, planning, purposeful action, and self-awareness and
selfmonitoring. Impairments are associated with prefrontal
lesions and may be seen in all of these components, with one or
two areas of impairment especially prominent (Lezak et al.,
2004). Volition is the capacity to formulate an intention or goal
and to initiate action. Planning involves the ability to efficiently
organize the steps or elements of a behavior or activity and
includes the ability to look ahead, anticipate consequences,
weigh and make choices, conceive of alternatives, sustain
attention, and sequence the activity. Purposeful action is the
translation of an intention into an activity, requiring the ability to
initiate, switch, and stop sequences (flexibility), as well as self-
regulation. Selfregulation involves the ability to monitor, self-
correct, and evaluate performance. Executive function
impairments significantly influence social participation, daily
activity, and functional outcome (Goverover, 2002, 2004; Reeder,
Newton, Frangou, & Wykes, 2004). Clients who display executive
dysfunction may be able to verbalize plans but have difficulty
carrying them out. There is often a disassociation between stated
intentions and actions. This creates gaps between what a person
needs to do or wants to do and what the person actually does
(Eriksson, Tham, & Borg, 2006). Decreased initiation, flexibility,
impulsivity, or perseveration may be observed during
performance. Often, the client’s approach is haphazard or
consists of trial and error, and there is decreased ability to
maintain goal-directed actions and to monitor or modify
behaviors. For example, when grocery shopping, the client might
proceed in an unorganized manner, not using a list or the aisle
headings and reentering the same aisle multiple times. The client
might have difficulty deciding on appropriate substitute items,
buy items that are not needed, and forget items that were needed
(Sohlberg & Mateer, 2001). Rempfer, Hamera, Brown, and
Cromwell (2003) found that grocery shopping accuracy and
efficiency were significantly associated with measures of
executive functions in people with chronic schizophrenia. In
addition, limitations in the ability to view information from
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different perspectives, generate alternative solutions, and
respond flexibly can reduce the ability to cope, adapt to everyday
demands, and relate to others. Executive functions impairments
represent a distinct challenge because they can be masked within
familiar ADLs or routines but are most apparent when the client
is required to function in situations that are less structured,
require multitasking, or require dealing with novelty and
unexpected situations (Burgess et al., 2006; Katz & Hartman-
Maeir, 2005). Examples of activities that might present difficulty
include following directions to a new location; selecting and
ordering a gift from a catalogue; organizing a day’s activities;
planning a menu, lunch, picnic, vacation, or social gathering;
investigating and comparing prices for delivery of flowers; mailing
a package; or purchasing an electronic device.

Evaluation
Most standardized cognitive assessments are structured and do
not adequately examine the area of executive functions (Sohlberg
& Mateer, 2001) (see Table 57.1). Several assessments for
executive functions have recently been developed (Bamdad, Ryan,
& Warden, 2003; Birnboim & Miller, 2004; Wilson, Alderman,
Burgess, Emslie, & Evans, 1996). Although these assessments
appear more “ecologically valid” (i.e., able to predict behavior in
everyday situations) than previous assessments were, further
research data on the reliability and validity of these assessment
tools are needed.

INTERVENTION
STRATEGY TRAINING
Strategies that maximize executive functioning can be practiced
in a variety of unstructured tasks that require initiation,
planning, organization, and decision making, such as organizing
medications according to a schedule, planning an overnight trip
and packing a suitcase, obtaining and organizing a list of local
business phone numbers, and organizing tools Verbal mediation
has been reported to be an effective strategy in improving
executive function and self-regulation deficits. For example,
Cicerone and Wood (1987) reported the successful use of a self-
instructional procedure in a client with impaired planning ability
and poor self-control secondary to brain injury. Intervention
involved requiring the client to verbalize a plan of action before
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and during execution of a task. Gradually, the client was
instructed to whisper rather than talk aloud. Generalization to
real-life situations was observed after an extended period of time
that included training in self-monitoring. Training in problem
solving strategies involves teaching the person to break down
complex activities into smaller, more manageable steps.
Strategies may also aim to help the person to maintain the focus
of goals and intentions (Katz & Hartman-Maeir, 2005). An
evidenced based review (Cicerone et al., 2000, 2005) concluded
that there is evidence to support the use of formal problem-
solving training with application to everyday activities. The
authors recommended such training as a practice guideline for
people with stroke or brain injury during postacute
rehabilitation. The intervention goal is to replace an impulsive,
disorganized approach with a systematic and controlled approach
to planning activities, maintaining goal intentions, and solving
problems. The steps of the problem-solving process are reinforced
with use of self-questioning techniques. For example, self-
questioning cue cards with the following types of questions can
be used during problem-solving tasks: What do I need to do? Do I
need more information? What do I have to do next? Have I
identified all the critical information? Do I understand the
problem? What are all the possible solutions? Did I choose the
best one? Broad checklists or task guidance systems are
commonly used to assist the client in initiating, planning, and
carrying out an activity systematically. Checklists may be specific
to a particular activity (e.g., following steps to operate a computer
program), or they may be designed broadly so that they can be
used in a variety of similar activities (e.g., a checklist for food
preparation or cooking activities). Interventions should
incorporate practice in identifying the situations or activities in
which use of a checklist could be helpful. The client may be given
the opportunity to practice the same activity with and without
the use of a checklist to enhance awareness. Initially, the goal
might be to have a client follow a checklist established by the
practitioner or significant other. Eventually, the client might be
given checklists with missing steps and be asked to review the
lists to identify the missing components. Finally, the client might
be required to create a checklist independently. Burke, Zencius,
Wesolowskis, and Doubleday (1991) describe four cases of
individuals with executive dysfunction for whom checklists were
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successfully used to improve the ability to carry out routine
vocational tasks. Decreased initiation, one of the hallmark
features executive dysfunction, can significantly interfere with
the ability to use and apply a learned strategy. For example, a
person with deficits in executive functions might use a strategy
effectively when cued but not use the strategy spontaneously
because of a failure to initiate its use. External cues such as
alarm signals can be used to prompt the client to initiate a task,
switch to a different task component, or use a particular strategy
within an activity (Evans, Emslie, & Wilson, 1998; Manly,
Hawkins, Evans, Wodlt, & Robertson, 2002).

ADAPTATIONS OF TASK OR ENVIRONMENT

Adaptations that minimize demands on executive functions
include training a significant other to preorganize an activity or
activity materials. For example, all the items needed for grooming
can be prearranged on the sink in the sequence in which they are
used. As an alternative, one task step can be introduced at a
time. These adaptations limit the need for planning and
organization (Sohlberg & Mateer, 2001). People who have
difficulty with initiation, organization, and decision making
require structure. Open ended questions such as “What do you
want to eat” should be avoided. Clients who have difficulty in
initiation will have a great deal of difficulty in answering open-
ended questions. Questions should provide a limited number of
choices whenever feasible. A predictable and structured daily
routine enhances the client’s ability to initiate tasks and should
be estab- lished and monitored by a significant other. Audiotape
instructions that cue the client to initiate an activity and perform
each step at a time in its proper sequence have been reported to
be successful within the context of daily routines (Schwartz,
1995).

GROUP INTERVENTIONS
Cognitive rehabilitation principles and strategies can be
incorporated within group programs and combined with
psychosocial or psychoeducational interventions. The group
format can be used to target specific cognitive skills, or it can be
used to teach compensatory strategies (Revheim & Marcopulos,
2006; Schwarztberg, 1999; Stuss et al., 2007). Group activities
can emphasize interpersonal skills within cooperative tasks, such
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as planning a bake sale or publishing a newsletter, or role-
playing scenarios involving interviews, conflicts, or on-the-spot
problem solving. Strategies that include monitoring the tendency
to respond impulsively, become stuck in one viewpoint, or
wander off task can be practiced within social contexts (Toglia,
2005). Group programs that center on teaching self-monitoring
techniques and strategies for paying attention, remembering,
organization, or problem solving can be applied to a wide
spectrum of clients. Activities such as remembering names and
facts about group members, recalling directions for operating a
new electronic device, or creating a checklist for a complex task
can provide opportunity to practice different strategies and share
experiences within a group context. Group members can be
encouraged to reflect on performance and identify strategies that
would be useful in their everyday activities. Group interventions
that simultaneously address subtle cognitive difficulties and
emotional issues have demonstrated value in improving self
awareness, self-efficacy, coping skills, psychosocial skills, and
perceived daily functioning (Harrison et al., 2005; Rath, Smon,
Langenbahn, Sherr, & Diller, 2003; Toglia, 2005).

SUMMARY
Recently, there has been a move away from intervention
programs that focus exclusively on remediation of cognitive
impairments. There is increasing evidence that supports the use
of comprehensive and holistic cognitive rehabilitation programs
that address a combination of cognitive, emotional, functional,
and social participation skills in people with brain injury (Cappa
et al., 2005; Cicerone et al., 2005, Cicerone, Mott, Azulay, &
Friel, 2004; Sarajuuri et al., 2005; Tiersky et al., 2005). The need
to blend cognitive interventions with those that address
interpersonal and real-world functioning has been emphasized in
recent literature; however, the outcome of cognitive rehabilitation
is most commonly measured at the impairment level. As
occupational therapists return to more community focused
intervention, we need to widen our perspective on the influence
that cognitive perceptual impairments have on our clients’ ability
to engage in the occupations they need or want to do within the
contexts of their lives. We need to explore the effect of cognitive
rehabilitation on occu- pational engagement and social
participation, for even subtle cognitive impairments can decrease
125
satisfaction, participation, and quality of life, preventing our
clients from leading enriching lives (McDowd, Filion, Pohl,
Richards, & Stiers, 2003). The outcome or benefit of cognitive
rehabilitation needs to be examined broadly across different
populations, including effects on changing existing habits;
routines or increasing productive activity patterns; increasing the
frequency and quality of social participation; decreasing caregiver
assistance, stress, or burden; improving subjectivwell-being,
including self-efficacy, self-esteem, satisfaction and quality of life;
and preventing functional decline.

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 CHAPTER 14
MOTOR NEURON DISEASE
AMYOTROPHIC LATERAL SCLEROSIS

Amyotrophic lateral sclerosis (ALS), also referred to as Lou

Gehrig’s disease, is a rare, progressive, degenerative disease that
affects the motor neurons in the corticospinal pathways, the
motor nuclei of the brain stem, and the anterior horn cells of the
spinal cord. ALS, like Parkinson’s disease and multiple sclerosis,
is a motor neuron disease. Decreased function of the nerve cells
in the brain, brain stem, and spinal cord caused by ALS results
in weakening of the muscles, which eventually leads to paralysis
but does not affect personality or cognition. No known cure for
ALS exists.

INCIDENCE AND PREVALENCE

 In the United States, 20,000 people currently have ALS, and
5,000 additional people are diagnosed with ALS each year.
 Individuals of all races are affected by ALS.
 The age of onset is typically between 40 and 60 years.
 More men are affected than women.
 90–95% of all cases are of no known cause.
 5–10% of all cases are of genetic origin.

