ccupational therapy for adults with percep­

A Critical Analysis of O tual dysfunction secondary to brain in­

jury often includes perceptual retraining
(Holzer, Stiassny, Senner-Hurley, & Lefkowitz, 1982;
Occupational Therapy Hopkins & Smith, 1983; Prigitano, 1986; Siev, Freish­
tat, & Zoltan, 1986; Trombly, 1983; Van Deusen, 1988;
Approaches for Wahlstrom, 1983). Occupational therapists use a vari­
ety of approaches for this retraining, and different au­
Perceptual Deficits in thors have categorized these approaches differently
(Abreu & Toglia, 1987; Neistadt, 1988; Siev et aI.,
Adults With Brain Injury 1986; Trombly, 1983) Only two of these categoriza­
tions-Trombly's and mine-are based on the COI11­
mon assumptions underlying different treatment
approaches, and neither has fully explicated the as­
Maureen E. Neistadt sumptions underlying the classifications. Identifica­
tion of the assumptions underlying our treatments can
help us to identify pertinent questions for efficacy
Key Words: modalities, occupational research.
therapy. perception. research This paper will (a) delineate all of the assump­
tions of my preViously proposed remedial ancl adap­
tive classification of perceptual treatment approaches
Research about occupational therapy interventions (Neistadt, 1988), (b) examine occupational therapy's
for adult perceptual dejicits is needed to examine perceptual retraining literatllre to see which assump­
the relative efficacy of different treatments and to tions underlie different treatments, and (c) suggest
scrutinize the theoretical assumptions underlying some assumption-derived questions for future re­
those treatments. The former pUipose relates to pro­ search. General approaches to perceptual retraining
Viding optimal services to consumers; the latter, to wi II be explored first, followed by approaches [Q re­
advancing the knowledge base of the profession. training constructional deficits as a specific example
Both of these purposes can be achieued if research of approach applications.
questions are derived from the assumptions under­
lying treatments. This paper delineates those as­ Classification
sumptions and suggests some research questions
and strategies with which to test them. Occupational therapy treatment techniques for per­
ceptual deficits fall into two general categories: adap­
tive and remedial. Adaptive, functional occupational
therapy approaches, such as the developmental,
adaptive skills, occupational behavior, and rehabilita­
tion treatment paradigms (Hopkins & Smith, 1983),
promote adaptation of and to the environment to capi­
talize on the client's inherent strengths and situa­
tional advantages. These approaches proVide training
not in the perceptual skills of functional behavior but
in the activity of daily living behaviors themselves.
Remedial approaches, such as perceptllal-motor
training (Abreu, 1985), sensory integration (Ayres,
1972), and neuroclevelopmental treatment (Bobath,
1978), seek to promote the recovery or reorganization
of impaired central nervous system functions Percep­
tual-motor training focuses on perceptual funerioning
specifically, whereas sensory integration techniques
address the sensory processing upon which percep­
tual discriminations are based. (Sensory integration
was not developed for clients with frank brain lesions
Maureen E. Neisladt. MS, 0"1"1</1., is a Senior Lecturer, Tufts
University-Boston School of Occupational Therapy, Med· and so is not applicable, in its entirety, to this popula­
ford, Massachusetts 02155. tion. Some sensory integration techniques, however,
can he used cautiously with adults with brain injury
This article was accepted for publication }/11)' /1, 1989
[Fisher, 1989).) Neurodevelopmental treatment deals

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 with proprioceptive and kinesthetic perceptions as response to the nervous system's interpretation of
they relate to functional movement patterns. These sensory inputs, normal sensory processing should
approaches provide training in the perceptual pro­ help the client to make more normal perceptual­
cessing components of functional behavior with per­ motor responses. In the transfer of training approach,
ceptual drills or specific sequences of sensorimotor the therapist uses activities like puzzles and peg­
exercises. The common assumptions underlying the boards to prOVide practice in the perceptual skills
adaptive and remedial treatment categories are listed judged to be needed for those actiVities. The client
in Table 1 practices those skills that have been impaired by their
brain injury. Improvement in deficit skills is assumed
Literature Review to transfer to other activities requiring that skill. Be­
General Approaches cause all tasks require the use of more than one per­
ceptual skill, however, it is difficult to know exactly
Occupational therapy's perceptual retraining litera­ which perceptual skills are being trained with any
ture includes descriptions of both adaptive and reme­ given treatment activity or which skills a client is actu­
dial approaches. Siev et al. (1986), for instance, de­ ally using to accomplish functional actiVities. The ex­
scribed four perceptual treatment approaches for pectation of improvement and transfer of skills im­
adults: (a) sensory integration, (b) transfer of train­ plies that tasks used in this approach force the brain to
ing, (c) functional training, and (d) neurodevelop­ repair or reorganize itself to effect a successful behav­
mental. Three of these approaches-sensory integra­ ioral response to the perceptual tasks.
