Relation of Perceptual

and Body Image

Dysfunction to Activities
of Daily Living of
Persons After Stroke
Kerry Brockmann Rubio, Julia Van
Deusen
Key Words: cerebrovascular disorders.
intervention. self-care

Perceptual and body image disturbances are COmJ1lOn

sequelae in persons who have had stroke. There is
much evidence to substantiate a relationship between
impaired perceptualfunctioning and impairedfunctioning in activities of dailv liVing (ADL) In regard to
body image C~)lsfunetion. the /inking 0/ unilateral neglect and poor ADLfunctioning has heen widelv examined, however, the relationship 0/ other bod]' image disturbances, such as somatoagnosia. to ADL has
received little examination. Research on the aboue
relationships are reviewed in this artie/e. The Behaviountllnattention Test and Amado!tir OT-ADL
Neurobehavioral Evaluation are discussed as tu.m CISsessments that dete17nine perceptual and bo~v image
dYifunetion through ADL. The literature on intervention for perceptual and bo~v image dvsjimction in relation to ADL primarily concerns tbe difference between the restorative and jimctional retrain ing
approaches and treatment suggestions. Because speci!
ic gaps are noted in this area of stuqv. jilture researcb
ideas are suggested.

Kerry Brockmann Rubio, MHS. (H!\ I.. is Staff Occupational

Therapist, Shands Hospital at the Universitv of Floriua, Box
100341, Occupational Therapy Department. Gainesville, Florida 32610
Julia Van Deusen. PhD. OTRIL. is a Professor. University of Florida, Department of Occupational Therapy, Health Science
Center, Gainesville, Florida.
Tbis article was accepted(or publication januaJy

Tbe American. journal of Occupatiunal Therapy

4.

t995

ersons who ha.ve had stroke arc among the patients

most commonly treated by occupational therapists
(Trombly, 1989). With 350,000 stroke survivors
each year, stroke is the major cause of disability in the
United States. Eighteen billion dollars were spent in 1993
for stroke-relatecl care and lost pl'Oduetivity (Goldstein &
Matchar, 1994). Consequently, there is continued need
for occupational therapists to examine the research perraining to our intelvention for persons who have had
stroke.
The purpose of this article is to review the research
results in two areas of clysfunction that are major concerns for occupational therapists involved in intervention
to improve activities of d8ilv living (ADL) of persons after
stroke. These two areas involve the performance components of perceptual processing and self-concept (which
subsumes body image) as they are defined in the current

Uni/orm Terminology/or Occupational Tberapy-Third

Edition (American Occupational Therapy Association
[AOTA), 1994). To conform to current theory and rese8rch and ro limit our content, we have deviated from
the definitions and organization of the Uniform Terminology in a few instances. To clarify our perspective, we
have included definitions for terminologv used in this
arricle.
After the section on definitions. we have organized
the literature on our topic inro four c8tegories: (a) documentation of the pt'esence of perceptual and body image
dysfunction in stroke, (b) litCl'8ture relating problems
with ADL to perceptual and body image dvsfunction, (c)
instruments providing information on body image 8nd
perceptual dysfunction from ADL assessments, and (d)
research and case studies on stroke interventions for
body image and perceptual dysfunction, directly or inclireuly, related to improved ADL. We conclude with suggestions for research and patient service.

Terminology
In this 8rticle. ADL refel's (0 performance of self-maintenance tasks such as feeding. dressing, grooming. bathing
and toilet hvgiene, functional mobility, community mobility (driving. map reading), and functional communication
(AOTA, 1994) Because few work-related and productive
acrivities were apparent from the literature review, such
t8sks as use of money have been treated here as ADL tasks
despite the devi8tion from Uniform Terminologv. Because manv different scales are used (0 evaluate ADL,
operation81 definitions vary with the particular studv
reviewed.
Perceptual dvsfunction refers ro "the inabilitv to perform specified acrivities relevant to the interpretation and
use of sensory stimuli" (Van Deusen. 1993, pp. 244-24'5).
Perceptual dysfunction involves problems with perceptual processing as defined in UJ1l/urm Terminologv (AOTA,
1994) and includes difficulty with tasks requiring depth

551

perception. visual figure-ground differentiation. stereognosis, am.! similar pmblems. Because AOTA's Terminologv Task Force did nor include praxis as a part of perceptual processing, we have Idt it out of our review. We
included the literature dealing with constructional praxis
because this complex construct includes perception of
spatial relation as well as motor planning. Perceptual dysfunction has been operationallv defined in the research
literature through the use of numerous tests (Foss, 1993).
Bodl' image dl'::,jimction refers to the disturbances
in the synthesis of the neural body scheme and its psvchological representation that relate to !)erformance
problems. Bodv image dysfunction involves disturbances
of the body scheme and aspects of the psychological selfconcept as defined in Unzform Terminology (AOTA,
1994). Although body image disturbance may involve perceptual dysfunction, body image rroblems are not primarily perceptual. Problems can result from neural lesions affeering attention, from physical bodily changes, or
from psychosocial disturbances. Typically, body image
disturbances have both physical and psychosocial components. In persons who have had stroke, unilateral neglect is an example of a neural-based body image disturbance that can be very disturbing to the person and the
family. Unilateral neglect has been operationalized for
research purposes in many ways (Van Deusen, 1993).

Presence of Perceptual and Body Image

Dysfunction in Stroke
Perceptual and body image dysfunction in patients who
have had stroke has been documented by many research
studies (Benton, de Hamsher, Varney, & Spreen, 1983;
Edmans & Lincoln, 1989; Lorenze & Cancro, 1962; Marsh
& KerseJ, 1993; Schenkenberg, Bradford, & Ajax, 1980;
Sivak, Olson, Kewman, Won, & Henson, 1981; Wilson,
Cockburn, & Halligan, 1987b; Zoltan, Siev, & Freishtat,
1986). In an early study about perceptual dysfunction
(Lorenze & Cancro, 1962), only 3 of the 35 selected patients with hemiplegia showed no visual-perceptual problems. Sivak et al. (1981) found that subjects with brain
injury (n = 23) performed significantly worse than control subjects without brain injury on a number of perceptual tests. Edmans and Lincoln (1989) assessed 75 patients with right hemiplegia and 75 with left hemiplegia
with the Rivermead Perceptual Assessment Battery (\Y/hiting, Lincoln. Bhavani, & Cockburn, 1985); 76% of all subjeers presented with perceptual problems. No differences
were noted between right and left hemisphere damage in
relation to perceptual problems. These studies indicate
that perceptual dysfunction is a frequent result of both
right and left hemisphere stroke.
There is research documentation of body image disturbances such as unilateral neglect and body part agnosia in persons who have had stroke. Schenkenberg et al.
(1980) cited the previous research of others showing that

