CHAPTER 1

OVERVIEW OF NERO- ANATOMY

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Neuroanatomy
The brain is divided into four main areas

Forebrain-
Ø Cerebrum divides into two hemispheres with four lobes (frontal, parietal,
temporal and occipital lobes)
Ø Internal capsule
Ø Basal ganglia (caudate nucleus, globus pallidus and putamen)
Ø Diencephalon (thalamus and hypothalamus)

Midbrain (brainstem)-
Ø Mesencephalon (midbrain).
Ø Pons.
Ø Medulla oblongata.

Hindbrain-
Ø Cerebellum
Ø Spinal medulla
Cerebrum-
Ø Conscious thought processes, intellectual functions
Ø Memory storage and processing
Ø Conscious and subconscious regulation of skeletal muscle contractions.

Thalamus-
Ø Relay and processing centers for sensory and motor information.

Hypothalamus-
Ø Centres controlling emotions, autonomic functions and hormone
production.
Ø Mesencephalo
Ø Processing of visual and auditory data
Ø Generation of reflexive somatic motor responses
Ø Maintenance of consciousness.

Pons-
Ø Relays sensory information to cerebellum and thalamus
Ø Subconscious somatic and visceral motor centers.

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

Cerebellum-
Ø Coordinates complex somatic motor patterns
Ø Adjusts output of other somatic motor centers 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:
Ø Anterior cerebral artery.
Ø Middle cerebral artery.

The posterior circulation comprising two vertebral arteries which lead to:
Ø Posterior inferior cerebellar artery.
Ø Basilar artery.
Ø 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 example, the left hemisphere senses and controls movement on the right side of
the body and specializes 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 specialized in more creative, spatial and interpretive skills
Testani-Dufour and Morrison (1997) summarized the arterial supply of the brain
and the results of occlusion to those arteries. They also summarized the functions
of the different areas of the brain and the impairments that can occur as a result of
damage (occlusion) to those areas.

CHAPTER 2
ACUTE NEURO/NEUROSURGICAL CARE
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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

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 disoriented in time and place

Words – Utters occasional words rather than sentences

Sounds – Groans or grunts, but no words

None

Supraorbital nerve or fingernails pressure

Spontaneous To speech, To pain and None

MOTOR RESPONSE – 5 categories

Obeys commands

Localizing 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 = ‘localizing to pain’. (Pressure
to nail beds or sternum at this stage may not differentiate ‘localizing’ 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 localize 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

Testing requires alertness and is not possible in a confused or dysphasic patient.

IMMEDIATE memory – Digit span – ask patients to repeat a sequence of 5, 6, or 7

random numbers.
RECENT memory – Ask patients 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 a patient to remember a sentence or a short story and test
after 15 minutes.

VISUAL memory – Ask patients 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 the patient to reverse 3 or 4 random numbers.

Ask patients to explain proverbs.

Ask patients 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 fibers in the nasal mucosa, e.g. soap, tobacco.
One nostril is closed while the patient.

OPTIC NERVE (II)

Light? Severe deficit – Can a patient see movement? Visual acuity: Can a 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

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 map out ‘cone’ vision. A 2 mm pin will
define central field defects which may only manifest as a loss of color 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 eyes.
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 a 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 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 the patient's
jaws by applying pressure to the chin. Ask the 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 the 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.

FACIAL NERVE (VII)

Observe patient as he talks and smiles, watching for:

Ø eye closure
Ø asymmetrical elevation of one corner of mouth
Ø Flattening of nasolabial fold.
Patient is then instructed to: wrinkle forehead (frontalis) (by looking upwards)
Ø close eyes while examiner attempts to open them (orbicularis oculi)
Ø purse lips while examiner presses cheeks (buccinator)
Ø 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 the patient to open their
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 Depresses
the patient’s tongue and touches the 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

Ask the 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 patients 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 the patient to open mouth; inspect tongue. Look for – evidence of atrophy
(increased folds, wasting) fibrillation (small wriggling movements). Ask the
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 the 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

Ø muscle wasting If in doubt, measure circumference at fixed distance
Ø Muscle hypertrophy above/below joint. Note muscle group involved.
Ø Muscle fasciculation irregular, non-rhythmical contraction of muscle
fascicles, increased after exercise and on tapping muscle surface.
 Ø muscle myokymia a rapid flickering of muscle fibers, 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.

