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Vision, Perception And Cognition: A Manual For Evaluation & Treatment Of The Neurologically Impaired Adult / Edition 3

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The best-selling book, The Adult Stroke Patient, Second Edition, has b een completely revised and updated to become Vision, Perception, and C ognition: A Manual for the Evaluation and Treatment of the Neurologica lly Impaired Adult, Third Edition. The new edition of this extraordin ary book is an indispensable reference for outlining the theoretical b asis for visual, perceptual, and cognitive deficits, as well as specif ic procedures for the evaluation and treatment of these deficits. The book clearly explains each deficit and provides step-by-step testing t echniques along with complete treatment guidelines. The author has ad ded additional theoretical information to back up evaluation and treat ment decisions that are discussed. All the sections have been updated to represent the most current information available. This essential t ext now provides information for a more holistic approach as well as i dentifies subcomponent skills.

The book contains black-and-white illustrations.

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Product Details

  • ISBN-13: 9781556422652
  • Publisher: SLACK, Incorporated
  • Publication date: 1/1/1996
  • Edition description: Older Edition
  • Edition number: 3
  • Pages: 232
  • Product dimensions: 7.00 (w) x 10.00 (h) x 0.50 (d)

Meet the Author

Barbara Zoltan, MA, OTR
Barbara Zoltan, MA, OTR, is a consultant in private practice in Northern California. She obtained her BS In Occupational Therapy from Tufts University and her master's degree from the University of Southern California. She holds certifications in both sensory integration and neurodevelopmental treatment and serves on the editorial boards of the Journal of Head Trauma Rehabilitation and Occupational Therapy in Health Care. Her 20 years of experience specializing in neurological rehabilitation has included a broad range of research, teaching, administrative and clinical practice. She has published over 20 articles, chapters amd books related to the rehabilitation of the adult with neurological deficits.
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Read an Excerpt

Chapter 1: Theoretical Basis for Evaluation andTreatment

Occupational therapy, as with any scientific profession, requires a conceptual foundation with underlying assumptions to guide practice decisions. These theoretical concepts are generally structured into models. Portions of these models, which are methodological in emphasis, form a frame of reference.' The frame of reference is the mechanism which links theory to practice.' Occupational therapy contains many frames of reference depending on the patient population or specific area of focus. Although these frames of reference have been effective to some degree, it is only recently that the profession has begun to relate them to an overall theoretical basis for occupational therapy practice.

Every occupational therapist would agree that the profession is based on the concept of human occupation. Referrals are made because of the patient's inability to perform daily life tasks, which prevents independence and return to previous social roles. Not all occupational therapists however, would agree on how to evaluate and treat these inabilities. Many therapists advocate for the need to evaluate component skills such as attention, memory or strength as a means to help clarify the cause of occupational performance deficits and assist in treatment planning. Assumptions are made based on established research, about the correlation of specific component deficits to the patient's problems with occupational performance.' This method of evaluating and testing component skills has recently come into question. Some therapists believe this approach to be reductionistic and recommend a more holistic focus of evaluation and treatments. It is felt that "...while a certain causal relationship does exist whereby improvement in the microlevel of cognitive components of performance may result in improved occupational performance in real life, a large variance in actual performance abilities cannot be explained by looking at or treating the micro-level alone:'6 These therapists believe that occupational performance should be the primary focus of occupational therapy assessment and treatment.

As with any controversy, critical thinking or questioning often results in an improved perspective. This perspective leads to the incorporation of ideas from many sides and the formation of a solution which is useful and beneficial to all practitioners. Catherine Trombly, for example, answers to the labeling of component skills evaluation as "reductionistic" as follows.

If a hierarchical theory of occupational functioning that includes abilities and capacities is accepted, then the assessment process should include these levels ....the assessment should not be considered a reductionistic one, but rather an augmentative one that relates and extends each level toward occupational functioning.

Abreu et al support the need for multiple level evaluation and treatment in their description of the new functional treatment. They encourage therapists to evaluate the patient at both the micro and macro levels of occupational functioning so that abilities and skills can be reliably monitored at both levels. Ben-Yishay and Diner describe cognitive difficulties as "layered and coexistent." They also recommend a systematic, multi-model approach to cognitive rehabilitation. Farrell et al, believe the effective remediation of visuo-motor deficits requires a systematic approach within a hierarchical framework.

Research which clarifies the relationship between components and higher level skills, as well as the minimal abilities required to accomplish activities that compose tasks of particular roles, is needed.' Extensive tool development is also needed for the evaluation of role performance, occupational performance and performance components. Measures which evaluate the thinking demands of day to day living are just recently being developed. The processes by which patients solve problems are being analyzed in addition to the scores themselves."

In summary, the theoretical basis for evaluation and treatment need not include one level of focus to the exclusion of another. Evaluation and treatment which focus on deficits of components of function thought to be prerequisites of occupational performance have been termed bottom-up assessment.' Examining role competence, the tasks which define these roles and what the patient can and cannot do, is termed top-down assessment. The combination of both top-down and bottom-up assessment and treatment of occupational functioning will give the clearest picture of the patient's overall functioning at all levels. The therapist should choose a combination of assessments and treatments to provide the most complete picture of the patient in the least amount of time.' In order to make these decisions, the therapist must understand the underlying concepts and have a framework for organizing and interpreting information.

The theoretical basis r the treatment of visual, perceptual and cognitive deficits has traditionally been divided into two categories, adaptive and remedial." There are many factors which may dictate whether the remedial or adaptive approach or a combination of the two approaches is utilized. The current state of the health care system in general and trend of shorter hospital stays, for example, may necessitate the use of an adaptive approach. Many believe, however, that by combining both schools of thought we can best meet the needs of our patients.

