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Outcomes after Cognitive Perceptual Motor retraining (CPM) of patients with acquired brain injury (ABI).

Occupational therapists are typically part of an interdisciplinary team of professionals involved in the rehabilitation of patients with acquired brain injury (ABI). Many factors determine the goals that occupational therapists establish and the types of services they provide. One important client factor is the potential for change or improvement. According to the Occupational Therapy Practice Guidelines for Adults with Traumatic Brain Injury (TBI),

If the individual with TBI demonstrates potential for improvement in underlying cognitive and motor impairments, shows awareness of current limitations, and shows the ability to alter performance when provided cues and feedback, the occupational therapist may choose to focus intervention on restoring underlying cognitive and motor impairments that contribute to difficulties in the performance of functional tasks (Golisz, 2009, Intervention Addressing Areas of Occupation, para. 5).

The remediation approach uses activities that challenge current abilities, with the therapist providing opportunities for practice using graded tasks in controlled therapeutic settings. Cognitive Perceptual Motor Retraining (CPM; Kulkarni, 1993; Westfall, Moore, Kulkarni, Cook, & de Leon, 2005) is one therapy that uses the remediation approach for rehabilitation of TBI. This approach is systematic and hierarchical in nature, while using a bottom-up approach and repetition.

An Overview of CPM

Occupational therapists use CPM in treatment at the Origami Brain Injury Rehabilitation Center, a post-acute facility providing residential, community-based, and outpatient therapy services for individuals with ABI. Developed by Madhav Kulkarni, Ph.D., OTR., CPM is used for remediation of deficits in cognitive, perceptualmotor, and sensory-motor functioning following brain injury (Westfall et al., 2005). CPM's remedial approach is based on the premise that due to plasticity, the brain can reacquire function through environmental stimulation. Recent evidence for neuroplasticity after cognitive rehabilitation supports the remediation approach to treatment after TBI. Neuroimaging studies have documented changes in brain activation and connectivity during a recognition task (Ueno et al., 2009), visuospatial attention tasks (Kim et al., 2009), and perceptual organization and working memory (Castellanos et al., 2010) after subjects with TBI completed cognitive training.

The CPM therapist and client identify remediation goals at the initial evaluation. CPM postulates that reacquisition of skills must follow the original path of development of brain functions and therefore uses a hierarchical approach to the ordering of the identified goals and corresponding therapeutic activities (Piaget, 1973; Warren, 1993). CPM uses a variety of paper-and-pencil tasks, computerized activities, graduated manipulation of objects, and other activities that have specific remediation goals. CPM treatment tasks are specifically chosen for placing increasing demands on the brain in order to sequentially restore disrupted brain processes (Piaget, 1973). All clients begin with the same sensory-motor and perceptual tasks because these tasks are assumed to precede cognitive processes. Restoration and integration of affected sensory-motor and perceptual skills will ultimately enhance cognition (Ayres, 1975, 2005).

In addition, the tasks are initially rudimentary and become more complex as the treatment is successful, with a strong emphasis on repeated practice, mastery of skills, and the reacquisition of competence (Luria, 1970; Piaget, 1973).

Therapeutic activities include those similarly used in cognitive rehabilitation (Cappa et al., 2005; Helmick, 2010), such as process, strategy and functional training activities, errorless learning, and awareness training (Golisz, 2009; Malia et al., 2004; Ueno et al., 2009). Other goals include increasing tactile sensitivity and other visual-spatial, tactile-kinesthetic, and fine motor skills. Several studies provide evidence for successful remediation of deficits after TBI in attention and working memory (Stablum, Umilta, Mazzoldi, Pastore, & Magon, 2007; Westerberg et al., 2007), processing speed (Klonoff et al., 2007), executive functioning (Serino et al., 2007), and visual-spatial deficits (Antonucci et al., 1995; Klonoff et al., 2007; Poggel, Kasten, & Sabel, 2004).

When clients have successfully attained most of the remediation goals, a discharge evaluation is completed to determine status and further recommendations. The remediation process is determined to by complete when the client demonstrates successful performance in the graduated tasks and significant improvements to within the normal range in a battery of tests. Remediation activities can also be terminated when the client is observed to have reached a plateau (i.e., the client is no longer demonstrating gains and continued participation would not be of additional benefit). After remediation, CPM begins the more traditional occupational therapy approach of practicing skills in the environment in which the client will use them. This includes assessing the individual's ability to generalize his or her newly retrained skills to relevant environments such as home, work, or school. In cases when deficits remain after maximal progress has been attained, the therapist and client work on compensatory strategies and identifying alterations to the environment.

CPM is a remediation approach used by occupational therapists. It differs from traditional occupational therapy practice in that it combines therapies that are typically provided by different professionals. These include sensory integration activities, which are provided by occupational therapists, and cognitive remediation, which is more typically addressed by speech and language pathologists and neuropsychologists. This bottom-up approach also differs from the typical occupational performance focus (AOTA, 2008). There is an emphasis on large amounts of repeated practice of basic foundational skills. The reacquisition of skills is evaluated in formal retesting. Similar to occupational therapy practice is the additional evaluation of skills through observations of the client's ability to function in his or her environment through the use of the underlying reacquired skills. For example, improvements in occupational skills (e.g., visual scanning during driving simulation and left to right tracking in reading), speed of processing during daily activities (e.g., meal preparation and safety in the community), and mental tracking and sequencing in daily tasks (e.g., dressing or completing learned work tasks).