552

33% to 66% of patients with right hemisphere damage

demonstrated left side neglect, depending on the measurement used. Of the 20 patients studied by Schenkenberg et aI., 90% :-;howed neglect on a draWing test (daisy,
wheel, clock, human figures) but as few as 30% showed
neglect on a version of a line bisection test. In two other
studies, 48% to 50% of subjects with cerebrovascular accident (CVA) showed neglect on a test of behavioral items
such as a simulation of meal eating (\Y/ilson et aI., 1987b)
and on tests such as Star Cancellation and Line Bisection
(Mar:-;h & Kersel, 1993). By 90 days after the stroke, 22%
of the subjects in the Marsh and KerseJ study who were
available for retest still showed neglect. It is clear, therefore, that unilateral neglect poses a challenge to a large
portion of rersons who have had stroke.
Benton et al. (1983) cited the classic studies of Gerstmann in the 1920s, which showed problems with finger
schema (finger agnosia) in patients with brain damage.
Since that time, various types offinger localization deficits
have been observed in patients with brain lesions. Benton
et al. (1983) found that out of 61 subjects (41 with brain
injury from vascular disease), only 26 showed normal
performances on tests of finger localization. Somatoagnosia, the inability to identify one's body parts and their
relationship to each other, also has been documented in
persons after stroke (Zoltan et aI., 1986). Thus research
has shown that body image disturbances frequently occur
after stroke.

Relation of Perceptual and Body Image

Dysfunction to ADL Performance Problems
Many studies have found a relationship between perceptual and body image dysfunction and ADL problems in
subjects with CVA. Studies have ranged from those correlating a few rerceptual test scores with one self-care activity (such as putting on a shirt) to comrlex prediction
studies involving many perceptual and ADL variables and
often other variables as well. In these studies, ADL was
measured with tests such as the Modified Barthel Inclex
(Granger, Albrecht, & Hamilton, 1979) and the Klein-Bell
ADL Scale (Klein & Bell, 1982). Some of these studies are
reviewed below.
The classic study in the rehabilitation literature relating perceptual dysfunction to ADL problems was by Lorenze and Cancro (1962), who studied 41 patients with
CVA, 25 of \-vhom had right hemisphere damage. Upper
extremity dressing and grooming were evaluated byoccupational thnapists' ratings, and perception was operationalized by standardized tests. The biserial correlation:-;
(.82; .98) showed a strong relationship between lack of
success in dressing and grooming, respectively, and low
perceptual scores. Edrnans and Lincoln (1990) showed
that patients without perceptual deficits, as measured by
the Rivermead Perceptual Assessment Battery, were more
independent in ADL than those patients with perceptual

June I')')'). Volume 49, Number 6

deficits (p < .01). Significant relationships (p <001)

were found between perceptual abilities and 3 ADL scores
(self-care and two levels of household ADL tasks). A more
recent study showed that 8 of the 16 subtests of the
Rivermead Battery were moderately correlated with ADI.
scores (Matthey, Donnelly, & Hextell, 1993).
In several studies, moderate relationships between
perceptual skills and upper extremity dressing skills were
found, with coefficients ranging from r = .43 to r = .84
(Bradley, 1982; Kowalski-Lundi & Mitcham, 1984; Mitcham, 1982; Warren, 1981). Walker ancl Lincoln (1991)
noted a significant relationship between overall dressing
score and perceptual skills (p < .05). These authors
found dressing skills to be most highly associated with
spatial abilities, visual matching, and visual inattention.
To study more specific relationships, Titus, Gall,
Yerxa, Roberson, and Mack (1991) assessed patients who
had stroke (N = 25) with the Klein-Bell ADL Scale and a
wide array of perceptual tests. According to the report of
these authors, ADL function was found to con-elate most
consistently with agnosia, an impairmel1l in object recognition, (1' = .51,p < .01), and three-dimensional apraxia
(1' = .41, P < .04). Dressing skills related significantly to
agnosia; hygiene and feeding were correlated with a wide
variety of perceptual skills. The perceptual assessmenrs
most consistent in their correlations with ADL were the
Test of Three-Dimensional Constructional Praxis (Benton, 1973), the Block Design of the WAlS-R (Wechsler,
1981), the HapticVisual Discrimination Test (McCarron &
Dial, 1979), and the Adult Visual-Perceptual Assessment
(Baylor University Medical Center, Occupation:J1 Therapy
Department, 1980).
Two studies examined the effects of motor versus
perceptual dysfunctions on the ability to perform c1ailv
tasks In the earlier study (Eriksson, Bernsp3ng, & FuglMeyer, 1988) motor impairments affected ADL perfurmance more than perceptual impairment in a sample uf
109 patients within 2 weeks of stroke. In the seconel study
(Bernspang, Viiranen, & Eriksson, 1989), which used the
same assessments as the previous study, 75 different suhjects were assessed 4 to 6 years after stmke. The results
were reversed: perceptual dysfunction, especially visuospatial and visual-motor dysfunction, was more likely than
mOtor dysfunction to impair lung-term ADL status.
In summary, studies have indicated that perceptual
dysfunction plays a large role in the ADL impairments of
persons who have had stroke. These problems may be
difficult to overcome, because perceptual impairments
affect ADL status for many years after stroke. Perh:Jps
improved occupational ther:1py intervention with this
population can evcntu:1l1y better this situation.

