NEUROPSYCHOLOGY FOR OCCUPATIONAL

THERAPIST

(OCT 413)

GROUP : NHSO4

WRITTEN ASSIGNMENT :

The Chessington Occupational Therapy Neurological Assessment

Battery (COTNAB)

PREPARED FOR :
DR. SYAMSUL ANWAR BIN SULTAN IBRAHIM

PREPARED BY :

NAME MATRIC NUMBER

SYAZLEEN NATASYA BINTI SHAIK ALLAWOODIN 2021890822

NUR FARHANIM BINTI ABDULLAH ZAWAWI 2021664962

NORAFIDAH BINTI BAHARUDDIN 2021253546

NEUROPSYCHOLOGY FOR OCCUPATIONAL

THERAPIST
 WRITTEN ASSIGNMENT ON:

The Chessington Occupational Therapy Neurological Assessment

Battery (COTNAB)
I. INTRODUCTION

a.) Description of assessment

● The COTNAB is a fully validated battery of tests for the assessment of

perceptual and functional deficits in neurological patients including
stroke and brain injury.The comprehensive tests evaluate four
functional areas, with three tests of increasing sensitivity.

● The purpose of assessment is to assess functional ability of

neurological patients on a standardized battery of tests. This
assessment aims to identify functional and guide the therapist in the
planning and implementation of appropriate and therapeutic treatment
programmes.

● The COTNAB consist of four modules: Visual Perception (VP),

Constructional Ability (CA), Sensory Motor Ability (SMA) and Ability to
Follow Instruction (AFI).The Visual perception module contains the
Overlapping Figure Test, Hidden Figures Test and the Sequencing
Ability Test. The Constructional Ability module has three sets of tests,
namely, 2D Construction, 3D Construction Test and also Block Printing
Test. The Sensory Motor Ability module consist of 3 tests, i.e.
Stereognosis / Tactical Discrimination Test, Dexterity Test, and the
Coordination Test. The fourth COTNAB module is the Ability follow
Instructions module, consisting of Written Instruction Test, Verbal
Instruction Test and Spoken Instruction Test.

● Each test has been standardized against a cross section of the

population within the age ranges of 16-65+ years.Divided into 3 age
 groups which is 16 – 30 years old ,31 -49 years old and 50 – 65 years
old

● Target population in using this Chessington Occupational Therapy

Neurological Assessment Battery (COTNAB) is Stroke and head injury
patients.

● Includes treatment resource file with programs for specific diagnoses,

pads of scoring forms and functional profiles, introductory manual
including case studies and printed test materials. Includes a sturdy
wooden box with casters for easy transport and storage.

● These contain a variety of drawing and picture-recognition tests which

are used to determine what the patient can see in the visual field, how
they interpret this information, their level of object recognition and
memory functioning.

● Both ability and time taken to complete the task are recorded during
the assessment and the results are combined to give a measure of the
overall performance. This gives the most appropriate evaluation of a
person’s functional performance.

b) Approaches to assessment

● The Chessington Occupational Therapy Neurological Assessment

Battery (COTNAB) assessment has an important role in identifying
underlying cognitive strengths and deficits at the ‘body structure and
function’ level.

● Focus on early identification of performance/ skill -based cognitive

impairments to allow for the timely implementation of an occupational
therapy care plan.

● Use of the “bottom-up” approach . Evaluate an individual’s cognitive

performance through body structure and function including cognitive
components.
 ● Bottom-up approaches are considered beneficial for foundational
cognitive domains.Focuses on the cause of deficits in foundational
skills. The evaluation and treatment plan is designed to address deficits
in foundational skills, allowing for increased performance during daily
activities.

● To acquire or restore the skills necessary to participate in occupation

and to address the level of impairment in order to improve functional
skills.

● The bottom-up approach involves assessment of impairments in

cognitive function. In this study, bottom-up assessments were reported
to be used to identify deficits.