tion, transfer of training, and neurodevelopmental­ The functional approach could be classified as
can be classified as remedial because their underlying adaptive, because its underlying assumptions match
assumptions match the remedial assumptions out­ the adaptive assumptions outlined above. In the func­
lined above. tional approach, perceptual retraining is included in
In the sensory integration and neurodevelop­ activities of daily living training. Clients are taught, in
mental approaches, the therapist proVides controlled the process of such training, how to compensate for
vestibular, tactile, proprioceptive, and kinesthetic whatever perceptual deficits they may have by chang­
stimulation to promote normal central nervous system ing their approaches to functional tasks to take maxi­
processing of sensory information. Theoretically, be mum advantage of intact perceptual skills.
cause perceptual motor behaviors are performed in Abreu and Toglia (1987) described a cognitive
rehabilitation model that views perception from an
information processing perspective. This model can
Table 1
Common Assumptions of the Adaptive and Remedial be classified as remedial because its assumptions
Treatment Approaches match the remedial assumptions outlined above. In
Adaptive Approach Remedial Approach
this model, the perceptual process involves (a) sen­
sory detection; (b) analysis; (c) hypothesis formation,
The adult brain has limited The adult brain can repair
potential 10 repair and and reorganize itself after that is, comparing the analysis with prior experiences
reorganize itself after injury. injury. and relating it to the overall purpose ancl goal of the
I ntact be haviors can be used to Th is repa i rand activity; and (d) response. Responses can be data­
compensate for impaired reorganization is
ones. influenced bv driven, which are direct responses to external stimuli,
environmental stimuli. or conceptually driven, which proceed from internal
Adaptive retraining can facilitate Perceptual and expectations of incoming data.
the substitution of imact sensorimotor exercises
behaviors for impaired ones. can promote brain Treatment in the cognitive rehabilitation model
recovery and is "designed to ameliorate deficiencies along the
reorganization. continuum of the perceptual system" (Abreu & Tog­
Adaptive activities of daily living Perceptual and
provide training in functional sensorimOlOr exercises lia, 1987, p. 443) by emphasiZing the cognitive strate­
behaviors provide training in the gies that underlie the performance of a variety of tasks
perceptual skills needed in different environments with different body posi­
for those exercises.
Training in specific, essemial Remedial training in tions and active movement patterns. Strategies are
activities of daily living tasks perceptual skills will be defined as organized sets of rules that operate to se­
is necessary because adults generalized across all lect and guide the ability to process information.
with brain injury have activities requiring those
difficulty generalizing perceptual skills Treatment strategies include haVing clients plan
learning. ahead, control their speed of response, check their
Functional activities require Functional activities reqUire work, and scan from left to right. These strategies can
perceptual skills. perceptual skills.
Perceptual adaptation will Perceptual remediation will be emphasized with computer games, gross motor
improve functional improve functional tasks, group activities, games, and crafts. The goal of
performance. performance. treatment is to improve the client's ability to handle

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 increasing amounts of information by developing ef­ lesions (Agostoni, Colletti, Orlando, & Tredici,
ficient mental strategies and an efficient behavioral 1983). Some degree of impairment in constructional
repertoire. This model, then, seeks to stimulate im­ skill could, therefore, be expected in nearly all adults
provement in the central nervous system's perceptual with brain injury
processing capabilities. All of the occupational therapy literature relative
Abreu and Toglia (1987) also discussed other to constructional deficits offers remedial treatment
treatment approaches for adults with perceptual defi­ recommendations exclusively. That is, treatment is di­
cits. They named these the functional, sensory inte­ rected at relieving the deficit rather than at accentuat­
gration, and perceptual-motor training approaches. ing the client's other strengths to compensate for the
This categorization corresponds to Siev et al.'s (1986) deficit.
