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The official web site of Allen Cognitive Levels.
There is a continual struggle going on between the craft industry, which thrives on seasonal change and therapists who traditionally long for stability over the years.. On a regular basis, the craft industry changes its entire line, sometimes as often as every three months.. The first benefit of the collaboration between S&S and OT’s was to save therapists valuable money and time by creating products that vastly cut down on preparation, allowing more patient time. S&S uses its resources to help find reliable vendors whose lines reflect the quality and stability that the OTs strive for . Martha Franz, an S&S employee, is another benefit which we OT’s have been receiving. She is the one who has searched the not only the USA, Canada, and China but the four corners of the world, keeping prices down, calling at all hours asking, “Is this really necessary?” and last but not least tracking down replacements which have been necessary to keep the ADM viable. We as OTs owe her a large debt of gratitude for all her long years of work: Sal- lute!
Contact Jim at Allen Conferences (1 800 853 2472) to have Claudia speak at your facility or organization. Speaking engagements can be combined with using Claudia as a consultant to applying the ACLs to your program and facility.
Gwen Clark in Nashville TN has found a wonderful new product to help in your setup of the Large ACL Screen. Quick Fix is a solid white-out correction stick found in Office Depot or other large supply houses. She found that if you substitutive Quick fix for the white dye in Coloring the back of the leather lacing, you reduce a half hour task to a couple of minutes. Simple apply one coat to the rough side of the lacing, allow to dry for thirty seconds, and re-apply a second time.
If you have found or if you use different beads than are in the kit, make sure you only use two colors of beads. People in 4.2 or below get very frustrated if more than two colors are in use. This frustration will make your scoring inaccurate.
The first safety series project you should try is the coaster project. This kit contains a detailed rating sheet. The remainder of the safety series kits do not contain rating sheets – the coaster rating sheet should be used for all the other projects. You should make a copy of the coaster rating sheets and adapt them to each of the safety series projects.
The principal milestone for each mode is contained within the title of each mode. For instance, the title of mode 2.4 is “When the Person Can Walk”; 4.0’s title is “When the Person Can Sequence Through the Steps to do a Short Term Activity”. Thus the titles of the modes provide a quick guide to the significant milestones of each mode. Look in the table of contents of Understanding Cognitive Performance Modes for a two page index of the titles.
Other self tests that you can perform to test your understanding of the ACLs include
Can you call to mind the Can Do, Will Do, May Do chart? What does this mean? Which are a biological process?
Can you draw the Information Processing Model? Can you name all the boxes?
Can you recall the name of the six cognitive levels?
Answers to these questions are the most basic information that entry level therapists should know and commit to memory. When doing in-service education, be sure to high-light this information as being basic.
Tina Patrick developed the best visual explanation of how therapists generalize from crafts to activities of daily living. All of us are using this figure to educate others about what we are doing. You can find this figure in the Workshop in a Box in the handout about task equivalency. The Workshop in a Box is available free of charge from S&S.
Question: What is the validity of the ACLS when using it with adolescents? We have consistently gotten scores in the 5 range. Is this because it is a small sample of behavior? Has any research been done using the ACLS/ADM with adolescents? Are there norms? How can results of these measures be supported? What is the relationship of the cognitive level score to an adolescent diagnosis of ADHD? Learning disabilities? What is the relationship between normal adolescent development and a measured cognitive impairment?
Answer: There has not been a lot of research with adolescents and the ACL. We can offer some comments and answer a few of the questions. The question of normal adolescent development versus cognitive disability does not take into two major factors: The enormous amount of energy that children demonstrate and the amount of previous learning present in adults. We have compared the ACL modes to the developmental age of children as a rough approximation in the understanding of the modes. The questions you raise are indeed the source of several research projects.
Question: At what age do we expect adolescents to function at level 6?
Answer: Usually about age 26.
Question: Sometimes patients do the whip stitch backward. First stitch looks different but after that it doesn’t look so bad. Is that still scored at 3.5? Answer: Yes.
Question: If the patient has difficulty with the ACLS can you mildly correct them? In the instructions it seems that you can give another demonstration. How much verbiage are you allowed to give? Answer: In the cordovan, the instructions are quite clear. You are trying to see how much information they can assume on their own. Then more instructions or demos are given to determine their ACL level. In the running stitch and whip stitch, it doesn’t seem to matter; they probably just don’t get it anyway.