CPM is typically administered as part of integrated rehabilitation services, which include physical therapy, speech therapy, psychology, and vocational therapy. It is often used as one of the initial therapies that prepare a client for more advanced rehabilitation activities, such as vocational rehabilitation and the return to driving. The improvements following CPM enable patients to engage in more challenging therapies that prepare them for a return to productivity.

Study Objectives

The primary aim of this retrospective study was to examine the outcomes of individuals with ABI after participation in CPM. Specifically, this study (a) compares initial and discharge CPM evaluation test scores and (b) describes the discharge status of clients.

A secondary aim was to identify the clients' demographic and injury characteristics that are associated with outcomes. Demographic characteristics include age, gender, educational attainment, marital status, and work/school status at time of injury. Injury characteristics include brain injury severity and time since injury. Other variables include litigation status and concurrent psychiatric diagnosis.


This retrospective study is a report of outcomes after CPM, which was delivered as part of a standard treatment and was not designed for research purposes. We retrospectively reviewed and analyzed 59 client records. Occupational therapists provided CPM assessments and treatments. The therapists were trained in CPM while they were clinical interns prior to their subsequent hiring. The training typically occurred during a one-semester internship (40 hr per week for 3 months) and involved assigned readings, lectures/discussions on the CPM theoretical framework, initial shadowing of a CPM-trained therapist, testing and treatment laboratory, supervised test administration, treatment and report writing, and weekly meetings to discuss clients and the CPM approach.

We identified clients through the medical records. Clients were eligible for inclusion if they received and had been discharged from CPM services between 1998 and 2009, had initial and discharge CPM evaluations, and were between the ages of 18-64 years. We excluded clients older than 64 years of age because of the increased likelihood of other health issues, such as cardiovascular conditions, arthritis, and mild cognitive decline that may affect cognitive and sensorimotor functioning. We excluded clients who did not speak English in order to exclude poor performance that may be due to a lack of language proficiency. We also excluded clients with other diagnoses indicative of cognitive disorder not due to TBI (e.g., dementia). We had initially included three clients with ABI due to stroke, but excluded them from analysis because of the differences in injury mechanisms (i.e., injury due to occlusion of oxygen rather than injury due to force trauma). We had also initially reviewed three client records that we removed from analysis because of dual diagnosis (e.g., electrocution resulting in a fall with TBI). The dual diagnosis made it difficult to attribute the post-injury deficits to TBI alone. The authors included in the analysis 53 of the 59 records that were reviewed. Three of the authors were involved in administering CPM and associated assessments to some of the clients in the sample. The first author, who had no contact with any of the clients, conducted the identification of clients, data extraction from the medical records, and data coding for statistical analyses.

The Biomedical and Health Institutional Review Board of Michigan State University (MSU) approved the research protocol. Because we had no contact with clients throughout the conduct of this study, we received a waiver of authorization from the MSU Research Privacy Board.

The sample represented clients with varying time since injury through stratified random sampling based on proportions obtained through a preliminary analysis of medical records from 1998 to 2009 (i.e., 77% of all clients seen at the facility were less than a year postinjury and 23% more than a year postinjury). Table 1 summarizes the demographic and injury characteristics of the clients.

The mean age of the clients was 35.8 [+ or -] 1.9 years (SD = 13.7, Median = 36.0). Most of the clients were working at least part-time at the time of the injury (61%). TBI severity ranged from mild to severe. We determined brain injury severity based on the VA/DoD Clinical Practice Guideline (Department of Veteran Affairs, 2009) using a combination of information, such as the Glasgow Coma Scale (GCS) score, length of loss of consciousness (LOC), and/or post-traumatic amnesia (PTA). The criteria used were: (a) mild TBI - GCS 13-15, LOC [less than or equal to] 30 min, PTA [less than or equal to] 1 day, (b) moderate TBI - GCS 9-12, LOC > 30 min, < 24 hr, PTA > 1 day, < 7 days, and (c) severe TBI - GCS < 9, LOC > 24 hr, PTA > 7 days. Median time since injury was five months. Duration of CPM varied from 7 to 58 weeks (27.0 [+ or -] 1.5, SD = 10.8, Median = 27.0 weeks). Most of the clients received multiple services, most commonly psychology, speech-language pathology, and vocational rehabilitation.

Main Outcome Measures

The main outcomes examined were changes in CPM evaluation test scores and the discharge status of clients.

CPM tests. The CPM battery of tests includes standardized assessments of cognitive, perceptual, and motor functions. Although tests are classified into subsections based on the primary skills to be assessed, these skills are interdependent. Several tests overlap into other areas of function. The CPM battery includes tests of visual-spatial and tactile-kinesthetic perception, motor functions, and cognition. For this study, we selected a subset of tests that represent evaluations of perceptual, hand motor, and cognitive functions. Table 2 lists the tests and norms used.

The perceptual portion of the CPM battery is divided into tactile-kinesthetic and visual-spatial. The tests of tactile-kinesthetic perception, Graphesthesia and Manual Form Perception, assess proprioception and kinesthesia and higher-level skills, such as tactile-kinesthetic memory, tactile-kinesthetic discrimination, stereognosis, and tactile-kinesthetic processing speed.