TYPICAL COURSE
The onset of the disease varies from one individual to another.
Some people experience a weakness in the arms with difficulty
lifting or doing fine motor tasks or in the legs with difficulty
walking or in the muscles that control speech and swallowing.
Some experience generalizedmuscle fatigue. If the weakening
begins in the hand, it will progress through the affected limb
before becoming more generalized. Problems with speech or
swallowing occur when motor neurons die in the brain stem. The
disease progresses and eventually affects the person’s ability to
walk and continue performing ADL. The disease affects only the
motor pathways; therefore, eye movement, bowel and bladder
functions, cognition, personality, and skin sensation remain
intact. Respiratory weakness ultimately is affected as the
muscles deteriorate, and death usually follows unless the
individual is put on a ventilator.
POTENTIAL SYMPTOMS
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  Damage to lower motor neurons (in the spinal cord) leading
to flaccid paralysis, decreased muscle tone, and decreased
reflexes
 Damage to upper motor neurons (in the brain) and to the
corticospinal tract leading to spasticity and hyper- reflexia
(exaggerated reflexes)
 Muscle weakness
 Muscle atrophy (distal to proximal)—a symptom that is
unique to ALS
 Fatigue
 Stumbling and falling due to lower extremity weakness
 Fasciculation (muscle twitching)
 Decreased ability to regulate body temperature
 Loss of emotional control/depression
 Dysphagia (difficulty swallowing)
 Dysarthria (difficulty speaking) due to impaired cranial
nerves controlling speech
 Impaired respiration due to muscle weakness
 Sialorrhea (excess drooling)
 Night cramps
 Weight loss
 Loss of endurance
 Loss of dexterity

MEDICAL MANAGEMENT
No specific assessment is used to diagnose ALS. Magnetic
resonance imaging (MRI), electromyography, blood tests, and/or
nerve conduction velocity are done to eliminate other diseases as
possibilities. Currently, no known cure or treatment to reverse
ALS exists. In 1995, the Food and Drug Administration approved
Rilozule, the first drug to result in prolonging survival by several
months. The drug is believed to work by decreasing damage due
to the release of glutamate. The drug may extend the length of
time before a person needs ventilation support. Respiratory
therapists, speech pathologists, physical therapists, occupational
therapists, psychologists, and social workers typically work
together to sustain the client’s quality of life and to support the
family. Compensatory strategies using adaptive equipment and
energy conservation are common foci of treatment for an
individual with ALS.

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PROGNOSIS
 Most people with ALS die secondary to respiratory failure
 People who go on a ventilator generally live longer than
people who do not
 90% of people with ALS live 3–5 years after the onset of the
disease
 10% of people with ALS survive for 10 or more years after
the onset

PRECAUTIONS
 Pneumonia and pulmonary emboli
 Ventilators: intermittent positive pressure ventilation (IPPV)
or bilevel positive airway pressure (BiPap)
 Inability to cough to clear normal amount of mucus from
airway
 Pressure sores due to decreased mobility
 Swallowing problems could lead to choking
 Posture and balance could lead to falls
 Emotional lability (outbursts of laughing or crying)
 Difficulty maintaining weight
 Shoulder subluxation
 Joint contractures

OCCUPATIONAL THERAPY EVALUATIONS

Comprehensive Evaluations
 ALS Functional Rating Scale
IADL/Leisure Evaluations
 Activity Card Sort
Upper Extremity Function Evaluation
 Purdue Pegboard
 Manual muscle testing
 Range-of-motion testing
Balance Evaluations
 Berg Balance Scale
Quality of Life/Life Satisfaction Evaluations
 COPM (Canadian Occupational Therapy Performance
Measure)

OCCUPATIONAL THERAPY INTERVENTIONS

129
  Energy conservation: choosing which activities are most
important to the client
 Compensatory strategies, such as using gravity- eliminating
devices
 Use of adaptive equipment (e.g., raised toilet seat, built-up
handles)
 Prevent deconditioning of remaining muscles
 Continue meaningful life roles and occupations to pro- vide
a sense of accomplishment
 Therapeutic exercise to preserve strength
 PROM (passive range of motion) and/or AROM (active range
of motion) to prevent contractures at joints
 Thermoplastic resting splints for wrists and hands to assist
in maintaining muscle length
 Shoulder supports to prevent subluxation
 Augmentative communication
 Postural support
 Home modifications

OT AND THE EVIDENCE

When a person is facing a life-threatening illness, the use of
occupation is more powerful than ever. Occupation during this
phase of life can carry many meanings. Being engaged in
occupation can help to remediate physical function, challenge the
mind, provide meaning in the person’s new stage of life, and offer
a sense of well-being to a person with ALS. Learning new skills
and being challenged can be very rewarding for someone with a
terminal illness, even though the person might be constrained by
the illness. Bremer, Simone, Walsh, Simmons, and Felgoise
(2007) suggest that maintaining an individual’s quality of life as
ALS progresses should also be focused on as an important part of
occupational therapy intervention. They found that two major
contributing factors to good quality of life were the individual’s
perception of his or her health and the person’s religiosity. Bello-
Haas et al. (2007) examined another aspect of quality of life in
their study concerning the efficacy of resistance exercise in
individuals with ALS. They found that resistance exercise
contributed to better function as measured by the ALS
Functional Rating Scale as well as improved overall quality of life.

CAREGIVER CONCERNS
130
People who develop ALS experience a sudden change in life roles
that can be overwhelming. Because of the rapid progression of
ALS, it can be difficult for caregivers to adapt to a loved one’s
inability to continue life roles. Discontinuation of work after the
diagnosis of ALS is common and can lead to financial strain. The
sudden decrease in ADL/IADL capabilities can be difficult for the
family. Caring for a family member with ALS can be physically
and psychologically demanding and draining. It is important to
address the issue of coping not only with the client but also with
the family members. Because so much is unknown about ALS,
caregivers often have many unanswered questions. Caregiver
support groups can be beneficial in providing the family with
necessary support and information.

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 CHAPTER 15
BELLY'S PALSY

Bell’s palsy is characterised by an acute paralysis of the face

related to ‘inflammation’ and swelling of the facial nerve within
the facial canal or at the stylomastoid foramen. It is usually
unilateral, rarely bilateral, and may occur repetitively. In some, a
family history of the condition is evident. Incidence
25/100,000/year.

Aetiology
Uncertain, but may be associated with viral infections, e.g.
herpes simplex and varicella- zoster; epidemics of Bell’s palsy
occur sporadically.

Symptoms
Pain of variable intensity over the ipsilateral mastoid precedes
weakness, which develops over a 48hour period. Impairment of
taste, hyperacusis and salivation depend on the extent of
inflammation and will be lost in more severe cases. Lacrimation
is seldom affected.

Treatment During the acute stage protect the exposed eye

during sleep. There is good evidence prednisolone given in high
dosage in the acute stage (50 mg per day for 10 days) improves
recovery. The role of antiviral therapy is less clear as conflicting
results have been found in recent large trials. Eye care (shielding
and artificial tears) is important in preventing corneal abrasion.

Prognosis
Most patients (70%) recover in 4–8 weeks without treatment. In
the remainder, residual facial asymmetry may require corrective
surgery. Incomplete paralysis indicates a good prognosis. In
patients with complete paralysis, electrical absence of
denervation on electromyography is an optimistic sign.
Occasionally aberrant reinnervation occurs movement of the
angle of the mouth on closing the eyes (jaw winking) or
lacrimation when facial muscles contract (crocodile tears). On
attempting to close the eyes and show the teeth, the one eye
does not close and the eyeball rotates upwards and outwards
Bell’s phenomenon (normal eyeball movement on eye closure).
132
Diagnosis
Based on typical presentation and exclusion of middle ear
disease, diabetes, sarcoidosis and Lyme disease.

133
 CHAPTER 16
MOVEMENT DISORDERS

Cerebellar Dysfunction
Three major phylogenetic subdivisions of the cerebellum are
recognised.
1. The anterior lobe (paleocerebellum)
2. The posterior lobe (neocerebellum)
3. The flocculonodular lobe (archicerebellum)

CEREBELLAR DYSFUNCTION
CLINICAL PRESENTATION, ANATOMICAL CONCEPTS AND
DIAGNOSTIC APPROACH
180 Anatomy
The cerebellum lies in the posterior fossa, posterior to the brain
stem, separated from the cerebrum above by the tentorium
cerebelli. The cerebellum consists of two laterally placed
hemispheres and the midline structure the vermis. Receives
afferent fibres from (spinocerebellar pathways) in the spinal cord.

Function: maintenance of gait. Receives afferent fibres and

projects efferent fibres from and to motor cortex/vestibular
nuclei, basal ganglia and pons.
Function: maintenance of postural tone and modulation
of motor skills.Receives afferent fibres from vestibular system.
The cerebellar cortex is made up of three cell layers. The middle
or Purkinje layer contains Purkinje cells. These are the only
neurons capable of transmitting efferent impulses. Deep within
the cerebellar hemispheres in the roof of the 4th ventricle, lie four
paired nuclei separated by white matter from the cortex.

The efferent system

The Purkinje cells give rise to all efferent axons. These pass either
to the deep nuclei of the cerebellum and thence to the brain
stem, or to the vestibular nuclei of the brain stem. From there
fibres relay back to the cerebral cortex and thalamus, or project
into the spinal cord, The afferent systemConnections between the
vestibular system and the cerebellum are described on page 173.
The spinocerebellar pathways form a major afferent input. These
transmit ‘subconscious’ proprioception from muscles, joints and
skin especially of the lower limbs.
134
SYMPTOMS AND SIGNS OF CEREBELLAR DYSFUNCTION
The close relationship of structures within the posterior fossa
makes the identification of exclusively cerebellar symptoms and
signs difficult. Disease of the brain stem and its connections may
produce identical results.Damage to midline structures vermis
(and flocculonodular lobe) Results in: disturbance of equilibrium
with unsteadiness on standing, walking and even sitting (truncal
ataxia). The patient’s gait is broad based and reeling. Eye closure
does not affect balance (see Romberg’s test). Tests of vestibular
function, e.g. calorics, may be impaired. Damage to hemisphere
structures always produces signs ipsilateral to the side of the
lesion. Results in: a loss of the normal capacity to modulate fine
voluntary movements. Errors or inaccuracies cannot be
corrected. The patient complains of impaired limb co-ordination
and certain signs are recognised:Ataxia of extremities with
unsteadiness of gait towards the side of the lesion.
Dysmetria: a breakdown of movement with the patient
‘overshooting’ the target when performing a specific motor task,
e.g. finger-to-nose test.
Dysdiadochokinesia: a failure to perform a rapid alternating
movement.
Intention tremor: a tremor which increases as the limb
approaches its target
Eye movements
Nystagmus results from disease affecting cerebellar connections
to the vestibular nuclei. In unilateral disease, amplitude and rate
increase when looking towards the diseased side. Other ocular
signs may occur, e.g. ocular dysmetria an ‘overshoot’ when the
eyes voluntarily fixate.
Rebound phenomenon: the outstretched arm swings excessively
when displaced. ‘Pendular’ reflexes: the leg swings backwards
and forwards when the knee jerk is elicited.
Disturbance of speech
Scanning dysarthria (where the same emphasis is put on each
syllable like scanning a poem) may occur with speech
occasionally delivered with sudden unexpected force explosive
speech. Whether dysarthria results from hemisphere or midline
vermis disease remains debatable. Dysarthria, like nystagmus, is
an inconsistent finding in cerebellar disease.

135
Titubation
Titubation is a rhythmic ‘nodding’ tremor of the head from side to
side or to and fro, usually associated with distal limb tremor. It
appears to be of little localising value.

Head tilt
Abnormal head tilt suggests a lesion of the anterior vermis. Note
that a IV (trochlear) cranial nerve palsy and tonsillar herniation
also produce this abnormal posture.

Involuntary movements
Myoclonic jerks and choreiform involuntary movements occur
with extensive cerebellar disease involving the deep nuclei.
NOTE: Cerebellar lesions may cause symptoms and signs
relating to
 obstructive hydrocephalus
 cranial nerve involvement
 brain stem involvement.
(Extensor spasms from brain stem damage may be wrongly
described as ‘cerebellar fits’.)

CLASSIFICATION OF CEREBELLAR DYSFUNCTION

The following disorders are dealt with in their specific sections.
Developmental Infectious
 agenesis – abscess formation
 Dandy-Walker malformation – acute cerebellitis (viral)
 Arnold-Chiari malformations – Creutzfeldt–Jakob disease
 Von Hippel Lindau disease. Metabolic
Demyelinative – myxedema
 multiple sclerosis. – hypoxia, hypoglycaemia.
 acute disseminated – alcohol (vitamin B1 deficiency)
encephalomyelitis (ADEM) – inborn disorders of metabolism.
Degenerative/Hereditary (lipid or amino acid metabolism)
 cerebellar degeneration Vascular
 multi-system atrophy (MSA) – cerebellar haemorrhage
 spino-cerebellar ataxias (SCA) – cerebellar infarction.
Neoplastic Drugs/toxins
 astrocytoma, medulloblastoma, – alcohol haemangio
blastoma, metastasis – phenytoin.
136
  Paraneoplastic – carbamazepine.