● Previous studies have provided comprehensive comparisons on utility

including cognitions metric properties of these assessments, including
which tools are better able to predict an individual's functional outcome
(Douglas, Letts & Liu, 2008; Lewis, Babbage & Leathem, 2011;
Woodford & George, 2007; Zwecker et al., 2002)

II. THE CONTENT OF ASSESSMENT

A) Client’s fitness to participate

● The Assessment Battery may be administered to people between the

ages of 16-65 with acquired neurological damage i.e. head injury,
stroke, anoxia, cerebral tumour, encephalitis, meningitis and other
neurological disorders. The assessment has been found to be
particularly useful when employed as part of an integrated
multidisciplinary assessment and treatment programme for
neurological patients.

B) Preparation of the client and environment

● Therapists need to collect the data about the patient, such as personal
history. Cultural background, educational record or qualification,
occupational training and employment records of patients because the
factors will often influence test performance and plan for patients.
Patients' medication may also influence test results. This may need to
be taken into account and the possible effect upon test performance
clarified.

● Other than that, therapist also need consider the emotional state of the
patient and the presence of other deficits, that can affect general
performance and individual test score :

i) Emotional State - Mood

- Personality

- Attitude to testing

- Motivation

ii) Cognitive State - Post-traumatic amnesia

- General orientation

- Attention span

- Insight into difficulties

- Intellectual level

- Language function

iii) Physical Ability - Degree of physical recovery:

g spasticity or ataxia (especially affecting

hand function)

- Balance and co-ordination

iv) Vision - Hemianopia

 - Double vision

- Visual acuity - if a patient wears glasses for

reading these should be

- worn during the assessment.

v) Hearing - If the patient uses a hearing aid this should

also be worn

C) Procedure of administration

Equipment

(The only equipment needed other than test material)

1. A reasonable size desk/table

2. A pencil for 2D construction
3. A4 plain paper for block printing
4. A quiet stopwatch
5. Coat hanger wire

Setting of area

It is recommended that the testing should be conducted in a quiet area,

ideally in a separate room with few distractions. The therapist should try to
ensure that adequate time is set aside, with minimal risk of interruption.

Procedure
Before commencing the Assessment, therapist need to reassures the patient
and explain the purpose of the Assessment as follows:

"This is a routine assessment that we give to patients who

have suffered illness or injuries similar to yours. These tests
will help us to identify any difficulties you might have, so
that we can plan a course of treatment to meet your needs.
There are a number of different tests, all of which will be
timed"

a) SECTION 1 VISUAL PERCEPTION

i) Overlapping Figure

AIMS: To assess a patient's ability to analyse the composition of a given

design and select the component part from a multiple choice array.

ADMINISTRATION

- Read the verbal instructions to the patient and give the patient the
practice design to complete. This is not timed.
- Place shape cards on the patient's RIGHT, place design cards on the
patient's LEFT.
- After each design the patient may turn over their shape cards, but the
therapist should turn over the design card. The design should not be
turned up before the patient has turned over their card.
- TIMING: For each design start timing when the design has been turned
over. Stop timing when the patient has pointed to the shapes.

ii) Hidden Figures

 AIMS : To assess patient's ability to recognise a stimulus shape within a
design and abstract it from the surrounding lines (figure-ground
discrimination).

ADMINISTRATION

- Place cards in front of the patient.

- Read verbal instructions to the patient and demonstrate what is
required on the practice card.
- When the patient understands the instructions, the O.T. should turn
over the test card and start timing.
- Stop timing when the patient has traced off all five shapes or is unable
to continue

iii) Sequencing Ability

AIMS : To assess the patient's ability to identify a given sequence of

events and determine their logical spatial, size or temporal order.

ADMINISTRATION

- Before testing ensure that each set of cards is shuffled, the cards are
the same way round and face up.
- Read the verbal instructions to the patient, then place the first set of
cards in a pile in front of the patient and start timing.
- Stop timing when the patient has put the cards in order or is unable to
continue.
- Record the order of cards as placed by the patient.
- Repeat the procedure for sets 2-5, recording the time for each set
separately.

b) SECTION 2 CONSTRUCTIONAL ABILITY

i) 2D Construction

AIMS : To assess patients' ability to complete simple constructional tasks,

working in two dimensions.

ADMINISTRATION

- Place paper centrally in front of the patient.

- Give the patient a pencil.
- Read the verbal instructions to the patient.
- Start timing when the patient begins drawing, stop when the patient
finishes.

ii) 3D Construction

AIMS : To assess ability to copy a complex three dimensional construction

from component parts.

