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.

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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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