Loewenstein Occupational Therapy Cognitive Assessment (LOTCA)

Purpose

The Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) battery was developed as a measure of basic cognitive skills and visual perception in older adults with neurological impairment. The LOTCA provides an in-depth assessment of basic cognitive abilities and can also be used in treatment planningPlanning ability involves anticipating future events, formulating a goal or endpoint, and devising a sequence of steps or actions that will achieve the goal or endpoint” (Anderson, 2008, p. 17)
and review of progress over time.

In-Depth Review

Purpose of the measure

The Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) is a cognitive battery that measures basic cognitive skills required for everyday function including orientation, visual perceptual and psychomotor abilities, problem-solving"Goal-directed cognitive activity that arises in situations for which no response is immediately apparent or available" (Luria, 1966; as cited in (Rath et al., 2004))
skills and thinking operations. Development of the battery was based on information from clinical experience and neuropsychological and developmental theories. The LOTCA is typically used in the initial phase of patient assessment but can also be used to establish therapeutic goals and to review cognitive status over time (Annes, Katz & Cermak, 1996; Zwecker et al., 2002).

Available versions

The original LOTCA was developed by Itzkovich, Averbuch, Elazar and Katz for use with individuals below the age of 70 years with neurological dysfunction and consisted of a total of 20 items within 4 areas: Orientation (2 items); Perception (6 items); Visuomotor Organization (7 items); and Thinking Operations (5 items).

The LOTCA-II was modified by separating the Perceptual area into three separate areas (Visual Perception, Spatial Perception and Motor Praxis), revising items and including an additional Thinking Operations subtest. The LOTCA-II consists of a total of 26 subtests within 6 areas: Orientation (2 items); Visual Perception (4 items); Spatial Perception (3 items); Motor Praxis (3 items); Visuomotor Organization (7 items); and Thinking Operations (7 items).

The LOTCA-II includes multi-choice questions in the Orientation area to accommodate language difficulties. The manual has been updated to provide more accurate assessment and administration guidelines (Su, Lin, Chen-Sea & Yang, 2007).

Features of the measure

Description of Tasks:

The original LOTCA contains 20 subtests in 4 areas. The LOTCA-II contains 26 subtests in 6 areas:

• Orientation (2 subtests): Assesses the individual’s orientation to place and time.
• Visual Perception (4 subtests): Assesses the individual’s ability to identify pictures of everyday objects, objects photographed from unusual angles, distinguish between overlapping figures, and recognize spatial relations between objects.
• Spatial Perception (3 subtests): Assesses the individual’s ability to differentiate between right and left to determine spatial relationships between objects and self.
• Motor Praxis (3 subtests): Asesses the individual’s ability to imitate motor actions, use objects and perform symbolic actions.
• Visuomotor Organization (7 subtests): Assesses the individual’s ability to copy geometric figures, reproduce a 2D model, copy a coloured block design and a plain block design, reproduce a puzzle and complete a pegboard task, and draw a clock.
• Thinking Operations (7 subtests): Assesses the individual’s ability to complete tasks including sorting, categorization, and picture and geometric sequences (Annes et al., 1996).

Scoring and Score Interpretation:

Most subtests of the LOTCA are scored from 1 to 4, where:

• 1 = Patient fails to perform the task
• 2 = Patient is able to perform part of the task
• 3 = Patient is able to perform most of the task
• 4 = Patient demonstrates good performance of the task

However, three Thinking Operations subtests (Categorisation, Risk Object Classification – ROC – Unstructured, ROC Structured subtests) are scored on a scale from 1 to 5 (Josman, Abdallah & Engel-Yegar, 2010; Zwecker et al., 2002).

Most subtests of the LOTCA-II are also scored from 1 to 4 using the scale above. However, Orientation subtests are scored on a scale from 1 to 8 and three Thinking Operations subtests (Categorization, ROC Unstructured, ROC Structured) are scored on a scale from 1 to 5. Accordingly, the overall LOTCA-II score ranges from 26 to 115 points. Task completion through trial-and-error is penalized in three subtests. Performance elements such as the number of prompts provided to the individual to assist him/her in completing the task, the individual’s attention/concentration and length of time taken to complete the assessment are also recorded.