Nystagmus
Nystagmus is defined as an involuntary ‘to and fro’ movement of
the eyes in a horizontal, vertical, rotatory or mixed direction. The
presence and characteristics of such movements help localise to
the site of neurological disease.Nystagmus may be pendular –
equal velocity and amplitude in all directions, or jerk – with a fast
phase (specifying the direction) and a slow phase. The normal
maintenance of ocular posture and alignment of the eyes with the
environment
Nystagmus may result from:
 retinal disease
 labyrinthine disease, or
 disorders affecting the cerebellum or a substantial portion of
the brain stem.

Examination for nystagmus

‘Nystagmoid’ movements of the eyes are present in many people
at extremes of gaze. Nystagmus present with the eyes deviated
less than 30° from the midline is abnormal. When nystagmus is
present only with the eyes deviated to one side
 1st degree nystagmus. With eyes deviated to one side and in
the midline position also
 2nd degree nystagmus.
When present in all directions of gaze
 3rd degree nystagmus.
If nystagmus is detected, note the type (jerk or pendular),
direction (of fast phase) and degree. Nystagmus suppressed by
visual fixation may appear in darkness, but this requires
specialised techniques (electronystagmography – see page 65) to
demonstrate.

RETINAL OR OCULAR nystagmus

Physiological: following moving objects beyond the limits of gaze
opticokinetic nystagmus.
Pathological: occurs when vision is defective. Fixation is
impaired and the eyes vainly

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VESTIBULAR NYSTAGMUS
Nystagmus arises from:
 natural stimulation of the vestibular apparatus
 rotational or linear acceleration.
 artificially removing or increasing the stimulus from one
labyrinth (e.g. caloric testing).
 damage to vestibular apparatus or the vestibular nerve.

Physiological
1. Rotational acceleration produces nystagmus in the plane of
rotation. Creates an imbalance between each side resulting
in a slow drift of the eyes towards the damaged side (or side
with the reduction in stimulus) followed by a fast
compensatory movement to the opposite side. Slow phase in
a direction tending to maintain the visual image. Fast phase
in the opposite direction. Slow Fast Slow Fast
2. Caloric testing sets up convection currents in the lateral
semicircular canal producing a horizontal nystagmus (see
page 65).

Pathological
Damage to labyrinth or vestibular nerve. Slow Fast Slow phase to
side of lesion. Quick or fast phase to normal side. Rotatory
component often present.Turning eyes away from the side of the
lesion increases amplitude but does not change direction of
nystagmus. In severe cases, the nystagmus is 3rd degree and
gradually settles to 1st degree with recovery. Enhanced by loss of
ocular fixation. Vertigo accompanies nystagmus. After a delay of
several seconds, nystagmus develops often with a rotatory
component. With repeated testing, the nystagmus fatigues. To
elicit, suddenly reposition the patient: Often associated with
tinnitus and hearing loss. Vertigo and nystagmus settle
simultaneously. Occurs in acute labyrinthine disease Menière’s
disease, vestibular neuronitis, vascular disease.

POSITIONAL
nystagmus: this may occur in labyrinthine disease in association
with INTRACRANIAL TUMOURS
AETIOLOGY/INCIDENCE
AETIOLOGY (cont’d)

138
 a. Inactivation of expression of tumour suppressor genes (e.g.
mutation of the p53 gene with loss of heterozygosity on the
17p chromosome in many patients with low grade
astrocytoma).
b. Over expression of genes controlling growth factor (e.g.
amplification of EGFR in primary glioblastoma).
Clearly defined inherited factors play a minor role. Only 5% of
patients have a family history of brain tumour and with the
exception of tuberous sclerosis (related to the formation of
subependymal astrocytomas) and neurofibromatosis (linked to an
increased incidence of schwannoma, optic nerve glioma and
meningioma) do not fall into an obvious autosomal recessive or
dominant pattern. Others include von Hippel-Lindau disease,
Cowden’s disease and Li-Fraumeni syndrome.
Cranial irradiation: long term follow-up of patients undergoing
whole head irradiation for treatment of tinea capitis and
childhood leukemia shows an increased incidence of both benign
and malignant tumours e.g. astrocytoma, meningioma.
Immunosuppression: increased incidence of lymphoma.

INCIDENCE
The table below shows the approximate incidence of intracranial
tumours extracted from large series.

Adults Children
Glioblastoma 15% Medulloblastoma/PNET 16% Low grade glioma
5% Low grade glioma 33% Meningioma 25% Malignant glioma
14% Pituitary adenoma 25% Ependymoma 10%Primary CNS
Lymphoma 4% Craniopharyngioma 6% Peripheral Nerve Sheath
Tumour 8% Germ cell tumours 2.5% (schwannoma) Meningioma
2.5% Others 18% Others 16% Adapted from Louis et al. Adapted
from Rickert & Paulus Child’s WHO Classification of Tumours
Nervous System Symptoms tend to develop insidiously, gradually
progressing over a few weeks or years, depending on the degree of
malignancy (cf. acute onset of a cerebrovascular accident
followed by a gradual improvement if the patient survives).
Occasionally tumours present acutely due to haemorrhage or the
development of hydrocephalus.

CLINICAL EFFECTS RAISED INTRACRANIAL PRESSURE

headache, papilloedema
139
BRAIN SHIFT – vomiting, deterioration of conscious level,
pupillary dilatation

INTRACRANIAL TUMOURS – CLINICAL FEATURES

DISTURBED FUNCTION
Supratentorial – higher cortical dysfunction, FRONTAL LOBE
Contralateral face, arm or leg weakness Expressive dysphasia
(dominant hemisphere). Personality change
 antisocial behavior
 loss of inhibitions
 loss of initiative
 intellectual impairment
 profound dementia especially if the corpus callosum is
involved
OCCIPITAL LOBE
Visual field defect homonymous hemianopia
CORPUS CALLOSUM – dysconnection
 syndrome
 Apraxia
 Word blindness
TEMPORAL LOBE
Receptive dysphasia (dominant hemisphere) Visual field defect –
upper homonymous quadrantanopia Sensory or non-dominant
Motor neglect hemisphere (e.g. dressing apraxia)

HYPOTHALAMUS/PITUITARY
 Endocrine dysfunction.
 Right/left confusion
 Finger agnosia dominant
 Acalculia hemisphere
 Agraphia

PARIETAL LOBE
Disturbed sensation
 localisation of touch
 two point discrimination
 passive movement
 astereognosis
 sensory inattention
Visual field defect
 lower homonymous quadrantanopia
140
N.B. Intrinsic brain stem tumours in contrast to extrinsic
tumours are more likely to produce long tract (motor and
sensory) signs early in the course of the disease.

CEREBELLUM
 Ataxic gait
 Intention tremor
 Dysmetria
 Dysarthria
 Nystagmus
 Infratentorial

MIDBRAIN/BRAIN STEM
 Cranial nerve lesions III–XII
 Long tract signs – motor and sensory
 Deterioration of conscious level
 Tremor (red nucleus)
 Impaired eye movements
 Pupillary abnormalities
 Vomiting, hiccough

INTRACRANIAL TUMOURS – INVESTIGATION

Chest X-ray, The high incidence of metastatic tumour makes
these tests mandatory in ESR, CRP patients with suspected
intracranial tumour. Skull X-ray (if performed) Note:Pineal shift–
if gland is calcified (ensure ‘shift’ is not Towne’s view due to film
rotation). Single or multiple lesions if multiple → metastasis
Effect of contrast enhancement e.g. none – low grade astrocytoma
irregular – malignant astrocytoma homogeneous – meningioma
Effect on adjacent bone i.e. if meningioma → hyperostosis

MASS EFFECT
 midline shift.
 ventricular compression.
 hydrocephalus (secondary to 3rd ventricular or posterior
fossa lesion).
 obliteration of basal cisterns
CT scanning Note: SITE e.g. frontal, occipital
 extrinsic: outwith brain substance, e.g. meningioma
 intrinsic: within brain parenchyma, e.g. astrocytoma.

141
  useful in demonstrating the vertical extent of a tumour and
its relationship with other structures, especially when
intraventricular or arising from the pituitary fossa or skull
base.
HIGH DEFINITION SCANS (1 mm slice width) useful in the
detection of pituitary, orbital and posterior fossa tumours.

CORONAL AND SAGITTAL RECONSTRUCTION

Lateral view
Signs of raised intracranial pressure
 Suture separation (diastasis) in infants‘Beaten

INTRACRANIAL TUMOURS – MANAGEMENT

The subsequent procedure biopsy, partial tumour
removal/internal decompression or complete removal depends on
the nature of the tumour and its site. The infiltrative nature of
primary malignant tumours prevents complete removal and often
operation is restricted to biopsy or tumour decompression.
Prospects of complete removal improve with benign tumours
such as meningioma or craniopharyngioma; if any tumour tissue
is overlooked, or if fragments remain attached to deep structures,
then recurrence will result.

STEROID THERAPY
Steroids dramatically reduce oedema surrounding intracranial
tumours, but do not affect tumour growth. A loading dose of 12
mg i.v. dexamethasone followed by 4 mg q.i.d. orally or by
injection often reverses progressive clinical deterioration within a
few hours. After several days treatment, gradual dose reduction
minimises the risk of unwanted side effects. Sellar/parasellar
tumours occasionally present with steroid insufficiency. In these
patients, steroid cover is an essential prerequisite of any
anaesthetic or operative procedure.

OPERATIVE MANAGEMENT
Most patients with intracranial tumours require one or more of
the following approaches:
Craniotomy: flap of bone cut and reflected.
If necessary, combined with image guidance to aid positioning
the flap and to give accurate lesion localisation

142
Transphenoidal route: through the sphenoid sinus to the
pituitary fossa
Burr hole: for stereotactic or hand-held, ultrasound
guided biopsy
Transoral route: removal of the arch of the atlas, odontoid peg
and clivus provides access to the anterior aspect of the brain
stem and upper cervical cord. Rarely required for anteriorly
situated tumours, e.g. neurofibromas, chordoma.
Craniectomy: burr hole followed by removal of surrounding
bone to extend the exposure routinely used to approach the
posterior fossa

OPERATIVE MANAGEMENT (cont’d)

Image Guided Surgery
It is essential to accurately identify the tumour site on
preoperative imaging and to be able to use this information to
guide the surgeon to the tumour whether for biopsy or for
resection. Various techniques are available
Stereotactic surgery: by rigidly attaching the frame to the
patient’s head and using a CT or MR to identify the position of
the locating rods, coordinates are determined for a selected target
allowing accurate placement of a biopsy needle to within 1 mm
(see page 384). This technique is routinely used to biopsy
selected points within the tumour. It is possible to perform a
craniotomy and tumour resection with the frame in place, but the
frame tends to impede access and after opening the bone flap,
the brain may shift introducing errors of localisation. When a
craniotomy is planned, most now use neuronavigation
(‘frameless’ stereotaxy) if available.
Neuronavigation: this technique requires rigid fixation of the
head in a standard three pin head holder, but avoids the use of a
cumbersome frame (see page 386). The system accurately detects
the position of the handheld probe in relation to the skull and
allows the surgeon to see where the probe tip lies in relation to
pre-operative imaging. Although often routinely used, this
technique also fails to take into account brain shift which can
occur on opening the bone flap or if cerebrospinal fluid is drained
off thus limiting accuracy.
Real-time intra-operative imaging: some centres have now
acquired CT or MR imaging available within the operative theatre.
Although costly, this real-time imaging overcomes problems
143
encountered with brain shift and not only helps to locate the
tumour, but also shows the extent of tumour resection as the
operation progresses. Ultrasound has also been combined with
neuronavigation to provide real-time imaging at a more realistic
expense.