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. Memorizing 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 the 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:
Ø Two point discrimination: the ability to discrimination.
Ø 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).
Ø Sensory inattention (perceptual rivalry): the ability to detect stimuli (pin
prick or touch) in both limbs, when applied to both limbs simultaneously.
Ø Stereognosis: the ability to recognise objects placed in the hand.
 Ø Graphesthesia: 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 the 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 the patient to repeatedly run the heel from the opposite knee down the shin to
the big toe. Look for ATAXIA (in coordination). Ask the patient to repeatedly tap
the floor with the foot. Note: any DYSDIADOCHOKINESIA (difficulty with
rapidly alternating.
GAIT

Note:
Ø Length of step and width of base Normal
Ø Abnormal leg movements (e.g. excessively high step)
Ø Instability (gait ataxia)
Ø Associated postural movements (e.g. pelvic swinging.

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 different
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 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
bilateral innervation of 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 vascular 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 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.

Pseudobulbar 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 pseudobulbar
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
unable to breathe and generally dies from respiratory failure. It most commonly
affects 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.

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).

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 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) described a
model of stroke 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 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 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 because 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 find 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

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 act on 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
affects 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 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.

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 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 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 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 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 experiences
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 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 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 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 details 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 present 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 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:
Ø 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.
Ø 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.
Ø 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.
Ø 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, &
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 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:
Ø 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.
Ø The patient will improve postural control in order to perform daily living
tasks requiring balance and changes in body position.
Ø The patient will gain increased somatosensory perception and/or will
employ compensatory strategies in order to perform ADL safely.
Ø 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.
 Ø 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.
Ø The patient will gain visual function or will employ compensatory
strategies in order to safely resume previously performed ADL.
Ø The patient will improve motor planning ability in order to relearn old
methods or learn new methods of performing ADL.
Ø The patient and/or caregiver will demonstrate appropriate strategies for
improving or compensating for cognitive deficits during the performance of
ADL.
Ø 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 adjust to living with a stroke.
Ø The caregiver will demonstrate appropriate methods and problem-solving
strategies for assisting the patient with ADL and with home activities to
improve/preserve performance skills.
Ø 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 control over the environment and to 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 rehabilitation 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, 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:
Ø Using proper transfer and mobility techniques to avoid undue skin friction
Ø Recommending appropriate bed and seated positioning and participating
in scheduled position changes as needed
Ø Assisting with wheelchair and seating selection and adaptation
Ø Teaching patient and caregiver precautions to avoid injury to insensitive
skin and involved side of body
Ø 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 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, therapists 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
treatment gains. Because the period after stroke is stressful, emotional, and tiring
for both the patient and family, education sessions provided 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 resources
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, & 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 al2007)
found that OT focused on improving BAD 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:
 Ø 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)
Ø 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)
Ø Somatosensory perception (the texture of the shirt, the position of the
affected arm)
Ø Postural adaptations (anterior pelvic tilt, trunk rotation, sitting/standing
balance, weight shifting)
Ø Visual-perceptual skills (finding the shirt in the visual field, distinguishing
top from bottom, finding the sleeve opening)
Ø 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 requires higher level
problem-solving and social skills than BADAL 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

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 example, 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.

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
Ø her detailed description of reflexes and associated reactions exhibited by
patients with post-stroke hemiplegia
Ø the concept of flexor and extensor synergy patterns in the paretic arm and
leg
 Ø 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 reflexive 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 Assessment, is a
widely used adaptation of Brunnstrom’s Hemiplegia Classification 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 therapy.
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 specific “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 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.

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 house cleaning 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 flex 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
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 GABAergic
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 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.

