Evaluation and Intervention with Executive Functions Impairment/ AMPS Skill Items Dr. Fernandez OTR 615

Disorders of Executive Function Considered impairments within the World Health Organization (WHO) Manifested as disability, become disorders of occupational performance See definitions of Executive Function Pg. 211

Consist of: Executive Function Volition: requires the capacity to formulate a goal or and intention and then to initiate task performance Planning: involves the capacity to look ahead and conceptualize change, conceive of alternatives weigh and make choices, and develop a plan Purposive action: Capacities for productivity and self regulation Effective Performance: Capacity for quality control, including the ability to monitor and correct one’s behavior.

Assessment and Treatment Resources The direct observation on occupational performance is a more useful and efficient way to assess executive abilities. The AMPS is a standardized test that provides the occupational therapist with a method for detailed analysis of a person's executive abilities. Strong support in the literature

The Assessment of Motor and Process Skills Begin with the idea that the AMPS is an occupational therapy evaluation, and it reflects the unique focus of OT (occupational performance, the doing)

The Assessment of Motor and Process Skills (AMPS) An observational assessment Used to measure the quality of ADL performance Standardized on over 100,000 clients worldwide The AMPS is an observational assessment, used to evaluate people in the context of familiar and relevant tasks. The AMPS is used to measure the quality of task performance. The AMPS is a standardized assessment that can be used with clients aged three or older, with any diagnosis or disability. It is currently in use in Europe, North and South America, Asia, Nordic Countries, Australia, New Zealand, Israel, the United Kingdom, and South Africa.

An AMPS Assessment Begins with an interview to determine the tasks that are familiar and relevant to the client There are 85 standardized AMPS tasks, ranging from easy to hard Includes the observation of at least two chosen ADL tasks A core concept in the AMPS is the importance of client choice, as engagement in chosen and meaningful activities is at the core of occupational therapy. Client motivation and performance is believed to be best when he or she can choose the activity. An AMPS assessment begins, therefore, with an interview of the client so that the therapist can determine which standardized AMPS tasks are familiar, relevant and of sufficient challenge to the client. For an AMPS assessment, the client at least 2 AMPS tasks to perform from a subset of tasks offered by the therapist. The therapist must also ensure that the tasks offered as choices are hard enough to offer a “just right” challenge to the person – not too easy and not too hard. AMPS tasks include a variety of ADL tasks – personal ADL (eating, dressing, grooming, etc) and domestic ADL (simple to complex cooking, home maintenance, outdoor tasks, etc)

Standardization of Tasks Each task includes: Specific criteria that must be met to maintain standardization Flexible options that allow for client-centered ways of doing The standardized challenge of the tasks is maintained by establishing essential criteria that all clients who do this particular task must complete. Within these standardized guidelines, however, each task is flexible enough to allow a the client some choice and variety in the tools and materials he or she uses in completing the task.

Task A-3. Pot of coffee or tea – one or two persons Essential task: Prepare pot of boiled or brewed coffee or tea Pour into cups Serve with a container of milk or cream at a counter or table Specific criteria: Must pour coffee or tea into cups Must serve with a container of milk or cream It is often helpful to show an example of a task. Task A-3 is a good one, because it has a variety of tools that can be used (electric kettle, drip coffee maker, stovetop percolator, etc.) as well as a variety of options of ingredients such as coffee, tea, and sugar. The “essential task” is a description of the basic steps of the task.

Task A-3. Pot of coffee or tea – one or two persons Options: Coffee or tea Coffee can be boiled or brewed in an automatic drip coffee-maker, French press, or electric percolator Water for tea may be heated in electric kettle, on stove, or in microwave Sweetener optional Within the structure of the essential task and the specific criteria are options that allow for choice and for the client to be able to use tools and materials that are preferred and culturally relevant. Each of the 85 AMPS tasks has been standardized in this manner. Specific criteria are things that must be done in order to maintain the standardized challenge of the task.