Predicting Self-Care From Perceptual

Dysfunction
Attempts to correlate percertual scores with illlprove-

The American Journal of Occupational Therapy

ment in ADL for purposes of prediction have not all been

positive. One study (Rosenthal. Pearson, Medenica, Manaster, & Smith, 196')) found no significant con-clations
between scores from standardized visual perceptual tests
and self-care improvement in a rehabilitation selting.
Other studies have shown different results. Bourestom
and Howard (1968) were able to differentiate self-care
improvement of persons with eVA by means of three
standardized tests requiring perceptual performance.
Carter, Oliveira, Duponte, and Lynch C,(988) studied 21
patients after stroke and found that Visual-spatial perceptual abilities strongly predicted posttest ADL functioning
in areas of dressing, hygiene, and bed mObility. Visual
scanning \Vas also found to be significantly predictive of
personal hygiene function. Finally, in a study of hundreds
of predictor variables, Anderson and colleagues found
that subjects who improved least after stroke were distinguished from those who improved most by lack of mOtivation, emotional disturbances, and gross perceptual dysfunction. The authors believed that these variables could
be assessed bv clinical ob "ervations (Anderson, Bourestom, Greenberg. & Hildyard, 1974).

Predicting Driving Ability From Perceptual

Dysfunction
Because driving poses serious safety issues, a number of
studies have addressed the predictability of perceptual
test scores to driving ability of persons with brain injur}/,
including that from evA. Sivak et al. (198]) demonstrated
that five of the eight perceptual tests used in their study
could predict prohlems with driving. Simms (1985) found
perceptual test scores predictive of driVing success (N =
52). A I-vear follow-up survel- showed that all but two
current drivers had been ['ecommended to drive from the
asse.ssment results the previoUS veal'. Unfonunately, only
2.3 of the 52 subjects in the follow-up studl' r-eturned the
questionnaire.
In 1990, repons on driving studies began appearing
from a Kessler Institute research group (GaJski, Bruno, &
Ehle, 1992, 1993: Galski, Ehle, & Bruno, 1990). In the
initial study, only 4 of 21 variables were found to predict
results of the driver assessment, none of which involved
perception. These authors then developed a CybernetiC
Model of Driving (1992); the resulting test battery was
used to prediCt driving in 3'5 subjects with CVA and brain
injury. Visual-perceptual test scores explained 64% of the
variance in the driving assessment. The tests of vi suospatial analrsis and synthesis, Visual-mOtor coordination, and
constructive abilities were predictive of driving performance of {Jersons with cerebral damage. Behavioral observations_ especially attentional ones, were also important in prediction. This research group noted that use of
the perce{Jtual tests identified performance deficits that
could he amenable to remediation or compensation for
clriving skill.

553

In conclusion, much evidence shows perceptual dysfunction to be predictive of poor ADL performance, including that of driving performance. Other variahles hesides perceptual status also contribute to the potential for
ADL independence of persons after stroke.

Relation Between Body Image Dysfunction and

ADL
In persons with CVA, body image problems are fundamentally due to injury affecting the neural foundation,
that is, to body scheme disturbances. Somatoagnosia and
finger agnosia were related to the ADL performance of 85
[lersons with CVA in Warren's (1981) study, which significantly correlated scores on a body scheme measure to
their scores on an upper extremity dressing performance
scale (r = .67). However, much of the literature dealing
with body image disturbances in stroke as they relate to
ADL is concerned with the problem of unilateral neglect,
which involves attentional deficits such that the body side
contralateral to the cerebral lesion is ignored. Movement
of limbs in relation to objects in space contralateral to
lesion site may also be affected (Heilman, Valenstcin, &
Watson, 1985).
Many studies have addressed the relation of unilateral neglect to ADL. Forty-eight patients with CVA were
administered various motor and neuropsychological assessments, a 51-[Joint ADL scale, and a test of unilateral
neglect involving cO[Jying crosses (Denes, Semenza,
Swppa, & Lis, 1982). The authors concluded that the test
of unilateral neglect was the only variable related to the 6month improvement found in ADL, but cautioned that
this association did not necessarily mean that unilateral
neglect was responsihle for the poor ADL improvement.
Marsh and Kersel (1993) found a correlation between
scores of the unilateral neglect suhtest, Star Cancellation,
and the Modified Barthel (r = .5'5) for 27 subjects from a
New Zealand stroke unit. In their studies of Australian
subjects after stroke, researchers (Kinsella & Ford, 1980;
Kinsella, Olver, Ng, Packer, & Stark, 1993) found that
poor ADL outcome was not associated with right side
cerebral lesions unless suhjects had unilateral neglect.
After their research identified two unilateral neglect factors, they found that both were strongly related to ADL for
their subjects at 6 months after stroke. In a study that
analyzed three components of the unilateral neglect syndrome (hemispatial neglect, inability to recognize the
limb, and unawareness of the disease or anosognosia),
Gialanella and Mattioli (1992) concluded that the kind of
unilateral neglect associated with lack of ADL improvement was anosognosia. However, only 10 [Joints on the
140-point ADL assessment related to areas other than
ambulation, so relevance to self-care tasks is unclear.
Chen-Sea, Henderson, and Cermak (1993) investigated the relationship of lateralized and nonlateralizcd
inattention to ADL in 64 Chinese patients with right le-

554

sions by using the Random Chinese Word Cancellation

Test (\Xfeintraub & Mesulam, 1985) and the Klein-Bell
ADL Scale. The grou[J with hem i-inattention demonstrated Significantly poorer ADL [lerformance than did both
the group with nonJateralized inattention and the group
with normal attention. There were no differences in ADI.
measures between the groups with nonlateralized inattention and normal attention. After the effects of physical variables were panialled out, moderate correlations
were still found between hemi-inattention and ADL performance (r = .48), with subscores from the dressing
and mobility tasks being strongest (r = - .48; - .52,
respectively) .
In a study of subjects with CVA, 12 persons without
unilateral neglect were compared to 12 with unilateral
neglect on their wheelchair performance on an obstacle
course (Webster, Cottam, Gouvier, & Blanton, 1989). Although the group with unilateral neglect struck more leftside obstacles than did the control group, both groups
struck more left-side than right-Side obstacles. There was
a significant difference in type of left-side errors hy the
two groups: the subjects with unilateral neglect more
often struck the obstacles by direct frontal contact.
In a London hospital follow-up study, Stone, Patel,
and Greenwood (1993) found that severity of unilateral
neglect, severity of motor weakness, and age predicted
90% of subjects who were inde[Jendent in ADL and 80% of
subjects who were moderately or severely de[Jendenr at
3-month follow-up (N = 89) At 6 months, 91% of subjects who were inde[Jendent in ADL and 71 % of subjects
who were moderately or severely dependent were correctly predicted (N = 84) Prediction for mildly de[Jendent subjects lacked accuracy.
Several other researchers (Fullerton, McSherry, &
Stout, 1986; ]essho[Je, Clark, & Smith, 1991, Kotila,
Niemi, & I.aaksonen, 1986) also showed relationships between ADL and measures of unilateral neglect. Although
an occasional report suggested little relationship (Edmans & Lincoln, 1990), there is clear evidence to substantiate an association between unilateral neglect of [Jersons
with stroke and poor prognosis for ADL recovery. Because similar results have been ohtained with subjects
from different countries, evidence is strong that the obse[\'ed relationshi[J is not a cultural artifact.