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 protracted
and upward 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),
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 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 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 fluid, dynamic system. Through
repetitive but varied practice, people develop motor programs 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 specific
applications to OT and 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.
Ø 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 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.
Ø 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.
 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 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 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-term memory, and working memory. The term primary
memory pertains to a pattern of neural firing 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 plus or 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 on electrochemical
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
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 declarative memory, 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 describe 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 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 tasks by counting episodes of distraction in a
specific area. 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 prepared 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 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.
 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 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. Characteristics 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. 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 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 subconsciously
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 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 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 be 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.
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
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. 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 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 coordinate 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 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
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
coordinate movements as part of the person’s need 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 is the
therapist’s support of 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 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, Vercruyssen, 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 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 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 tasks,
objects, and environments 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,
discoordination 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 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 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 the 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 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 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

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 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 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 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 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 asserts 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 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 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 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 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 Pattern 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.

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?

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 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
 Ø 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.
Ø Motor control is exercised in both anticipatory and ongoing modes.
Ø Sensory input is related to motor output and helps to modulate action.
Ø Control of a specific task can be effectively regained by practice of that
specific motor task in various contexts.
Ø Conscious practice of tasks builds up awareness of the ability to elicit
motor control activity.
Ø Progression of practice is from conscious awareness to practice at a more
automatic level in order to ensure that a skill is learned.
Ø Cognitive function is emphasized. If the client is to learn, then the
environment must encourage the learning process.
Ø When clients can perform a task effectively and efficiently without
thinking about it in a variety of contexts, learning has occurred.
Ø 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.
Ø 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.
Ø The role of the therapist is to prevent the use of inefficient strategies by
the client.
Ø The program addresses seven categories of functional daily activities:
upper limb function, or facial function, sitting up 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:
Ø Environmental modification
Ø Manipulating or grading the task
Ø 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. 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

Ø 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).
Ø Occupational performance emerges from the interaction of multiple
systems that represent the unique characteristics of the person and the
performance context.
Ø After CNS damage or other changes in personal or environmental systems,
clients’ behavioral changes reflect their attempts to compensate and achieve
functional goals.
Ø 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.
Ø A person must practice and experiment with varied strategies to find
optimal solutions for motor problems and develop skill in performance.
Ø 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.
Ø 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.
Ø 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.
Ø Evaluation strategies consider all personal and environmental systems.
The ones that interfere the most with performance are evaluated first.
Ø 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 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.
 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 support, 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's 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 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 that it 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 a 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, 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 for 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 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 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
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 hemianopia 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 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 outcomes 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 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 non neglected 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 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 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 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 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.

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 coffee pot).
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 coffee pot. 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 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
lunch box, 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.

VISUAL FOUNDATION SKILLS

Treatment of visual foundation skills such as visual acuity and contrast sensitivity,
oculomotor skills, and visual fields generally involves adaptations 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 soup
spoons); 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,
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 tape on 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 (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 to use 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 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 provides 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
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 in non-trained 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 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 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 remembered (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:
Ø Chunking or grouping similar items
Ø The story method, or linking a series of facts or events into a story
Ø Rehearsal, or repeating information over and over silently
Ø Rhymes, or recalling a fact by changing the fact into a rhyme
Ø Visual imagery

Retrieval strategies include the following:

Ø Alphabetical searching, or going through the alphabet to find the first
letter of a forgotten item
Ø Retracing one’s steps to find a missing object or to recall an event
Ø Thinking of associated information to cue the recall of a new fact or event
Ø 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 planners, 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 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:
Ø Cue cards or signs in key places (e.g., a sign on door where it will be seen
before leaving: “Take keys and . . .”)
Ø Labeling the outside of drawers or closets to minimize the need to recall
the location of items
Ø Providing step-by-step directions to reduce memory demands
Ø 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-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 self monitoring. 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. Self Regulation 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 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 catalog; 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 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 successfully used to improve the ability to carry out routine
vocational tasks. Decreased initiation, one of the hallmark features of 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, Wodly, & 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
established 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 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 opportunities 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 occupational engagement and
social participation, for even subtle cognitive impairments can decrease
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
subjective well-being, including self-efficacy, self-esteem, satisfaction and quality
of life; and preventing functional decline.

