NeuroRehlbilitation ELSEVIER

NeuroRehabilitation 8 (1997) 31-41

Occupational therapy: current practice and training issues in the treatment of cognitive dysfunction Carolyn S. Hanson*a, Orit S~echtmana, Joanne Jackson Fossa, Alice Krauss-Hooker b aDepartment of Occupational Therapy, b Genesis

University of Florida, PO Box 100164, Gainesville, Florida 32610-0164, USA Rehabilitation Hospital, PO Box 16406, Jacksonville, FL 32216, USA

Abstract A significant relationship exists between cognitive abilities and functional performance in activities of daily living. Occupational therapists are involved in providing cognitive rehabilitation to individuals with brain damage by assisting them in fulfilling self-care, work and leisure roles. Since occupational therapists specialize in functioning in the real world, they should have a primary role on the interdisciplinary team in assessing and treating cognition as it relates to function. Particular areas of expertise include assessment and intervention in daily living tasks, safety issues and cognitive/perceptual dysfunction. Treatment strategies in occupational therapy are classified into two approaches: remedial and compensatory. A combination of the two approaches has been found to be the most beneficial method of intervention. Though current training guidelines for occupational therapists in cognitive rehabilitation are vague, the major focus has been on evaluating functional status and intervening when cognitive/perceptual deficits are present. Future training for practitioners in this area will require more specialized experiences and education. Additional research will need to be conducted by therapists to document treatment efficacy. Despite current health care constraints, occupational therapists must not lose sight of delivering quality care in an individualized and holistic manner. Copyright © 1997 Elsevier Science Ireland Ltd.

Keywords: Cognitive function; Cognitive/perceptual skills; Occupational roles; Intervention approaches

* Corresponding author. Tel.: + 1 352 8461023; fax: + 1 3528461042. 1053-8135/97/$17.00 Copyright ©1997 Elsevier Science Ireland Ltd. All rights reserved PII S1053-8135(96)00206-5

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1. Introduction

The involvement of occupational therapy in cognitive rehabilitation is based on the premise that there is a significant relationship between cognitive abilities and functional performance in activities of daily living [1]. Occupational therapy presence in cognitive rehabilitation was initially prompted by the First and Second World Wars which resulted in many head injured soldiers who needed rehabilitation [2,3]. More recently, the American Occupational Therapy Association [4] defined the different populations and the nature of impairments that are treated in occupational therapy under the umbrella of cognitive rehabilitation. In its statement paper, AOTA [4] described cognitive impairment as '... confusion, disorientation, limited attention, memory impairment, decreased capability for learning, disorganization of verbal and non-verbal activity, incompleteness of thought and action, and an inability to solve problems and adapt behavioral responses' (p. 1067). Cognitive impairment may be found in persons with mental retardation, learning disabilities, developmental disabilities, cerebrovascular accidents, substance abuse, traumatic brain injuries, schizophrenia, Alzheimer's disease and other dementias, as well as in persons who have suffered malnutrition or a deprived environment [4]. Different labels are used to refer to the rehabilitation of persons with cognitive dysfunction. In the literature the terms cognitive rehabilitation, cognitive retraining, and cognitive remediation are often used interchangeably. These terms are actually not synonymous and the more general term of cognitive rehabilitation refers to a clinical practice with two different orientations of treatment: compensatory or remedial approaches [5]. The definition of cognitive rehabilitation depends on the theory used by the author. Some define cognitive rehabilitation as an endeavor to improve or relearn certain cognitive functions and abilities impaired as a result of damage to the central nervous system [6,7]. Others view it as merely a component of a whole readaptation treatment program, a part of a global approach [8]. Yet, others believe that cognitive rehabilita-

tion is designed to remediate disorders in information processing (which includes perception, memory, language, concept formation, reasoning, and problem solving) in brain injured persons [9,10]. Cognitive rehabilitation is most commonly used in the treatment of persons with brain damage stemming from either traumatic brain injury (TBI) or cerebrovascular accident (CVA) [7,10]. It is estimated that 'More than 50% of the patients seen by occupational therapists in acute and long-term rehabilitation facilities are suffering from cognitive impairment and disability' [11]. In this paper we will review the involvement of occupational therapy in cognitive rehabilitation by discussing current educational training guidelines and future educational needs as well as present and future practice boundaries. 2. Current training guidelines

In this section, we will first discuss the educational background of occupational therapists which prepares us to be an essential member of the interdisciplinary team. Specifically, we will address the different aspects of the educational training of occupational therapists supporting our involvement in cognitive rehabilitation. These aspects include our theoretical background in intervention approaches, our expertise in assessing and treating functional deficits (specifically deficits in activities of daily living and visuoperceptual skills) and in recommending discharge placement, and our holistic frame of reference. We will also examine the importance of treating cognitive disabilities using an interdisciplinary team approach. Finally, we will review and critique current educational training and make suggestions for enhancing future training.