The tests of visual-spatial perception include Cancellation of H, Alternating Dot-to-Dot, and Minnesota Spatial Relations. These tests assess visual attention (focused, shifting, and selective), visual scanning, visual sequencing, figure-ground perception, size and shape discrimination, visual matching, depth perception, visual organization, and visual-spatial processing speed. Tests of motor functioning included the Slosson Copying and Purdue Pegboard. These tests assess manual motor functioning, which includes motor planning, motor control, gross motor coordination, fine motor coordination, hand/eye coordination, bilateral coordination, motor sequencing, and motor speed. Grip strength, in pounds, was assessed using a standard adjustable-handle Jamar Dynamometer.

The Symbol Digit Modalities Test assesses attention, short-term visual memory, encoding and decoding of information, and incidental and intentional learning. The Arithmetic subtest of the Wide Range Achievement Test assesses logical quantitative reasoning and arithmetic calculations. CPM therapists have been using the Object Sequences and Letter Sequences of the Detroit Tests of Learning Aptitude-2 (DTLA-2; Hammill, 1985) to assess short-term visual and linguistic memory. These tests have since been replaced. However, for this study, we included DTLA-2 scores because of the inclusion of older records.

Discharge status. We assessed discharge status in several ways: (a) percentage of goals met, (b) discharge location, (c) reasons for discharge, (d) productivity status at time of discharge, and (e) duration of CPM. The percentage of goals met was calculated based on the number of goals achieved prior to discharge compared to the number of goals set at the initial evaluation by the therapist and the client. Typically, three long-term goals were set in each of the overarching treatment areas, including visual perceptual, tactile kinesthetic/motor, and cognitive perceptual skills. Treatment objectives were made specifically in each long term goal area, incorporating various session activities based on information gathered from initial evaluation and standardized assessment scores. For example, a therapist could establish the objective to independently complete a tactile-input and tactile-output 17-peg display with 100% accuracy on the Tactile Kinesthetic Pegboard to address the long-term goal in tactile kinesthetic and motor perception skills. Once objectives were met or plateaued, retesting occurred to determine if the long-term goals were met. Clinical reasoning is heavily involved in setting session treatment objectives and determining plateau status.

The discharge location was categorized according to the site to where the client was moving after discharge from CPM. It also included the client's level of supervision because it is possible for clients to be discharged to the same location type but with varying degrees of supervision needed. Discharge locations included home with independent status, home with some supervision, home or another facility with full supervision, and/or another facility to continue rehabilitation.

Reasons for discharge from CPM services included: goals have been met, maximum remediation has been achieved, or CPM was not completed due to other reasons. Goals were considered met when the client had demonstrated improvements on re-evaluation to the level of initial established goals. For example, "Visual perceptual skills will improve into the low average range as determined by the Developmental Tests of Visual Perception in figure-ground perception, visual closure, and form constancy." Clients should have also shown a return to some form of productivity and improved independence for met goals. In cases when the client has not met all of the goals and was no longer showing improvements, the client was determined to have achieved maximum remediation.

Duration of CPM treatment was measured in terms of weeks from the initial evaluation to discharge from CPM. At this rehabilitation facility, client progress is assessed at weekly meetings and the anticipated duration of treatment for each service is determined in terms of number of weeks.

Demographic and injury characteristics as correlates. Demographic variables included age, gender, race, education, pre-injury work status, TBI severity, and marital status.

Data Analyses

The Statistical Package for the Social Sciences, SPSS versions 17 and 19 for statistical calculations (IBM, 2010; SPSS, 2008) was used for all data analyses. Two-tailed tests of significance were calculated with alpha set at .05. Descriptive statistics, such as mean scores, standard deviations, and standard error summarized demographic and injury characteristics. The median was also reported when distributions were skewed. The 95% confidence interval was calculated when appropriate.

We analyzed the distribution of scores using the Kolmogorov-Smirnov and Shapiro-Wilk (SPSS) tests of normality and a visual examination of histograms. This analysis showed non-normal distributions of most of the test scores. Therefore, we used the nonparametric Wilcoxon signed-ranks test to compare initial and discharge CPM evaluation test scores. We calculated effect size for the Wilcoxon test using the formula r = [absolute value of Z]/[square root of N], where Z is the approximation of the Wilcoxon statistic, and N is the number of observations x 2 (Cohen, 1988; Grissom & Kim, 2005). Cohen (1988) recommends a cut-off of .30 to signify a medium effect and .50 to signify a large effect.

To determine associations between discharge status and demographic and injury characteristics of clients, we used a variety of tests depending on the data level: Pearson r when both variables were interval level (e.g., time since injury in months and percentage of goals met), Chi Square tests of independence or the Fisher test when both variables were categorical (e.g., TBI severity and discharge to home with independent status), and the Mann-Whitney U test when one variable was categorical and the other variable was interval level (e.g., has a psychiatric diagnosis and duration of CPM in weeks).


We examined outcomes after participation in CPM by clients with TBI. We also identified client characteristics that were associated with discharge outcomes.

Comparison of Initial and Discharge Evaluation Test Scores

Table 3 summarizes the CPM test scores at the initial and follow-up evaluations. There were significant improvements in almost all test scores except for the Slosson Copying subtest. Using Cohen's recommended cut-off values of r = .30 for medium and r = .50 for large effect sizes, 15 of the 19 tests showed medium effect size and three showed large effect size.