Conceptual Model (Fisher, 2003 When discussing the conceptual model, stress the following points: When the AMPS is given, the focus is on the quality of the occupational performance – the quality of the “doing”. Characteristics of the person, the environment, and the task the person does will impact the skill of the task performance we observe; but we when score the AMPS do not score these aspects, we score the quality of the doing. After scoring the AMPS, we can then interpret the results by considering the person, the task, an/or the environment. In OT practice, it has been common to start evaluation at the level of the person (e.g., ROM, strength, perception, memory, etc.) and to assume or infer relationships between body function impairments and global performance (bottom-up approach) In an AMPS assessment, we are not evaluating the person (motivation, body functions, etc.) nor are we evaluating the environment. We use the AMPS in a top-down manner, beginning with a client interview and progressing to observing the quality of his or her performance of chosen and meaningful tasks. We then assess the quality of the person’s ADL motor and ADL process skills – which are smallest, goal-directed units of performance. Lastly, we consider the impact of environmental features and body functions on the quality of performance we observed. You might also want to use Figure 2-2 (p. 26 in Volume 1 of the 5th Edition of the AMPS Manual) to discuss the AMPS in relation to the WHO/ICIDH-2 classifications of body functions, activities, and participation. If you do, feel free to make one overhead of Figure 2-2 to use in your presentation. Refer to section 2.4, (p. 25) of Volume 1 of the 5th Edition of the AMPS Manual for more information on AMPS and WHO/ICIDH-2. The AMPS ADL motor and ADL process skills are individual units of goal-directed action, scored at the WHO/ICIDH-2 level of activity. The interpretation of the AMPS scores takes into account the impact of elements of the person and the environment on the observed performance, and so is made at the WHO level of participation.

(World Health Organization [WHO], 2001) Performance Skills Analogous to the goal-directed actions defined under the Activities and Participation domains of the International Classification of Functioning Disability and Health (World Health Organization [WHO], 2001) A common source of confusion is the difference between skills and body functions. Stress the idea that skills are goal- directed actions (e.g., reaching for this glass from this cupboard) not the person’s reaching capacity (e.g., the person’s maximal degrees of humeral flexion).

Performance Skills The smallest units of observable action that are linked together one-by-one in the process of building a task performance If we think of a task performance as a chain – performance skills are the individual links that must be connected together to construct the entire chain (the task) Thus, the ADL motor and ADL process skills are the smallest observable units of performance, that when compiled together result in the task being completed

Occupational Performance – a Sequence of Actions

ADL Motor Skills Interacting with and moving task objects Observable, goal-directed actions the person enacts when Interacting with and moving task objects Moving oneself around the task environment What are motor skills? Note that they are goal-directed actions. They are not physical capacities. For example, within the context of preparing toast with strawberry jam and a cup of coffee, we can observe the person walking to the cupboard, pulling the cupboard door open, reaching for a coffee cup, grasping the cup, lifting the cup, and transporting the cup to the table. Build on the idea that the motor skills are performed one-by-one – the skills are linked together to “build” the entire task performance (e.g., the preparation of a pot of coffee)

ADL Motor Skills Moving self & objects Moves Lifts Walks Transports Calibrates Flows Sustaining performance Endures Paces Body position Stabilizes Aligns Positions Obtaining & holding objects Reaches Bends Grips Manipulates Coordinates ADL

ADL Process Skills Observable, goal-directed actions the person enacts when Selecting, interacting with, and using task tools and materials Carrying out individual task actions and steps Modifying task performance when problems are encountered Process skills are also goal-directed actions! They are not cognitive capacities such as problem solving or memory. For example, as a person is preparing toast and coffee, we can observe the person searching for, locating, and choosing the strawberry jam, gathering the jam to the workspace, pausing before opening the jar, supporting the jar of jam so that it does not slip, and using a spoon to scoop the jam onto the toast. Adaptation is a critical feature of the AMPS. When the person experiences a problem, we consider what he or she does about it. Do problems happen? If so, does he or she prevent the problem from recurring?