Surgery in Eloquent Areas

When intrinsic tumours lie adjacent to or within eloquent areas
within the brain, i.e. speech area, motor strip, basal ganglia and
internal capsule, resection is potentially hazardous. Various
techniques have been developed to try to minimise this risk
fMRI/Diffusion Tensor Imaging (Tractography): Superimposing
speech and/or motor strip areas seen on fMRI and white matter
tracts seen on tractography on to the standard MR image,
demonstrates the relationship of the tumour to these crucial
structures. When these images are incorporated into the neuro-
navigation system it enables the surgeon to avoid extending the
tumour resection into these areas and causing irreversible
neurological deficits. The reliability of each technique, however, is
still in question and benefits remain uncertain. ‘Awake’
craniotomy: by either performing the surgery wholly under
sedation with local anaesthetic, or by giving an anaesthetic for
opening and closing the craniotomy and waking the patient up in
between, gives the surgeon the opportunity to identify eloquent
areas by applying electrical stimulation direct to the cortical
surface and observing the functional effect. Studies show that
patients tolerate the technique well and maximal tumour
resection is possible with a low risk of deficits.

RADIOTHERAPY
Treatment of intracranial tumours with radiotherapy utilises one
of the following:
 megavoltage X-rays (by far the most common method)
 electron beam from a linear accelerator (which can also
produce megavoltage X-rays)
 accelerated particles from a cyclotron, e.g. nuclei of helium,
protons (awaits full evaluation)
 γ rays from cobalt 60.
In contrast to older methods, these modern techniques produce
greater tissue penetration and avoid radiation damage to the skin
surface. The effect of radiotherapy depends on the total dose
144
usually up to 60 Gy, and the treatment duration. This must be
balanced against the risk to normal structures. Treatment aims
to provide the highest possible dose to a specified region whilst
minimising irradiation to adjacent normal brain. Various
methods have been developed to achieve this
 Conformal therapy where standard radiotherapy is
administered, but the beams are shaped by the use of
variable collimators or blocks which conform with the shape
of the tumour, thereby eliminating normal brain.
 Stereotactic radiosurgery (SRS) where multiple converging
beams from a linear accelerator or from multiple cobalt60
sources are focused on a selected target in a single
treatment. Stereotactic radiotherapy (SRT) uses the same
localisation method but with fractionated treatment as used
in conventional radiotherapy (see page 385).
 Interstitial techniques where the tumour is treated from
within (brachytherapy) by the implantation of multiple
radioactive seeds, e.g. iodine125.
 Beam intensity modulated radiotherapy (IMRT) uses non-
uniform beams of varying intensity (in contrast to the
conventional uniform dose intensity) to complex tumour
volumes. This helps protect surrounding structures, yet
allows a higher dose. Proton therapy is available in only a
few centres. It allows the delivery of high doses of radiation
to very localised regions adjacent to vital structures such as
the skull base.
Radiotherapy is of particular value in the management of
malignant tumours malignant astrocytoma, metastasis,
medulloblastoma and germinoma, but also plays an important
part in the management of some benign tumours – pituitary
adenoma, craniopharyngioma. With some tumours that seed
throughout the CSF pathways, e.g. medulloblastoma, whole
neural axis irradiation minimises the risk of a distant recurrence.
Complications of radiotherapy: following treatment, deterioration
in a patient’s condition may occur for a variety of reasons:
 Increased oedema – during treatment – reversible.
 Demyelination – after weeks, months – usually reversible.
 Radionecrosis – in usually 1–2 years (range 6 months–10
years) – irreversible.
 Cognitive impairment – whole brain irradiation causes
dementia, ataxia and incontinence in over 10% at one year.
145
 Radiotherapy should be avoided in children under 3 years of
age.
 Radiation induced tumours e.g. meningioma, may result
many years after the treatment.
Oedema, demyelination and radionecrosis may involve the spinal
cord after irradiation of spinal tumours. Other harmful effects
include hair loss, skin reactions and endocrine reaction.

CHEMOTHERAPY
Chemotherapeutic agents have been used for many years in the
management of malignant brain tumours, but their benefits
remain limited. Historically drugs most commonly used include
nitrosoureas (e.g. BCNU, CCNU), procarbazine, vincristine and
methotrexate (for lymphoma). Temozolomide, an oral alkylating
agent with excellent blood brain barrier penetration and modest
toxicity is established as an alternative treatment for patients
with recurrent high grade gliomas. It has also been shown to
improve survival for patients with newly diagnosed glioblastoma
when given concomitantly with radiotherapy. A combination of
maximal safe surgery followed by combined chemoradiotherapy is
now the standard of care for good performance patients with
glioblastoma. Patients with methylation of the MGMT gene in the
tumour appear particularly to benefit. Carmustine impregnated
wafers (Gliadel) may also be considered both as a primary
treatment or for tumour recurrence (see below). Patients with
anaplastic oligodendrogliomas and oligoastrocytoma with loss of
heterozygosity on chromosomes 1p and 19q have a good
prognosis and respond well to both radiation and to alkylating
agent based chemotherapy (nitrosoureas, Temozolomide).
Chemotherapy may be used either at initial diagnosis or at
relapse in these patients. Other tumours where chemotherapy
plays an important role include medullo-blastomas, primary CNS
lymphomas and germ cell tumours. Traditionally, chemotherapy
has had a lesser role in low grade glial tumours but current
studies are examining its use in both astrocytomas and
oligodendrogliomas as an alternative to radiation in newly
diagnosed patients. Problems of drug administration
Toxicity: The ideal cytotoxic drug selectively kills

146
 CHAPTER 17
HYDROCEPHALUS LOCALISED NEUROLOGICAL DISEASE
AND ITS MANAGEMENT A. INTRACRANIAL
DEFINITION

Hydrocephalus is an active distension of the ventricular system

of the brain arising when an imbalance exists between
cerebrospinal fluid (CSF) production and absorption. This
definition excludes ventricular expansion secondary to brain
shrinkage from a diffuse atrophic process (hydrocephalus ex
vacuo).

CSF FORMATION AND ABSORPTION

CSF forms at a rate of 500 ml/day (0.35 ml/min), secreted
predominantly by the choroid plexus of the lateral, third and
fourth ventricles. CSF flows in a caudal direction through the
ventricular system and exits through the foramina of Luschka
and Magendie into the subarachnoid space. After passing
through the tentorial hiatus and over the hemispheric convexity,
absorption occurs through the arachnoid granulations into the
venous system.

CLASSIFICATION
‘Obstructive’ hydrocephalus – obstruction of CSF flow within the
ventricular system. ‘Communicating’ hydrocephalus obstruction
to CSF flow outwith the ventricular system i.e. ventricular CSF
‘communicates’ with the subarachnoid space.

CAUSES OF HYDROCEPHALUS
Obstructive Communicating Acquired – Acquired aqueduct
stenosis Thickening of the leptomeninges (adhesions following
infection and/or involvement of the arachnoid or haemorrhage)
granulations
 Supratentorial masses causing infection (pyogenic, TB,
fungal) tentorial herniation subarachnoid haemorrhage
 Intraventricular haematoma spontaneous
 Tumours ventricular, e.g. traumacolloid cyst postoperative
 pineal region carcinomatous meningitis
 posterior fossa Increased CSF viscosity, e.g.
 Abscesses/granuloma high protein content

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  Arachnoid cysts Excessive CSF production choroid plexus
papilloma (rare)
 Congenital – Aqueduct stenosis or forking
 Dandy-Walker syndrome (atresia of foramina of Magendie
and Luschka)
 Chiari malformation

PATHOLOGICAL EFFECTS
In the infant, prior to suture fusion, head expansion and massive
ventricular dilatation may occur, often leaving only a thin rim of
cerebral ‘mantle’. Untreated, death may result, but in many cases
the hydrocephalus ‘arrests’; although the ventricles remain
dilated, intracranial pressure (ICP) returns to normal and CSF
absorption appears to balance production. When hydrocephalus
arrests, normal developmental patterns resume, although pre-
existing mental or physical damage may leave a permanent
handicap. In these patients, the rapid return of further pressure
symptoms following a minor injury or infection suggests that the
CSF

INVESTIGATIONS
Skull X-ray
Note: – skull size and suture width.
 Evidence of chronic raised pressure – posterior clinoid
erosion, ‘copper beating’.
 associated defects – platybasia, basilar invagination.

CT scan
The pattern of ventricular enlargement helps determine the
cause, i.e. Periventricular lucency (if present normal 4th –
suggests suggests raised CS lateral ventricle aqueduct pressure.
stenosis. (Wide sulci suggests 3rd ventricular deviated or –
suggests a ventricular

Dilatation
MANAGEMENT
Acute ventricular drainage or deterioration ventriculo-peritoneal
(VP) shunt or 3rd ventriculostomy (if tri-ventricular – obstructive
hydrocephalus) lumbar puncture if communicating
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hydrocephalus, e.g. following subarachnoid haemorrhage.
Gradual VP shunt (lumboperitoneal shunts are occasionally used
for deterioration communicating hydrocephalus) or 3rd
ventriculostomy. removal of a mass lesion if present – this may
obviate the need for a shunt. ‘Arrested hydrocephalus’
symptomless ventricular dilatation requires no treatment, but
regular developmental or psychometric assessment ensures no ill
effects develop from this potentially unstable state.
Shunt techniques
A reservoir permits CSF aspiration for analysis.
A valve is incorporated in the system, with either fixed opening
pressure e.g. Heyer-Schulte, Hakim variable opening pressure
(flow regulated) e.g. Orbis sigma, Delta programmable e.g. Medos,
Sophy. Valve opening pressures range from 5–150 mmH2O
[Lumboperitoneal shunt catheter inserted into the lumbar theca
either directly at open operation or percutaneously through a
Tuohy needle. The distal end is sited in the peritoneal cavity.]

Complications of shunting
Infection: results in meningitis, peritonitis or inflammation
extending along the subcutaneous channel. With a V-A shunt,
bacteraemia may lead to shunt ‘nephritis’. Staphylococcus
epidermidis or aureus are usually involved, with infants at
particular risk. Minimise the risk of infection with prophylactic
antibiotics and in neonates, with antibiotic impregnated shunt
systems. When established, eradication usually requires shunt
removal.
Subdural haematoma: ventricular collapse pulls the cortical
surface from the dura and leaves a subdural CSF collection or
tears bridging veins causing subdural haemorrhage. The risk
may be reduced with a variable pressure or programmable valve.
Shunt obstruction: blockage of the shunt system with choroid
plexus, debris, omentum or blood clot results in intermittent or
persistent recurrence of symptoms. Demonstration of an increase
in ventricular size compared to a previous baseline CT scan
confirms shunt malfunction. Over a third require revision within
1 year and 80% within 10 years.
Low pressure state: following shunting, some patients develop
headache and vomiting on sitting or standing. This low pressure
state usually resolves with a high fluid intake and gradual

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mobilisation. If not, insertion of an antisyphon device or
conversion to a high pressure valve is required.
Third ventriculostomy: Suitable for patients with tri-ventricular
hydrocephalus e.g. obstructive hydrocephalus caused by
aquaduct stenosis or a pineal or posterior fossa tumour
occluding the posterior end of the 3rd ventricle/aqueduct. By
using a flexible or rigid endoscope introduced through a frontal
burrhole, a fistula is created in the floor of the 3rd ventricle. This
provides an alternative method of treatment, which if successful,
avoids the above problems of shunt insertion. About 2⁄3 of
patients obtain permanent benefit.

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 CHAPTER 18
GUILLIAN BARRE SYNDROME
GUILLAIN BARRÉ SYNDROME (ACUTE INFLAMMATORY
DEMYELINATING POLYNEUROPATHY)

Incidence: 2 per 100 000 population per year. Characteristically

it occurs 1–3 weeks after a viral or other infection or
immunisation.