Question: What should I do if they do more than 3 stitches? Answer: Ignore it. Originally we thought limiting the test to three stitches would be a test for perseveration, but there are many other factors. Just stop them and proceed to the next stitch.
Question: On a single cordovan, how important is the tightening process? Answer: The tension is very important. We are looking at the volume of the information being processed by the patient.
Question: Why does the score for the single cordovan drop back after the highest score for the whip stitch? Answer: Sometimes it validates the whip stitch score. Even after people have trouble with the whip stitch, some therapists will let the patient go on to try the single cordovan to get a higher score. Generally the higher score doesn’t happen. If you have doubts, always use either the abilities or an ADM project to validate.
Question: In 3.0 there is a phrase: “Tunnel vision requires attention…” Can you clarify this description of behavior? Do you mean that if a person is not able to touch the object, the person would score 2.8? Answer: At 3.0, the person does not look around, and their range of vision is very narrow. . If an object is placed in their vision, they will reach for it. We used the term “tunnel vision” as a short description of this effect. A significant feature of 3.0 is that the person will grasp an object that they see. The book Understanding Cognitive Performance Modes contains an elaboration of mode 3.0’s abilities.
Question: In 3.2 there is a phrase: “application to customary surfaces requires attention to the direction of the tool or item (table, wood, paper)” Can you clarify this description? Answer: In 3.2, the person will move objects back and forth but may not look at the results of their action. This applies to sanding, coloring, any repetitive action. With sequencing they can complete some actions. They require 60% cognitive assistance.
Question: 3.6 on “Noting gender”, do you mean the person uses correct pronouns in regular speech? Answer: Yes, refer to Verbal communication in 3.6’s list of abilities in Understanding Cognitive Performance Modes and to the last functional goal in the same book.
Question: 3.8 Can you clarify: “Locating a room used daily?”‘ Answer: In a nursing home, the dining room, the rehab department.
Question: 4.0: Can you clarify “Possessing a project requires attention to ownership ; the person can keep the project or take it with them.” Answer: At 4.0 the person first recognizes ownership, that a person can keep the project or give it away. Refer to Understanding Cognitive Performance Modes.
Question: What is the safety series? How would I know about it? How do I use it? Answer: The safety series is an addition to the ADM projects. The items in the safety series are shown below.:These items are intended for level five patients. The items require use of an iron to fuse the material. Use of the iron introduces a consideration of the person’s awareness of the need for safety, hence the title “safety series”. They have been in the S&S catalog for almost three years. Each year we introduce new items and the method we to announce their introduction is the S&S catalog. As you recognize new items that are introduced, ask S&S for an update for your ADM manual. These same comments about the ADM manual update apply to the one-handed projects issued in January 98.
|Red coasters S&S Number CU-165||Candy Dish S&S Number CU-168|
|Blue Coasters S&S Number CU-185||Quilt Block Tote Bag, Red S&S Number CU-170|
|Portable Pocket, Red S&S Number CU-166||Quilt Block Tote Bag, Black S&S Number CU-187|
|Portable Pocket, Blue S&S Number CU-186|
Question: I just got the stencil card set. Making samples has been interesting. Our therapy aid and OT intern were unable to make successful sample without a model. I was able to do shading but had trouble with paint seeping out. I have done stenciling before on wood but found this more difficult. I find it hard to believe a successful card can be done in 15-20 minutes. Am I just a 5.0 or has this been difficult for others to master? Answer: Stenciling is hard. There is a lot of learning involved in stenciling. It probably takes 1 ½ to 2 ½ hours to learn. The common mistake (which everyone seems to make) is to put too much paint on the brush. After the learning process, stenciling can be done in 15 – 20 minutes.
There is another factor here: OT’s should make their own samples! I know all the excuses, but the samples have to be perfect. There is a lot the OT has to know about the project that can be learned in the first few trys. Don’t expect your interns or COTAs to have the same desire for perfection in the first sample that you will.
Question: I run a sensory stimulation group for geriatric women. The ACLS is too high level for them. What is an appropriate tool? Answer: Check out either the Sensory Stim kit One or Two, CU195 and CU200 respectively. These kits were designed to cover the ACL ranges from 1.0 to 3.2. Use the abilities in Understanding Cognitive Performance
Question: I’m not clear on the use of the pocket on the back of the LACLS and the “no-pocket” on the ACLS. Answer: The pocket can be used on both the LACLS and the ACLS. You can make a little pocket on the back of the smaller ACLS using an index card.