Differences in change scores according to injury characteristics. Examination of demographic and injury characteristics revealed that change scores tapered off with increasing time since injury (see Table 4). Those who participated in CPM within six months of their injury significantly improved in all tests. Those who participated within 7-11 months of injury improved in 58% of tests, and those who participated a year or more postinjury improved in 50% of tests. Although gains were made in fewer tests for those with more remote injuries, effect sizes were moderate to strong for these groups as well.

Injury severity showed an unpredictable pattern of change scores (see Table 5). Both those with mild or severe TBI showed significant improvements in more test scores (79% and 89% of test scores, respectively) than those with moderate TBI (58%). This finding may be due to the relatively small sample of moderate TBI clients (N = 10), which requires larger differences between scores to reach statistical significance. The results show that even those with severe TBI had significant improvements at re-evaluation.

Other Discharge Outcomes and Associated Characteristics

We analyzed other discharge outcomes, such as duration of participation in CPM, percentage of goals met, locations of and reasons for discharge, and productivity status at the time of discharge. For this paper, discharge refers to termination of CPM services rather than to the release from all or other rehabilitation services.

Duration of participation in CPM. The mean duration of CPM was 27.0 [+ or -] 1.5 weeks (SD = 10.8, Median = 27.0 weeks, 95% CI = 24.0 - 29.9). There was a significant difference in CPM duration between those with and without a psychiatric diagnosis (Mann-Whitney U = 206.5.5, p = .019, effect size r = .323). Those with a concurrent psychiatric diagnosis participated in CPM approximately seven weeks longer than those who did not have a psychiatric diagnosis (with psychiatric diagnosis: 29.9 [+ or -] 1.9 weeks, SD = 10.9, 95% CI = 26.0 - 33.8, without psychiatric diagnosis: 22.5 [+ or -] 2.0 weeks, SD = 9.3, 95% CI = 18.3 - 26.7). None of the other injury or demographic characteristics were significantly associated with CPM duration.

Percentage of goals met and readiness for discharge. CPM therapists and clients identified goals for remediation after the initial evaluation. Therapists partially determined readiness for discharge from CPM through the client's successful completion of the initial goals. Clients met a mean of 78.7 [+ or -] 3% of initial goals (SD = 16.8, Median = 81.8%, 95% CI = 74.0 - 83.4). None of the demographic or injury characteristics were significantly associated with percentage of goals met.

Forty clients (75.5%) were discharged because they had demonstrated significant gains on retesting and had resumed occupations. Seven clients (13.2%) were discharged even though they did not complete the set goals because the therapists determined that these clients had achieved maximum remediation and no additional progress was anticipated. For the latter clients, CPM therapists shifted focus from remediation to the teaching and practice of compensatory strategies and environmental accommodations through traditional occupational therapy practice. This may have been completed by the treating therapist or transferred to another occupational therapist for community-based functional therapy.

Table 1 lists other reasons for premature discharge without completing CPM. These include transfer to another facility, termination or loss of funding, and the need to address a medical or psychiatric issue before continuing therapeutic services.

Discharge locations. Table 1 lists the locations to where clients moved at the completion of CPM. Most clients were discharged to their homes, although approximately a third were recommended to have some initial supervision. Six (11.3%) were transferred to another facility for continued rehabilitation. Only two (3.8%) were discharged to either a nursing home or adult foster care facility with recommended full supervision.

Marital status, time since injury, and TBI severity were moderately associated with being discharged to home with independent status. However, partial correlations analysis showed that only TBI severity remains associated with discharge status after partialling out the contributions of the other variables. Clients were more likely to be discharged to home with independent status if they had mild or moderate TBI. Significantly fewer clients with severe TBI (34.8%) were discharged to home with independent status compared to 81.8% of those with mild TBI and 73.7% with moderate TBI (Chi Square = 9.60, df = 2, p = .008, Cramer's V = .426). There were no significant associations between discharge to home with independent status and the other demographic variables (age, education, and pre-injury work status) and litigation status.

Productivity at discharge. Of the 43 clients who were working or in school prior to injury, 28 (65%) had resumed or attained productive activity at the time of discharge. Seven (16%) were still engaged in vocational rehabilitation activities in preparation for either finding new employment or returning to their previous employment. Three (7%) were on medical leave or on short-term disability. Eight (18.6%) were unable to resume work. None of the demographic or injury characteristics were significantly associated with resuming productive activity. Further examination of individual records focused on the return to work full- or part-time, the place of employment, and accommodations, if any, provided by the employer. This post-hoc examination of individual outcomes showed a greater tendency for employers to provide more flexibility to employees who were working full-time at the time of their injury, including allowing a medical leave of absence and a gradual return to employment accompanied by reasonable accommodations to facilitate an earlier return.


As part of an interdisciplinary team's plan of care for individuals with brain injury, CPM is used as one of the initial therapies that aim at restoring tactile-kinesthetic, visual-spatial, manual motor, and cognitive skills lost to injury. This retrospective study examined the status of clients with TBI at the point of discharge from CPM. There were improvements in test scores from the initial and discharge evaluations. Those who were within six months postinjury improved in more tests than those 7-11 months and 1 year or more postinjury. Progress was more modest with those who participated in CPM more than six months after injury. However, effect sizes remained moderate to strong in tests that improved. Studies have demonstrated the importance of environmental enrichment in the post-acute or chronic stages of TBI, with either continued improvement (Frasca, Tomaszczyk, McFadyen, & Green, 2013) or prevention of neural atrophy and consequent decline (Miller, Collela, Mikulis, Maller, & Green, 2013).

