LITERATIVE REVIEW Essay

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LITERATIVE REVIEW

The purpose of my literature review is to examine the various

therapeutic intervention strategies being administered to adult and

children who have perceptual,spacial, gross and fine motor proficient

disabilities.Furthermore what approaches appear to be working in their

rehabilitation process.adults with perceptual dysfunction secondary to

brain injury often includesOccupational therapy has been one of the

main therapeutic strategies used for perceptual retraining according to

(Holzer, Strassny, Senner-Hurley & Lefkowitz, 1982; Hopkins & Smith,

1983; Prigitano, 1986; Siev Freishtat, & Zoltan, 1986; Trombly, 1983, Van

Deusen, 1988; Wahlstrom. 1983).A variety of approaches for this

retraining has been offered by various occupational therapists. Several

authors have categorized these approaches differently (Abreu & Toglis,

1987; Neistadt, 1988; Siev et al., 1986; Trombly, 1983) It appears that

amongst all of these authors only Tromblys and Neistadt go on the

common assumptions underlying different treatment approaches, and

neither of the two authors have fully explicated the assumptions

underlying the classifications.Occupational therapy treatment

techniques for perceptualdeficits fall into two categories.

Adaptive and Remedial.Adaptive, functional occupational therapy

approaches, such as the developmental.Adaptive skills, occupational

behavior, and rehabilitation treatment paradigms (Hopkins & Smith,

1983),promote adaptation of and to the environment to capitalize on

the clients inherent strengths and situational advantages. These

approaches provide training not in the perceptual skills of functional

behavior but in the activity of daily living behaviors themselves.

On the other hand remedial approaches, such as perceptual

motor training (Abreu, 1985), sensory integration(Ayres, 1972)and

neurodevelopmentaltreatment (Bobath, 1978) seek to promote the

recovery or reorganization of impaired central nervous system

functions, specifically.Whereas sensory integration techniques address

the sensory processing upon which perceptual discriminations are

based. Sensory integration was not developed for clients with frank

brain lesions and so they are not applicable, in its entirety, to this

population.But some sensory integration techniques.However can be

used cautiously withSome adults with brain injury (Fisher, 1989).

Neurodevelopmental treatment deals withproprioceptive and Kinesthetic

perceptious as they relate to functional movement patterns. These

approaches provide training in the perceptual processing components of

functional behavior withperceptual drills or specific sequences of

sensorimotorexercises.

These are the common assumptions underlying the adaptive and

remedial treatments used currently.Occupational therapys perceptual

retraining literature includes description of both adaptive and remedial

approaches. (Siev et al. 1986), for

example four perceptual treatment Approaches for adults:

A) Sensory integration

B) Transfer of training

C) Functional training and

D) Neurodevelopmental.

Three of these approachessensory integration, transfer of training,

and neurodevelopmental canbe classifiedasremedialbecausetheir

underlying assumptionsmatchtheremedialassumptionoutlined

previouslysuchasthe retrainingsequences.

Inthe sensory integration and neurodevelopmentalapproaches,

the therapist provides controlledvestibular,tactile,proprioceptive,and

kenestheticstimulation to promotenormalcentralnervoussystem

processing of sensory information. Theoretically, because perceptual

motor behaviors are performed in response to the nervous systems

interpretation of sensory inputs, normal sensory processing should help

the client to make more normalperceptualmotor responses.In the

transfer of training approach, therapists have been known to use such

activities like puzzles and pegboards to provide practice in the

perceptualskills judged to be needed for those activities. The client

practices those skills that have been impaired by their brain injury.

Improvement in deficit skills is assumed to transfer the other activities

requiring that skill.Authors have stated that because all tasks require

the use of more than one perceptual skill, it is difficult to know

exactly which skills a client is actually using to accomplish functional

activities. The expectation of improvement and transfer of skills

implies that tasks used in this approach force the brain repair or

recognize itself to effect a successful behavioral response to the

perceptualtasks.

The functional approach could be classified as adaptive, because

its underlying assumptionmatchthe adaptive assumption.In the

functional approach, perceptual retraining is included in areas of daily

living training .Clients are taught, in the process of such training,

how to compensate for whatever perceptual deficits they may have by

changing theirapproaches to functional tasks to take maximum

advantage of intactperceptual skills.