Results are provided as a profile for each subtest, where higher scores indicate less cognitive impairment (Su et al., 2000). While summation of subtest scores is accepted, the authors warn that analysis of a total score impacts on the ability to identify the individual’s aptitude for each cognitive area (Katz, Itzkovich & Averbuch, 2002).

LOTCA scores were normed on an Israeli population of adults aged 20 – 70 years (Annes et al., 1996), and have since been deemed suitable for use with the US population (Annes et al., 1996; Cermak, Katz, McGuire, Greenbaum, Peralta & Maser-Flanagan, 1995; Katz et al., 1997). Age-related change in scores is not accounted for, as score norms are provided for one group of all individuals aged 20 – 70 years.

Time:

The LOTCA and LOTCA-II take approximately 45 minutes to administer, with a reported range from 30 to 90 minutes (Annes et al., 1996; Zwecker et al., 2002).

Equipment:

The LOTCA kit contains testing materials (card decks, coloured blocks, pegboard set and other materials) and a manual that includes definitions of the cognitive domains assessed, instructions for administration and specific scoring guidelines.

Alternative forms of the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA)

The LOTCA Geriatric version (LOTCA-G) is a modified version of the original LOTCA that was designed for use with individuals aged 70 – 91 years. The LOTCA-G was developed in response to difficulties that elderly patients experienced using the LOTCA (e.g. difficulty seeing and using small materials, and duration of assessment). Accordingly, it contains modifications to allow for age-related cognitive decline and sensorimotor difficulties including larger materials to compensate for visual and motor deficits, less visual detail, shorter subtests, multiple-choice questions, and additional memory tests not included in the original LOTCA (Cooke et al., 2006a, b; Bar-Haim Erez & Katz, 2003).

The LOTCA-G includes 23 subtests in 7 cognitive areas:

• Orientation (2 subtests): Orientation to place; and orientation to time
• Visual Perception (4 subtests): Object identification; shape identification; overlapping figures; and object consistency
• Spatial Perception (3 subtests): On self; on examiner; and self and surroundings
• Praxis (3 subtests): Motor imitation; utilization of objects; and symbolic actions
• Visuomotor Organization (6 subtests): Copy geometric forms; two-dimension model pegboard construction; block design (colour); reproducation of a puzzle; and drawing a clock
• Thinking Operations (2 subtests): Categorization; and pictorial sequencing“The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
  
• Memory (3 subtests): Famous personality; personal possession; and everyday objects

The Orientation subtests are scored from 1 – 8 while all other subtests of the LOTCA-G are scored on an ordinal scale from 1 to 4, where 1 indicates severe deficit and 4 indicates average performance. The LOTCA-G takes approximately 30-45 minutes to administer (Bar-Haim Erez & Katz, 2003, Cermak, et al., 1995). It is available in English and Hebrew.

Client suitability

Can be used with:

• Patients following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (Bar-Haim Erez & Katz, 2003)
• Older individuals with dementia (Bar-Haim Erez & Katz, 2003)
• Individuals with traumatic brain injury (Annes et al., 1996)
• Individuals with CNS dysfunction (Annes et al., 1996)
• Individuals with intellectual disabilities (Jang, Chern & Lin, 2009)
• Individuals with mental illness (Jang et al., 2009; Josman & Katz, 2006)
• An adapted version has also been developed for use with children with learning difficulties (Josman et al., 2010)
• Patients with aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
  An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) – procedures for assessing the patient with aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
  An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) are included (Jang et al., 2009).

Should not be used in:

• An individual’s culture can affect the construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
  of the LOTCA when used with a pediatric population (Josman et al., 2010)

In what languages is the measure available?