Assessments
Although there are numerous tests for perceptual and
body image dysfunCtion and for ADI. being used in clinical
intervention as well as in research, we have found only
two batteries that directly assess perceptual and body
image dysfunction from ADL performance. Such tests are
particularly valuahle for occupational therapists because
they proVide a direct guide to the patient's treatment
needs.

june /995. VolLime 49. Number (,

Behavioural Inattention Test

Behavioral ADL items designed for a test of unilateral
visual neglect were reported by Wilson et '11. (l987b). This
test has changed through the usual development process
involved in test construction, and the current version, the
Behavioural Inattention Test, (Wilson, Cockburn, & Halligan, 1987a) is distributed in the United States The test
manual proVides normative data on only 80 adults who
have had stroke and 50 control subjects, but the test is
shorr, practical, and easy to administer Initially, the ADL
items were validated by relating scores to those of six
conventional tests of unilateral neglect obtained from
previously published studies. Except for a line bisection
test, correlation coefficients ranged from r = .59 to r =
.87. Interrater reliabilitv for the ADL items was excellent
with 1.00% agreement between two raters. Alternate form
reliability was r = .83 The current names of the ADI.
items are: Picture Scanning, Telephone Dialing, Menu
Reading, Article Reading, Telling and Setting the Time,
Coin Sorting, Address and Sentence Copying, Map Navigation, and Card Sorting (Wilson et al., 1987a) and vary
somewhat from those originally reported (Wilson et aI.,
I987b). SL" conventional unilateral neglect subtests were
added to make up the current batten l : Line Crossing,
I.errel' Cancellation, Star Cancellation, Figure and Shape
Copying, Line Bisection, and Representational Dra\ving.
Research has shown these conventional subtests to have
construct validit)' as measures of vbual neglect, with the
Star Cancellation subtest being the single most sensitive
instrument (Halligan, Marshall, & Wade. 1989; Marsh &
Kersel, 1993). Because the ADt items on the Behavioural
Inattention Test do not include the typical self-care items
(e.g., dressing, grooming), the fact thm the Star Cancellation subtest is related to these skills (Marsh & Kersel,
1993) is important to the use of this test in occupational
therapy. The only test we have located that actuallv assesses unilateral neglect from such self-care observations
is the Arnadottir OT-ADL Neurobehavioral Evaluation (AONE) (Arnadottir. 1990)

A-ONE
The A-ONE is an assessment tool that links functional
perfmmance in daily activities to neurohehavimal deficits
(Arnadottir, 1990). The tool inclucles (a) a Functional
Independence Scale, which determines the level of ass istance needed on five ADL domains: dressing, grooming
and hvgiene, mobility. feeding, and communication. with
each one of these domains having suhcomponents that
arc separately assessed; (b) a Specific Neurobehavi()('al
Scale, which assesses the type and amount of interference
of 10 specific neurobehavioral impairments on each of
the subcategories within each ADL domain: and (C) a
Pervasive Neurobehavioral Scale. which determines the
presence or absence of other neurobehavioral impair-

The American journal of Occupational Therapy

ments throughout the assessment. Assessment of neurobehavioral impairments is done through analysis of the
ADL tasks that a patient performs; the severity of the
neurobehavioral impairment depends on the extent to
which it affects ADL task completion. Some of the perceptual and body image impairments that the A-ONE assesses include spatial relations dysfunction, unilateral
body neglect, unilateral spatial neglect, somatoagnosia,
topographical disorientation, anosognosia, visual object
agnosia, and right-Jeft disorientation. The A-ONE also
allows for the ability to localize possible lesion sites by
comparing the information from both the Specific and
Pervasive Neurobehavioral Scales to an available chart;
however, more research is needed to use this part of the
A-ONE with confidence .
Studies have established good interrater reliability
(kappa = .84) for the A-ONE Content validity has been
established through literature review and expert opinion,
and concurrent validity has been established on populations with CVA and with dementia. Contribution to
construct validitv has been initiated through exploratory
factor analysis. Multiple studies are currently being
conducted to further establish reliability and validity of
the A-ONE (Arnadottir, 1990; G. Arnadorrir, personal
communication, March, 1993, July 1994).

Intervention by Occupational Therapy

Because we found little literature dealing specifically with
ADL intervention for persons with perceptual or body
image dysfunction, some of the follOWing studies have
indirect rather than direct implications for ADL functioning. Edmans and Lincoln (1991) used a multiple-baseline,
single-case experimental design to evaluate the effectiveness of the transfer of training (restorative) approach
to perceptual treatment. The transfer of training approach assumes thm practice of perceptual tasks (threedimensional copving. using sequencing cards, placing ob,
jects in size order) will carr)! over into ADL skill improvement. Analysis using this transfer of training approach
revealed no evidence of improved ADL status in four
patients with right hemiplegia from stroke.
Caner, Howard, and O'Neal (1983) sought to determine the effects of a cognitive-perceptual skill remediation program for 33 patients who had had acute stroke.
Three areas were addressed in this study: visual scanning,
visual-spatial orientation, and time judgment. The experimental group received routine stroke program intervention plus one-an-one remedial treatment for deficits in
the above-mentioned areas, and the control group received only the routine stroke program intervention. Results revealed ~ignificantly higher overall improvement
(in the three specific areas) in the experimental group
(p < .00'3) than in the control group. In a post hoc analysis
of these data (Carter et aI., 1988) the change in Barthel
scores between experimental and control groups was ex-