In the workshops, we say, “Use the pocket if your patient has had a CVA but don’t use the pocket if your patient is suffering from depression.” For a deeper explanation, it seems that the ACLS (or LACLS) can pick up an organicity focal deficit (or problem). . The focal deficit involves imagining a line. This focal deficit involves anatomical damage that is not always picked up on a CAT scan or an MRI scan. This is not well documented in the neuroscience or psychology literature. When the patient picks up the wrong lace or wrong puts the needle in the wrong hole, you can further check for the focal deficit with the Bargello bookmark and mosaic tiles. If they have similar problems with the Bargello, but can imagine the diagonal line with the tiles, it indicates they have this particular “focal visual perceptual deficit”. If your patient is suffering from depression only, they’ll be able to handle the loose strings.
So in summary, be aware of this problem. It seems we have an ever more powerful tool in the ACLS!
Blue Shield of Texas is starting to require use of CPT codes for all treatment modalities. Claudia suggests the use of the following CPT codes for ADM activities:
97770 Use this CPT if you are seeing patients one to one.
97150 Use this CPT if you are seeing patients in a group.
97530 Can be used for therapeutic activities.
97535 Can be used for self-care and home management activities.
97537 Can be used for Community and work related activities.
CPT code 96115 was written for neuro behavioral psychological tests and isn’t recommended for ADM use.
The following article was presented by Carol Bertrand at the National Geriatric Rehab Conference in Boston, MA, in March, 1997.
When working with the geriatric population, medical professionals are challenged to consider a myriad of complexities. The aging process itself often causes a decline in the cognitive abilities. Cognitive abilities are also affected by many factors such as sensory deficits affecting hearing loss, visual loss, loss of kinesthetic awareness. Pain, stress and depression are frequently complications to primary diagnoses. In geriatric rehab, treatments are complicated not only by a physical decline, but also by a cognitive decline.
While there are many quick assessments for determining cognitive level, the Allen’s Cognitive Levels is the only one that defines cognitive functioning in a practical way. It is useful to all disciplines in the rehab department. Allen defines cognition as the processing capacity that defines what a person pays attention to, their motor response and their verbal performance. This processing capacity determines what a person does. It focuses on ability and/or disability to DO, and takes into consideration what the person can do, may do, and will do.
The clinical reasoning of the Allen Cognitive Levels is based on the scientific assumption that human functioning is a general qualitative capacity to use mental energy to guide motor and verbal performance. Cognitive and physical components are intrinsically related since the brain guides physical behavior. Medicare requires that rehab goals be functional, practical, sustainable and completed in a reasonable period of time. For the long term patients, the goals must establish safe and effective maintenance programs that will be sustained after therapy is discontinued. The cognitive and physical components have been historically assessed and treated separately. Using the Allen’s, the rehab goals will be relevant, reasonable, and possible.
The ACL divides the qualitative capacity to function into six levels, with 10 modes in each level. The levels measure with a high degree of sensitivity to what a person pays attention and how the use of this information is expressed in motor and verbal performance. An initial assessment of a patient’s cognitive level can be obtained using an Allen Cognitive Level Screen, or ACLS. The ACLS is administered by asking the patient to perform several leather lacing tasks while the therapist observes. The screen takes just a few minutes to administer. The ACL score is then verified by observing the patient doing two craft projects or two tasks that require non-routine performance. These projects are outlined in a manual of instructions and guidelines for observations called the Allen Diagnostic Manual or ADM. A third component, called the Routine Task Inventory or RTI, can also be used. This is a standardized listing of routine tasks including dressing, bathing, toileting, and ten other activities of daily living. The therapist must observe the patient carefully to determine what the patient pays attention to, what their motor response is, and what verbal performance is happening during the task. For very low cognitive functioning patients the Allen Battery has a sensory stimulation kit, which presents a set of stimulations to the patient who is observed in the same manner–i.e., what does the patient pay attention to, what is the motor response, and what is the verbal response to each stimulation.