2.1. Theoretical background As Bracy [12] stated regarding cognitive rehabilitation, 'Without a unifying and guiding theoretical framework, our efforts would not amount to much more than random stabs in the dark' (p. 11). Many occupational therapy theorists have proposed models of cognition and cognitive func-

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tion. These theoretical models include: the profession's domain of concern (Mosey), Nelson's Model of Occupational Form and Performance, the Model Of Human Occupation (Kielhofner), Allen's cognitive disabilities model, and the model for occupational science (for a summary of models for intervention and research on cognition in occupational therapy, refer to Katz [11]). By having a solid theoretical base, therapists can provide a rationale for the selection of treatment activities as theory undergirds remediation efforts. Ben-Yishay and Diller [6] emphasized that a theory of cognitive rehabilitation must 'confront the issue of how exactly one teaches a brain-injured person to successfully overcome cognitive deficits and to perform certain functional tasks more adequately' (p. 206). They concluded that a cognitive rehabilitation 'multimodal approach may be the most appropriate' for obtaining meaningful improvement (p. 210). In the same fashion, Toglia [13] recommended a multicontextual approach. This approach emphasized the processing skills necessary for learning, metacognitive abilities (or self-monitoring skills such as anticipating and detecting errors), and the criteria and context of the

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task's environment. While the performance strategies basically remain the same, the properties of task activities (such as the environment) are gradually changed, thereby increasing the challenge for adaptation. This theoretical approach "involves the practicing of a targeted strategy in multiple environments with varied tasks and movement demands. Task parameters are analyzed and graded to place increasing demands on the ability to transfer learning. Direct training of metacognitive skills and self-awareness is incorporated throughout treatment" [13] (p. 506). The multicontext treatment approach is an example of a guiding framework for our intervention with cognitively impaired individuals.

2.2. Function Occupational therapists have a diverse and extensive background in functional activity-skill analysis and cognition [14]. With academic preparation in the behavioral and biological sciences, activity analysis, and the human components of performance (i.e. sensorimotor, cognitive, and

Table 1 Current entry level curriculum Academic coursework

Didactics

Experiential/laboratory

Basic science

OTprocess

Biology Anatomy Human physiology Nervous system anatomy and function

Activity analysis Activity selection Clinical observation, decision making, and reasoning

Community-based activities Group process Clinical practica and internships

Applied science

Screening / assessment

Lab experiences

Kinesiology Pathophysiology Abnormal psychology Developmental psychology Research Process and application

ADL/functional Cognitive Perceptual Psychosocial

Role playing Intervention simulation Disability simulation Case planning Work simulation

OT theory and practice

Remediation strategies

Psychosocial rehabilitation Biomechanical rehabilitation Neurorehabilitation Therapeutic activities

Task and environmental, e.g., modification, cuing, gradation, sequencing, safety analysis Assistive technology

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psychosocial components), occupational therapy practitioners contribute to the rehabilitation of persons with cognitive disorders (see Table 1). Occupational therapists are trained in evaluating and teaching daily living skills, also known as activities of daily living (ADL). Functional problem areas of both ADL (mostly self-care activities) and instrumental activities of daily living (IADL) such as household chores, financial management, transportation, and use of community resources have underlying cognitive dimensions. Both ADL and IADL require attention, awareness, concentration, motivation, initiation, sequencing, judgment, memory, orientation, organization, safety awareness and problem solving skills [14]. By focusing on underlying cognitive deficits and promoting the maximum level of independence in functional performance, occupational therapists play an important part in helping persons meet daily living requirements such as fulfilling self-care, home, community, social, and vocational roles [4]. Occupational therapists evaluate the functional status of an individual and intervene when necessary by selecting and grading appropriate tasks, teaching compensatory techniques, providing adaptive equipment, and modifying the environment. Skilled clinical observation and formal evaluations are used to assess the impact of cognitive impairments on performance of daily living tasks. Training in clinical and behavioral observations is also essential for continuous assessment of the patient. Assessment items include the component task requirements, the demands of the environment, and the confounding difficulties of the overall deficits created by the insult [4]. Occupational therapists are trained to analyze functional tasks in terms of cognitive, behavioral, and physical components. We are capable of predicting and taking into consideration how these components will affect the patient's ability to carry out an activity. For example, when performing a functional activity as a shopping trip, the occupational therapist analyzes the task and considers its physical components such as mobility, strength, endurance, etc., perceptual components such as visual scanning, figure ground deficits, spatial relations, etc., and cognitive com-