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

Ø In the United States, 20,000 people currently have ALS, and 5,000
additional people are diagnosed with ALS each year.
Ø Individuals of all races are affected by ALS.
Ø The age of onset is typically between 40 and 60 years.
Ø More men are affected than women.
Ø 90–95% of all cases are of no known cause.
Ø 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 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 generalized muscle 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
Ø Damage to lower motor neurons (in the spinal cord) leading to flaccid
paralysis, decreased muscle tone, and decreased reflexes
Ø Damage to upper motor neurons (in the brain) and to the corticospinal
tract leading to spasticity and hyper- reflexia (exaggerated reflexes)
Ø Muscle weakness
Ø Muscle atrophy (distal to proximal)—a symptom that is unique to ALS
Ø Fatigue
Ø Stumbling and falling due to lower extremity weakness
Ø Fasciculation (muscle twitching)
Ø Decreased ability to regulate body temperature
Ø Loss of emotional control/depression
Ø Dysphagia (difficulty swallowing)
Ø Dysarthria (difficulty speaking) due to impaired cranial nerves controlling
speech
Ø Impaired respiration due to muscle weakness
Ø Sialorrhea (excess drooling)
Ø Night cramps
Ø Weight loss
Ø Loss of endurance
Ø 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
Riluzole, 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.

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

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

OCCUPATIONAL THERAPY EVALUATIONS

Comprehensive Evaluations
Ø ALS Functional Rating Scale

IADL/Leisure Evaluations
Ø Activity Card Sort

Upper Extremity Function Evaluation

Ø Purdue Pegboard
Ø Manual muscle testing
Ø Range-of-motion testing

Balance Evaluations
Ø Berg Balance Scale

Quality of Life/Life Satisfaction Evaluations

Ø COPM (Canadian Occupational Therapy Performance Measure)

OCCUPATIONAL THERAPY INTERVENTIONS

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

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.

CHAPTER 15

BELL'S PALSY

Bell’s palsy is characterized 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 48 hour 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 protects 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).

Diagnosis

Based on typical presentation and exclusion of middle ear disease, diabetes,

sarcoidosis and Lyme disease.

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 fibers from (spinocerebellar pathways) in the spinal cord.

Function: maintenance of gait. Receives afferent fibers and projects different

fibers from and to motor cortex/vestibular nuclei, basal ganglia and pons.

Function: maintenance of postural tone and modulation

of motor skills.Receives afferent fibers 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 different
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 different axons. These pass either to the deep
nuclei of the cerebellum and then to the brain stem, or to the vestibular nuclei of
the brain stem. From there fibers 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.

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
brainstem 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 coordination 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.

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 localizing
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
 Ø obstructive hydrocephalus
Ø cranial nerve involvement
Ø 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
Ø agenesis – abscess formation
Ø Dandy-Walker malformation – acute cerebellitis (viral)
Ø Arnold-Chiari malformations – Creutzfeldt–Jakob disease
Ø Von Hippel Lindau disease. Metabolic

Demyelinative – myxedema
Ø multiple sclerosis. – hypoxia, hypoglycaemia.
Ø acute disseminated – alcohol (vitamin B1 deficiency) encephalomyelitis
(ADEM) – inborn disorders of metabolism.

Degenerative/Hereditary (lipid or amino acid metabolism)

Ø cerebellar degeneration Vascular
Ø multi-system atrophy (MSA) – cerebellar hemorrhage
Ø spino-cerebellar ataxias (SCA) – cerebellar infarction.

Neoplastic Drugs/toxins
Ø Astrocytoma, medulloblastoma, – alcohol hemangioblastoma, metastasis –
phenytoin.
Ø 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 localize 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:

Ø retinal disease
Ø labyrinthine disease, or
Ø 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
Ø 1st degree nystagmus. With eyes deviated to one side and in the midline
position also
Ø 2nd degree nystagmus.

When present in all directions of gaze

Ø 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 specialized techniques (electronystagmography – see page 65) to
demonstrate.

RETINAL OR OCULAR nystagmus

Physiological: following moving objects beyond the limits of gaze optokinetic

nystagmus.
Pathological: occurs when vision is defective. Fixation is impaired and the eyes
vainly

VESTIBULAR NYSTAGMUS

Nystagmus arises from:

Ø natural stimulation of the vestibular apparatus
Ø rotational or linear acceleration.
Ø artificially removing or increasing the stimulus from one labyrinth (e.g.
caloric testing).
Ø 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 components are 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 TUMORS

AETIOLOGY/INCIDENCE

AETIOLOGY (cont’d)
a. Inactivation of expression of tumor 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. Overexpression 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 tumor 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 tumors e.g. astrocytoma,
meningioma.