Aetiology/pathology
The condition may follow viral infection, e.g. varicella-zoster,
mumps and cytomegalovirus. It is also associated with
Mycoplasma, Campylobacter, infections, immunisations with
both live and dead vaccines, antitoxins, trauma, surgery and,
rarely, malignant disease and immunodeficiency. Both antibody
and cell-mediated reactions to peripheral nerve myelin are
involved. Some patients produce antibodies to myelin
glycoproteins or gangliosides, others develop a T cell mediated
assault on myelin basic protein. Segmental demyelination results
with secondary axonal damage if the process is severe.
Perivascular infiltration with lymphocytes occurs within
peripheral nerves and nerve roots. Lymphocytes and
macrophages release cytotoxic substances (cytokines) which
damage Schwann cell/myelin. When axon damage and nerve cell
death occur, regeneration cannot take place.

Clinical features
Sensory symptoms predominate at the beginning with
paraesthesia of the feet, then hands. Pain, especially back pain,
is an occasional initial symptom. Weakness next develops this
may be generalised, proximal in distribution or commence
distally and ascend. Tendon reflexes are absent or depressed. In
severe cases, respiratory and bulbar involvement occurs.
Weakness is maximal three weeks after the onset.
Tracheostomy/ventilation is required in 20% of cases. Facial
weakness is present to some extent in 50% of cases.
Papilloedema may occur when CSF protein is markedly elevated
(blocked arachnoid villi?). Autonomic involvement – tachycardia,
fluctuating blood pressure, retention of urine – develops in some
cases. Variants are common (20% of cases).

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  Acute motor axonal neuropathy (AMAN) – often after
campylobacter infection
 acute motor, sensory axonal neuropathy (AMSAN)

Investigations
CSF protein is elevated in most patients but often not until the
second or third week of illness. Cells are usually absent but in
20% up to 50 cells/mm3 may be found.

Nerve conduction studies

When carried out early in the illness, these may be normal.
Findings of multifocal demyelination soon develops with slowing
of motor conduction, conduction block and prolonged distal
motor latencies.

Ancillary investigations
Performed to identify any precipitating infection: e.g. viral and
bacterial studies. Electrolytes are checked for inappropriate
secretion of antidiuretic hormone and immune complex
Diagnosis is based on clinical history supported by CSF and
neurophysiological investigation and exclusion of acute spinal
cord disease, porphyria and myasthenia gravis. Some antibodies
have been identified as being associated with some sub-types
including:
AMAN: anti-GD1a and GM1
Acute sensory neuropathy: anti-GD1b

Treatment
Supportive care in HDU/ITU with prevention of respiratory and
autonomic complications provides the best chance of a
favourable outcome. Signs of impending respiratory failure forced
vital capacity (FVC) below 18 ml/kg, arterial PaCO2 > 6.5 kPa
and PaO2 < 8 kPa on oxygen – indicate elective intubation for
ventilation. When respiratory assistance is likely to exceed 2
weeks, tracheotomy should be performed. Subcutaneous low
molecular weight heparin with support stockings must be given
where the degree of immobility makes thromboembolism a
possible complication. Both plasma exchange (PE) and
intravenous immune globulin (IVIG), 0.4 g/kg daily for 5 days –
are equally effective at speeding recovery and improving outcome.
IVIG is the preferred treatment because of ease of administration
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but is not without side effects (flu-like symptoms, vasomotor
instability, congestive cardiac failure, thrombotic complications
strokes and myocardial ischaemia, transient renal failure and
anaphylaxis. There is a very small risk of infection, including
theoretically variant CJD) Treatment is generally given to those
who can no longer walk and is deferred in milder cases. Steroids
are not indicated, two trials showing no benefit.

Outcome
Mortality – 2%. Of those progressing to respiratory failure, 20%
are left severely disabled and 10% moderately disabled. In milder
cases the outcome is excellent. Recurrence – 3%. Miller Fisher
variant of Guillain Barré The Miller Fisher syndrome consists of
ophthalmoplegia, areflexia and ataxia without significant limb
weakness. Serum IgG antibodies to a specific ganglioside are
characteristic (anti-GQ1B antibodies). Management is that of
Guillain Barré.
Occupational Therapy Applied in Neurological Conditions.
Course Code: OCT 231: 3 Units Course.

IDENTIFYING SENSORY INTEGRATION DYSFUNCTION

Dr. Ayres analyzed test scores and clinical observations of
children with learning disabilities to empirically identify patterns
of dysfunction (Ayres, 1974, 1989). Later, Mulligan (1998a,
1998b, 2000) conducted confirmatory factor and cluster analyses
that supported Dr. Ayres’ original patterns of dysfunction.
Consequently, the strongest research in sensory integration is in
the identification of the types and patterns of sensory integration
dysfunction using the Sensory Integration and Praxis Tests
(Ayres, 1989; Mulligan, 1998a, 1998b, 2000). Various types and
patterns of sensory processing dysfunction continue to be
examined (Ayres & Tickle, 1980; Brown & Dunn, 2002; Dunn,
1999, 2002a, 2002b; Miller, McIntosh, McGrath, Shyu, Lampe, &
Taylor, 1999; Miller & Summers, 2001). These studies suggest
that sensory integrative dysfunction is not a single disorder but a
spectrum of disorders (Parham & Mailloux, 2005) related to the
following processes.

Sensory Modulation
Dr. Ayres (1979, 2005) proposed that the “combination of
facilitatory and inhibitory messages produces modulation, which
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is the nervous system’s process of self-organization” Sensory
modulation disorder is one type of SI dysfunction characterized
by fluctuating or extremes in the responsiveness to the intensity
of one or more sensations. Difficulties with sensory modulation
are often observed during everyday activities such as grooming,
social events, or transitions. Specific behaviors may include
auditory hypersensitivity or tactile defensiveness, gravitational
insecurity, aversion to movement, or feeling over- whelmed in
high-stimulus environments such as shopping malls (Koomar,
1995; Weisberg, 1984). Sensory modulation disorders are seen in
conjunction with arousal, external regulation, or self-regulation
issues, including colic and poor rhythmic respiration, digestion,
and elimination; arousal and attention deficits; hyperactivity;
anxiety and other signs of emotional instability; and social
problem.

Sensory Discrimination
Sensory discrimination is the interpretation of sensory
information that allows you to know efficiently and accurately
where your body is, where other people are, and details about the
environment from multiple sensory channels. Sensory
discrimination disorders are a result of slow and inaccurate
processing of one or more types of sensory information, under
responsiveness to sensation, inadequate perception formation,
and poor sensory associations. Patterns of dysfunction that have
been identified through factor and cluster analyses indicate that
poor vestibular proprioceptive processing is often associated with
poor anticipatory and reactive postural control and inadequate
bilateral integration and sequencing. Tactile discrimination
deficits are often associated with poor fine motor skills and
praxis. It is as if the child is trying to do precise work with his or
her hands while wearing winter gloves. Visual perceptual deficits
are associated with poor visual construction ability and visual
motor skills. Auditory perceptual deficits often contribute to poor
auditory language skills.

Praxis
Praxis is the ability to conceptualize, plan, and execute skilled
tasks. It underlies engagement in purposeful activity. Any non-
habitual motor task that the child needs to think through
requires praxis. The child who is learning how to dive needs to
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stand at the water’s edge, get the arms in position over the head,
shift the weight forward, tuck the chin against the chest, and
then maintain this position as he or she falls head first into the
water. All of this requires cognitive effort as well as physical
coordination. Dr. Ayres (1972) hypothesized that sensory
discrimination, particularly of tactile, vestibular, and
proprioceptive sensations along with visual input, was the
foundation for praxis. The resulting sensation from the activity is
processed by the brain, and this further informs individuals
about their body in relation to itself as well as to other people and
objects in the environment (Ayres, 1989, 2004). Through her
factor analyses, she later found a consistent relationship,
particularly between the tactile system and praxis. There are a
variety of different types of praxis dis- orders, including poor
ideation of creative or novel activities (e.g., the child in the
sandbox who shovels sand into the pail and then pours it out
and repeats the process but does not come up with the idea that
she can “make a cake” by filling the pail with sand and then
turning the pail over to form a mound that she can then
decorate); somatodyspraxia, or poor use of the body to motor
plan action sequences; poor use of language for sequencing and
planning; poor ability to modify an action while in motion to
enhance skill and precision; poor visual construction (e.g.,
difficulty replicating a block design); and poor ability to organize
behavior in future time and space. Conceptualizing an action, or
forming the idea about what one wants to do, is a critical aspect
of praxis. This is ideation, and it is a cognitive function (May-
Benson, 2001). Planning how one intends to engage in the task is
also cognitive. A child observing a newly constructed playground
with swings, slides, tree house, poles, and sand will have 101
ideas about what to do and will want to do them all. The actual
execution of the activity is the part of praxis that we can observe,
and this is the part that is assessed to determine a child’s skill
for motor tasks. The child then sequences these ideas into
swinging, sliding, and digging activities and modifies the
sequence or the challenge so that it is more fun and successful.

ASSESSMENT
The process of sensory integration cannot be observed directly,
which is why Dr. Ayres used the term “hidden disabilities” when
referring to SI dysfunction
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INTERVENTION PLANNING
Occupational therapy using a sensory integrative approach is
guided by the evaluation data. On the basis of the information
from the occupational profile, the therapist con- siders the
identified occupationally related outcomes that are important to
the client, the family, and the reimbursement agency. The
analysis of performance provides detailed information on client
factors, performance skills, and pat- terns that contribute to the
development of client-directed interventions, therapeutic
activities, and environmental modifications. Additionally,
education and consultation are required so that the team
understands the relationship of the child’s sensory integrative
functions to participation in daily life activities. Therapeutic
activities to address the identified deficits are designed with
specific attention to the contribution of the tactile, proprioceptive,
and vestibular sensations to function (Figures 59.5, 59.6, and
59.7).
 Special consideration is given to including proprioception in
the form of active movement and heavy work activities.
Proprioception exerts a regulatory influence on other
sensations (Blanche & Schaaf, 2001).
 Vestibular activities are especially important so that the
child can develop the capacity to hold the body upright
against gravity while holding still and while moving (Ayres,
1972). Processing vestibular information is important for
the development of the sense of space and navigation
(Berthoz, 2000).
 Tactile information is essential for refined interactions with
the external social and physical environment (Ayres, 1972,
2005; Montegue, 1986).

INTERVENTION
Central to intervention using sensory integration principles is a
unique philosophy that reflects Dr. Ayres’ sense of trust,
compassion, and respect for children (Spitzer & Smith Roley,
2001). She proposed that intervention delivered in a playful style
at the child’s level could elicit the child’s “inner drive” to learn
and develop. we facilitate enhanced neuronal growth and
development that lead to increased skill and independence in
156
daily life activities (Ayres, 1972). The therapeutic environment
designed by Dr. Ayres was unique in its ability to safely provide
opportunities for vestibular, proprioceptive, and tactile
sensations and adaptive motor responses. She used simple and
readily available objects such as tires, ropes, wood, hula hoops,
and rocker boards and created unusual obstacle courses and
games with them. She used ceiling beams and devices so that she
could suspend equipment that allowed the child to swing safely
through space. She invented this equipment as the need arose for
individual clients. Although a clinic filled with ceiling hooks,
swings, mats, carpeted barrels, scooter boards, ramps, and
pillows is commonly associated with pediatric occupational
therapy using “classic” SI intervention methods, the environment
alone is not sufficient to define intervention using sensory
integration theory. Dr. Ayres described not only the environment,
but also what might be considered the therapeutic alliance.
Parham and her colleagues (2007) report that intervention using
sensory integration principles should be faithful to the methods
and principles that are considered essential and distinctive to
this particular therapeutic method. The authors examined the
literature and gathered expert opinion to specify the essential
and distinctive sensory integration methods and principles. By
using these principles, a therapist is demonstrating fidelity to the
intervention. Classic SI intervention comprises both structural
processes (e.g., length of the session, therapist’s training,
equipment used) and therapeutic processes (e.g., therapist
creates an environment that invites play and ensures safety,
fosters a therapeutic alliance). Establishing fidelity helps to
clearly delineate the qualities that must be present to define the
intervention as sensory integration, and for the practitioner, it
clearly articulates the specific strategies and process that are
linked to an underlying theoretical base and supporting evidence.