ponents such as memory, planning ability, money management, etc. Communication and social behavior are also taken into consideration [14]. Treatment skills include task gradation, providing cues to facilitate performance, and employing personally relevant purposeful activity. The knowledge of performing activity analysis is necessary during gradation of tasks. Task gradation includes the following components: shifting from simple to complex tasks to ensure success, gradually withdrawing cues (physical, verbal, visual) to increase the challenge, and changing from structured to unstructured activities to promote independence. These principles, which occupational therapists learn as part of standard treatment procedure, are used in cognitive rehabilitation [3]. Primary responsibilities of occupational therapists on the cognitive remediation team include assessing and treating functional problems which stem from cognitive and visuoperceptual disorders. Currently these disorders are being treated together because they have a great impact on the performance of daily living skills [15-17]. Functionally, visuospatial disorders may result in increased difficulties with activities requiring the use of objects and with the concept of space. These disorders include figure-ground deficits, form and space constancy, visual memory, position in space, spatial relations, and topographical disorientation [18]. Visuospatial abilities are often addressed in cognitive training programs but the transfer of the various remedial exercises to functional adaptation is questionable [7]. Cobble et al. [19] suggested that post-acute rehabilitation goals for persons with brain disorders are no longer medical, but rather should center around developing adaptive behaviors for the person's successful re-entry into the home, community or work place. They recommended that the multidisciplinary team leader providing these services should be an individual who is ' ... capable of assessing and promoting progress in this non-medical, occasionally untraditional model of care' [19] (p. S-324). Based on our ability to assess the patient's cognitive status as it relates to function and safety, occupational therapists playa major role in recommending an appropriate discharge environment. Miller [20] remarked that

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retraining in independent living skills is an important feature of rehabilitation of persons with severe brain injury. Rehabilitation should be based on retraining those skills needed for maximum level of independence by emphasizing functioning in the real world. Performance of basic activities of daily living as well as achieving safety in these activities are important components in both ADL retraining and discharge placement [21].

2.3. Holistic approach Ben-Yishay and Diller [6] stated that cognitive rehabilitation of a brain injured patient should be performed in a holistic fashion. Occupational therapists are trained to treat patients in a holistic way, considering the individual's physical, emotiona~ mental, and social state. As efficient daily functioning requires adequate organizational skills and processes in all of these areas, intervention must consider the multiple roles of the whole person. Viewing the patient in a holistic manner traces back to the early days of our profession. Adolph Meyer [22], a founding member, proclaimed that: The whole of human organization has its shape in a kind of rhythm... there are many other rhythms which we must be attuned to... finally the big four-work and play and rest and sleep, which our organism must be able to balance even under difficulty. The only way to attain balance in all this is actual doing, actual practice, a program of wholesome living as the basis of wholesome feeling and thinking and fancy and interests (p. 641).

2.4. The interdisciplinary team In 1980, Gianutsos [10] suggested that cognitive rehabilitation was a specialty in its infancy. She further stated that disorders of perception, memory, and language were interrelated and often occurred together but are usually treated by separate rehabilitation specialists who address different problem areas. The rehabilitation specialists who are most often involved in cognitive rehabilitation are clinical psychologists, speech therapists, and occupational therapists [3,10]. These professionals comprise a team geared towards meeting the wide range of difficulties experienced by peo-

35

pIe with cognitive disabilities. Typically, professionals at each facility negotiate the area of intervention for each of the different rehabilitation specialists. These negotiations need to be based on specific professional educational background and clinical practice expertise. Commonly, occupational therapy treatment emphasis in neurorehabilitation has been placed on sensory, motor, visual, and perceptual deficits. However, disturbances in cognitive functioning frequently cause performance deficits that are most often manifested in problems with independent functioning [5]. As a member of the cognitive rehabilitation team, the occupational therapist treats patients whose cognitive and perceptual losses interfere with normal functioning despite the return of motor capabilities [23]. In summary, our primary roles as members of the interdisciplinary team include assessing and treating functional deficits in daily living and visuoperceptual skills, and safety issues which impact the recommendation of an appropriate discharge environment.