555

amined. No significant differences were found between

groups in overall improvement scores of the Barthel. Significantly greater improvements (p < .05) were noted in
areas of personal hygiene, bathing, and toileting for the
experimental group
Sivak et a!. (1984) studied whether therapy aimed at
imrroving percertual skills of subjects with brain damage
(N = 8) would result in improved driving performance
without driver's training. Individualized perceptual training was provided on tasks requiring scanning, Figureground differentiation, sratial perception, attention, and
visual imagery. Significant improvements were found for
both perception and driving. A significant coefficient of r
= .73 was obtained for the relationship between perceptual and driving changes. Lack of a control group makes
interpretation of results difficult.
A pilot study (Kumar, Powell, Tani, Naliboff, & Metter, 1991) was conducted to determine whether persons
who have had stroke can be trained to return to limited
safe driving despite perceptual deficits. Standardized perceptual tests were administered and patients entered a
driver program with the instructor blind to test results.
The program was graded from a simulator to three levels
of in-traffic training. At the 6-month follow-up, 13 of the
16 had passed the state motor vehicle license test. From
follow-up information, the subjects were divided into
three driving groups: (a) drove anywhere at any time, (b)
drove on familiar surface roads in good driving conditions, and (c) did not receive license. By the 2-year followup, only one person reported an accident and one had
changed from group 1 to group 2. Analysis of the perceptual test results showed that test scores were significantly
better for group 1 but were not different between groups
2 and 3. The researchers concluded that some persons
who have received a rehabilitation driver's training program can return to safe but limited driVing despite perceptual deficits.
Several studies investigated the effects of treatment
for unilateral neglect. Webster et al. (1984,1989) and King
(1993) were concerned with scanning training to improve
ADL of persons with unilateral neglect after stroke. Webster et al. (1984) obtained positive results in a singlesubject design study. The three subjects improved on a
wheelchair obstacle course assessment after participating
in a scanning program involVing colored light anchors
and in-wheelchair movement. In a scanning training
study with 13 subjects with eVA, Webster et a!. (1989)
found that, although frontal contact with obstacles on the
wheelchair obstacle course declined, sideswipe errors
did not. King (1993) believed that scanning training often
fails to improve ADL because the size of the visual field
used is not adequate for ADL. He evaluated the usc of a
computer-projected image on a 5-ft wide screen for scanning practice of 21 persons with unilateral neglect with
what he considered positive results. There was no control
group.

556

Encouraged by positive results from their singlesubject design studies, Robertson, Gray, Pentland, and
Waite (1990) evaluated the effects of computerized training for 36 subjects with unilateral neglect. Twenty experimental subjeccs received 14 seSsions of scanning and
attention training with programs based in learning theory Sixteen control subjects used motivating computer
games screened to rule out scanning activity. Because of
its ADL items, the Behavioural Inattention Test was the
principal outcome measure, but no differences were observed between experimental and control subjects; neither group improved. When results were analyzed for
only subjects with severe unilateral neglect, there werc
still no significant group differences.
The role of motivation to assist with lessening the
effect of unilateral neglect was studied by Ishiai, Sugishita,
Odajima, and Yaginuma (1990). Eight subjects with right
CVA, serving as their own control subjects, were twice
assessed on a line cancellation task using AJbert's test.
During the second assessment, the subjects were instructed to number the lines found (motivating factor)
instead of crossing them out. Results revealed imrroved
left spatial neglect for the second trial, which the authors
attributed to increased subject motivation during the
task. These authors further stated that lack of motivation
may be a contributing factor in unilateral neglecT AJthough not directly related to ADL, the implications of
this study are relevant to occupational thcrapy and could
lead to an interesting project if related to ADL improvement.
Literature is available that compared the use of different treatment approaches to intervene for perceptual
and body image dysfunction. The two most common approaches are the functional training approach and the
specific skill retraining (restorative) approach (Abreu,
Duval, Gerber, & Wood, 1994). The functional training
(or adaptive) approach uses functional or occupational
tasks as treatment modalities to maximize patients' independence. This approach can include the use of environmental or task modification and practice of specific functional activities to increase a person's independence in
his occurations. The restorative approach emphasizes
specific perceptual skill retraining (including pen-andpaper, card, and computer activities) to improve deficits
in specific skills. This approach assumes that improvement in srecific perceptual skills will generalize to imrroved performance in functional activities (Abreu et al.).
Jonghloed, Stacey, and Brighton (1989) investigated
these two treatment approaches in stroke rehabilitation,
including percertual cognitive intervention. Ninety patients who had had stroke were randomly assigned to
t1'eatment grours, each grour receiving treatment related
to either the functional or restorative approach. No control grour was used. No significant differences were noted between groups on self-care or sensorimotor integration measures. Pedro-Cuesta, Widen-Holmqvist, and

June 1995. VolulJle 49. Number 6

Bach-y-Rita (1992) reviewed 20 controlled, randomized

studies of rehahilitation after stroke Their analyses revealed that rehahilitation for perceptual deficits arpear<.>d
to be effective for several months aft<.>r stroke, but no
difference was noted he tween programs emphasiZing retraining of specific perceptual deficits (such as use of
computers or biofeedback) versus the traditional functional retraining approach.
Two case studies illustrated the relationship in occupational therapy intervention hetween percertual dysfunction and ADL performance Cook, I.uschen, and Sikes
(1991) were concerned with the clressing prohlem of a
woman with visual-percerwal impairment as well as other cognitive dysfunction. A comrensatorv program was
developed so that this elclerly patient could dress hy cues
from an audiotape. Discharge to her son's home was
made possible hecause her dressing assistance meant
only that he neecled to rrearrange clothing and turn on
the audiotape. Borst and Peterson (1993) worked With a
woman who showed a severe spatial rclations perceptual
deficit and topographical disorientation after stroh'. Intervention dealt with these pr-ohlems through practice
with various tasks involving maz<.>s, mars, and parquetry
hlocks as well as practice following actual routes. Her
clinical evaluation showecl suhstantial imrrovement