The improvements after CPM enabled clients to engage in more challenging therapies, such as vocational therapy, that prepare them for a return to productivity. At the completion of CPM, more than half of the clients were engaged in productive activity, such as return to employment, had returned to previous employment, started a new job, or returned to school. There were some who were not ready to return to work at the time of discharge from CPM but were engaged in prevocational activities, such as participation in vocational rehabilitation. None of the injury or demographic variables were associated with return to work or school. The ability or opportunity to return to work may be a combination of different factors that affect individuals specifically. One such factor is employer support.

Another positive outcome of CPM is discharge to home with independent status. More than half of the clients attained this goal. One-fourth were discharged to home but initially with some supervision. TBI severity was associated with this outcome. Fewer clients with severe TBI were deemed to have the ability to regain independent status. For these clients, maximum remediation was reached in CPM, and additional significant progress was not anticipated. For two of the clients, full supervision was recommended at either a nursing home or an adult foster care facility, and environmental modifications were also recommended to enable these clients to have as much independence as their persisting deficits allowed.

Conversely, there were variables that interfered with progress in CPM during the course of this study. For example, having a psychiatric diagnosis and the severity of the TBI prolonged provision of CPM and likely of rehabilitation in general. When psychiatric issues arise, CPM is occasionally placed on hold while these issues are addressed. Not surprisingly, those with severe TBI needed longer rehabilitation services. Maximum remediation was observed in 13% of the clients with severe TBI. Careful monitoring of such clients through more frequent follow-up assessments would ensure that continued progress is being made. When progress is observed to plateau, CPM can then more quickly switch from remediation activities to the teaching of compensatory strategies and environmental accommodations.

Study Limitations

There are limitations due to the retrospective nature of the study. This study examined CPM as typically delivered in the framework of a team. Concurrent therapies do occur, and it is, therefore, difficult to identify how much of the client's progress is specifically due to CPM, especially in areas that overlap with other therapies. However, progress was also observed in areas that are uniquely addressed by CPM (e.g., tactile-kinesthetic and visual-spatial skills). It is also possible that spontaneous recovery may have occurred.

However, the considerable time that had elapsed since injury for some of the clients demonstrates that improvements could be observed even past the time when spontaneous recovery could be expected. In addition, the moderate to strong effect sizes suggests that more than spontaneous recovery was likely in effect. Castellanos and colleagues (2010) have demonstrated changes in neural connectivity after participation in a neurorehabilitation program by clients who were on average three months postinjury. The brain changes were associated with improvements in neuropsychological tests. Animal models have also demonstrated the enhancement of spontaneous neural restoration by external stimulation (Wieloch & Nicolish, 2006). A review of neuroimaging studies on brain plasticity after brain injury shows that rehabilitation can interact with spontaneous factors as part of the recovery process (Chen, Epstein, & Stern, 2010).

CPM treatment begins with a prescribed set of activities and proceeds hierarchically. The length of treatment depends on the speed of client progress. CPM is also constantly evolving. Some of the tests included in this study are no longer used because of the lack of norms that are appropriate for adults with brain injury. The weakness of a lack of appropriate norms for the DTLA-2 warrants caution in interpreting results based on these two subtests. Implications and Recommendations

Results of this study are useful for CPM practitioners to evaluate current practices in the administration of CPM. Identification of psychiatric issues at the initial evaluation is recommended, as such issues may interfere with the client's ability to benefit from CPM or any other therapy. The VA/DoD practice guidelines for treatment of TBI emphasize the interactions between physical, cognitive, and psychological symptoms and recommend that the presence of comorbid psychiatric conditions should be treated aggressively. We recommend regular follow-up assessments so therapists can more quickly identify when maximum remediation has been achieved. When clients are unable to remediate all skills, they should then shift focus from remediation to compensation. This ensures maximal and cost-effective use of CPM.

We acknowledge that these results are preliminary and recommend additional research, particularly using prospective designs that include a control or comparison group. The results of this study can be used in determining which variables are important to include and control in future studies. This study showed that although most clients did benefit from CPM, a small number experienced limited benefits. Identification of additional client personal factors could help in the development of criteria for initiation of CPM.

There is a need, for example, to identify the minimum level of cognitive, perceptual, and motor skills that will allow the client to maximally benefit from participation in CPM. Knowledge of such factors can be used to determine if clients are ready or appropriate for a remediation type of therapy. According to the guidelines for occupational therapists (Golisz, 2009), remediation may be considered when clients show the potential for improvement, awareness of current limitations, and the ability to benefit from feedback. In addition, supportive environments, such as the home, work, or school, may facilitate therapeutic success. This study shows that there are positive outcomes after participation in CPM. We also recognize the role of multiple factors contributing separately or in conjunction with CPM to successful rehabilitation after brain injury.