ADMINISTRATION

- Place individual blocks in front of the patient on the table.

- Place the 3D model opposite the patient on the other side of the table.
- Read the verbal instructions to the patient.
- Start timing when the patient begins to move the blocks, stop when the
patient completes the reproduction or is unable to continue.

iii) BLOCK PRINTING

AIMS : To assess ability to analyse a complex design, integrate information,

select component shapes and reconstruct a given design in the correct
spatial orientation.

ADMINISTRATION

- Place a blank sheet of paper centrally in front of the patient.

- Place the ten printing blocks on their sides with their printing surfaces
facing the patient.* The larger blocks should be placed at the back and
the smallest at the front, so that all blocks can be seen clearly.
 Although the blocks are initially laid out in a prescribed manner the
patient may replace them as he/she wishes.
- Place the ink pad on the patient's dominant side and the designs on the
opposite side.
- Read the verbal instructions to the patient and give the practical
demonstration.
- The therapist should turn over the designs, timing each one separately.
Start timing when the design has been revealed, stop when the patient
has reproduced the design or is unable to continue.

Note Correction of Errors - if the patient is aware of an error while he is

working he is allowed to correct this or start again, but the stopwatch is left
running. If the patient has completed the design and the timing stopped a
further attempt is not permitted.

c) SECTION 3 SENSORY MOTOR ABILITY

i) Stereognosis/Tactile Discrimination

AIMS : To assess ability to recognise objects and textures by touch.

ADMINISTRATION

- Remove the sliding lid from the box and place the box in front of the
patient. Affix fabric to box with Velcro to form a flap under which the
patient's hand can be placed (to ensure that the patient cannot view
objects).
- Read the verbal instructions to the patient.
- Present the objects followed by the textures first to the dominant hand
and then to the non-dominant hand within the box ensuring that the
patient cannot see the test item.
- Generally, place larger objects into the palm of the hand and smaller
objects between fingertips and put the patient's finger tips onto the
textures. When a patient has named an item, move onto the next,
whether the answer is right or wrong, record responses.
 - Patients are timed separately for their dominant and non-dominant
hands. Start timing when you give the patient the first object, stop when
the last texture has been named. Repeat procedure for the non-
dominant hand.

NOTE: Ensure that all 10 items for each hand are assembled (out of sight
of the patient) ready for presentation.

ii) Dexterity

AIMS : To assess the patients fine finger dexterity, involving hand-eye co-
ordination, grip and the range, speed and accuracy of movement.

ADMINISTRATION

- Place the board centrally in front of the patient, square to the table. The
24 discs must be spread in random colour order at the bottom of the
board.
- Read verbal instructions to the patient and demonstrate.
- Give the instructions to begin and start timing. Stop timing when all
discs have been moved or when the patient is unable to continue.
- Replace the discs and repeat the procedure for non-dominant hand
and bilateral performance. Patients are timed separately for each of the
three trials.

NOTE: The discs must be moved in the stated order on each trial. On the
bilateral trial both hands must move simultaneously, not sequentially. If the
patient moves the discs in a different way the patient should be stopped,
the test instructions repeated once only and the test re-commenced. Timing
has started afresh. If the patient moves the discs out of order a second
time, allow them to continue, but only score those discs moved in the stated
order. The time should be taken to the end.
 iii) Co-Ordination

AIMS : To assess speed and accuracy of hand-eye co-ordination.

ADMINISTRATION

- Place the board centrally in front of the patient, square to the table.
- Read verbal instructions to the patient and demonstrate up to hole
number 9.
- Give the instruction to begin with the dominant hand and start timing.
- The therapist should check that the pointer is actually inserted into
each hole. If this is not the case the patient has failed this attempt and
is asked to repeat this hole. When the pointer touches the side of a
hole (buzzer sounds), the patient is asked to try again. After 3
successive failures at any given hole the test is discontinued and the
time recorded.
- The procedure is repeated for the non-dominant hand.

NOTE: The patient must follow the stated order. If a patient deviates from
the order, the test is halted, the test instructions repeated once only and the
test re-commenced. The timing is re•started. If the error is repeated the test
is discontinued.

d) SECTION 4 ABILITY TO FOLLOW INSTRUCTIONS

i) Written Instructions

AIMS : To assess ability to understand and execute a series of written

instructions.