Immunosuppression: increased incidence of lymphoma.

INCIDENCE
The table below shows the approximate incidence of intracranial tumors 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 Tumor 8% Germ cell tumors 2.5% (schwannoma)
Meningioma 2.5% Others 18% Others 16% Adapted from Louis et al. Adapted
from Rickert & Paulus Child’s WHO Classification of Tumors 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
tumors present acutely due to hemorrhage or the development of hydrocephalus.

CLINICAL EFFECTS RAISED INTRACRANIAL PRESSURE headache,

papilloedema

BRAIN SHIFT – vomiting, deterioration of conscious level, pupillary dilatation

INTRACRANIAL TUMORS – CLINICAL FEATURES DISTURBED

FUNCTION

Supratentorial – higher cortical dysfunction, FRONTAL LOBE Contralateral face,

arm or leg weakness Expressive dysphasia (dominant hemisphere). Personality
change
Ø antisocial behavior
Ø loss of inhibitions
Ø loss of initiative
Ø intellectual impairment
Ø profound dementia especially if the corpus callosum is involved
OCCIPITAL LOBE

Visual field defect homonymous hemianopia

CORPUS CALLOSUM – disconnection

Ø syndrome
Ø Apraxia
Ø 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
Ø Endocrine dysfunction.
Ø Right/left confusion
Ø Finger agnosia dominant
Ø Acalculia hemisphere
Ø Agraphia

PARIETAL LOBE

Disturbed sensation
Ø localisation of touch
Ø two point discrimination
Ø passive movement
Ø astereognosis
Ø sensory inattention

Visual field defect

Ø lower homonymous quadrantanopia
N.B. Intrinsic brain stem tumors in contrast to extrinsic tumors are more likely to
produce long tract (motor and sensory) signs early in the course of the disease.

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

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

INTRACRANIAL TUMORS – INVESTIGATION

Chest X-ray, The high incidence of metastatic tumor makes these tests mandatory
in ESR, CRP patients with suspected intracranial tumors. 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
Ø midline shift.
Ø ventricular compression.
Ø hydrocephalus (secondary to 3rd ventricular or posterior fossa lesion).
Ø obliteration of basal cisterns

CT scanning Note: SITE e.g. frontal, occipital

ü extrinsic: outwith brain substance, e.g. meningioma
ü intrinsic: within brain parenchyma, e.g. astrocytoma.
ü useful in demonstrating the vertical extent of a tumor 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 tumors.

CORONAL AND SAGITTAL RECONSTRUCTION

Lateral view

Signs of raised intracranial pressure

Ø Suture separation (diastasis) in infants Beaten

INTRACRANIAL TUMORS – MANAGEMENT

The subsequent procedure biopsy, partial tumor removal/internal decompression or

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

Steroids dramatically reduce oedema surrounding intracranial tumors, but do not

affect tumor 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 of treatment, gradual dose reduction
minimizes the risk of unwanted side effects. Sellar/parasellar tumors occasionally
present with steroid insufficiency. In these patients, steroid cover is an essential
prerequisite of any anesthetic or operative procedure.

OPERATIVE MANAGEMENT

Most patients with intracranial tumors 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

Transsphenoidal 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 tumors, 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 tumor site on preoperative imaging and to

be able to use this information to guide the surgeon to the tumor 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 tumor. It is possible to perform a craniotomy and tumor 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 centers have now acquired CT or MR

imaging available within the operative theatre. Although costly, this real-time
imaging overcomes problems encountered with brain shift and not only helps to
locate the tumor, but also shows the extent of tumor 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 tumors 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 minimize 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 tumor to these crucial
structures. When these images are incorporated into the neuro-navigation system it
enables the surgeon to avoid extending the tumor 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 anesthetic, or by
giving an anesthetic 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 tumor resection is possible with a low risk of deficits.