Hallmark Features of Intervention Using Sensory Integration

Intervention using SI should include the following:
 A qualified therapist with an understanding of the
neurobiological principles of sensory integration theory and
its methods. Postgraduate certification in sensory
integration is available for occupational therapists, speech
and language therapists, and physical therapists only.

157
  The use of sensory opportunities that feature varied and
appropriate vestibular, tactile, and proprioceptive
sensations, including thick mats, large overstuffed pillows,
swings, ramps, ladders, ropes, targets, manipulatives, balls,
vibrating toys, various textures such as stretchy soft or
furry fabrics, brushes, props, and materials that are used
during daily routines.
 Opportunities to move through space so that the child can
achieve increasingly complex somatomotor adaptive
responses.
 The therapist’s scaffolding of success emotionally,
physically, cognitively, and socially.
 Facilitating the just-right challenge: The therapist
collaborates with the child on choice and sequence of
activities and equipment and adjusts the intervention
accordingly to ensure success.
 Providing environmental affordances (the opportunities that
the environment affords children to do things) that invite
interactions with the environment, including space to move,
jump, and crash and items that stimulate creativity and
engagement.
 Assisting in organization of behavior relative to physically
interacting with objects and people in time and space,
including the opportunity to rearrange the environment and
the way in which it is used (Parham et al., 2007).

Guiding Principles of the Actual Intervention\

Intervention based on sensory integration theory is child-
directed. This concept has often been misunderstood. It does not
mean that there is no structure. Rather, it means that the
therapist vigilantly observes the child to understand the child’s
current capabilities, structures the activities around the child’s
interests and abilities, and engages the child by eliciting his or
her intrinsic motivation to play. Sensory integration methods are
provided in the context of play, and the therapist, who is inviting
the child’s active participation, is focused on the desired outcome
of an adaptive response. “When the therapist is doing her job
effectively and the child is organizing his nervous system, it looks
as if the child is merely playing” (Ayres, 2005, p. 142).

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Basic Tenets of Sensory Integration
Following are the classic principles of intervention using a
sensory integration approach:
 Integrated sensation is “nourishment for the brain”(Ayres,
1979).
 Adaptive responses are required to successfully meet
challenges essential for growth and development (Ayres,
1972). The adaptive response is essential to increased
sensory integration.
 The inner drive of the human being invites the experience of
life. It is this motivation to enjoy life that Dr. Ayres wished
to engage during intervention.
 Active participation promotes organization.
 Artful vigilance is essential on the part of the therapist to
facilitate the just-right challenge.
When using sensory integration intervention strategies, the
practitioner will provide a balance of structure and freedom so
that the child has opportunities to problem-solve and make some
of his or her own choices. Some essential characteristics that
differentiate sensory integration methods from other frames of
reference are freedom within the structure of a sensory-rich
environment, the ability to physically move through space and
move objects in space, and the assistance of the practitioner so
that the child can learn to use his or her body in new and novel
ways so that increasingly complex possibilities for physical
engagement emerge. Sensory integration is not sensory
stimulation, due to the imperative of the adaptive response and
modification of the activity based on the child’s reaction
(Anzalone & Murray, 2002). It is not adult planned and designed;
rather, the adult sets up the structure and possibilities in which
the child’s interests and ability to cope with the sensory, motor,
and organization demands dictate the level of challenge and
intensity of the activities. Therefore, the equipment does not stay
in the same place each time, and the therapy does not follow an
orderly and predictable sequence, so each session is somewhat
novel. The intervention is not provided with the expectation of a
subsequent reward. The activities are intended to be fun and
inviting and therefore are rewarding in and of themselves. Play is
one of the most important and powerful parts of the process of
intervention using sensory integration strategies and one that
facilitates the intrinsic reward of this kind of occupational
159
engagement (Bundy, 2002). Sensory integrative dysfunction
commonly occurs in children with diagnoses such as autism,
fragile X syndrome, and cerebral palsy. These children will
benefit from a variety of approaches in addition to sensory
integration methods (Mailloux, 2001; Mailloux & Smith Roley,
2004; Schaaf & Smith Roley, 2006; Smith Roley et al., 2001).
During a typical occupational therapy session, sensory
integration methods are often used in conjunction with
complementary methods such as neurodevelopmental treatment
(Blanche, Botticelli, & Hallway, 1995), play- based approaches
(Burke & Mailloux, 1997; Knox & Mailloux, 1997), developmental
and behavioral approaches (Anzalone & Murray, 2002), and
cognitive approaches such as the Alert Program for Self-
Regulation (Williams & Shellenberger, 1996). This is especially
true for children with multiple impairments.

GOALS OF OCCUPATIONAL THERAPY USING SENSORY

INTEGRATION STRATEGIES
Sensory integration principles applied within occupational
therapy practice results in improved occupational engagement
and social participation (Figure 59.8). To accomplish the
overarching goals of occupational therapy, sensory integration
strategies are used to facilitate adaptive responses in various
domains. In addition to the somatomotor adaptive response
described by Ayres (1972), Parham & Mailloux (2005, p. 393)
identified the following expected goals as a result of intervention
using SI that could be used as outcome measures:
 Increase in the frequency or duration of adaptive responses
 Cognitive, language, and academic skills
 Gross and fine motor skills
 Self confidence and self-esteem
 Enhanced occupational performance and social
participation
 Enhanced family life

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 CHAPTER 19
OCCUPATIONAL THERAPY ROLE WITHIN A MULTI
DISCIPLINARY TEAM

Currently, there is no single discipline that is responsible for the

evaluation and intervention of cognitive-perceptual impairments.
Multiple team members have the potential to make valuable
contributions to understanding the client who has a cognitive-
perceptual impairment. A strong inter disciplinary approach is
needed to address the complex of issues that arise from
cognitive-perceptual problems. Team goals should be identified,
as well as specific discipline goals. The family and client are also
members of the team and should be involved in team discussions
and provide input into the overall intervention plan.
Occupational therapists provide a unique contribution to the
evaluation and rehabilitation of cognitive perceptual process
skills because of their educational background, knowledge of
occupation, training in activity analysis, and ability to analyze
how cognitive-perceptual symptoms are affected by changes in
activity demands and context. The role of the occupational
therapist in evaluating cognition and perception is to provide
clear, comprehensive information on the effect of cognitive-
perceptual impairments on activities of daily living (ADLs),
instrumental activities of daily living (IADLs), education, work,
play and leisure, and social participation. The work environment
in which the therapist practices may determine the depth of the
occupational therapist’s involvement because of the nature of the
practice setting and the client’s length of stay. An
interdisciplinary intervention program should emphasize the
same major goals during intervention rather than working on
separate skills. For example, the speech language pathologist
might address attention problems within the context of language
material, such as listening to tapes or conversations; the
neuropsychologist might use remedial attentional exercises; the
physical therapist might reinforce attention through motor tasks;
and the occupational therapy practitioner might address
attentional strategies within the context of self-care, leisure,
community, or work activities. An integrated approach that
assists the per- son in seeing patterns of behaviors across
different activities is strongly advocated, rather than one that
reinforces the fragmentation that the client already perceives.
161
The occupational therapy assistant works in cooperation with the
occupational therapist to contribute to the evaluation process
and implement aspects of the occupational therapy intervention
plan (AOTA, 1999). If state licensure permits and service
competency has been demonstrated, an occupational therapy
assistant can administer selected portions of cognitive
assessments as directed by the occupational therapist, provide
clinical observations, and complete behavioral checklists. Once
the targeted behaviors for intervention have been clearly
identified, the occupational therapy assistant and occupational
therapist collaborate to choose a variety of different activities that
can be used to reinforce the desired behaviors.

162
 CHAPTER 20
THE PROCESS OF COGNITIVE REHABILITATION
EVALUATION

This section provides detailed information about cognitive

evaluation issues that are necessary for practitioners to
understand before choosing and performing appropriate
evaluations and assessments. We present the importance of the
evaluation process, its goals, and important considerations in
choosing an assessment. The evaluation process begins with an
occupational profile that considers the client’s typical routines
and occupations (AOTA, 2002). The client is usually asked to
identify everyday activities that he or she is most concerned
about or would like to be able to do with greater ease. However,
people with cognitive impairments often have limited awareness
of their impairments and limited understanding of the
implications of these impairments (Goverover, Chiaravalloti, &
DeLuca, 2005); therefore, a close relative or friend should
participate in identifying concerns and priorities for intervention.
It should be kept in mind that in inpatient settings, clients and
their relatives might be unaware of the presence of mild cognitive
impairments. Subtle cognitive symptoms tend to be apparent
only n higher-level activities such as driving, social participation,
shopping, or using public transportation. A client in an acute or
rehabilitation inpatient setting has not yet had the opportunity to
resume these higher-level activities. Comprehensive cognitive
evaluations are needed for two primary reasons. First,
evaluations provide evidence and information about the presence
of impairments and competencies. Such information can be used
to establish baselines, to plan discharge, and to measure
intervention effectiveness (e.g., rehabilitation outcomes). Second,
evaluations are needed to gather information for intervention
planning. Models for cognitive intervention in occupational
therapy often guide the focus of evaluation. For example, the
cognitive disability model (Allen, 1985) and the neuro functional
model (Giles, 2005) focus on occupational performance and are
not concerned with identifying specific cognitive impairments.
The cognitive disability approach (Allen, 1985) describes
hierarchical levels of cognitive function. Evaluation focuses on
identifying the cognitive level at which the person is functioning.
The neuro functional approach (Giles, 2005) emphasizes training
163
functional skills and habits within naturalistic settings;
therefore, evaluation emphasizes observation of real-life
functioning. The quadrophonic approach (Abreu & Peloquin,
2005) and the cognitive retraining model (Averbuch & Katz, 2005)
are concerned with identifying and understanding the cognitive
impairments that are influencing occupational performance.
Measures of cognitive impairment are examined in combination
with broader measures of occupation to guide intervention. The
multi context approach (Toglia, 2005) is concerned with
facilitating transfer of learning, so evaluation emphasizes
evaluation of learning potential or dynamic assessment. Each of
these perspectives is described in greater detail later in the
chapter.

Approaches to Evaluation of Cognitive Impairments

Traditional Approaches to the Evaluation Process Standardized
cognitive assessments have specific administration guidelines
and compare the client’s performance to normative data. They
are static in nature, evaluating “here and now” performance.
Standardized assessments can help the occupational therapist to
determine whether a cognitive impairment exists and to quantify
the severity of such impairments. These types of assessments are
also useful as baselines against which changes in condition or
ability can be measured over time. Examples of standardized
assessments are summarized in Table 57.1. Cognitive-screening
assessments are a type of standardized assessment designed to
identify problems that need special or further attention. They
typically comprise subtests that are divided into specific cognitive
sub skills such as attention, visual processing, memory, and
executive functions. These assessments are either general in
nature, addressing all cognitive sub skills, such as the
Lowenstein Occupational Therapy Cognitive Assessment, (Katz,
Itzkovich, Averbuch, & Elazar, 1990), or more focused
evaluations of a particular subskill, such as the Motor Free
Visual Perception Test (Colarusso & Hammill, 2002). Impaired
performance on a specific task or subtest is typically used to
define the impairment. For example, difficulty differentiating
foreground objects or figures from background objects (e.g.,
picking up a white sock off a white sheet) would be identified as a
figure-ground impairment (Zoltan, 1996). Many cognitive-
screening assessments were designed to be used with specific
164
populations, such as clients with strokes (Hajek, Rutman, &
Scher, 1989), multiple sclerosis (Rao, Leo, Bernardin, &
Unverzagt, 1991), dementia (Mattis, 1976), or traumatic brain
injury (Ansell & Keenan, 1989) or elderly clients (Golding, 1989).
These assessments have subtests that focus on areas of
impairment that are typically seen within the diagnostic
population. Mental status exams, such as the popular Mini
Mental State Exam (Folstein, Folstein, & McHugh, 1975) and
cognitive screening assessments have some disadvantages, as
they rely heavily on verbal skills, can be culturally biased (owing
to comparison to normative populations), and have substantial
false-negative rates (i.e., missing possible cognitive impairments).
The deficits of clients with focal lesions, particularly right-
hemisphere lesions, or mild diffuse cognitive disorders are often
missed (Nelson, Fogel, & Faust, 1986). Cognitive-screening
assessments usually miss more subtle impairments that are
displayed by higher- level, clients as the breadth and depth of
item content are limited (Doninger, Bode, Heinemann, &
Ambrose, 2000).