ADMINISTRATION

- Place the jig centrally in front of the patient. (It may be necessary to
clamp the jig to the table). Ensure that the handles on the jig are not
located within the white parallel lines. Place the coat hanger wire and
bending tool on the table.
- Read verbal instructions to the patient.
- Give the instructions to begin and start timing.
- Stop timing when the patient finishes or cannot continue.

NOTE

(1). A prompt may be required at instruction No. 9 for the patient to move
back.

(2). The patient should work alone without interruption, even when errors
are made.

(3). If patients ask for assistance, they should be encouraged initially to

persevere alone. If the patient is unable to continue and again seeks
assistance on the same instruction, then they have failed to complete the
task, but help should be given to see if they can then continue.

(4). Where a patient has only one functional arm assistance may be given
where normally 2 hands are required.
ii) Visual Instructions

AIMS :To assess ability to understand and execute a series of

photographic instructions to assemble a complex construction.

ADMINISTRATION

- Place the base board centrally in front of the patient square to the table
(black dot facing the patient). Place 3 plates to one side of the patient
and the photographic manual on the other, in accordance with the
patient's preference. The remaining component parts should be placed
in the middle of the table in no specific order.
- Read verbal instructions to the patient.
- Give the instruction to begin and start timing.
- Stop timing when the patient finishes or cannot continue.

NOTE

(1). The patient should work alone without interruption, even when errors
are made.

(2). If the patient asks for assistance, they should be encouraged initially to
persevere alone. If the patient is unable to continue and again seeks
assistance on the same instruction, then they have failed to complete the
task, but help should be given to see if they can continue.

ii) Spoken Instructions

AIMS : To assess ability to follow a series of instructions, remember the

sequence of events and reconstruct the associated story from a selection
of picture cards.

ADMINISTRATION

- Before testing ensure that the cards are shuffled, the same way round
and face up.
- Read verbal instructions to the patient.
 - Read a list of instructions (story) once only to the patient (It is important
that these instructions are read clearly and at a reasonably slow
speed).
- Place the cards face upwards in a pile in front of the patient.
- Give the instruction to begin and start timing.
- Stop timing when the patient has finished or is unable to continue.
- Collect the cards in the order placed by the patient.

Test Selection

- If patients have difficulty in Section 1-3 of assessment, it is not

appropriate to continue with section 4. Usually, it occurs with patients in
the upper age group, for whom visual instruction and written instruction
should not be administered unless the patient has completed section 1
and 2 without undue difficulty.

D) Analysing and interpreting the result

The Assessment was standardised within 3 age-groups - 16-30, 31-49.

50-65. The patient's ability to complete the tasks is obviously of primary
interest. The time taken is often unacceptable when compared with the work
pace required for open or sheltered employment.to record both Ability and
Time and to combine these to give a measure of Overall Performance, to
provide the most appropriate evaluation of patient's functional ability.Three
measures are, therefore, obtained for each test - Ability, Time and Overall
Performance. Where a patient is either unable or unwilling to make a
reasonable attempt on a given task they are assigned a grade of 'O' (zero) for
Ability

ABILITY

Ability represents the number correct for each test, except for Written and
Verbal Instructions, where completion of the task is the vital factor. The Ability
scoring table for each test gives details of scores, corresponding grades,
percentage of 'normals' attaining that grade and its classification. There are 4
ability grades - 'A, 'B, 'C, and'O".

TIME

A total time is recorded for each test, timed either as a whole or in component
parts. Scoring tables on each test give a breakdown of times, corresponding
grades, percentage of 'normals attaining that grade and its classification for
each age-group. There are 6 time grades - 'a ++'a+', 'a', 'b', 'c' and 'O'.

OVERALL PERFORMANCE
For each test there is a sliding scale to convert Ability and Time grades to
Overall Performance (see below). This method was adopted to ensure that
Ability and Time grades were of equal value. Locate the relevant Ability grade
and Time grade and record the Overall Performance grade at the intersection.
In the example below a 'B' Ability grade with a 'c' Time grade becomes an
Overall Performance grade of '2'. The classification is impaired.