functional training, sensory integration, and transfer Siev et al. (1986) suggested having the client
of training categories, respectively. with constructional deficits practice simple copying
Trombly (1983) discussed neurophysiological or construction tasks, "assuming that improvement on
and compensatory approaches to perceptual retrain one task will transfer to similar tasks" (p. 44). For
ing, which correspond to remedial and adaptive ap­ simple copying, they recommended haVing the client
proaches, respectively. In the neurophysiological cat­ draw designs in a clay board rather than with paper
egory, Trombly listed such techniques as sensory re­ and pencil to proVide additional proprioceptive anel
training and visual scanning training. Under kinesthetic input. Recommended construction tasks
compensatory education, she listed backward chain­ include (a) block designs with the designs in Frostig's
ing for specific functional activities and structuring of teacher's book (Frostig & Horne, 1973), Koh's block
the environment as techniques. deSigns (Arthur, 1947) on the Wechsler Adult Intelli­
Wahlstrom (1983) recommended a perceptual gence Scale (WAIS) (Wechsler, 1955) or Wechsler
retraining program of sensory integration, positioning Intelligence Scale for Children (WISC) (Wechsler,
according to neurodevelopmental treatment princi­ 1949), or parquetry block deSigns, where the client
ples, and perceptual retraining with puzzles, peg­ copies a deSign made by the therapist; (b) matchstick
boards, and games, for all clients with head injury, designs where the client copies an arrangement made
except those experiencing confusion. For confused by the therapist; (c) pegboards where the client
clients, Wahlstrom recommended a functional ap­ copies a pattern made by the therapist; (d) connecting
proach of self-care training to address perceptual defi­ dots with a design in Frostig's workbook (Frostig &
cits. The former recommendation is clearly remedial; Horne, 1973); (e) pegboards, blocks, or parquetry
the latter, adaptive. blocks where the client converts a two-dimensional
paper pattern to a three-dimensional one; and ([)
Constructional Deficit Approaches puzzles, beginning with large four-piece puzzles of
Constructional skill is the ability to articulate parts single objects or persons familiar to the client.
into a single entity or object (Benton, 1979). This skill These recommendations clearly derive from Siev
is considered essential to draWing, both with and et ai's (1986) transfer of training approach, which is
without a model; matching blocks, sticks, or shapes to remedial, not adaptive. In addition to the assumptions
a model; building blocks, sticks, or shapes from a outlined above for the remedial approach, there are
model; and performing functional activities, such as several others inherent in these proposed activities.
dressing or setting a table. The successful perfor­ One is that materials developed for perceptual train­
mance of these activities requires the integration of ing in a pediatric population, for example, Frostig's
(a) visual perception, (b) motor planning, and (c) workbooks (Frostig & Horne, 1973), are appropriate
motor execution (Banus, 1971; Benton, 1979; Fall, for training with adults. This assumption is grounded
1987; Lezak, 1983; Strub & Black, 1977). Construc­ in an assumption that adult recovery from central ner­
tional impairment in adults has been associated with vous system trauma recapitulates the ontogeny of
bilateral brain lesions (Critchley, 1953; Strub & Black, early development.
1977), with lesions to either cortical hemisphere Yet another assumption derived from the recapit­
(Benton, Hamsher, Varney, & Spreen, 1983; Black & ulation of ontogeny idea is that the stimu Ii prOVided
Strub, 1976; Costa & Vaughan, 1962; Critchley, 1953; to an adult recovering from central nervous system
Goodglass & Kaplan, 1979; Hecaen & Assai, 1970; trauma should follow a developmental sequence. For
Piercy, Hecaen, & deAjuriaguerra, 1960; Strub & example, because children can accurately draw cir­
Black, 1977), with posterior hemispheric lesions cles, squares, triangles, and diamonds at ages 3, 4, 5,
(Benton et aI., 1983; Black & Strub, 1976), with frontal and 7 to 8 years respectively (Henderson, 1986; Rand,
lobe lesions (Luria & Tsvetkova, 1964), with corpus 1973), adults with constructional deficits should be
callosal lesions (Gersh & Damasio, 1981; Graff- Rad­ asked to copy Simple shapes in that order. In this
ford, Welsh, & Godersky, 1987), and with subcortical scheme, circles would be regarded as the lowest level

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 of difficulty and diamonds as the highest level in The therapeutic techniques that Bouska et al.
copying simple two-dimensional shapes. (1985) suggested to organize and mon itor these tasks
Abreu and Toglia (987) have argued against as­ for a client are saturational cuing and backward
sumptions of a developmental sequence: chaining. The former involves the presentation of
One must also caution against applying any theor)' or tech controlled verbal instruction on task analysis and se·
nique that was designed for children 10 an adult population quence and the presentation of cues on spatial bound­
without extensive modification. The recovery of cognitive
perceptual function after brain damage cannot simply be de
aries. The latter involves the progress of clients from
scribed as a recapitulation of an ontOgenetic sequence. The perceptual tasks that are nearly complete (e.g., all but
neurological organization, aClivation, and inhibition of the a few blocks left out of a block design) to perceptual
brain varies according to age.