DOI: 10.15453/2168-6408.1076

Kara Christy

Origami Brain Injury Rehabilitation Center,

Natasha Huffine

Origami Brain Injury Rehabilitation Center,


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Table 1
Demographic, Injury, and Therapy Characteristics
and Outcomes (N = 53)

Demographic Variable            N    % *

  Male                          30   57
  Female                        23   43
Age Categories
  18-29                         20   38
  30-39                         9    17
  40-49                         16   30
  50-59                         5    9
  60-64                         3    6
Marital Status
  Single                        28   53
  Married                       18   34
  Divorced or separated         7    13
  Caucasian                     41   77
  African American              5    9
  Hispanic                      5    9
  Other                         2    4
  No high school diploma        10   19
  High school graduate or GED
  Some college, no degree       17   32
  Associate Degree
  College/Bachelor's Degree     12   23
  Master's Degree or higher     6    11
  Unknown                       3    6
                                4    8
                                1    2
Pre-injury Work Status
  Working full-time             22   42
  Working part-time             12   23
  Student                       9    17
  Not working                   10   19
TBI Severity
  Mild                          20   38
  Moderate                      10   19
  Severe                        23   43
Cause of Injury
  Vehicular (4-wheeled)         40   76
  Other vehicular               5    9
  Pedestrian                    3    6
  Fall/hit by moving object     1    2
  Assault                       1    2
  Other                         3    6
Time Since Injury
  3 months or less              22   42
  4-6 months                    10   19
  7-11 months                   9    17
  1 year or more                12   23
Rehabilitation Service
  Residential                   14   26
  Outpatient                    23   43
  Day treatment                 12   23
  Community integration/        4    8
  semi-independent Living

CPM Duration
  12 weeks or less              4    8
  13-24 weeks                   19   36
  25-36 weeks                   18   34
  37-52 weeks                   11   21
  More than one year            1    2
Reasons for Discharge
  Goals met                     40   75
  Reached maximum               7    13
    remediation                 3    6
  Transfer to another           3    6
  Other (loss of funding,
    services needed, return
    to work)
Discharge Locations
  Home with independent         31   58
    status                      14   26
  Home with recommended         6    11
  Transfer to another           2    4
    for continued
  Another facility for full
Work Status at CPM Discharge
  Working full-time             6    11
  Working part-time             10   19
  Supported employment          6    11
  Student                       8    15
  Not working                   8    15
    Prevocational activities
    Medical leave or short-     3    6
     term disability            12   23
    Not working

Note. Percentages total may not be equal to 100 due to rounding.

Table 2
Tests Used in the CPM Evaluation

Tests                       Protocol Source   Norms Used

Graphesthesia subtest of    Ayers, 1975       Hsu &
the Southern California                       Nelson, 1981
Sensory Integration Test
Manual Form Perception      Ayers, 1975       Hsu &
subtest (SCSIT)                               Nelson, 1981
Cancellation of H           Kulkarni et       Kulkarni et
                            al., 2013         al., 2013
Alternating Dot-to-Dot      Kulkarni et       Kulkarni et
                            al., 2013         al., 2013
Minnesota Spatial           Dawis, 1979       Dawis, 1979
Slosson copying of the      Slosson,          Slosson, 1996
Slosson Visual Motor        1996
Performance Test
Purdue Pegboard             Tifflin, 1948     Desrosiers et
                                              al., 1995;
                                              Yeudall et al.,
Grip strength               Mathiowetz        Mathiowetz
                            et al., 1985      et al., 1985
Object Sequence of the      Hammill,          Hammill,
Detroit Tests of Learning   1985              1985
Aptitude-2 (DTLA-2)
Letter Sequences of the     Hammill,          Hammill,
DTLA-2                      1985              1985
Symbol Digit Modalities     Smith, 1991       Smith, 1991
Arithmetic subtest of the   Wilkinson,        Wilkinson,
WRAT-3/WRAT-4               1993;             1993;
                            Wilkinson &       Wilkinson &
                            Robertson,        Robertson,
                            2006              2006

Table 3
Comparison of Pre and Posttest Scores on CPM Evaluation Battery

                         N      Pre-CPM M (SD)   Pre-     Post-
                         (1)                     CPM      CPM M
                                                 Median   (SD)

Graphesthesia            41     8.1 (3.0)        9.0      9.4 (2.2)
  Right Hand
Graphesthesia            41     8.3 (2.7)        8.0      9.8 (1.8)
  Left Hand
Manual Form Adjusted     48     6.4 (3.0)        7.0      7.8 (2.8)
Figure-Ground Total      46     33.6 (5.7)       34.0     37.4 (5.8)
Cancellation of H        57     90.0 (40.7)      83.0     77.5 (27.8)
Alternating Dot-to-Dot   49     65.4 (39.5)      55.0     44.8 (28.6)
Minnesota Spatial        42     676.0            610.8    521.8
  Relations (score)             (196.2)                   (145.5)
Slosson Copying          35     26.1 (8.3)       27.0     29.5 (7.3)
Purdue Pegboard          56     12.3 (3.6)       12.5     14.3 (3.1)
  Dominant Hand
Purdue Pegboard          54     11.5 (3.5)       11.5     13.3 (3.2)
  Nondominant Hand
Purdue Pegboard Both     55     9.3 (3.1)        10.0     10.9 (2.9)
Purdue Pegboard          53     25.2 (9.2)       25.0     30.5 (9.8)
Grip strength            48     58.6 (32.4)      58.0     71.4
  Dominant Hand                                           (31.2)
Grip strength            46     59.2 (33.0)      53.5     69.9 (30.1)
  Nondominant Hand
DTLA-2 Object            40     37.9 (7.9)       39.0     44.1 (7.0)
DTLA-2 Letter            36     47.5 (11.4)      51.0     50.9 (9.1)
SDMT-Written             56     35.3 (13.6)      38.5     46.7 (12.0)
SDMT-Oral                53     40.4 (15.4)      41.0     50.3 (15.9)
WRAT-3                   43     35.0 (7.2)       36.0     38.7 (6.9)