• English
• Spanish
• Hebrew
• Chinese (Mandarin)
• Taiwanese
• Iranian

Summary

What does the tool measure?	Basic cognitive skills required for everyday function including orientation, visual perceptual and psychomotor abilities, problem-solving“Goal-directed cognitive activity that arises in situations for which no response is immediately apparent or available” (Luria, 1966; as cited in (Rath et al., 2004)) skills and thinking operations.
What types of clients can the tool be used for?	The LOTCA was designed for individuals aged up to 70 years with neurological deficit.
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	Assessment tool
Time to administer	The LOTCA and LOTCA-II take approximately 45 minutes to administer. The LOTCA-G takes approximately 30-45 minutes to administer.
Versions	LOTCA-II LOTCA – G (for individuals aged 70-91)
Other Languages	Spanish, Hebrew, Chinese (Mandarin), Taiwanese and Iranian.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: One study reported excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the original LOTCA. Test-retest: No studies have reported on test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the LOTCA with patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Intra-rater: No studies have reported on the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings. of the LOTCA. Inter-rater: – One study reported excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the LOTCA. – One study reported excellent inter-rater agreement for the LOTCA-G.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: One study has reported on the content validityRefers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension. of the original LOTCA using factor analysis. Criterion: Concurrent: – One study reported adequate correlations between areas of the LOTCA-G and the MMSE, using Spearman correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. analysis. – One study reported poor to excellent correlations between the LOTCA-II and the OT-APST in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., using Somers’s d concordance correlations. – One study reported poor to adequate correlations between the LOTCA and functional motor outcomes (as measured by FIM motor and MRFS scores) in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., using Pearson correlations. Predictive: No studies have reported on the predictive validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. of the LOTCA. Construct: Two studies report suitable construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed. of LOTCA subtests. Convergent/Discriminant: – One study reported a statistically significant difference in the time taken to complete the LOTCA and the LOTCA-G in a group of healthy adults. – Four studies have reported poor to excellent correlations between the original LOTCA and MMSE, FIM, Rivermead Perceptual Assessment Battery (RPAB), Motor-Free Visual Perception Test (MVPT), Rabideau Kitchen Evaluation – Revised or Phone Use tests. – One study reported adequate to excellent convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other. of the LOTCA-II and the OT-APST, using Spearman’s rho correlations. Known Groups: – Two studies have reported that the LOTCA-G is able to differentiate healthy adults, adults with dementia and adults with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. – Six studies have reported that LOTCA is able to differentiate healthy young adults, healthy elderly adults, individuals with schizophrenia, patients with dementia, patients with intracerebral hemorrhage, ischemia or strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., patients with unilateral spatial neglect, and patients with traumatic brain injury. – One study reported that different versions of the puzzle reproduction task are able to differentiate younger and older adults. – While one study reported that the LOTCA could differentiate between left vs. right strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., another study found no differences with regard to side of lesion. – One study reported differences between American and Israeli patients with CVA on several subtests of the LOTCA.
Floor/Ceiling Effects	One study reported ceiling effects from 23% to 96.9%, and negligible floor effects for most items of the LOTCA One study examined the floor/ceiling effects of the LOTCA-II in a group of individuals with schizophrenia and reported no ceiling effects.
SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” / SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).	No studies have examined the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” or the specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative). of the LOTCA.
Does the tool detect change in patients?	No studies have reported on the responsivenessThe ability of an instrument to detect clinically important change over time. of the LOTCA.
Acceptability	The LOTCA has been described as time-consuming, although it can be completed over several sessions. The LOTCA has adaptations for use with individuals with communication difficulties.
Feasibility	The LOTCA can be time-consuming to administer. The LOTCA permits use of domain-specific scores rather than just a global score, allowing for assessment of many aspects of the client’s cognitive and perceptual abilities.
How to obtain the tool?	The LOTCA can be purchased from http://store.grovergear.com/, http://www.ot-innovations.com, or http://therapro.com.

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the LOTCA. While this assessment can be used with various populations, this module addresses the psychometric properties of the measure specifically when used with patients with stroke. Eleven studies were identified.