Direct Observation of Function

Direct observation of function is an alternative method that is
used to identify cognitive-perceptual impairments. A variety of
standardized functional assessments (presented in Table 57.1)
use a numerical or descriptive scale to rate performance and the
amount of cognitive cueing and/or physical assistance required
to complete a particular task. Some functional assessments are
designed to identify the cognitive and perceptual impairments
that interfere with successful performance on such tasks. For
example, in the OT-ADL Neurobehavioral Evaluation (A-ONE)
(Arnadottir, 1990), a client is observed performing a basic ADL
activity (e.g., putting on a shirt) for possible cognitive
impairments such as spatial relation difficulties, unilateral
spatial or body neglect, and the like. The Executive Function
Performance Test (Baum, Edwards, Morrison, & Hahn, 2003;
Goverover et al., 2005) is another functional performance test
that analyzes cognitive impairments such as initiation,
organization, and safety by observing client performance on IADL
activities such as making a phone call. Functional tasks require
the integration of a variety of skills, so it can be difficult to isolate
the specific cognitive problems interfering with performance.
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Some functional assessments try to identify broad areas of
cognitive and perceptual strengths and weaknesses by identifying
the underlying processes that contribute to difficulty in per-
forming functional tasks. Therefore, subtle cognitive impairments
might not be readily apparent in familiar activities. Functional
assessments that simulate performance in a treatment setting
might not be predictive of performance in natural contexts in
which the person has to set goals, plan, initiate, problem-solve,
and deal with subtle and complex environmental cues. Situations
that require higher-level cognitive perceptual skills are difficult to
capture in structured treatment environments. In addition,
contextual factors can increase or decrease cognitive demands of
performance, so it important to consider the context in which an
activity is performed. Hamera and Brown (2000) developed the
Test of Grocery Shopping Skills as a real-world measure of
community function for people with chronic schizophrenia.
Clients are asked to shop for a list of 10 grocery items in a
natural context. In hospital-based treatment settings, the
occupational therapist might not be able to create a close enough
approximation of a real-world environment. The contextual
influence on performance needs to be kept in mind, and if
feasible, performance should be observed across real-world
contexts. Other tools that involve direct observation of
performance have been developed to measure the cognitive levels
associated with the cognitive disability model. For example, the
Allen Cognitive Level Screen (ACLS) (Allen, 1985) uses a leather-
lacing task to provide a quick measure of learning and an initial
estimate of cognitive function. The ACLS screen is then validated
by further observations of performance in craft activities or
ADL/IADL activities using additional tools such as the Routine
Task Inventory (RTI), Allen Diagnostic Module craft projects, or
the Cognitive Performance Test (Allen, 1993; Allen, Earhart, &
Blue, 1992). These tools are interpreted within Allen’s conceptual
framework and focus on broadly identifying the person’s cognitive
level or general information-processing capacities. In contrast to
functional assessments that are concerned with rating specific
cognitive skills or the degree of assistance that is required on
specific functional tasks, assessment of the person’s cognitive
level involves global functional abilities and is meant to explain
and predict ability to function in various activities and contexts.

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OVERVIEW OF INTERVENTION APPROACHES
Interventions for people with cognitive dysfunction differ in the
areas that are targeted for intervention and in the underlying
assumptions about individuals’ abilities to learn and generalize
information. The characteristics and underlying assumptions of
the different intervention approaches are explored in this section.
Factors that are critical in the selection of these intervention
approaches as well as methods for systematically integrating
them are also discussed. As you read this section, review the
case study on cognition and performance context.

Capitalizing on the Assets: The Functional Approach:

The functional approach capitalizes on the person’s assets to
improve occupational performance. The emphasis is on reducing
activity limitations and participation restrictions rather than on
remediating or restoring impaired skills .The functional approach
can be subdivided into three intervention techniques: adaptation
of the activity or context, functional task training, and
compensation. The Cognitive Disability Model (Allen, 1985)
emphasizes use of adaptation, while the Neuro functional
Approach (Giles, 2005) focuses on functional task training.

Adaptation of the Activity or Context

Adaptation involves changing, altering, or structuring the activity
demands or context to prevent disruptive behaviors or accidents,
minimize cognitive or perceptual demands of a task, minimize
caregiver burden, and maintain the client’s level of functioning
(Erikson, Karlsson, Soderstrom, Tham, 2004; Radomski,
Dougherty, Fine, & Baum, 1993). Rather than providing direct
intervention to the client, the focus is on providing support,
education, and training to the caregiver, family, or employer
(Sohlberg, Glang, & Todis, 1998). Adaptations should directly
address the problems and needs that have been identified by the
client or significant other and be designed in collaboration with
them (Campbell, Duffy, & Salloway, 1994) Adaptations might be
fixed (e.g., installing an alarm on a door to prevent wandering), or
they might require ongoing implementation and monitoring (e.g.,
preselecting clothes from the closet on a daily basis). In the latter
case, implementation depends on the ability, consistency, and
reliability of another person. In some cases, a significant other
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can be trained to alter or structure the activity demands or
context to maintain the person’s performance capabilities. For
instance, the person might not be able to attend to the task of
preparing a meal but might be able to perform individual
components, such as mixing the salad or folding napkins in half
for the table setting. Engagement in such meaningful activity
components can help to maintain the client’s performance
capabilities and prevent disruptive behaviors (Levy & Burns,
2005). Although adaptations can produce rapid changes in
function, the effects are limited to the activity or environment
that is adapted, and success often depends on the extent to
which other people are able to consistently follow through with
the adaptations.

Adaptation
The Cognitive Disability Approach Allen (1985, 1993) designed a
cognitive disability approach that provides guidelines for
matching and adapting the individual’s cognitive level with
activity demands. This approach for evaluation and intervention
was designed initially for people with psychiatric disorders and
chronic cognitive disabilities (e.g., dementia) and later was
expanded for individuals with different central nervous system
problems resulting in cognitive impairments (e.g., stroke). In this
model, function is organized into six ordinal levels of global
function ranging from normal (level 6) to profoundly disabled
(level 1). Modes of performance within each level further qualify
behavior variations and allow for more sensitive measurement of
the person’s capacity. To get an elaborated description of the
Allen Cognitive Level, refer to Allen (1985) and Levy and Burns
2005). Each of Allen’s cognitive levels has three components:
attention, motor control, and verbal performance. The person’s
cognitive progress can be seen as a continuum along two
dimensions, motor and verbal performance, which are linked by
attention. The six cognitive levels are used to describe functional
profiles of capacities and limitations that help to clarify and
direct interventions and care. Allen’s model provides clinicians
with intervention guidelines for different levels of cognitive
function. For example, the cognitive levels identify the required
assistance needed, as well as what the person is still able to do
safely. This information is used to educate and train caregivers
and to make recommendations for assistance and environmental
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adaptations to optimize function and safety. It is also used to
select activities that match the person’s cognitive level and
maximize participation in meaningful occupations (Allen, 1985;
Allen et al., 1992; Levy & Burns, 2005).

Functional Task Training:

The Neuro functional Approach Giles (2005) describes a neuro
functional approach that emphasizes the use of task-specific
training or rote repetition of a specific task or routine within
natural contexts to develop habits or functional behavioral
routines. Emphasis is on the mastery of functional task
performance through practice rather than on the underlying
skills that are needed to perform the task. Giles (2006) states
that development of new functional habits and routines can
occur in clients who have decision-making deficits and only
minimal awareness of their impairments. Behavioral techniques,
including reinforcement and chaining, are incorporated into
practice sessions. Intervention involves breaking down a
functional task into small subcomponents (Giles, 2005; Glisky,
Schacter, & Butters, 1994). Techniques such as errorless
learning or the method of vanishing cues may be used. In
errorless learning, the person is prevented from making incorrect
or inappropriate responses during the learning process. The
vanishing cue method involves systematically reducing or fading
the cues that are required to perform a task. There is evidence
that errorless learning techniques are more effective than the
vanishing cue method in people with severe memory impairment
(Evans, Levine, & Bateman, 2004; Kessels & de Haan, 2003;
Page, Wilson, Sheil, Carter, & Norris, 2006). Functional task
training capitalizes on procedural or implicit memory. Case
studies have demonstrated that functional task training can
produce significant changes in activities of daily living and work
tasks in people with severe impairments (Giles, 2005; Giles,
Rideley, Dill, & Frye, 1997; Giles & Shore, 1989; Glisky et al.,
1994, Hallgren & Kottorp, 2005; Kottorp, Hallgren, Bernspang, &
Fisher, 2003). However, intervention addresses only one task or
routine at a time, and extensive training, time, and effort may be
required to achieve success within one task sequence and
environment. The person might have difficulty in dealing with
minor changes in the task stimuli or the environment.
Proponents of this method argue that people with cognitive
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impairment should be treated in the natural context in which
they will function, because people with brain injury have
difficulty generalizing learning (Giles, 2005; Glisky et al., 1994).

Compensation
Compensation teaches the person to bypass or minimize the
effects of the impairment by modifying the method that is used to
perform an activity. The client is expected to initiate and
implement the use of an external aid or strategy to enhance
occupational performance in a variety of different situations
(AOTA, 1999). The complexity of the task and the compensatory
strategy may require awareness and acceptance to be generalized
and independently applied to a variety of situations (Birnboim &
Miller, 2004; Toglia, 1993a). For example, a memory notebook
could be used to compensate for memory loss. Independent use
requires that the person recognize that he or she is having
difficulty with memory and perceive the need to write things
down to aid in remembering. It also requires initiation of use of
the book in multiple situations. Clients with more severe
cognitive impairments can be trained, through rote repetition and
errorless learning, to use simplistic compensatory strategies and
modifications with minimal awareness of why the strategy is
needed (Giles, 2006; Hallgren & Kottorp, 2005; Kottorp et al.,
2003). In these clients, the compensatory strategy becomes
automatic and integrated into the person’s habits or functional
routines.