In addition, an adult has acquired a fund of knowledge
tasks that are incomplete (e.g., none of the blocks
based on prior experience. which is stored in long term mem, placed in the client'S design). The therapist gradually
ory, ThiS fund of knowledge inevitably alIens thinking ami reduces the number of steps necessary for task com­
perception. Techniques that were designed for a young devel,
oping brain and emphasize acquiring new skills may not be
pletion to increase the challenge to the client.
easily applied to a brain that has already acqUired such skills. Once again, developmental sequence assump­
(pp. 445-446) tions underlie this remedial approach. Unlike Siev et
Another assumption of Siev et al.'s (986) con­ al. (986) however, Bouska et a!. (985) included
structional treatment recommendations is that evalua­ functional activities in their therapeutic task reper­
tion materials are appropriate for treatment. The use toire. The aim of treatment, however, is not to proVide
of evaluations (e.g., block deSigns from the WAIS and training in the tasks themselves, but to train the per­
WISC) for treatment invalidates those tools as evalua­ ceptual processes reqUired for those tasks. This activ­
tions by proViding speCific test practice to clients. The ity analysis approach to remedial task selection is
use of remedial tasks that are similar to those used in more flexible than reliance on evaluation-type tasks
reliable and validated evaluations, however, does but carries with it an assumption that occupational
help ensure that the tasks used for training are target­ therapy activity analyses are accurate, reliable, and
ing the deficit perceptual skill tapped by those tests. objective. Unfortunately, there is no standardized ap­
Tickle-Degnen and Rosenthal (986) also de­ proach to occupational therapy activity analysis for
scribed a remedial regimen for constructional deficits adults with neurological dysfunction. Consequently,
that involves training on variations of the WAIS block therapists often disagree about which perceptual and
designs. Again, treatment tasks are kept as close as cognitive skills are needed for any given activity (Ra­
possible to evaluation tasks. bideau, 1986).
Bouska, Kauffman, and Marcus (1985) also pro­ Najenson, Rahmani, Elazar, and Averbuch (984)
pounded a remedial approach to constructive deficits. described a remedial approach to constructional defi­
They suggested that visual analysis synthesis and vi­ cits that is more structured than the ones reviewed
suoconstructive skills be treated Simultaneously be­ above. The general purpose of their training is to
cause they are often used that way during task perfor­ "broaden the patient's capaCity to handle information
mance. Visual analysis skills include (a) an analysis of and transform it into purposeful actions" (p. 327).
similarities and differences; (b) an understanding of Training is expected to lead the client to a systematic
the relationship of parts to one another; (c) reason­ search for information, a process that can be general­
ing; and (d) deduction about the nature of visual ized across tasks. Clients are trained to see the
stimuli. structure of things and the relative roles of object
Bouska et a!. (1985) said that visuoconstructive attributes.
treatment should follow developmental consider­ The treatment program is divided into three
ations, progressing from "horizontal to vertical to levels, which progress from elementary to complex
oblique lines, from two-dimensional to three-dimen­ and from concrete to more abstract tasks. The amount
sional designs, and from tasks with common objects of information to be processed for successful com­
to tasks involVing abstract deSigns" (pp. 581-582). pletion of the therapeutic task also increases across
The tasks that can be varied along these parameters the levels.
can include simple puzzles; dot-to-dot tasks; draWing Levell is the most elementary level. Its purpose
from memory or copy; copying two·dimensional is to enable the client to transfer simple perceptual
block designs; copying three-dimensional designs; as­ models into motor acts, that is, to reproduce visual­
sembling woodwork projects, toys, or motors; sewing perceptual deSigns. The procedures used in this level
from a pattern; organizing kitchen or library shelves; are (a) copying simple forms and (b) reproducing
and setting a table. "The key to effective visuocon­ "simple designs compounded of clearly distinct parts
structive learning is, however, not the task itself, but which readily match the constructional pieces that
rather how carefully the therapist organizes it and have to be placed on the model" (Najenson et aI,
monitors performance" (Bouska et a!., 1985, p. 582) 1984, p. 330). Having a client place matchsticks on a

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 two-dimensional representation of a matchstick Can speCific treatment activities improve per­
design is an example of this type of constructional ceptual skills? One could research this question by
activity. examining perceptual test outcomes of adaptive and
In Level 2, the client is trained for more demand­ remedial treatments and by interviewing clients about
ing constructional tasks, that is, tasks with more com­ their approaches to perceptual tests before and after
ponents. Procedures used in this level are (a) "repro­ rehabilitation.