2.5. Critique and recommendations The occupational therapists of tomorrow will continue to require a good understanding of rehabilitation theory (including how trauma and disease affect normal brain functioning), learning theory (especially, information processing theory) and occupational therapy theory to better serve patients requiring cognitive rehabilitation. Although the undergraduate educational background presently prepares the occupational therapist to play an important role on the interdisciplinary team, there is a need for additional and advanced education in cognitive rehabilitation. Due to the vast amount of information already being taught in the entry level baccalaureate program, advanced training is necessary for this practice area. Based on our experience, insufficient time is spent on specific topics related to cognitive assessment and treatment as well as on promoting interdisciplinary team interaction and communication. Particularly, there is inadequate time devoted to (a) the study of both learning

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theory and information processing theory, (b) the application of occupational therapy theories to the practice of cognitive rehabilitation, and (c) the instruction of assistive technology for people with cognitive disabilities. There are also few opportunities to engage in experiential practicums and specialty internships emphasizing cognitive rehabilitation. Additionally, more focus should be placed on the relationship between cognition and human performance. Occupational therapists are being expected to demonstrate how they can use their specific training to engage in cognitive rehabilitation efforts with patients. As such, these skills can no longer be sufficiently acquired during standard undergraduate occupational therapy course work. Students will need more practice opportunities in the classroom and in clinical settings. Upon graduation, novice therapists will need to attend specialized workshops and engage in continuing education to hone the requisite skills. Working with patients requiring cognitive rehabilitation entails additional training in theoretical concepts, team approaches, experiential practicums, and advanced technology such as the use of video, computer, and virtual reality (see Table 2). AOTA has recently instituted a specialty certification process in neurorehabilitation, an area which includes cognitive rehabilitation. It is anticipated that a specific credentialing process in cognitive rehabilitation will occur [24].

The future involvement of occupational therapists in cognitive rehabilitation will be shaped by managed care criteria which have emphasized the role of cost containment in the provision of therapeutic services. The Pew Health Professions Commission's report [25] has suggested that multiskilling (also known as cross-training) is the solution to reducing and controlling health care costs. Though a core curriculum among the therapies such as speech, occupational, and physical therapy is touted as being cost effective, the essential nature and specialization of each of these professions will be lost if a universal therapist is the product [26]. The blending of unique theories, clinical reasoning processes and technical skills will dilute expertise and effectiveness. The initiation of a dialogue concerning seIVice provision has been demonstrated by the inception of the TriAlliance of Health and Rehabilitation Professions committee (consisting of the association presidents from occupational and physical therapy and speech-language pathology). The TriAlliance committee has recently recommended that an individual be cross-trained at the aide level as a workable method of cost containment and stated 'multiskilling at the professional or assistant level is likely to result in unacceptable levels of risk or professional negligence that could result in harm or poor outcome' [27]. It is crucial that occupational therapists emerge from their educational and clinical training with integrity and a strong sense

Table 2 Future additional training Academic coursework

Didactics

Experiential/laboratory

Cognitive rehabilitation approaches, e.g. multicontext treatment Team role delineation ()utcomesresearch Legal/ethical issues of regulation and reimbursement Additional theory Learning theory Information processing Systems theory Motor learning theory

Additional remedial activities Case planning and management Family/caregiver training Applied behavioral analysis Advanced psychometrics

Virtual reality simulations Computer training Video cases Consistent update workshops Advanced clinical practica inpatient and outpatient neurorehabilitation

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NeuroRehabilitation 8 (J997) 31-41

of professional identity by being able to clearly articulate our scope of practice. In addition, therapists of the future will need more knowledge about business and ethics to face these and other challenges. 3. Practice boundaries In this section we will discuss the remedial and compensatory approaches as applied to the practice of cognitive rehabilitation, briefly review current intervention theories, and address future practice boundaries.