Addressing the Cognitive Perceptual Impairment

The Remedial Approach
Remedial approaches place an emphasis on restoring impaired
cognitive-perceptual skills (Unsworth, 2007). The emphasis is on
changing the person’s underlying skills rather than on
manipulating the activity demands or context (Neistadt, 1990;
Zoltan, 1996). In traditional cognitive-perceptual remedial
approaches, cognitive skills are conceptualized in terms of higher
cortical skills, which are divided into a hierarchy of discrete sub
skills such as attention, discrimination, memory, sequencing,
categorization, concept formation, and problem solving. The
lower-level skills provide the foundation for more complex skills
and behaviors (Toglia, 1998). For example, attention skills are
addressed before higher level cognitive skills such as problem
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solving. Intervention emphasizes practice of the specific cognitive
or perceptual skills that are deficient, using worksheets,
computerized exercises, and electronic scanning devices. One
example of a remedial training program is the Attention Process
Training Program (Sohlberg & Mateer, 1989a, 2001). This pro-
gram includes graded worksheets and audiotapes that are
systematically graded to place increasing demands on different
aspects of attention. It is assumed that improvement in
underlying cognitive perceptual skills will have a greater
influence on behavior than will direct training of functional task
training because learning will spontaneously generalize to a wider
range of activities. For example, if block design construction
improves during remedial treatment, it is assumed that there will
also be improvement on a wide range of other tasks involving
constructional skills, such as dressing or making a sandwich.
Remedial training has also been referred to as the transfer
training approach (Toglia, 1998). Improving underlying cognitive
or perceptual deficits is thought to promote recovery or
reorganization of the impaired skill. Information on functional
reorganization and adult brain plasticity supports this view. For
example, it has been postulated that some parts of the brain may
assume new functions or work together in different ways as a
result of environmental experiences (Luria, 1973). Functional
magnetic resonance imaging that show changes after cognitive
rehabilitation provides preliminary support for this premise
(Laatsch, Little, & Thulborn, 2004; Laatsch, Thulborn, Krisky,
Shobat, & Sweeney, 2004; Wykes et al., 2002). However, Neisdadt
(1994) observed that “because both remedial and adaptive
intervention approaches stimulate clients to learn new behaviors,
neither approach can claim to take advantage of adult brain
plasticity more than the other” (p. 426). Dirette, Hinojosa, and
Carnevale (1999) compared remedial and compensatory training
and found no significant difference between the two approaches.
It was observed that participants in the remedial group began to
use compensatory strategies, thus confounding results. Remedial
activities focus on the area of impairment and provide structured
tasks that accentuate the problem areas; therefore, awareness
and insight into one’s impairments may improve as a secondary
effect. The emergence of awareness could allow some individuals
to initiate use of compensatory strategies. There is some evidence
that supports the effectiveness of remedial intervention for
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specific cognitive skills, such as attention and visual scanning.
However, intervention has been found to be more effective when
it incorporates use of self-monitoring techniques and strategy
training across a variety of activities (Cicerone et al., 2005).
Studies have not supported the isolated use of repetitive graded
memory drills, computerized memory games, logic games, or
other cognitive remedial activities.

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 CHAPTER 21
DISEASE OF THE SPINAL CORD
MULTIPLE SCLEROSIS

Multiple sclerosis (MS) is a progressive neurological condition

that is characterized by patches of demyelination of nerves in
areas of the brain and the spinal cord, which result in distorted
or interrupted transmission of nerve impulses to and from the
brain (Beers & Berkow, 1999). MS is considered to be an
autoimmune disease. The body’s own defense system attacks the
myelin sheath that surrounds and protects the nerve fibers of the
CNS. The sites where myelin is lost appear as hardened sclerotic
(scarred) areas in the CNS and cause a variety of physical and
neurological symptoms (Reed, 2001).

PREVALENCE/INCIDENCE
Approximately 400,000 Americans have MS, and every week,
about 200 people are diagnosed. Worldwide, MS may affect 2.5
million individuals. Most people with MS are diagnosed between
the ages of 20 and 50 years. It affects twice as many women as
men.

COURSE
People with MS can expect one of four clinical courses of disease,
each of which might be mild, moderate, or severe (National
Multiple Sclerosis Society, 2004).

Relapsing-Remitting
In the relapsing-remitting course, the person experiences clearly
defined exacerbations (relapses) and episodes of acute worsening
of neurological function that are followed by partial or complete
recovery periods (remissions) free of disease progression. This is
the most common form of MS at time of initial diagnosis (∼85%).

Primary Progressive
In the primary-progressive course, the person experiences a slow
but nearly continuous worsening of the disease from the onset,
with no distinct relapses or remissions. However, there are
variations in rates of progression over time, occasional plateaus,
and temporary minor improvements. This course is relatively rare
(∼10%).
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Secondary-Progressive
In the secondary-progressive course, the person experiences an
initial period of relapsing-remitting disease followed by a steadily
worsening, unpredictable disease course. About 50% of people
with relapsing-remitting MS developed this form of the disease
within 10 years of their initial diagnosis. However, there is
preliminary research to suggest that disease-modifying
treatments may significantly delay this progression.

Progressive-Relapsing
In the progressive-relapsing course, the person experiences a
steadily worsening disease from the onset but also has clear
acute relapses, with or without recovery. In contrast to relapsing-
remitting MS, the periods between relapses are characterized by
continuing disease progression. This course is relatively rare
(∼5%).

PROGNOSIS
According to Dirette (2007), approximately 60% of individuals
with MS can continue to be fully functional for up to 10 years
following their first exacerbation. In addition to this,
approximately 30% of individuals with MS continue to be able to
function 30 years after their first exacerbation. The fact that an
individual is diagnosed with MS does not mean that his or her
life expectancy is significantly decreased. There are some
individuals, however, who do become quite disabled secondary to
MS, and some even die prematurely from infections or
complications (Dirette, 2007).

SYMPTOMS
Primary Signs as a Result of Demyelination of the CNS
 Muscle stiffness (spasticity) or weakness
 Tremulousness in extremities
 Paresthesias, numbness, and blunting of sensation (e.g.,
reduced pain or temperature sense, disturbances of
vibratory or position sense)
 Partial or complete paralysis of extremities
 Visual deficits (vision loss, blurred or double vision)
 Extended periods of fatigue
 Interruptions in sexual functioning
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  Problems with memory, concentration, information
processing, or rapid problem solving skills
 Visual-spatial deficits
 Difficulty articulating speech
 Fluctuation in mood/depression
 Emotional lability

Secondary Signs
 Pain
 Staggering gait and/or loss of balance
 Poor coordination
 Loss of bladder or bowel control; frequent urinary tract
infections
 Anxiety and sleep disturbances
 Contractures and pressure sores
 Decreased ADL skills

Tertiary Signs
 Shift in roles, changing responsibilities
 Social isolation
 Divorce
 Loss of independence
 Stigma of disability (Shapiro, 2003)

INTERDISCIPLINARY TREATMENT
Medications
 Corticosteroids are used to shorten acute attacks, reduce
inflammation, and ease symptoms.
 Disease-modifying treatment with injections of the protein
interferon-beta reduces the frequency of re- lapses in MS
and might help to delay eventual disability. These
medications have shown effectiveness in modifying the
natural course of relapsing MS by altering the rate and/or
extent of disease progression. Medication management with
these “disease modifiers” is recommended as early as
possible for individuals with a relapsing course.
 More potent medications are being developed that are
effective in slowing down MS that is rapidly worsening or
becoming progressive (Beers & Berkow, 1999).

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 Rehabilitation
 Physical therapy: Physical therapy focuses primarily on
mobility and the use of mobility aids, spasticity of the
muscles, and physical fitness. Personalized exercise
programs may help people recover muscle control and
strength after an exacerbation. There is significant evi-
dence associating aerobic exercise with improved quality of
life, mobility, endurance, and reduction in fatigue (Mostert
& Kesselring, 2002). Hydrotherapy is a popular form of
aerobic exercise that addresses the fatigue and weakness
experienced by individuals with MS.
 Occupational therapy: Occupational therapy focuses on
strength, coordination, and fine motor control of the upper
extremities. Fatigue and pain management tech- niques
have been well supported as a means to improve
occupational performance and satisfaction. Psycho- social
intervention is embedded in the treatment plan to address
cognitive, emotional, and self-concept issues.
 Speech therapy: In progressive forms of MS, problems with
speech or swallowing due to muscle weakness or a lack of
coordination may need to be addressed.
 Psychosocial support/counseling: Individual or
grouptherapy can help individuals with MS and their
families to deal with depression, anxiety, and the
unpredictability of the disease process. Evidence suggests
that a personalized psychosocial rehabilitation program
encourages active participation, increased autonomy, and
improved quality of life (Ferriani et al., 2002).

OCCUPATIONAL THERAPY EVALUATIONS

Comprehensive Evaluations
 The Functional Assessment of Multiple Sclerosis (FAMS)
 Functional Independence Measure (FIM)
 Multiple Sclerosis Impact Scale (MSIS-29)
ADL Evaluations
 Assessment of Motor and Process Skills (AMPS)
 Barthel Index (BI)
Fatigue Evaluations
 Fatigue Severity Scale (FSS)
 Modified Fatigue Impact Scale (MFIS)
Psychosocial Evaluations
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  Beck Depression Inventory (BDI)
 Self-Perceived Burden Scale (SPBS)
 Ways of Coping Checklist (WCC)
Quality of Life/Life Satisfaction Evaluations
 Canadian Occupational Therapy Performance Measure
(COPM)
 Health Status Questionnaire
Multiple Sclerosis QOL Inventory (MSQLI)
 Multiple Sclerosis Quality of Life-54 (MSQOL-54)
 Occupational Performance History Interview (OPHI)
Other Areas to Address
 Balance and coordination
 Caregiver adjustment
 Cognition and memory
 Coping skills
 Daily living skills
 Driving skills
 Environmental barriers
 Fine motor skills
 Leisure interests
 Locus of control
 Muscle strength and spasticity
 Pain and sensation
 Self-concept
 Sexuality
 Vision and perception
OT INTERVENTIONS
 ADL training
 Assistive technology
 Cognitive retraining
 Employment modifications
 Energy conservation
 Environmental modifications
 Home management
 Pain treatment
 ROM/endurance/strengthening for functional activity
 Safety awareness
 Splinting
 Stress management

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OT AND THE EVIDENCE
Meta-analysis suggests that occupational therapy–related
treatments are effective in treating the deficits associated with
MS, particularly for outcomes in the capacity and ability (e.g.,
muscle strength, ROM, mood) and task and activity (e.g.,
dressing, bathing, ambulation) levels of performance. The effect
sizes for the capacities and abilities outcomes were generally
large for studies that examined a specific intervention method,
such as exercise, fatigue management, cooling, and
transcutaneous electrical nerve stimulator application for pain. A
smaller effect size has been shown for emotional and cognitive
outcomes, such as stress management, skills training in
socialization, and attention training (Baker & Tickle-Degnen,
2001). Alternative therapies including acupuncture, massage,
yoga, meditation, and dietary modifications have shown
encouraging results as part of the treatment program for
individuals with MS (MS Australia, 2001). Fatigue is one of the
most common targets of OT intervention. It impedes an affected
person’s ability to fully engage in desired occupational
performance and roles. There is significant evidence to support
the use of energy conservation education within both community
based and inpatient rehabilitation settings to reduce the impact
of fatigue among people with MS and possible positive change
associated with peer support (Vanage, Gilbertson, & Mathiowetz,
2003). Energy conservation courses, including education about
rest and delegation of tasks to others, have been found to be
effective intervenetions (Holberg & Finlayson, 2007; Matuska,
Mathiowetz, & Finlayson, 2007; Vanage et al., 2006). Coping
involves cognitive and behavioral efforts to master, reduce or
tolerate an external or internal demand created by a stressful
situation. Certain types of coping strategies have been shown to
be associated with better or worse adjustment in MS. Many
studies in the chronic illness literature have demonstrated that
high levels of increasing feelings of self-efficacy, improving quality
of life, and lower levels of depression are associated with
emotion-focused coping. In contrast, problem-focused coping has
been shown to be associated with lower levels of depression and
higher levels of adjustment. OT intervention should involve
teaching successful coping and integrating it into daily life
(Artnett, Higginson, Voss, Randolph, & Grandey, 2002).

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CAREGIVER CONCERNS
MS affects people in their most productive years: young adults
readying themselves to leave home in pursuit of academic,
vocational, or social goals; men and women starting their careers
and families of their own; and those in middle age who are
enjoying their productive years and planning for retirement. In
each of these age groups, the diagnosis of MS has a significant
impact on the individual and the family members and/or loved
ones in his or her life. Challenges to family coping include the
following:
 Individual needs and coping styles
 Disruption in family rhythm
 Disruption in family communication
 Uncertainty and anxiety
 Adaptation and adjustment
 Impact of cognitive changes
Approximately 100,000 people who have MS require help with
daily activities or personal care. They receive most of their help
from spouses, who typically have major additional
responsibilities, including employment and child care. Caregiver
burnout has many different causes, including physical strain and
emotional stress. Some ways to address these issues include the
following:
 Effective communication
 Relieving pressures of caregiving
 Planning and decision making for the future (Kalb.

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