Authors (Klonoff, H. Clark, & Kloproff. PS 1993) described a

cognitive rehabilatation model that views perception from an

information processing perspective.This model can be classified as

remedial because its assumption matches the remedial assumption.In

this model, the perceptual process involves:

A) Sensory detection

B) Analysis

C) Hypothesis formation, that is comparing the analysis with prior experiences and relating it

To the overall purpose and goal of the activity;

D) Response.

Responses can be data driven, which are direct responses to external stimuli

or conceptually driven, which proceed from external expectations of

incoming data.

Treatment in the cognitive rehabilitation model is designed to

ameliorate deficiencies along thecontinuum of the perceptual system.

(Abreu & Toglia, 1987, p. 493)by emphasizing the cognitive strategies

that underlie the performance of a variety of tasks in different

environments with differentbody positions and active movement

patterns.Strategies are defined as organized sets of rules that operate

to select and guide the ability to process information.Treatment

strategies include having clients planahead, control their speed of

response, check their work, and scan from left to right. These strategies

can be brought about and emphasized with computer games, gross

motor tasks, group activities, games and crafts.The ultimate goal of

this treatment is to improve the clients ability to handle increasing

amounts of information by developing efficient mental strategies and

an efficient behavioral repertiore. This model,then seeks to stimulate

improvements in the central nervous systems perceptualprocessing

capabilities.

In light of all the strategies that have been mentioned,(Abreu and

Toglia 1987) also discusssed other treatment approaches for adults with

perceptual deficits. They named these the functional, sensory

integration, and perceptual motor training approaches. The catergorization

correspondes to Siev at al,s (1986) functional training, sensory

integration, and transfer oftraining categories, respectively.

Trombly (1983) discussed neurophysiological and compensatory

approaches to perceptual retraining,which correspond to remedial and

adaptive approaches, respectively.

In the neurophysiological category,Trombly listed such techniques as

sensory retraining and visual scanning training.Also under

compensatory education, she listed backward training for specific

functional activities and structuring of the environment as techniques.

Wahlstrom ( 1983) recommended a perceptual retraining program

of sensory integration,positioning according to neurodeveloponental

treatment principles, and perceptual retraining with puzzles, pegboards

and games for all clients with head injury, except those experiencing

confusion. For confused clients, Wahlstrom recommended a functional

approach of self-care training to address perceptual deficits. Wahlstrom

earlier recommendation is clearly Remedial; and the latter one is

Adaptive.

One of the last strategies I would like to mention is known at

the Constructional Deficit Approach.Constructional skill is the ability

to articulate parts into a single entity or object (Benton, 1979).This

skill is considered essential in drawing, both with or without a model;

building blocks, sticks, or shapes from a model; and performing

functional activities, such as dressing or setting a table.The successful

performance of these activities requires the integration of:

A) Visual perception

B) Motor planning

C) Motor execution ( Banus, 1971; Benton, 1979, Fall, 1987; Lezak 1983; Strub & Black, 1977).

All of the occupational therapy literature that I reviewed,

relative to constructional deficits offered only remedialtreatment

exclusively.The treatment is directed at relieving the deficit rather

than at accentuating the clients other strengths to compensate for the

deficit.Sieve et a. (1986) suggests thatclients who have constructional

deficits.practice simple copying or construction tasks, assuming that

improvement on one task willtransfer to similar tasks.These authors

also recommend that the clients draw designs in a clay board rather

than with paper and pencil to provide additional proprioceptive and

Kinesthetic input.

Recommended constructions tasks include:

A) Block designs in Frostigs teacher book(Frostig & Horne 1973).Kohs.

Block designs(Arthur, 1947) on the Wechsler Adult Intelligence Scale

(WAIS) (Wescholer, 1955) orparquetry block designs, where the client

copies an arrangement made by therapist;

B) match sticks designs where the client copies an arrangement made by

the therapist ;

C)pegboards where the client copies apattern made by the therapist;

D) connecting dots with a design in Frostigsworkbook (Frostig & Horne. 1973);

E) pegboards blocks where a client converts a two dimensional paper pattern to a three – dimensional one; and

F) puzzles, beginning with large fourpiece puzzles of single objects or persons familiar to the client.