3.1. Remedial and compensatory approaches In the field of occupational therapy, the remedial and compensatory approaches are most commonly used in treating individuals with cognitive impairment Remedial treatment methods seek to restore lost cognitive functions (cognitive remediation or retraining), while compensatory treatment approaches help provide methods to adapt performance in order to counteract cognitive deficits [24]. A multicontext treatment approach which combines the remedial and compensatory approaches is suggested by Abreu and Toglia [5,28]. In practice, this combination of approaches is commonly used [1]. The remedial or restorative approach utilizes the concept of the plasticity and reorganization of the damaged adult brain and is based on changing the deficits in the central nervous system. Sensory integration and neurodevelopmental treatment fall under this category [1,11,19,29-31]. On the other hand, the compensatory or adaptive approach which is based on learning theory, utilizes the patient's residual strengths to compensate for deficits. It is also referred to as the functional or behavioral approach in which the goal is to eliminate problems of everyday living despite the deficit [1,11,21,30,31]. Environmental modification may be a part of the compensatory approach [19]. Remedial or retraining approaches are deficit specific and target an isolated deficit using table top pencil/paper or computer tasks. These approaches assume that the skills acquired through repetitive drill-like exercises will transfer or generalize to actual daily living tasks such as manag-

37

ing finances, planning and preparing household tasks, keeping an appointment, etc. Computers are also used in cognitive rehabilitation as part of the remedial approach [32-34]. The remedial approach may assist in enhancing concentration, organization, abstract reasoning, attention, and problem solving. However, these newly learned mental strategies may not be transferred to daily living activities. The problem with the remedial approach, whether using computers or tabletop activities, is whether generalization can occur [4,19,34]. Thus, computers are better used as part of therapy and not as total therapy. With the development of new software, programs are beginning to address enhancement of real life skills, such as shopping in the mall, being a client or a clerk [34]. For example, virtual reality combines computer applications with life-like environments to assist individuals in learning basic skills. Adaptive or functional approaches seek to capitalize on the patient's residual strengths and provide direct training in functional activities [13]. Using these methods minimizes the need for the patient to generalize performance [35]. The assumption is that the compensatory strategies will carry over from therapy to everyday life [19]. Examples of the compensatory approach include functional skills training such as the use of memory aids (notebooks and diaries), continence training, and riding public transportation [2]. Also, specific mnemonic aids may be used for teaching safety in transfer techniques with patients who have the physical capacity to perform transfers but need supervision because they forget basic safety procedures [10]. It is important that the learning which takes place during cognitive remediation is generalized so that the performance in everyday tasks is improved. It is not enough to show improvement in the performance of neuropsychological test scores and specific task skills. The treatment is considered to be effective only when the person shows improvement in performing real life activities at home, work/school and leisure [36]. Therefore, comprehensive and effective cognitive rehabilitation intervention will teach the patient how to apply the skills and principles of the

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C.S. Hanson et al. / NeuroRehabilitation 8 (1997) 31-41

remedial approach to their natural environments and everyday life [3]. Most authors agree that combining remedial and compensatory approaches in an individualized intervention program may produce the best results [1,6,7,10,18]. Both Katz et al. and Gianutsos [l,lD] stated that cognitive rehabilitation should incorporate both compensatory and restorative approaches, depending on the individual patient. Pepin et al. [7] asserted that the combination of approaches should facilitate the generalization of gains achieved through the remedial approach, and that using this mixed approach is only a part of a more global readaptation program. The authors stressed that due to the vast diversity which exists in brain damaged patients, individualized treatment based on learning principles is essential. Combining the two approaches during intervention is used to reinforce the observed improvement in remedial tasks into the context of daily living activities which may produce the greatest functional improvement. Adaptation of the environment and/or the task can help the person learn compensation strategies thereby increasing the level of independence [4]. 3.2. Cummt intervention theories