Treatment Recommendations
Treatment recommendations for percertual and body
image dysfunction are frequent in the literature. Unfortunately, little research is available to suhstantiate many of
these recommendations. Most of the authors have supported the use of the functional training approach (Butler
& Namerow, 1988; Neistadt, 1992; Neistadt, 1988; Rohertson et aI., 1990), or a comhination of functional and specific percertual remediation (Edmans & Lincoln, 1991;
Lin & Cermak, 1991) to improve overall function in daily
tasks.
When offering recommendations, authors often fo
cused on treatment of neglect (Cooke, 1992; Ishiai et aI.,
1990; Lin & Cermak, 1991; Olson, 1991; Rohertson,
North, & Geggie, 1992) They supported (a) visual scanning training and verhal cuing for visual anchoring, (h)
increasing patients' awareness of negleer to foster compensation mechanisms, (c) increased stimulation to the
affected side, (d) using visual markers, and (e) activating
of the affeered extremity in the affected hemispace to
decrease the effects of neglect. As preViously reported,
Ishiai et al. (1990) also noted that motivating activities
tended to lessen the effects of neglect more than nonmotivating activities.
Olson (1991) has suggested treatment techniques
for some specific perceptual impairments. For sratial impairments, Olson recommended encouraging patients to
touch objects, teaching patients to move slowly during

The American Journal 0/ Occupational The/apr

tasks and handle ohjects at their hase, and talking patients through activities instead of using gestures. For
treatment of agnosias, training the patient to use the
intact sensory modalities is recommended.
We have concluded from the current evidence that
the functional training approach will best facilitate improved self-care of patients with unilateral neglect or perceptual dysfunction resulting from stroke. However,
there is evidence that a combined restorative-functional
approach may be the most effective means when wheelchair mohility or driving skill is the ADL task of interest.

Research Recommendations
Although much research has examined perceptual and
hody image dysfunction in relation to ADL, there is much
more to he learned. Few studies examined the relation of
bodv scheme impairments, other than unilateral neglect,
to ADt function. Greater understanding about these relationships and the impact of treatment programs for these
impairments could improve our effectiveness of intervention Sturlies are needed that also examine the impact of
the psychological dlsturhances of hody image on the ADL
of persons after stroke.
Little information is availahle regarding the longterm effects of percertual deficits on ADL performance or
long-term effects of intervention for perceptual and hody
image dysfunction (either hy functional or restorative approaches) Although Bernspang et al. (1989) did reveal
that perceptual deficits remain many years after stroke
and appear to significantly impair ADI. functioning, more
information is needed from longitudinal studies. It is important to find out the type of rerceptual deficits that
impair ADL most notahly over time, and what type and
length of interventions might he effectively applied even
months and years after stroke.
Another area of research interest is contextual. What
kinds of home and community modifications best serve
the rerceptually dysfunctional person after stroke? How
can environments be adapted to ensure the safety of
persons with rerceptual rrohlems or to increase their
independence in ADt?
AJthough little evidence suPpOrts use of only the
restorative approach for perceptual and bocly image dysfunction to imrrove functional status, insufficient information is availahle on actual time gUidelines for optimal
treatment for using either the functional or restorative
approaches. Neither is research available about which
perceptual or body image deficits may he more or less
influenced by different treatment approaches. Continued
study of the A-ONE and of the Behavioural Inattention
Test is necessary, along with work on innovative research
methods that allow rigor in design without compromising
our ethical stance.
Because of the complexity of body image and perceptual dysfunction as they relate to ADL performance,

557

interdi.~ciplinary

research

is

mandated.

Collaborative

research with neuropsychologists, physical therapists,

speech pathologists, and others who have relevant expertise can add both breadth and depth to our research
efforts. Major changes in health care will require us to
work efficiently with others as we continue to document
the effectiveness of occupational therapy interventions
for body image and perceptual dysfunction as they affect
the ADL status of persons after stroke ....

Dressing training for an clderlv woman with cognitive and perceptual imlJairrnents. Americanjou17lal o/Occupalional Ther-

0Pl', 45, 652-654

Cooke, D. (1992). Remediation of unilateral neglect: What
do we knolV/ Australian Occupalional Tbe7'UP.l' journal,
39(2), 19-25
Denes, G., Semenza, C, Stopra, E., & Lis, A, (19H2). Unilateral spatial neglect and recovery from hemirlegia: A follow-up
studl'. f3min, J05, ')43-552
Edmans, J. A, & Lincoln, N. B. (1989). The frequencv of
perceptual deficits after stroke British journal of Occupation-

al TherajJl', 52, 266-270.

Edmans, ]. A., & Lincoln, N.B. (1990). The relation hetween rerceptual deficits after ~troke and independence in
activities of daily living. British journal of Occupational Tber-

References
Abreu, B., Duval, M., Gerher, 0, & Wood, W. (1994). OCCLlrational performance and the functional approach. AOTA selfstudy series. Cognitive rebahilitation. Rockville, MD: American
Occupational Therapy Association.
American Occupational Therapy Association (1994). Uniform terminology for occurational therapy- Third edition.

American journal of Occupational Tberapy, 48, 1047-1054

Anderson, T. P., Bourestom, N., Greenberg, F. R., & HiIdyard, V. G. (1974). Predictive factors in stroke rehabilitation
Archives ofPhysical Medicine and Rehahilitation, 55, 545-553.
Arnadottir, G. (1990). The hrain and behavior. Assessing
cortical dysfunction througb activities ofdaill' 1i1'ing. Sr. Louis:
Moshy.
Baylor University Medical Center, Occupational Therapy
Derartmenr. (19HO). Adult Visual-Perceptual Assessment. Dallas: Titus.
Benton, A. I.. (1973). Test of Three-Dimensional Constructional Praxis. Iowa City, IA: University Hospitals, Department
of Neurology.
Benton, A., de Hamsher, K. S., Varney, N. L, & Spreen, O.
(1983) Contributions to neuropSl'chological assessment. New
York: Oxford University Press.
Bernsrllng, B., Viitanen, M., & Eriksson, S. (1989). Impairments of perceptual and motor functions: Their influence on
self-care ability 4 to 6 years after a stroke. Occupational Tber-

apI', 53, 1,39-142

Edmans,]. A., &. Lincoln, N. 13. (1991). Treatment of visual

rerceptual deficits after strokc: Single case studies on four ratients with right hemirlegia. British journal 0/ Occupational

Therapl' , 54, 1:39-144

Eriksson, S, Bernspng, B., & Fugl-Mel'er, A. R. (/988).
Perceptual and mmor impairment within 2 weeks after a stl'Oke:
A multifactorial Statistical approach. Occupational Thempl'

Journal of Research, S, 114-125

Foss,J (1993). Cerehral vascular accident: Visual pel-ceptual dysfunction. In J Van Deusen, Bodl' image and perceptual
d)'sfunction in adults (pp. 11-38). Philadelphia: Saunders.
Fullerton, K. .I., McSherrv, D., & Stout R. W. (19H6). AJbert's
Test: A negleCted test of perceptual neglect. Lancet, 1 (8478),
430-432.
'
Galski, T., Bruno, R L, &. Ehle, II. T (1992). Driving after
cerebral damage: A model with implications for evaluation.