Most of these recommendation that I have mentioned here

have been derived from Siev et.s(1986) transfer of training approach,

which is a remedial approach, oppose to the adaptive one.In addition

to some of the assumptions outline here for the remedial approach,

there are several others inherent in these proposed activities.One is

that materials developed for perceptual training in a pediatric

population; for example, Frostigs workbook (Frostig & Horne, 1973),

are also appropriate for adults.This assumption is grounded in an

assumption that adult recovery from central nervous systems trauma

recapitulates the ontogeny of early development.

I would also like to mention that another assumption derived

from the recapitulation of ontogenyidea is that the stimuli provided

to an adult recovering from central nervous system trauma should

follow a developmental sequence.For example because children can

accurately draw circles, squares, triangles, and diamonds at ages(3)

three, (4) four, (5) five and (7) seven to (8) eight years respectively

(Henderson, 1986; Rand, 1973),adultswithconstructionaldeficits

should be asked to copy simple shapes in that order.

In this activity, circles would be regarded as the lowest level of

difficulty and diamonds would be the highest level in copying simple

two dimensional shapes.

Researchers Bowska, Kauffman and Marcus (1985) also proposed

a remedial approach to Constructive deficits. They suggested that the

visual analysis synthesis andvisuoconstructive skills be treated

simultaneously because they are often used that way during task

performance.

Visual analysis skill include four different components.

1) An analysis of similarities and differences

2) An understanding of the relationship of parts to one another

3) Reasoning

4) Deduction about the nature of visual stimuli.

Bouska et a. ( 1985) also suggest that visuoconstructive treatment

shouldfollow developmentalconsideration,progressing from

horizontal to vertical to oblique lines, fromtwodimensional to

three dimensional designs and from tasks with common objects to

tasks involving abstract designs(pp. 581- 582). The tasks that can be

varied along these parameters can include simplepuzzles; dot to dot

tasks; drawing from memory or copy; copying twodimensional

block designs; assembling woodwork projects, to go, or motors;

sewing from a pattern; organizing kitchen or library shelves; and

setting a table.The key to effective visuoconstructive learning is

however, not the task the learner is asked to accomplish, but rather

how carefully the therapists organizes it and monitors performance

(Bouska et al., 1985 p. 582).

The therapeutictechniques that Bouska et a l., (1985) suggested

to organize and monitor these tasks for a client are saturational cuing

and backward chaining. The first step involvesthepresentationof

controlledverbalinstructionontask analysis and sequence and

presentation ofcues on spacialboundaries. The second step involves

the progress of clients from perceptualtasks that are nearly complete,

that is all but a few blocks left out of a block design, to perceptual

tasks that are incomplete; that is none of the blocks placed in the

clients design. The therapist gradually reduces the number of steps

necessary for task completion to increase the challenge to the client.

I would like to point out that developmental sequence

assumptions underlies this remedial approach. Unlike Siev et al. (1986)

however, Bouska et al. (1985) included functional activities in their

therapeutic task repertoire. The aim of the treatment, however, is not

to provide trainingin the tasks themselves, but to train the perceptual

processes required for those tasks.This activity analysis approach to

remedial task selection is more flexible than reliance on evaluation

type tasks, but carries with it an assumption that occupational therapy

activity analysis are accurate, reliable and objective.Unfortunately,

there is no standardized approach to occupational therapy activity

analysis for adults with neurologicaldysfunction.Consequently,

therapists often disagree about which perceptual and cognitive skills

are needed for any givenactivity. (Rabideau, 1986).

I would like to conclude my literature review by stating that

many occupational therapists seem to agree that both adaptive and

remedial approaches to perceptual retraining of clients suffering from

neurological brain dysfunction has been used successfully.But most of

the literature suggests that occupational therapistrely mostly on

remedial technique approaches, compared to the adaptive approaches.

It appears that more research needs to be done in both areas of

remedial and adaptive retraining in general;although more has been

published on the remedialapproach.Kunstaetter (1988) and I (Nei-

stat, 1986), seem to believe that remedialtechniques has been more

predominantinthe treatment of subjects minimalbrain dysfunctions.

Kunstaetter (1988) and I (Neistadt, 1986) have reviewed and charted

numerous occupational therapy treatment modalities, and foundthat

remedialtechniquesarepredominantlypracticed.Most researchers

feel that it is hard to know whether theory is informing practice or

practice is informing theory.Eitherway most researchers

acknowledge that theoretical assumptionsthat underliecertain

practices shouldbefurtherresearchedto make critical assumptions

toward theory and practice toprovide the bests possible services for

their clients.

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