RADIOTHERAPY

Treatment of intracranial tumors with radiotherapy utilizes one

of the following:
Ø megavoltage X-rays (by far the most common method)
Ø electron beam from a linear accelerator (which can also produce
megavoltage X-rays)
Ø accelerated particles from a cyclotron, e.g. nuclei of helium, protons
(awaits full evaluation)
Ø 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, 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 minimizing
irradiation to adjacent normal brains. Various methods have been developed to
achieve this
Ø 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 tumor, thereby eliminating normal brain.
Ø 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).
Ø Interstitial techniques where the tumor is treated from within
(brachytherapy) by the implantation of multiple radioactive seeds, e.g.
iodine125.
Ø Beam intensity modulated radiotherapy (IMRT) uses non-uniform beams
of varying intensity (in contrast to the conventional uniform dose intensity)
to complex tumor volumes. This helps protect surrounding structures, yet
allows a higher dose. Proton therapy is available in only a few centers. It
allows the delivery of high doses of radiation to very localized regions
adjacent to vital structures such as the skull base.

Radiotherapy is of particular value in the management of malignant tumors

malignant astrocytoma, metastasis, medulloblastoma and germinoma, but also
plays an important part in the management of some benign tumors – pituitary
adenoma, craniopharyngioma. With some tumors that seed throughout the CSF
pathways, e.g. medulloblastoma, whole neural axis irradiation minimizes the risk
of a distant recurrence. Complications of radiotherapy: following treatment,
deterioration in a patient’s condition may occur for a variety of reasons:
Ø Increased oedema – during treatment – reversible.
Ø Demyelination – after weeks, months – usually reversible.
Ø Radionecrosis – usually 1–2 years (range 6 months–10 years) –
irreversible.
Ø Cognitive impairment – whole brain irradiation causes dementia, ataxia
and incontinence in over 10% at one year. Radiotherapy should be avoided
in children under 3 years of age.
 Ø Radiation induced tumors e.g. meningioma, may result many years after
the treatment.

Oedema, demyelination and radionecrosis may involve the spinal cord after
irradiation of spinal tumors. 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 tumors, 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 tumor appear particularly to benefit.
Carmustine impregnated wafers (Gliadel) may also be considered both as a
primary treatment or for tumor 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 tumors where chemotherapy plays an important role include
medullo-blastomas, primary CNS lymphomas and germ cell tumors. Traditionally,
chemotherapy has had a lesser role in low grade glial tumors 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

 CHAPTER 17

HYDROCEPHALUS LOCALIZED 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 outside 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 hemorrhage) granulations
Ø Supratentorial masses causing infection (pyogenic, TB, fungal) tentorial
herniation subarachnoid hemorrhage
Ø Intraventricular haematoma spontaneous
Ø Tumors ventricular, e.g. trauma colloid cyst postoperative
Ø pineal region carcinomatous meningitis
Ø posterior fossa Increased CSF viscosity, e.g.
Ø Abscesses/granuloma high protein content
Ø Arachnoid cysts Excessive CSF production choroid plexus papilloma
(rare)
Ø Congenital – Aqueduct stenosis or forking
Ø Dandy-Walker syndrome (atresia of foramina of Magendie and Luschka)
Ø 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.

Ø Evidence of chronic raised pressure – posterior clinoid erosion, ‘copper beating’.

Ø 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 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 hydrocephalus, e.g. following subarachnoid hemorrhage. 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. Minimize 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
hemorrhage. 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 mobilization. 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 aqueduct stenosis or a pineal or posterior
fossa tumor occluding the posterior end of the 3rd ventricle/aqueduct. By using a
flexible or rigid endoscope introduced through a frontal burr hole, 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 benefits.

CHAPTER 18

GUILLAIN 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 immunization.

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 generalized, 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).

Ø Acute motor axonal neuropathy (AMAN) – often after campylobacter infection

Ø 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 develop 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 subtypes including:

AMAN: anti-GD1a and GM1

Acute sensory neuropathy: anti-GD1b

Treatment

Supportive care in HDU/ICU with prevention of respiratory and autonomic

complications provides the best chance of a favorable 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 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 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 problems.