There are 6 Overall Performance grades -'5, '4', 3', '2', 'I' & 'O', which are
classified.

● Grade '5' always represents 'within normal limits or above'

● Grade ‘4' varies from 'within normal limits' to below average' depending
upon the percentage of 'normals' attaining that grade. 'Below average 1
represents the bottom 20% of the 'normal' population.
● Grade ‘3' varies from 'borderline' to 'impaired', again depending on the
percentage of the' normals' attaining that grade. 'Borderline' represents
the bottom 10% of the 'normal' population. 'Impaired' represents the
bottom 2% of the 'normal' population.
● Grade '2' is always classified as 'impaired', representing the bottom 2%
of the 'normal' population. Grade '1' is classified as 'severely impaired',
by virtue of being 'impaired' in both Ability and Time. No-one in the
'normal population' attained this grade.
● Grade 'O' represents a person who is unwilling or unable to make a
reasonable attempt at any test.
 It is important to remember that failure on any or all tests does not
necessarily indicate a problem of neurological origin. Similarly, success on
any or all tests does not necessarily indicate the complete lack of related
problems. Subtle or selective impairment may be present, but not apparent on
this assessment. This is more common for those of high intellectual ability,
who may experience little difficulty in completing these functional tasks,
although their times may be lower than would be expected. In such cases the
O.T. assessment, in combination with that of the Clinical Psychologist, may
help to identify subtle impairments which may not be apparent in less
demanding situations.

In the interpretation of test results it is important to include observation

of the patient's responses, particularly their general approach to tasks, any
qualitative errors made and their awareness of such errors. This will give a
clearer understanding of the nature of problems, their functional implications
and also provide guidelines within which to plan an appropriate occupational
therapy programme. On occasions where the nature or implications of a
patient's problems are unclear these should be discussed with other
disciplines and further expert assessment may be required.

The graphs give an 'at a glance' impression of a patient's functional

profile, indicating both intact abilities and areas of difficulty. This has been
found useful to other disciplines who may not be familiar with the Assessment
Battery. Visual presentation of scores also enables easier comparison on
reassessment, by overlaying the graphs to see areas of improvement.
III. EVIDENCE /THEORY ON THE ASSESSMENT
a.) The practicality/acceptability/applicability

This assessment was derived to assess head injury and stroke patients on
their ability to perform and time taken to complete tasks. In the early
standardization, it involved 150 adults (75 males & 75 females) with age 16-
65 years old. The group was divided into 3 groups; 16-30 y/o, 31-49 y/o and
50-65 y/o. The group was restricted to those of working age. The majority
were employed in professional, technical, secretarial, clerical and other skilled
occupations with relatively few from unskilled occupation. The excluding
criteria is a patient who had suffered a period of unconsciousness or
neurological illness. Through the tests, they found out that the ability score
classifies as ‘below average’ is within the bottom 20% and a borderline score
in the bottom 10% of the population for each age-group. While ‘impaired’
score represents the bottom 2% of the population. Besides that, the studies
also proved that patients with head injury are common to have impairment in
visual perception, constructional skills, sensory motor functions and ability to
follow complex instructions. Thus, that means this assessment is acceptable
to assess the functional problems for patients with head injury or neurological
illness like stroke, meningitis, cerebral tumors etc within the age of 16-65
years old.

b.) The psychometric properties:

i) Reliability
Test–retest : not reported
Interrater : adequate rigor : (reported to be excellent, but data not included in
manual)

ii) Validity

Construct: discriminated between controls and head injury/CVA sample.

Criterion (concurrent): 1 study, correlated with 1 measure.

It was originally designed and early developed by Sue Brooks, Ann Brooks
and Ann Cornell. Then, controlled studies have been done by Ruth Tyerman,
Andy Tyerman, Prue Howard and Caroline Hadfield; standardized and
validated to provide a quantitative scoring system.

Through the studies, only 2% of the population was classified as superior

category with the score more than 2 standard deviations (s.d.) above mean.
68% of the population was classified within normal limits categories which
achieves scores within 1 s.d. of the mean. While 14% of the population
classified as above and below average each with the score achieves more
than 1 s.d. above mean and 1 s.d below mean respectively. Thus, 2% of the
population was classified impaired category with scores more than 2 s.d.
below means.