Current occupational therapy literature has proposed approaches for the rehabilitation of cognitive and perceptual impairments in adults with brain injuries that are based on the principles of learning theory, biomechanical and neurodevelopmental principles, and activity analysis [5,13,31,37]. Recent learning theory literature has suggested that the transfer of learning to a usable (generalized) skill takes place during the actual learning of that skill. For this reason occupational therapy evaluation and treatment is often based on an information processing approach. This theory, when applied to rehabilitation, assumes that brain injury reduces the adult's ability to process information and to use the strategies normally applied to organizing incoming information. These strategies help us select relevant information from the environment and provide a framework for the organization of that information [5]. The person with a head injury either fails to use these strate-

gies automatically and/or applies them inefficiently or incorrectly [38]. Evaluation therefore, emphasizes the quality and process of the patient's functional performance, rather than a more skill specific approach designed to identify the presence or absence of dysfunction. During evaluation, a series of graded tasks are presented, requiring increased challenges to the patient's processing capabilities. As independence requires the ability to handle both familiar and novel situations, tasks are presented in evaluation and treatment using multiple contexts and environments. The emphasis in treatment is not on the individual therapeutic activities themselves, but on the strategy and process by which tasks are performed and learned. Each activity is designed by the therapist for the specific patient. That patient's current learning strengths, the demands of the environment, and postural and biomechanical limitations dictate the features of the intervention plan. Claudia Allen and colleagues [39] have articulated another evaluation and treatment approach that is more task specific. This theory of evaluation and treatment provides a valuable tool for the accommodation of cognitive deficits. Allen's [40] work has been based on working with those patients with neuropsychiatric disorders that cause dementia, such as Alzheimer's Disease. However, with the advent of shorter hospital stays, community-based rehabilitation, and the Americans with Disabilities Act, caregivers and professionals find this system helpful in making decisions about intervention. Valuable input can be provided to public and private agencies for placement, legal, and accessibility issues. Through the use of the Allen Cognitive Level Scale [41], the patient's level of cognitive functioning is evaluated in a functional context. Six cognitive levels, ranging from normal functioning to severe impairment, have been identified based on functional ability, the type of compensatory assistance required, and environmental demand. According to Allen [41], successful cognitive retraining is contingent upon using treatment activities within the patient's cognitive level. Adaptation of the properties of the task and the environment can be anticipated through Allen's description of the learning needs

C.S. Hanson et al. / NeuroRehabilitation 8 (I997) 31-41

and cognitive functioning characteristics at each level. The therapist and caregivers can adjust their communication and task set-up according to these characteristics. In this manner the patient's difficulties may be circumvented thus capitalizing on the patient's strengths and the therapist's task adaptation and analysis skills.

3.3. Future practice boundaries Individual treatment is necessary and preferable due to the wide range of cognitive impairments. When inpatient care is provided, one-onone treatment in the clinic will be less frequently conducted as group treatment is more cost effective and has been found to be beneficial for participants [23]. Within groups, individualized treatment may be conducted by using dynamic interactional modules. While being supervised, patients will be issued various materials (i.e. specific modules) to simulate functional tasks that contain external cuing devices and methods of self-monitoring. These dynamic interactional modules will need to consist of elements designed for a wide variety of individuals. Modules of this nature will allow the patient to gradually rely less on the therapist for feedback [42]. After a comprehensive plan is designed, cross-trained aides and certified occupational therapy assistants will likely have more continuous contact with a patient than registered therapists. With decreased lengths of stay and limitations on rehabilitation coverage, family members will be responsible for facilitating the patient's performance at home [17]. Outpatient services and homecare will be more common arenas for the treatment of cognitive disabilities. Instruction in the familiarity of one's home has the advantage of individual contact and increased ecological validity. However, the disadvantage of the home setting is that the patient is not part of a therapeutic community [2]. Caregivers such as family members and close friends will need to be educated more thoroughly regarding effective strategies for the individual with cognitive deficits. Part of our new mission will be to spend more time instructing relatives and significant others on how to

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follow-up and sustain the gains that the patient has made in treatment. Radomski [24] emphasized that occupational therapists must define their role on the team ' ... with respect to other disciplines. In theory and under optimum conditions, transdisciplinary service provision portends team cooperation and suitable discipline-specific contributions to the effort' (p. 272). Collaborative efforts with other health professional team members will continue in the process of treating people with cognitive deficits. The team approach allows the needs of a patient to be fully addressed by a variety of health care workers since cognitive deficits are not always in isolation from perceptual, behavioral and perhaps physical problems. Morse and Morse [14] stated that the interaction among the interdisciplinary team members should be function-oriented and not discipline-oriented. They gave a specific example for the function-oriented approach in which the psychologist assessed and treated basic arithmetic skills of a person with brain injury while the occupational therapist assessed and treated functional money management skills. Gianutsos [10] advocated that cognitive rehabilitation be addressed in a comprehensive fashion that entails a variety of rehabilitation specialists. In clarifying our contribution, occupational therapists must provide functionally based evaluation and treatment and effectively communicate the evaluation results and treatment outcomes with other team members, other health professionals and third party payers. In addition, with the changes in health care delivery, we may be serving in a new capacity as case managers and consultants. In the future as in the past, occupational therapy will focus on functional and purposeful activity which is meaningful to the individual. Radomski [24] has recommended that 'Only those cognitive rehabilitation approaches regarded as effective at contributing to improved levels of selfmanagement and independence should be considered in establishing standards of practice for occupational therapy' (p. 272). As a profession, we should participate in the discussion on practice boundaries in the area of cognitive rehabilitation. By defining our practice and performing