The Allen Battery is usually used by the occupational therapist. However, after the level is determined, the manual, Understanding Cognitive Performance Modes, outlines each mode by description, tells the percentage of cognitive and physical assistance needed and the amount of supervision the patient will require to be safe. For example, a patient who is at 4.2 level will require 38% (or Moderate) cognitive assistance. This person needs 24 hour supervision to remove dangerous objects outside of the visual field and to solve problems arising from minor changes in the environment. This description is followed by a listing of the person’s best ability to function–i.e. what the person pays attention to, what is the motor control and what is the expected verbal communication, such , asks “What’s next?”, interrupts, and demands assistance. Following this description of abilities, the manual outlines the functional goals for this level, along with the treatment methods. For the OT, the goals will address feeding, oral hygiene, grooming, dressing, bathing and toileting. For the PT, the goals will address transfers, ambulation, therapeutic exercises and sensorimoter techniques. The Speech therapist can address the verbal components. The Activities directors has list of social projects that are mode-appropriate. Nursing is provided with what to expect regarding reality orientation. All disciplines will benefit from the listing of what adaptive equipment can be used, i.e. what the person can learn to use, what will make the person safe. There is a listing for each mode that tells what the caregiver needs to know. This is followed by the most valuable information for discharge planning–the SAFETY precautions. The safety lists address moving/walking, bathroom activities, ADLs, housekeeping, falls, fires, robbery. It address safety issues in work and social relations and in the community. The manual is also available in computerized form which will print out individual reports; the summary and mode description for the physician, the abilities for the caregivers and family, and the Safety lists for whomever will be with the patient after discharge from therapy.
In conclusion, the Allen Cognitive Levels offer the geriatric rehab team, nursing, PT, OT, ST, Activities, CNAs and Caregivers, the practical insights into what the patient can do, will do and may do. It serves to a guide for setting relevant goals for the patient that can be sustained and protect the patient. It gives the rehab team the ability to find the patient’s best ability to function.
Claudia has completed a review of the research that is available or has been done on the ACLs. Allen Conferences would like to keep this information updated and to share it with people who are writing papers on the ACLs.
Several requests: First, could you e-mail or snail mail us a short description of your thesis? We would like to start a file of research papers in process. Then we can serve as a resource for people writing papers. We will keep your short description on file here and add it to the research projects under-way.
Another request: When the thesis is accepted, could you send us a copy? We will include a synopsis of it in the monthly newsletter. And if other people want to reference it, we would have a copy to reproduce and send them. Too many thesis get buried in University libraries and no-one can find them.
And finally, if you have come up with other ACL related research projects not on the attached list, would you let us know?
In the September 1994 Physical Medicine And Rehabilitation Service newsletter published by the VA, Linda S. Cheatum, M. ED., OTR/L of the VAMC in Wilkes-Barre PA authored an article with the same title as this news item. She reports:
“Since 1992, at the request of the Surgery Department, I have been using the Allen Cognitive Level test preoperatively to screen candidates for total hip replacements.
The results have not been surprising for those of us familiar with the ACL. Total hip replacements are done for patients with degenerative joint disease affecting the ball and socket part of the hip joint. We use the Harris Galante Porous Coated Arthoplasty Hip which is a cementless symmetrical stem, that fits either the left or right femur. The socket, made of a metal alloy with a polyethylene acetabular line, which has a porous coating allowing for bony ingrowth. Pegs, spokes, or screws are used for initial stabilization. Total hip precautions need to be followed for one year to prevent dislocation.
The precautions are as follows:
- Don’t bend the hip more than 90 degrees.
- Don’t cross the operated leg over the other leg.
- Don’t turn the operated leg inward (pigeon-toed).
The Allen Cognitive Levels can be used to help identify those who are “good” candidates are people who can generalize the total hip precautions to everyday activities. Those who are “poor” candidates include individuals who are non-compliant, have histories of alcohol or drug abuse, and/or have dementia.
We studied 26 patients over the past 2 years who underwent total hip replacements (THR’)s. Our results are as follows:
- Anyone with a score of 4.4 or lower had a 100% dislocation (5/26).
- Anyone with a score of 4.7,4.8, and 5.0 had a 44% chance of dislocation (4/26).
- Anyone with a score if 5.2 or better had a 100% success rate(17/26).
The standard education for every patient is verbal cueing, written materials, and videos. For patients we suspected of being at risk (score 4.4 or lower), we modified the post-op treatment in an attempt to prevent dislocation. We tried hip spica casts, hip orthoses, made signs with the precautions, etc., however, we consistently were unsuccessful.
In conclusion, this study suggests that the ACL can be used as a preoperative cognitive screening tool to assist in identifying “good” candidates for elective total hip replacement, given the importance of cognition fir successful function outcomes. Other uses for the ACL may be in identifying patients at risk for hip fractures.”