                         Post-    Wilcoxon   p      r
                         CPM      Z (2)             (effect
                         Median                     size)

Graphesthesia            10.0     3.06       .002   .341
  Right Hand
Graphesthesia            10.0     3.50       .001   .390
  Left Hand
Manual Form Adjusted     9.0      4.44       .000   .453
Figure-Ground Total      38.0     4.13       .000   .431
Cancellation of H        70.0     3.61       .000   .335
Alternating Dot-to-Dot   40.0     4.61       .000   .471
Minnesota Spatial        990.5    5.10       .000   .557
  Relations (score)
Slosson Copying          32.0     2.42       .016   .289
Purdue Pegboard          15.0     5.14       .000   .482
  Dominant Hand
Purdue Pegboard          13.5     5.70       .000   .549
  Nondominant Hand
Purdue Pegboard Both     12.0     4.88       .000   .465
Purdue Pegboard          32.0     5.00       .000   .486
Grip strength            73.0     3.88       .000   .397
  Dominant Hand
Grip strength            68.0     4.16       .000   .434
  Nondominant Hand
DTLA-2 Object            45.5     4.27       .000   .477
DTLA-2 Letter            52.5     2.66       .008   .314
SDMT-Written             49.0     6.29       .000   .594
SDMT-Oral                53.0     4.77       .000   .463
WRAT-3                   40.0     4.19       .000   .453

Note. (1) N (sample size) varies because tests where clients scored
within the normal range at initial testing were not readministered at
the completion of CPM.

(2) Based on Wilcoxon signed ranks of raw scores.
Abbreviations: DTLA-2 (Detroit Test of Learning Aptitude, 2nd
edition), SDMT (Symbol Digit Modalities Test), WRAT-3/4 (Wide Range
Achievement Tests, 3rd and 4th editions).

Table 4
Effect Size and P Values of Change in Pre and Posttest Scores on
CPM Tests by Time Since Injury

                                      0-6 months postinjury

                                      N (1)  Z (2)   p      r (3)
Tactile Kinesthetic
Graphesthesia Right Hand              25     3.288   .001   0.465
Graphesthesia Left Hand               25     2.738   .006   0.387
Manual Form Adjusted Score            26     3.499   .000   0.485
Figure-Ground Total                   29     3.272   .001   0.430
Cancellation of H (seconds)           32     2.506   .012   0.313
Alternating Dot-to-Dot (seconds)      29     3.687   .000   0.484
Minnesota Spatial Relations (score)   24     4.200   .000   0.606
Slosson Copying                       21     2.173   030    0.335
Purdue Pegboard Dominant Hand         30     4.396   .000   0.568
Purdue Pegboard Nondominant Hand      28     4.046   .000   0.541
Purdue Pegboard Both                  29     4.423   .000   0.581
Purdue Pegboard Assembly              28     3.465   .001   0.463
Grip strength Dominant Hand           28     3.379   .001   0.452
Grip strength Nondominant Hand        26     3.811   .000   0.528
DTLA-2 Object sequences               23     3.091   .002   0.456
DTLA-2 Letter sequences               21     2.376   .018   0.367
SDMT-Written                          32     4.882   .000   0.610
SDMT-Oral                             30     2.267   .001   0.422
WRAT-3                                26     3.950   .000   0.548

                                      7-11 months postinjury

                                      N   Z       p           r
Tactile Kinesthetic
Graphesthesia Right Hand              8   0.105   .916 (NS)   0.026
Graphesthesia Left Hand               8   0.420   .680 (NS)   0.105
Manual Form Adjusted Score            9   2.226   .026        0.525
Figure-Ground Total                   7   2.371   .010        0.634
Cancellation of H (seconds)           9   2.192   .028        0.517
Alternating Dot-to-Dot (seconds)      8   2.521   .012        0.630
Minnesota Spatial Relations (score)   8   2.521   .012        0.630
Slosson Copying                       5   0.730   .465 (NS)   0.231
Purdue Pegboard Dominant Hand         9   1.372   .170 (NS)   0.323
Purdue Pegboard Nondominant Hand      9   2.588   .010        0.610
Purdue Pegboard Both                  9   2.232   .026        0.526
Purdue Pegboard Assembly              8   1.572   .116 (NS)   0.393
Grip strength Dominant Hand           9   1.841   .066 (NS)   0.434
Grip strength Nondominant Hand        9   2.176   .030        0.513
DTLA-2 Object sequences               7   2.214   .027        0.592
DTLA-2 Letter sequences               6   0.406   .684 (NS)   0.117
SDMT-Written                          7   2.371   .018        0.634
SDMT-Oral                             7   2.366   .018        0.632
WRAT-3                                7   0.530   .596 (NS)   0.142

                                           [grater than or equal
                                           to] 12 months postinjury