According to Sloan, Downie, & Petland (1991), COTNAB is a sensitive tool for
the detection of perceptual deficit. The form of recording deficit is more useful
for explaining to the other team member. It also designed specific uses for
occupational therapists.

c) Theory linked / related to :

According to the theories of neuroplasticity, thinking and learning change both

the brain's physical structure and functional organization. Basic mechanisms
that are involved in plasticity include neurogenesis, programmed cell death,
and activity-dependent synaptic plasticity. Repetitive stimulation of synapses
can cause long-term potential or long-term depression of neurotransmitter.
Together, these changes are associated with physical changes in dendritic
spines and neuronal circuits that eventually influence behavior. These same
mechanisms stand out as important contributors to the developing brain's
ability to acquire new information, adapt to the rapidly changing environment
and recover from injury [Johnston, 2009].
d) Limitation of COTNAB:

i) Language & culture

The language and culture do not suit to all country (Conti, 2017)

ii) Structure of component

Structure of the test is straightforward and does not accommodate the real
situation (real situation/ actual task, client takes time to respond/ react/
make decision.

iii) Influence factors

- The result of the test do not concern of influences factor of other cognitive
skill, physical capacity such as memory recall, concentration, speed,
coordination, hearing and vision which may decline due to aging process
(Dickerson & Fischer, 1993)
- Cristarella (1977) stated that anxiety, loss of interest and lowering
confidence may decline the task performance.

iv) Relevant age

The assessment designed to focus on functional work skills which may not
relevant for individual over 65 years old

v) Longer time taken to complete assessment

According to Laver and Huchison (1994), elderly took longer to complete
the test and scored lower compared to younger subjects.

vi) Process of administration :

The standardized instruction provided less information to the patient and
administrator.
- Block printing test : do not mention that the same block can be used more
than once. The confusion affected either score or time.
 - Stereognosis test :(1) no instruction stated to name the object/ texture,
thus, the participant described the texture of the object rather than object
itself. (2) the time is affected when the object/ texture is taken away.
- Sequencing test (egg turning to the right) : confusion instruction.

IV. CONCLUSION
In conclusion, understanding the cognitive impairments begins with a
complete evaluation of the patient’s deficits. The evaluation of the cognitive
abilities of individuals with cognitive deficits is vital to the therapeutic
process.These deficits have an impact on the functional status and quality of
life of patients. The use of valid standardized assessments which is COTNAB
match the need of the client is essential for successful and competent
therapeutic cognitive intervention.Skill-based cognitive assessments need to
be implemented in conjunction with occupation-based assessments to reflect
the core principles of occupational therapy practice.
V. REFERENCE

Conti, J. (2017, June 11). Cognitive Assessment : A challenge for

Occupational Therapists in Brazil. Dement Neuropsychol, 2, 121- 128.
doi:10.1590/1980-57642016dn11-020004

Douglas, A., Letts, L., & Liu, L. (2008). Review of cognitive assessments for
older adults. Physical & Occupational Therapy in Geriatrics, 26(4), 13-43.

Edwards DF, Hahn MG, Baum CM, Perlmutter MS, Sheedy C, Dromerick AW.
Screening patients with stroke for rehabilitation needs: validation of the post-
stroke rehabilitation guidelines. Neurorehabil Neural Repair. 2006;20:42– 48.

Sloan, R., Downie, C., & Petland, B. (1991). Routine Screening of Brain
Damaged Patients : A Comparison of the Rivermead Perceptual Assessment
Battery and The Chessington Occupational Therapy neurological Assessment
Battery. (E. Arnold, Ed.) Clinical rehabilitation(5), 265-272. Retrieved October
10, 2018

Stanley, M., Buttifield, J., Bowden, S., & Williams, C. (1995, January).
Chessington Occupational Therapy Neurological Assessment Battery :
Comparison of Performance of People Aged 50- 65 with People Aged 66
Years and Over. Australian Occupational Therapy Journal, 42, 55-65.
Retrieved September 30, 2018

Tyerman R, Tyerman A, Howard P, Hadfiled C. COTNAB: Chessington

Occupational Therapy Assessment Battery Introductory Manual. Nottingham:
Nottingham Rehab; 1986