ADL Process Skills Sustaining Performance Paces Attends Heeds Applying Knowledge Chooses Uses Handles Inquires Temporal Organization Initiates Continues Sequences Terminates Organizing space & objects Searches/Locates Gathers Organizes Restores Navigates

ADL Process Skills Adapting Performance Notices/Responds Adjusts Accommodates Benefits These are the skills that deal with adaptation – the person’s skill at doing something to prevent motor or process problems from happening or recurring during the task performance.

Skills are not body FUNCTIONS! Grip and Lift the coffee pot Reach for the faucet Notice water rising in the pot and Respond by turning off the faucet Body functions Grip and bicep strength Shoulder range of motion Problem solving Just to make the point again. . . Use examples from client populations that are relevant to your audience and/or practice setting. Also be sure use examples from whatever task (e.g., Pot of coffee) that you used earlier in the in-service.

Each skill is scored on a 4-point scale 4 = competent performance 3 = questionable performance 2 = ineffective performance 1 = unacceptable performance Once you’ve presented the skill items, begin to talk about how the AMPS is scored on a 4-point scale. The scale is criterion-referenced (as opposed to being norm-referenced) with the criteria being competent performance. On many norm-referenced tests, “normal” people would get perfect scores. Because the AMPS is criterion referenced, even “normal” people will get some scores of 2 if they are doing a task that is hard enough. None of us perform with perfect competence all of the time – we all occasionally do things like drop an egg, trip, or discontinue actions for no apparent reason. Competent (4) = no problems observed with this skill in this task Questionable (3) = the therapist questions whether or not there was a problem Ineffective (2) = some increased effort or inefficiency noted – could be slight or more pronounced Unacceptable (1) = an unacceptable amount of effort or inefficiency, imminent safety risk, or need for assistance was noted

Scores Computer program adjusts the raw scores for Rater severity Task challenge Item difficulty Computer scoring is what makes the AMPS such a sensitive tool. Through computer scoring, AMPS raw scores are adjusted for: The severity of the rater (this is why each person who gives the AMPS must be trained at an AMPS workshop and be calibrated) The challenge of the tasks that the person did (this is why the specific criteria of each task must be standardized) The difficulty of each motor and process skill item – lower scores on harder items are less of a big deal than lower scores on easier items. You might want to mention that the computer program is based on many-faceted Rasch measurement, which allows for this sort of complexity.

Computer Reports Narrative Report Performance Skill Summary Report Raw Scores Report Graphic Report Progress Report It is nice to show samples of each of these. If you are using a case study, make copies of these reports for the case. AMPS Narrative Report: Helps the practitioner communicate the client’s overall task performance in a personalized, written report. Aspects included in the Narrative Report: 1. Tasks performed 2. Overall statement about the quality of the client’s performance 3. Skills that most impacted performance – a list and description of the skills that the therapist is most concern about 4. Overall ADL motor & ADL process ability, with reference to how the client performed as compared to his/her healthy peers 5. Summary of main findings Performance Skill Summary Report: Communicates an overall picture of the quality of the person’s ADL task performance. AMPS Raw Scores Report: Shows patterns in the client’s skills across different tasks. While it is not usually placed in the chart, it is helpful to assist therapist reasoning in the intervention planning phase. AMPS Graphic Report: The quantitative aspect of the AMPS (more detail on next slide) AMPS Progress Report: Provides detailed information about the change in ADL motor and ADL process ability, with reference to whether such changes are statistically and/or clinically meaningful.

Graphic Report Quantitative measures of the client’s overall ADL motor and process abilities Adjusted by the computer for the challenge of the task, severity of the rater, and difficulty of the items Useful in demonstrating the degree of physical effort, efficiency, safety, and/or independence during ADL task performance Useful in planning intervention The person’s place on the lines of motor and process ability is calculated by the computer; and is adjusted for the challenge of the task, the severity of the rater, and the individual difficulty of each item. This report is useful to use in pre- and post- testing to show change over time. This is the report that is most interesting to third party payers

Plan and Implement Interventional Strategies 1st Collaborative consultation Method of building on a collaborative relationships necessary to foster the success of therapeutic interventions using principles of therapeutic rapport to foster openness and trust Based on the mutual and collaborative partnerships among equals Consultative partnerships may need to be revised or expanded as intervention progress

Collaborative consultation Process Determine members /partnerships appropriate to implement the intervention ( caregiver, service extender or other professional). Establish the client’s baseline level of occupational performance. Establish the expected functional outcomes ( set Goals). Develop mutually agree-upon strategies for intervention. Train recipient(S) in implementing the intervention (Principles of education, health literacy). Re-evaluate to verify that the consultative process was effective and the outcome attained (Teach-Back). Document effectiveness of intervention.