                                      N    Z       p           r
Tactile Kinesthetic
Graphesthesia Right Hand              3    0.447   .655 (NS)   0.182
Graphesthesia Left Hand               3    0.114   .655 (NS)   0.182
Manual Form Adjusted Score            8    2.549   .011        0.637
Figure-Ground Total                   5    1.625   .104 (NS)   0.514
Cancellation of H (seconds)           10   2.090   .037        0.467
Alternating Dot-to-Dot (seconds)      7    2.366   .018        0.632
Minnesota Spatial Relations (score)   6    1.992   .046        0.575
Slosson Copying                       5    1.753   .080 (NS)   0.554
Purdue Pegboard Dominant Hand         11   1.965   .049        0.419
Purdue Pegboard Nondominant Hand      11   2.812   .005        0.600
Purdue Pegboard Both                  11   1.901   .057 (NS)   0.405
Purdue Pegboard Assembly              11   2.705   .007        0.577
Grip strength Dominant Hand           5    0.674   .500 (NS)   0.213
Grip strength Nondominant Hand        5    0.405   .686 (NS)   0.128
DTLA-2 Object sequences               5    1.761   .078 (NS)   0.557
DTLA-2 Letter sequences               4    1.289   .197 (NS)   0.456
SDMT-Written                          11   2.851   .004        0.608
SDMT-Oral                             10   2.193   .028        0.490
WRAT-3                                5    1.753   .080 (NS)   0.554

Note. (1) N (sample size) varies because tests where clients scored
within the normal range at initial testing were not readministered at
completion of CPM.
(2) Z is based on Wilcoxon signed ranks test.
(3) r = effect size

Table 5
Effect Size and P Values of Change in Pre and Posttest Scores on CPM
Tests by TBI Severity

                                           Mild TBI
                                   N (1)   Z (2)   p           r (3)

Tactile Kinesthetic
Graphesthesia Right Hand           13      2.192   .028        .430
Graphesthesia Left Hand            13      2.410   .016        .473
Manual Form Adjusted Score         16      2.504   .012        .443
Figure-Ground Total                15      2.798   .005        .511
Cancellation of H (seconds)        20      1.157   .247 (NS)   .183
Alternating Dot-to-Dot             18      3.376   .001        .563
Minnesota Spatial Relations        15      2.812   .005        .513
Slosson Copying                    10      1.011   .312 (NS)   .226
Purdue Pegboard Dominant Hand      19      3.275   .001        .531
Purdue Pegboard Nondominant Hand   19      3.589   .000        .582
Purdue Pegboard Both               19      3.320   .001        .539
Purdue Pegboard Assembly           17      2.109   .035        .362
Grip strength Dominant Hand        15      2.901   .004        .530
Grip strength Nondominant          15      2.261   .024        .413
DTLA-2 Object sequences            14      3.116   .002        .589
DTLA-2 Letter sequences            13      1.533   .125 (NS)   .301
SDMT-Written                       16      2.778   .005        .491
SDMT-Oral                          19      3.422   .001        .555
WRAT-3                             18      1.570   .116 (NS)   .262

                                        Moderate TBI
                                   N    Z       p           r

Tactile Kinesthetic
Graphesthesia Right Hand           8    0.272   .785 (NS)   .068
Graphesthesia Left Hand            8    0.674   .500 (NS)   .169
Manual Form Adjusted Score         9    2.130   .033        .502
Figure-Ground Total                10   2.502   .012        .559
Cancellation of H (seconds)        10   1.172   .241 (NS)   .262
Alternating Dot-to-Dot             9    1.955   .051 (NS)   .461
Minnesota Spatial Relations      8    2.521   .012          .630
Slosson Copying                    7    0.530   .596 (NS)   .142
Purdue Pegboard Dominant Hand      9    2.539   .011        .598
Purdue Pegboard Nondominant Hand   9    2.232   .026        .526
Purdue Pegboard Both               9    1.983   .047        .467
Purdue Pegboard Assembly           9    1.969   .049        .464
Grip strength Dominant Hand        9    0.140   .888 (NS)   .033
Grip strength Nondominant          8    1.680   .093 (NS)   .420
DTLA-2 Object sequences            7    1.270   .204 (NS)   .339
DTLA-2 Letter sequences            6    1.897   .058 (NS)   .548
SDMT-Written                       7    2.117   .034        .566
SDMT-Oral                          10   2.807   .005        .628
WRAT-3                             10   2.668   .008        .597

                                        Severe TBI
                                   N    Z       p           r

Tactile Kinesthetic
Graphesthesia Right Hand           15   2.424   .015        .443
Graphesthesia Left Hand            15   1.561   .118 (NS)   .285
Manual Form Adjusted Score         18   3.551   .000        .592
Figure-Ground Total                16   2.310   .021        .408
Cancellation of H (seconds)        21   3.875   .000        .598
Alternating Dot-to-Dot             17   2.864   .004        .491
Minnesota Spatial Relations      15   3.408   .001          .622
Slosson Copying                    14   2.230   .026        .421
Purdue Pegboard Dominant Hand      22   2.981   .003        .449
Purdue Pegboard Nondominant Hand   20   3.634   .000        .575
Purdue Pegboard Both               21   3.172   .002        .489
Purdue Pegboard Assembly           21   3.727   .000        .575
Grip strength Dominant Hand        18   2.984   .003        .497
Grip strength Nondominant          17   3.101   .002        .532
DTLA-2 Object sequences            14   2.293   .022        .433
DTLA-2 Letter sequences            12   1.649   .099 (NS)   .337
SDMT-Written                       15   2.396   .017        .437
SDMT-Oral                          21   4.016   .000        .620
WRAT-3                             19   3.545   .000        .575

Note. (1) N (sample size) varies because tests where clients scored
within the normal range at initial testing were not readministered at
completion of CPM.
(2) Z is based on Wilcoxon signed ranks test.
(3) r = effect size
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Publication:Open Journal of Occupational Therapy
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2016
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