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 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
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 occupational- 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).
Ø 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).
Ø 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).
Ø 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 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
processes 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:

Ø 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.
Ø 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.
Ø Opportunities to move through space so that the child can achieve
increasingly complex somatomotor adaptive responses.
Ø The therapist’s scaffolding of success emotionally, physically,
cognitively, and socially.
Ø 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.
Ø 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.
Ø 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).
Basic Tenets of Sensory Integration

Following are the classic principles of intervention using a sensory integration

approach:
Ø Integrated sensation is “nourishment for the brain”(Ayres, 1979).
Ø Adaptive responses are required to successfully meet challenges essential
for growth and development (Ayres, 1972). The adaptive response is
essential to increased sensory integration.
Ø 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.
Ø Active participation promotes organization.
Ø 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 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:
Ø Increase in the frequency or duration of adaptive responses
Ø Cognitive, language, and academic skills
Ø Gross and fine motor skills
Ø Self confidence and self-esteem
Ø Enhanced occupational performance and social participation
Ø Enhanced family life
 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 interdisciplinary 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. 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.

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 in
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
functional skills and habits within naturalistic settings; therefore, evaluation
emphasizes observation of real-life functioning. The quadraphonic 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
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. 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 is 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.

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 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 elaborate 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 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 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 recognizes that he or she is having difficulty with memory and
perceives 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 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 shows 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 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.

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%).

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

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

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

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

INTERDISCIPLINARY TREATMENT

Medications
Ø Corticosteroids are used to shorten acute attacks, reduce inflammation,
and ease symptoms.
Ø 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.
Ø More potent medications are being developed that are effective in slowing
down MS that is rapidly worsening or becoming progressive (Beers &
Berkow, 1999).

Rehabilitation
Ø 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 evidence 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.
Ø Occupational therapy: Occupational therapy focuses on strength,
coordination, and fine motor control of the upper extremities. Fatigue and
pain management techniques 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.
Ø 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.
Ø Psychosocial support/counseling: Individual or group therapy 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
Ø The Functional Assessment of Multiple Sclerosis (FAMS)
Ø Functional Independence Measure (FIM)
Ø Multiple Sclerosis Impact Scale (MSIS-29)

ADL Evaluations
Ø Assessment of Motor and Process Skills (AMPS)
Ø Barthel Index (BI)

Fatigue Evaluations
Ø Fatigue Severity Scale (FSS)
Ø Modified Fatigue Impact Scale (MFIS)

Psychosocial Evaluations
Ø Beck Depression Inventory (BDI)
Ø Self-Perceived Burden Scale (SPBS)
Ø Ways of Coping Checklist (WCC)

Quality of Life/Life Satisfaction Evaluations

Ø Canadian Occupational Therapy Performance Measure (COPM)
 Ø Health Status Questionnaire

Multiple Sclerosis QOL Inventory (MYSQLI)

Ø Multiple Sclerosis Quality of Life-54 (MSQOL-54)
Ø Occupational Performance History Interview (OPHI)

Other Areas to Address

Ø Balance and coordination
Ø Caregiver adjustment
Ø Cognition and memory
Ø Coping skills
Ø Daily living skills
Ø Driving skills
Ø Environmental barriers
Ø Fine motor skills
Ø Leisure interests
Ø Locus of control
Ø Muscle strength and spasticity
Ø Pain and sensation
Ø Self-concept
Ø Sexuality
Ø Vision and perception

OT INTERVENTIONS
Ø ADL training
Ø Assistive technology
Ø Cognitive retraining
Ø Employment modifications
Ø Energy conservation
Ø Environmental modifications
Ø Home management
Ø Pain treatment
Ø ROM/endurance/strengthening for functional activity
Ø Safety awareness
Ø Splinting
Ø Stress management
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 interventions (Holberg & Finlayson, 2007; Matuska, Mathiowetz, &
Finlayson, 2007; Vantage 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).

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:
Ø Individual needs and coping styles
Ø Disruption in family rhythm
Ø Disruption in family communication
Ø Uncertainty and anxiety
Ø Adaptation and adjustment
Ø 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:
Ø Effective communication
Ø Relieving pressures of caregiving
Ø Planning and decision making for the future (Kalb.