duction of a model requiring counting (of dots) and Can specific treatment activities improve junc­
accurate location of compounding parts" (Najenson tional performance? Efficacy studies that examine
et aI., 1984, p. 330) (e.g., dot-to-dot design copying carryover into functional activities from adaptive and
and replication of pegboard designs); (b) "reproduc­ remedial treatments would address this question.
tion of models outside them, first with pieces readi ly Is there a relationship between perceptual and
matching the parts of the model, and then with pieces functional skills.? Correlational studies that examine
that have to be put together to obtain the compound­ the functional abilities of adults with perceptual defi­
ing parts of the model" (Najenson et aI., 1984, p. 330) cits and the functional abilities of adults with ex­
(e.g., reproducing matchstick designs from a two- or ceptional perceptual skills would help answer this
three-dimensional model, first with matchsticks that question.
match the size of the model lines and then with the The research strategies needed to address the
same size matchsticks cut in half; (c) "copying of above questions fall into three major categories: (a)
more complex forms such as a cube and reconstruc­ outcome studies about adaptive and remedial treat­
tion with cubes" (Najenson et aI., 1984, p. 330); anel ments, (b) correlational studies about the relation­
(d) reproduction of block designs. ship between perceptual and functional skills, and (c)
In Level 3, the most demanding level, the client collaborative studies with neurologists using PET
is expected to follow a given plan to make construc­ scanners to assess metabolic changes in the brain
tions with plastic interlocking blocks of various sizes. during the course of rehabilitation. Although some
In this system, the client would progress to a higher research has already been done in the first two catego­
level only after demonstrating competence in the pre­ ries, more is needed. Controlled experimental studies
ceding level comparing adaptive and remedial approaches would
Najenson et al. (1984), Iike Siev et al. (1986), be helpful. Occupational therapy research on the re­
have chosen tasks that are used in evaluations of con­ lationship between perceptual and functional ski lIs
structional deficits. They have not, however, refer­ has focused on adults with perceptual deficits. Re­
enced their sequence of difficulty to an ontogenic search with adults who have no perceptual deficits
sequence; they have, instead, chosen to ground their would expand our knowledge base beyond this defi­
system in adult information processing theories, as cit model and give therapists a more solid basis for
have Abreu and Toglia (987) perceptual task analysis. Therapists have not yet col­
laborated with neurologists to use PET scanning to
supplement behavioral observations. Though this
Research Questions and Strategies would be expensive, it would be one way to directly
The assumptions underlying the remedial and adap­ examine our assumptions about adult brain plasticity
tive approaches suggest several general research and response to treatment.
questions about the neurophysiological mechanisms
underlying recovery, treatment activities, and the re­ Conclusion
lationship between perception and function Each of Both adaptive and remedial approaches to perceptual
these questions, prOVided below, would require a retraining, in general, are described and suggested in
specific research strategy. the occupational therapy literature, but more has
Can particular treatment activities injluence been published on the remedial approach. In occupa­
central nervous system functioning? This question tional therapy practice with adults, there is a similar
would require research collaboration with a neurolo­ emphasis on remedial approaches. Kunstaetter
gist. A pOSitron emission tomography (PET) scan (1988) and I (Neistadt, 1986), in retrospective chart
would be used to follow metabolic changes through­ review studies about occupational therapy treatment
out the brain during particular treatment activities. modalities, found remedial techniques to be predom­
This would assess possible short-term effects of cer­ inant in practice. It is hard to know whether thiS is
tain activities on patterns of brain functioning. One theory informing practice or practice informing
could then examine possible long-term changes by theory. Either way, we must examine the theoretical
comparing the admission and discharge PET scans on assumptions that underlie our practice with research
matched clients engaging in treatment activities con­ that addresses questions derived from those assump­
sistent with either an adaptive or a remedial approach. tions. Only with such research can we as occupational

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