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those activities which are within our scope and expertise, we can communicate how occupational therapy is beneficial to patients and how it is unique with respect to other disciplines. It is necessary to increase data collection and scholarly activity to document treatment outcomes as our claims about the effectiveness of intervention need to be substantiated by research. We must not only demonstrate but also document how we can use our training and techniques to bring about a functional change in performance which is sustainable over time and across environments.

References [1]

[2] [3] [4]

4. Summary Occupational therapists play an important part in helping patients with cognitive disabilities reach their maximum level of functioning as a significant relationship exists between cognitive abilities and functional performance. Our current role on the multidisciplinary team is to maximize independence by emphasizing functioning in the real world which entails performing activities of daily living, dealing with safety issues, managing perceptual and cognitive disorders, and resuming occupational roles. Beside patient care, occupational therapists may also be acting in other capacities such as being case managers and consultants. Despite current changes in health care delivery, we will always be involved in teaching people how to become self-sufficient. This article advocates intervention combining remedial and compensatory approaches in order to facilitate effective and more complete community re-entry. Future needs include further defining our scope of practice in this specialty area and delineating our specific role on the multidisciplinary team. There is also a need to increase our involvement in conducting research, performing outcome studies, and developing more functional cognitive assessments. Additional training in the form of continuing education and specialty internships are necessary for occupational therapists who specialize in cognitive rehabilitation. While the emerging state of health care management places constraints on practice goals, we must not lose track of providing quality treatment in an individualized, compassionate fashion.

[5] [6] [7] [8] [9] [10] [11] [12] [13]

[14] [15]

[16] [17]

Katz N, Hefner D, Reuben R. Measuring clinical change in cognitive rehabilitation of patients with brain damage: two cases, traumatic brain injury and cerebral vascular accident. Occupational therapy approaches to traumatic brain injury. Binghamton, NY: Haworth Press, 1990. Giles GM. The status of brain injury rehabilitation. Am J Occup Ther 1994;48:199-205. Gordon WA, Hibbard MR, Kreutzer JS. Cognitive remediation: issues for research and practice. J Head Trauma Rehabil 1989;43:76-84. American Occupational Therapy Association. Statement: occupational therapy services of persons with cognitive impairments. Am J Occup Ther 1991;45:1067-1068. Abreu BC, Toglia JP. Cognitive rehabilitation: a model for occupational therapy. Am J Occup Ther 1987;41 :439-448. Ben-Yishay Y, Diller L. Cognitive remediation in traumatic brain injury: update and issues. Arch Phys Med Rehabil 1993;74:204-213. Pepin M, Loranger M, Benoit G. Efficiency of cognitive training: review and prospects. J Cognit Rehabil 1995;13:8-14. Greenwood R. Neurology and rehabilitation in the United Kingdom: a view. J Neurol, Neurosurg Psychiatry 1992;55:51-53. Diamant n, Hakkaart PJ. Cognitive rehabilitation in an information-processing perspective. Cognit Rehabil 1989;7:22-28. Gianutsos R. What is cognitive rehabilitation? J Rehabil 1980;1uly/ August:36-40. Katz N. Cognitive rehabilitation: models for intervention and research on cognition in occupational therapy. Occup Ther Int 1994;1:49-63. Bracy OL. Cognitive rehabilitation: a process approach. Cognit Rehabil 1986;4:10-17. Toglia IP. Generalization of treatment: a multicontextual approach to cognitive perceptual impairment in adults with brain injury. Am J Occup Ther 1991;45:505-516. Morse PA, Morse AR. Functional living skills: promoting the interaction between neuropsychology and occupational therapy. 1 Head Trauma Rehabil 1988;3:33-44. Bernspang B, Viitanen M, Eriksson S. Impairment in perceptual and motor functions: their influence on selfcare ability 4-6 years after stroke. Occup Ther 1 Res 1989;9:27-37. Carter LT, Howard BE, O'Neil WA. Effectiveness of cognitive skill remediation in acute stroke patients. Am J Occup Ther 1983;37:320-326. Carter LT, Oliveira DO, Duponte J, Lynch SV. The relationship of cognitive skills performance to activities of daily living in stroke patients. Am J Occup Ther 1988;42:449-455.