Adaptation Second interventional strategy is dependent on multiple factors to be success Client’s perception of the usefulness of the adaptation Willingness to accept the need for adaptation

Adaptation Principles Propose solutions based on knowledge and principles of adaptation Confirm proposed solutions will indeed benefit and acceptable to client Train the client in sage use of the adaptation ( Using principles of education) Re-evaluate to verify that the adaptation is effective and reliable and document effectiveness of intervention

Education Third interventional strategy Applied to clients, caregivers, service extenders or other professionals. Determination of the recipient of learning process is established using collaborative consultation. Strategies of education must be followed

Education Principles Establish a baseline by determining what the learner knows Establish the learning objective Choose teaching techniques Adapt the presentation to the learner's capabilities Provide opportunities for practice, considering context and schedule Offer useful feedback at the right time Re-evaluate the learner in an appropriate context to confirm that learning has occurred and document the effectiveness of the intervention.

APRAXIA Dr. Fernandez OTR 615

APRAXIA Cognitive disorder of purposeful and skilled movement Associated with LEFT hemisphere damage 1/3 of people with LEFT hemisphere CVA and often co-occurs with RIGHT hemiplegia and aphasia May also occur in other neurological conditions: Alzheimer’s, seizures, TBI Brushing Teeth??

Results from… Apraxia results from dysfunction of the cerebral hemispheres of the brain, especially the parietal lobe, and can arise from many diseases or damage to the brain.

Ideational Apraxia Loss of ability to conceptualize, plan, and execute motor actions involved in use of tools or objects. They have loss the perception of the objects purpose Difficulty with first step of motor planning, including: 1.Knowing what object to use and how Sequencing 2. Sequencing 3. Knowing what to do within the task

Ideational Apraxia Persons movements appear confused because he cannot form a plan on how to sequence these movements when using a tool The IDEA processing and planning areas are damaged They have lost the knowledge or thought of what an object represents

Ideational Clinical Examples The patient does not know what to do with toothbrush, toothpaste or shaving cream Uses tools inappropriately (i.e. smears toothpaste on face, uses washcloth to wash sink instead of face, eats soap, toothbrush as hairbrush Sequences activities steps incorrectly so that there are errors in the end result of task (i.e. put socks on top of shoes, washing body without soap, attempting to drink milk without opening container)

Ideomotor Apraxia Impinges on one’s ability to carry out common, familiar actions on command. Disturbance of voluntary movement in which a person cannot translate and IDEA into MOVEMENT A breakdown with the planning of the task despite understanding the concept of the task

Ideomotor Apraxia May experience: Sequencing of movements Choppy, clumsy, or irregular movements Inability to adjust grasp during tool Unable to perform task on command CAN describe how to perform the task; they know what an object is, patient knows how to perform task Can still perform automatic movements, such as cutting with scissors However disturbance when ASKED to do something upon request – poor ability to copy or gesture , such as wave good – bye!

Ideomotor Clinical Examples Awkward or clumsy movements Difficulties when planning movements to cross midline (i.e. adjusting the grasp on a hairbrush when moving it from one side of the head to other to turn the bristles toward the hair) Difficulty orienting the UE or hand to conform to objects such as picking up a juice bottle with the radial side of the hand down or via picking up bottle with a pinch grip on the lip of the bottle instead of a typical cylindrical grip on the base Ask a patient to give you a thumbs up Ask a patient to copy your movements

Ms. J. Ms. J has full movement and strength in her “good” right leg. She’s able to weight-bear through it and can kick her left shoe off. HOWEVER, she cannot use her right leg to foot propel her wheelchair. She can tell you what she needs to do, but she is not able to tie together the concept of moving her WC with the actual performance of using her “good” foot.