One factor which must be considered in making a choice between a remedial or adaptive approach is the patient's ability to learn." In order to utilize the remedial approach, the patient must have some learning capacity. 'I The therapist must identify what modes of input the patient can process most easily, what approaches to tasks are still available to the patient, and what tasks are still meaningful to the patient.

A variety of frames of reference for treatment have been operationalized and fall within either a remedial or adaptive conceptual base. The underlying assumptions of this conceptual base are subsequently described in this chapter. In addition, the frames of reference which are most widely utilized by occupational therapists are reviewed. The theoretical information presented is meant as an overview and the reader is encouraged to seek out additional references and certification as needed. The information presented in this chapter is then applied and integrated into later portions of the book which provide specific evaluation and treatment techniques.

Remedial Approach

The remedial approach, at times termed the restorative approach, focuses on the impairment underlying the disability. It utilizes repeated drills and exercises which are aimed at specific cognitive processes in an attempt to promote new neural connections and recovery of function. It is assumed that the brain can repair itself by reestablishing synaptic connections or growing new ones. It is also assumed with a remedial approach, that occupational performance is composed of subcomponents which can be "...remediated by a building block approach that emphasizes improvement of hierarchical elements/subcomponents to allow the structure of occupational performance to be reconstructed:" The goal of the remedial approach is to increase and improve the patient's ability to process and use incoming information so as to allow increased function in everyday life."' Remedial treatment is a bottom up approach which assumes the patient will be able to generalize to activities of daily living.' It is assumed that "...if one trains to remediate an impaired core area of cognitive function, the individual will be able to resume competent functioning in those daily life situations that involve these core functions." Some research has shown, however, that a restorative approach to some subcomponent skills has had a limited direct impact on the enhancement of functional activities. Some examples of remedial approaches are Sensory Integrative, Affolter and Neurodevelopmental.

Adaptive Approach

The adaptive approach is a top down approach which promotes adaptation of and to the environment to capitalize on the patient's abilities. Adaptive approaches provide training in actual occupational behaviors and are traditionally used when restoration is unlikely. Adaptive approaches facilitate improved function through compensation. Compensation is any practical environmental adjustment "...made to make up for performance deficits" (eg, adaptive equipment, assistance from a caregiver or training procedures that are activity or situation specific).

Compensation can be external, which is assistance provided by outside sources, or situationaL, which is a technique utilized by the patient so he does not depend on others. In order to utilize situational compensation techniques, the patient must have at least some awareness of existing deficits. This awareness may cause the patient to be frustrated with his performance, however, it will help motivate him to learn new strategies. Compensatory behaviors are most successful when they are overlearned to the point of automatic.' In addition, compensation strategies should be practiced in a variety of different environments. The choice and design of activity or environmental compensations is based on the therapist's understanding of disability and activity analysis. Some examples of adaptive approaches are Functional, Occupational Performance, and Dynamic Interactional Approach...

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Table of Contents

About the Author
Ch. 1 Theoretical Basis for Evaluation and Treatment 1
Ch. 2 General Evaluation Issues 21
Ch. 3 Visual Processing Skills 27
Ch. 4 Apraxia 53
Ch. 5 Body Scheme Disorders 73
Ch. 6 Visual Discrimination Skills 91
Ch. 7 Agnosia 109
Ch. 8 Orientation, Attention and Memory 121
Ch. 9 Executive Functions 149
Ch. 10 Acalculia 177
Ch. 11 Factors that Influence the Patient's Vision, Perception and Cognition 185
Ch. 12 The Use of Computers in Visual, Perceptual and Cognitive Retraining 193
Appendix A: Additional Current and Related Evaluations Developed by Occupational Therapists 199
Appendix B: Evaluation Index 201
Index 203
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More than half a million cerebral vascular accidents (C.V.A.) occur annually in the United States, and at any given time, there are 2 million people who have survived a C.V.A. Of those surviving the initial insult, 50 percent will live another five years and 75 percent will be rehabilitated to some degree of independence. Of these new patients, 60 to 70 percent can expect to become ambulatory, although significant functional return of the affected upper extremity is expected in only 30 to 40 percent. There are over 422,000 new cases of traumatic brain injury (T.B.I.) each year. 1,4 At any given time, approximately 926,000 people sustain deficits to the extent that they require services.

Until recently, rehabilitation focused on restoration of motion and compensation for lost functional skills. Visual, perceptual and cognitive deficits, noted for many years to exist as a result of cerebral vascular accidents or T.B.I., have only recently been acknowledged as a cause of continued confusion and lack of rehabilitation progress in many patients even though motor skills have returned. As many as two thirds of all T.B.I. patients experience some type of cognitive loss.' Recent research has clearly shown a significant relationship between visual, perceptual and/or cognitive loss and functional abilities.

Despite the prevalence of C.V.A and T.B.I. patients, the formulation of definitive evaluation and treatment techniques remains incomplete at best. This manual was completed after extensive research and clinical experience and is intended to reflect the current state of the art in the evaluation and treatment of visual, perceptual and cognitive processing deficits for the adult withneurological impairment. It is intended to be a resource book, and as such the material has been documented as closely as possible for future referencing. Generally, theoretical information is included as well as specific theoretical information pertaining to each sub-component skill. The application of this information to practice through specific frames of reference is also provided. Finally, specific evaluation and treatment techniques based on this theoretical information are outlined.

It is my goal that this manual be useful for both the student and the experienced clinician. It is also my hope that it will foster good clinical reasoning skills and stimulate future research.

Barbara Zoltan, MA, OTR

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