C.S. Hanson et at. / NeuroRehabilitation 8 (1997) 31-41 [18]

[19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30]

Foss JJ. Cerebral vascular accident: visual perceptual dysfunction. In: Van Deusen J. ed. Body Image and Perceptual Dysfunction in Adults. Philadelphia: WB Saunders, 1993 pp. 11-38. Cobble ND, Bontke CF, Brandstater ME, Horn U. Rehabilitation in brain disorders. Three intervention strategies. Arch Phys Med RehabilI991;72:324-331. Miller E. The training characteristics of severely headinjured patients: a preliminary study. J Neurol, Neurosurg Psychiatry 1980;43:525-528. Giles OM, Clark-Wilson J. The use of behavioral techniques in functional skills training after severe brain injury. Am J Occup Ther 1988;42:658-665. Meyer A. The philosophy of occupation therapy. Arch Occup Ther 1922;1:1-10. Thomas KS, Hicks JJ, Johnson OA. A pilot project for group cognitive retraining with elderly stroke patients. Phys Occup Ther Geriatr 1994;12:51-65. Radomski M. Cognitive rehabilitation: advancing the stature of occupational therapy. Am J Occup Ther 1994;48:271-273. Pew Health Professions Commission. Healthy America: Practitioners for 2005. A beginning dialogue for US Schools of Allied Health. San Francisco: Author, 1992. Foto M. New president's address: the future - challenges, choices, and change. Am J Occup Ther 1995;49:955-959. Use of Multiskilled Personnel. OT Week, Rockville, MD: AOTA, February 221996. Toglia JP. Approaches to cognitive assessment of the brain-injured adult: traditional methods and dynamic investigation. Occup Ther Practice 1989;1:36-57. Neistadt ME. Occupational therapy for adults with perceptual deficits. Am J Occup Ther 1988;42:434-440. Siev E, Freishtat B, Zoltan B. Perceptual and cognitive

[31] [32] [33] [34] [35] [36] [37] [38] [39]

[40] [41] [42]

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dysfunction in the adult stroke patient. Thorofare, NJ: Slack, 1986. Van Deusen J. Body image and perceptual dysfunction in adults. Philadelphia: WB Saunders, 1993. Gianutsos R. The computer in cognitive rehabilitation: it's not just a tool anymore. J Head Trauma Rehabil 1992;7:26-35. Hanson CS. Traumatic brain injury. In: Van Deusen J. ed. Body Image and Perceptual Dysfunction in Adults. Philadelphia: WB Saunders, 1993;39-63. Pipitone P. Yes or No? Computers in cognitive rehabilitation. Headlines, 1992;May/June:26. Neistadt ME. A critical analysis of occupational therapy approaches for perceptual deficits in adults with brain injury. Am J Occup Ther 1990;44:299-304. Hanson CS. Community activities. In: Van Deusen J and Brunt D eds. Assessment in occupational and physical therapy. Philadelphia: WB Saunders (in press). Schwartz SM. Adults with traumatic brain injury: three case studies of cognitive rehabilitation in the home setting. Am J Occup Ther 1995;49:655-665. Toglia JP, Golisz K. Cognitive rehabilitation group games and activities. Tucson: Therapy Skill Builders, 1990. Allen CK, Earhart CA, Blue T. Occupational therapy treatment goals for the physically and cognitively disabled. Rockville, MD: The American Occupational Therapy Association, 1992. Allen CK, Allen RE. Cognitive rehabilitation: measuring the social consequences of mental disorders. J Clin Psychiatry 1987;48:185-190. Allen CK. Occupational Therapy for Psychiatric Diseases: Measurement and Management of Cognitive Disabilities. Boston: Little and Brown, 1985. Toglia JP. Personal communication, 1996; April 29.