THINK….. What would you do…..

Ideas Facilitate Normal Motor Patterns Offer proprioceptive /kinesthetic input to the limb, like moving the limb through the desired motion. Guided performance Of whole activity

Apraxia Assessment Functional assessment of how apraxia affects daily living rather than simply the presence of apraxia should be the preferred method for Rehabilitation Professionals Rivermead Perceptual Assessment Battery (RPAB) Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) Praxis Test Solet Test for Apraxia

Combination of deficits Is it apraxia, something else, or a combination?” Body schema/visual-spatial impairments such as unilateral neglect Visual and sensory deficits Aphasia Attention, memory, or other cognitive deficits Hemiplegia Fear *OBSERVATION of the patient with OT/PT/Speech and nursing is vital to understanding their deficits

Clinical observations Feeding Uses a spoon as straw (IA) Puts butter in coffee (IA) Awkward grasp on knife interferes with cutting (MA) Unable to adjust movements to guide spoon to mouth smoothly without spilling (MA) Grooming Smears toothpaste on sink (IA) Doesn’t know how to turn on water faucet (IA) Grasp comp awkwardly ,resulting in in accuracy when combing hair (MA) Inability to pantomime toothbrush use(IMA) Dressing Attempts to put socks on hands (IA) Puts shirt over gown when dressing UB (IA) Not able to plan movement sequence for donning shirt upon command (IMA) Not able to re adjust sock within the hand after picking it up (IMA)

Clinical observations MOBILITY Attempts to propel WC by pushing on the brakes repeatedly (IA) Attempts to lock WC brakes by pulling on armrest (IA) Cannot plan movements to roll and sit up over the EOB (MA)

Recovery Improvement from ideomotor apraxia may be related to the site of the lesion, anterior lesions may fare better An exam of recovery of 26 clients with apraxia revealed that 13 remained apraxic 5 months later Age, gender, aphasia, education level, and lesion size do not seem to influence recovery from apraxia.

Effects of Apraxia on ADLs and Rehab outcomes It is well recognized that apraxia does have a substantial negative effect on an individual ability to engage in meaningful activities Apraxia Affects behavior during Meals Eating: used fewer utensils, were less organized, were less efficient, ate haphazardly, placed too much or too little food, and action deficits. Ideomotor apraxia increases dependency in grooming, bathing, and toileting

Effects of Apraxia on ADLs and Rehab outcomes 6 months after DC from hospital, apraxia and the need for assistance with ADLs are highly correlated. Those with apraxia require more assistance than those with other neurologic impairments The relationship of severity of apraxia to long term dependency after rehab is strong

Research Up to now, only a few studies have been published that investigated the efficacy of treatments for upper limb apraxia. This might be due to assumption that apraxia does not cause a significant impairment in daily life. Contrary to this assumption, it has been demonstrated that apraxia significantly affects patients in their everyday lives and has a negative impact on their rehabilitation.

Evidence-based interventions 2 Categories 1. Interventions focused on attempting to decrease the apraxia impairments itself. 2. focused on improving activity performance despite apraxia

Decreasing apraxia impairment Van Heugten states: “The recovery from apraxia is not a realistic goal for therapy, Instead, aim to help client develop new patterns of cognitive activity through compensatory mechanisms, or adaptation of tasks and environment.”

Evidence-based treatment approaches Focus on decreasing activity limitation and participation restrictions of those living with apraxia: Errorless Learning/Training of Details Combined Mental and Physical Practice Gesture Training Strategy Training

Errorless training Errorless learning…. A technique in which the person learns the activity by doing it The OT intervenes to prevent errors from occurring Errorless training of Detail…. Therapist provides support during critical stages of task to prevent errors Hand over hand guidance –Cuing Parallel demonstration

Examples Patient searches for armhole before completing whole task of UB dressing OT provides essential verbal cue’s and HOH assist to prevent errors Patient then practices threading sleeves, shirt around back (isolated) OT points out sensory aspects: fabric/buttons

Combined Mental and Physical Example: 30 minute instructional audiotape 5 minute progressive relaxation Sounds a lot like Mirror Therapy and Mental Imagery 20 minute mental practice emphasizing visual and kinesthetic details “Close your eyes, imagine the shirt in your lap, It is red and black, soft flannel, feel the texture, the buttons, draw attention to the right sleeve, hold shirt with your left hand while you search for the right sleeve, feel the opening, thread your arm through .....”