American Journal o/Occupationol TberajJl', 46, 324-:332.

Galski, T. Bruno, R. L, & Ehle, H. T (1993). Prediction of
hehind-the-wheel driving performance in patients with cerebral
bl'ain damage: A discriminant function ;lOalvsis. Americanjour-

nal of Occupational Therapl', 47, 391-390.

GaJski, T., Ehle, H. T, & Bruno, R. J.. (1990). An assessment
of measures to rrediCt the outcome of driving evaluations in
patients with cerebral damage. American journal o/Occupo-

apy journal of Research, 9, 27-37.

Borst, M. J., & Peterson, C Q. (1993). Case repon - Over-

tional Therapr, 44,709-713.

Gialanella, 13., & Mattioli, F. (1992). Anosognosia and extra-

coming topographical orientation deficits in an elderly woman

with a right cerebrovascular accident. Americanjournal ofOc-

personal neglect as preelictors of functional recovery following

right hemisrhere Stroke. Ne/IJ'ops)'cbological Rehahilitation,
2, 169-178
Goldstcin, 1.., & !'vlatchar, D. (1994). Clinical assessment of
stroke. journal 0./ tbe American .vledical Associalion, 27J,

cupational Therapl', 47,551-554.

Bouresrom, N. C, & Howard, M. T. (1968). Behavioral
con'elates of recovery of self-care in hemiplegic patiems. Ar-

chives of Physical /Vledicine and Rehabilitation, 49, 449-454.

Bradley, K. (1982). Brief: The effectiveness of constructional rraxis tests in predicting urper extremity dressing abilities. Occupational Therapy journal of Research, 2, 1H4-185.
Butler. R W. & Namerow, N. S. (1988). Cognitive retraining
in brain-injury rehabilitation: A critical review.jou171al ofNeurolop,ical Rehabilitation, 2(3),97-101. (From Sil/lerPlatter, AbstraCt No. 77-23646.)
Carter, L T., Howard, B. E, & O'Neal, W. A. (1983). Effectiveness of cognitive skiJI remediation in acute stroke patients.

American.loul'l1al

0/ Occupotiollal Thempr, 37, 320-326

Caner, L. T, Oliveira, D. 0., Duponte, j.. & Ll'nch, S V

(1988). The I'elationship of cognitive skills performance to actil'ities of daily Jiving in stroke patients. American journal of

Occupalioi1ttl Tbempl', 42. 449-455

Chen-Sea, M.,T., Henderson, A., & Cermak, S. A. (1993).
Patterns of\'isual spatial inattention and their funCtional significance in stroke patients. Archires of Phrsical Medicine and

Rehabilitotion, 74, :355-300

Cook, E. A, Luschen, L, & Sikes, S. (1991). Case report-

558

1114-1120
Granger, C, Albrecht, G., & Hamilton, B. (1979). OutCOme
of comprehenSive medical rehabilitation: Measurcment by
PULSES Profile and the Barthel Index. Archilles of Pbl'Sical

..
;\IIedicine and I?ehahilitation, 60,14')-154.
Halligan, P., Marshall, J, & Wade, D. (1989) Visuospatial
neglect: Underlying faerors and test sensitivity. The Lancet, ii,
908-911.
Heilman, K, Valenstcin, E., &. Watson, R (1985). The neglect Sl'ndrome. In .I. Fredericks (Ed), Handhook of clinical
neurology (/'01. 45-J): Clinicalneuropsycbologl' (pp. '153-183)
New York: Elsel'ier
Ishiai, S., Sugishi[a, M., Odajima, N., & Yaginuma, M.
(1990). Impr~vement of unilatel'al spatial neglect with numbering. Neurology, 40, 1:395-139H
Jesshope, H. J., Clark, [vi S, & Smith, D. S. (1991). Th<:
Rivennead Perceptual Assessment Batten': Jts arplication to
stroke patients and 1'Clationshir with function. Clinical Rebabilitation, 5, 115-122. (From Si/uerP/cltler, Abstract No. 79-

33699)

jlllu' 1995. Vulume 49. Number 6

Jongbloed, t, Stacey, S" & Brighton, C (1989), Stroke

rehahilitation: Sensorimotor integrative treatment versus functional treatment, American Journal of Occupational Therapy,
43, 391-397
King, T, (1993). Treatment of visual inattention using computerized ovel'head projection, Journal of Cognitive Rehabilitation, 11, 32-35,
Kinsella, G" & Ford, B, (1980), Acute recovery ratterns in
stroke patients: Neuropsychological fac[Ofs. The l\JIedica/}ournal of Australia, 2.663-666.
Kinsella, G., Olver,]., Ng, K., Packer, S, & Stark, R. (1993).
Analysis of the syndrome of unilateral neglect. Cortex, 29,
13';-140
Klein, R M" & Bell, B. (1982), Self-care skills: Behavioral
measurement with Klein-Bell ADL scale, Archives of Ph)'sical
Jl1edicine and Rebahilitation, 62, 33';-338
Kotila, M., Niemi. M .. & Laaksonen, R, (1986), Four-year
rrognosis of stroke patients with visuospatial inattention. Scandinavian journal of Rehabilitation Medicine, 18, 177-179.
(From SiluerPlatter, Abstract No. 87120150.)
Kowalski-Lundi, M. H., & Mitcham, M. (1984). Brief The
relationshir of constructional praxis [0 an upper extremity
dressing task. Occupational Therapl' journal of Researcb, 4,
)13-315
Kumar, R, Powell, B.. Tani, N., Naliboff, B.. & Metter, E,
(1991), Perceptual dysfunction in hemiplegia and automobile
driving, The GerontoloRist, 31, 807-HlO
Lill, K., & Cermak, S. A, (1991), Cognitive perceptual intervention in rost-stroke patients with unilateral neglect: An annotatec! hibliography. Physical and Occupalional Therapl' in