Gesture Training STEP 1- Demonstrate/Show use of an object (e.g. comb) STEP 2- Show a picture of a person appropriately using object and patient then pantomimes object use STEP 3-Show a picture of only the tool . Ask patient to pantomime appropriate use

Example Stage 1: Here is a toothbrush “Show me how you use it?” Stage 2: Picture of man brushing teeth, “Can you brush your teeth like in the picture?” Stage 3: Picture of toothbrush. “How do you use it?”

Gesture training in transition Challenge to perform tasks across contexts Example: (1) Show 2 pictures ie: donning hat and just the hat (2) Show only picture donning hat (3) Show new picture in different context ie: baseball cap

Strategy training Assuming that apraxia is a persistent and difficult-to-treat syndrome, this therapeutic approach is aimed at teaching patients strategies that might help to compensate for apraxia deficits in daily life

Strategy training Teaching client strategies to COMPENSATE for the presence of apraxia Focus on training activities that relevant to the client. This strategy training approach for apraxia has been tested with promising results. Authors concluded therapy programs succeeded in teaching client compensatory strategies, which enable them to function more independently.

Strategy training using internal and external cues Compensatory approach Training in self verbalization (internal) Provide cues to improve task (external) Physical assistance (external) Written list of steps to help with sequencing (external) Sequence of pictures as visual cues (external)

Strategy training using internal and external cues During strategy training, the patient practiced several ADLs with support by an occupational therapist. Dependent on the patient’s degree of impairment, the occupational therapist supported the patient at three different stages according to a detailed protocol

Strategy Training

Strategy Training Impaired in initiating an action= assist the patient by providing additional verbal instructions. If the patient still does not initiate the action, the OT might hand over the required objects to the patient. If on the other hand a patient has difficulties with the actual execution of an action, the occupational therapist can verbally describe the single steps needed for execution of the action or can provide direct physical support by, for example, correctly positioning the patients’ limbs. Finally, the OT can provide feedback to the patient regarding the outcome of his/her action and/or could ask the patient to monitor the results of the action.

Brushing Teeth

Strategy Training Brushing Teeth Example Instructions: – “Take this and brush your teeth” – “Pantomime use of toothbrush” – Show picture of activity “Again this is used for initiation of task if they do not perform the task on their own”

Used during Execution of task if there are issues Strategy Training Assistance Name steps of activity –Place toothbrush in mouth, now go in circular motion Direct the attention to the task at hand Stimulate verbalization of steps –Have patient do… Gestures or Mimic Show pictures of proper steps Physical Assistance  Guiding the limb  Take over until the patient starts performing to provoke movements Used during Execution of task if there are issues

Strategy Training Feedback… Verbal or physical feedback in terms of the result or performance Video recording of the patient’s performance and show the video Place patient in front of mirror Feedback used in term of CONTOL- correcting the activity to ensure adequate end result

Guiding… Guiding – A part of Assistance Guiding Techniques by Jane Davis

Guiding Requires lots of repetition Find what works with individual patients and stick with it CONSISTENCY!! Between all disciplines. Be sure PT/OT are teaching same transfer technique and making sure it works in the gym as well as in the bathroom! How are your techniques carrying over with nursing? Allow LOTS of extra time to process a request

Caregivers Be mindful that cognitive and perceptual deficits in general are not commonly understood in the community- EDUCATE Make sure they understand behaviors observed are not caused by LACK OF MOTIVATION Emphasize habits and routines and keeping a consistent sequence of ADLs

Caregivers Emphasize that client needs MORE TIME to complete ADLs- avoid rushing Teach caregiver what you have founds helps enhance function (gestures, tactile, visual) Emphasize the need to allow for Independence –educate on the importance of NOT over assisting