Geriatrics, lO, 63-79,

Lorenze, E" & Cancro, R (1962), Dysfunction in visual
perception with hemiplegia: Its relation to activities of daily
living. Archiues of Physical Medicine and Rehabilitation. 43,
514-';17
Marsh, N" & KerseJ, D, (1993) Screening tests for visual
negleCt following stroke, NeuropsJlchological Rehabilitation, 3,
24=;-2=;7
Matthey,S., Donnelly,S., & Hextell, D, (1993), The clinical
usefulness of the Rivermead Perceptual Assessment Battery:
Statistical considerations. Bvitish journal of Occupational
Tberapl', 56, 365-370
McCarron. L. T, & Dial,j (1979), flaptic Visual Discrimination Test. Dallas: j\llcCarron-Dial Systems,
Mitcham, M. (19H2). Brief Visual rerception and its relationship to an aCtivity of daily living. The Occupational Therapy
journal of Research, 2, 24'5-246,
Neistadt, M. E. (1988). Occupational therapy for adults with
percertual deficits. American Journal of Occupational Therap)!, 42, 434-440.
Neistadt, M, E, (1992), Occurational therarytreatments for
constructional deficits, American journal of Occupational
Therapy, 46. 141-148.
Olson, E (1991). Perceptual defiCits affecting the stroke
patient, Rehabilitation Nursing. 16,212-213
Pedro-Cuesta, J. de, Widen-Holmqvist, L., & Bach-y-Rita, P,
(1992). Evaluation of stroke rehabilitation by randomized controlled studies: A review. Acta Neurologica Scandinavica, 86,
4.'\3-439
Robertson, I., Gt-ay, ]., Pentland, G" & Waite, L. (1990),
Microcomputer-based rehabilitation for unilateral left visual neglect: A randomized controlled trial. Archives ofPh1'sical Nfedicine and Rehabilitation, 71, 663-668
Robertson, I. H" North, N, T, & Geggie, C. (1992), Spatio-

The American Journal o/Occupalional Therapl'

motor cueing in unilateral left neglect: Three case studies of its

therapeutic effects, .Journal of Neurolog1', Neurosurgely, and
P.,vchiatly, 55, 799-805
Rosenthal, A" Pearson, L., Medenica, B., Manastef, A., &
Smith, C (1905), Correlation of perceptual factors with rehabilitation of hemiplegic patients. Archives of Phvsical Medicine
and Rehabilitation, 46, 461-466.
Schenkenherg, T" Bradford, D" & Ajax, E. (1980). Line
bisection and unilateral visual neglect in patiems with neurologiC impairment, Neurologv, jO, 509-517
Simms. B. (198';). Perception and driVing: Theory and practice, British .Journal 0/ Occupational TherapJI, 48, 363-366.
Sivak, M" Hill, C, Henson, D, Butler, B., Silber, S, & Olson,
P, (1984), Improved driVing performance follOWing perceprual
training in persons with brain damage, Archil'es of Phl'sical
Medicine and Rehabilitation, 65, 163-167
Sivak, M., Olson, P., Kewman, D., Won, H., & Henson. D.
(981). Driving and perceptual!cognitive skills: Behavioral consequences of brain damage. Arcbil'es o/Ph 1'sical Jv1edicine and
Rehabilitation, 62, 476-483
Stone, S., Patel, P.. & Greenwood, R. (1993) Selection of
acute stroke patients for treatment of visual neglect.]ournal 0/
Neurology. Neurosurge7y, and Psychiatry, 56. 463-466
Titus, M, N, D .. Gall, N, G" Yerxa, E, J, Roberson, T, A, &
Mack, W (1991), Correlation of perceptual perfmmance and
activities of daily living in stroke patients. Americanjournal of
Occupational Therapy, 45, 410-41H
Tromhly, C A. (Ed,), (989). Occupational therapy for
phvsical d),sfunction (3rd ed,). Baltimore: Williams & Wilkins.
Van Deusen,). (199.'\) Bod)' image and perceplual dJ'sfunction in adults. Philadelphia Saunders.
Walker, M, F., & Lincoln, N, B. (1991) Factors influencing
dressing performance after stroke,.Journal ()fNeurolo#.y, !VeumSI.lrgelY, and Psychial1y, 54, 699-701,
Warren, M. (1981). Relationship of constructional apraxia
and body scheme disorders to dressing performance in
adult CVA. Amel-ican .Journal of Occupational Therapy, 35.
431-437
Webster.j .. Cottam, G .. Gouvier, W" & Blanton, P, (989).
Wheelchair obstacle course performance in right CVA victims.

journal

0/ Clinical and Experimental NeuropSl!cholop"l'. 11.

295-310
Webster, .1" jones. S" Blanton, P" Gross, R., Beissel, G., &
Wofford,). (1984), Visual scanning training with stroke patients,
Behavioral Therapy, 15, 129-143.
.
Wechsler, D, (1981) Wechsler Adult Intelligence Scale-Revised. New Ymk: Psychological.
Weintraub, S,. & Mesulam. !VI, IV!. (19H5), Mental st,lle assessment of young and eiderly adults in hehavioral neurology,
In lvi, M, Mesulam (Ed), Principles 0/ behavioral neurology
(PI" 71-124) Philadelphia Davis.
Whiting, S, Lincoln. N, B" Bhavani. G" & Cockburn, J
(198')), The Rivermead Perceptual Assessment Battery, Windsor: NFER-Nelson.
Wilson, B .. Cockburn, .J., & Halligan. P. (1987a). Behctl'ioural Inattention Test. Tichfield, Hampshire: Thames Valier
Test Company. (Distributed in the United States bv Western
Psychological Services. Los Angeles, CA.)
Wilson, B., Cockourn, J., & Halligan. P (19870). Development of a behavioral test of visuospatial neglect. Arcbi/Jes of
Physical JlJledicine and Nebabilitation, 68, 98-102.
Zoltan, B, Siev, E, & Freishtar. B. (1986), Tbe adult stroke

patient. A manualfor evaluation and treatment ofperceptual

and cognitive dvsfunction (ccv. 2nd ed.). Thorofare, N.J: Slack.

559