Reliability

Internal ConsistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
Katz, Itzkovich and Averbuch (1989) examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the original LOTCA with patients with traumatic head injury (n=20), patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (n=28) and health adults (n=55), and reported excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. with alpha coefficients of 0.85, 0.87 and 0.95 for in the areas of Thinking Operations, Perception and Visuomotor Organization (respectively).

Test-retest:
No studies have reported on the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the LOTCA when used with patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Intra-rater:
No studies have examined the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings.
of the LOTCA.

Inter-rater:
Katz et al (1989) reported excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
for subtests of the LOTCA, with Spearman’s rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients ranging from 0.82 to 0.97.

Katz, Elazer and Itzkovich (1995) reported an agreement rate of 90% between 2 raters who used the LOTCA-G to assess 5 healthy subjects and 5 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Validity

Katz et al. (1995) reported that the LOTCA-G was tested on patients and healthy volunteers during its development.

Katz et al. (1995) reported that the LOTCA-G takes only 30-45 minutes (as compared to 30-90 minutes for the LOTCA), which verifies the LOTCA-G as a useful tool for use with an older population who demonstrate slower performance and sensorimotor difficulties.

Content:
Katz et al. (1989) conducted a factor analysis to determine the construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
of the original LOTCA, using two groups of patients with traumatic head injury or strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (n=96), and health adults (n=55). In the patient group, Visuomotor Organisation loaded on Factor 1 with 44% variance, Perception loaded on Factor 2 with 12% variance, and Thinking Operations on Factor 3 with 10% variance. In contrast, in the control group, Perception loaded on Factor 1 with 33% variance, Thinking Operations on Factor 2 with 23% variance, and Visuomotor Organisation on Factor 3 with 6% variance. CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients within the Perception, Visuomotor Organisation and Thinking Operations subtests of the original LOTCA ranged from 0.40 to 0.80, indicating that subtests are not equivalent and the battery should be performed in full.

Su et al. (2000) examined the strength of correlations between LOTCA subtests on a sample of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (n=44), using Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients. Large correlations were found between the Visuomotor Organisation and Thinking Operations areas (r=0.66, p<0.0001); moderate correlations were found between the Orientation and Perception areas (r=0.55, p<0.0001), Thinking Operations and Orientation (r=0.47, p<0.01) and Perception (0.32 p<0.05); and small correlations were found between Visuomotor Organisation and Orientation (r=0.23) and Perception (r=0.25).

Criterion:
Concurrent:
Bar-Haim Erez & Katz (2003) reported adequate correlations (from r=0.55 to r=0.38) between the LOTCA-G areas and the MMSE total scores in patients with dementia (n=30), using Spearman correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
analysis.

Cooke et al. (2006a) examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the OT-APST in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (n=208) by comparing performance on 5 OT-APST subtests with performance on 5 corresponding LOTCA-II and LOTCA-G areas. Poor to excellent correlations were reported between OT-APST and LOTCA-II area scores (range d=0.27 to d=0.66); and poor to excellent correlations between OT-APST and LOTCA-G area scores (range d=0.25 to d=0.80), using Somers’s d concordance correlations.

Zwecker et al. (2002) reported on correlations between cognitive status and functional motor outcomes in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (n=66). Functional motor outcomes were measured according to efficacy and efficiency of FIM motor scores (isolated from total FIM scores) and Montebello Rehabilitation Factor Score (MRFS). An adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between LOTCA scores and MRFS efficacy (r=0.34, p<0.001) but poor correlations were reported between LOTCA scores and FIM motor efficacy (r=0.25, p<0.05), FIM efficiency (r=0.16) and MRFS efficiency (r=0.19), using Pearson correlations.

Predictive.
No studies have examined the predictive validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the LOTCA with patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Construct:
Katz et al. (1989) conducted factor analysis of the original LOTCA and reported suitable construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
for the Perception, Visuomotor Organization and Thinking Operations areas.

Su et al. (2000) reported that the LOTCA Orientation and Perception areas demonstrate suitable construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
to measure two theoretically and statistically distinct theoretical constructs.

Convergent/Discriminant.
Katz et al. (1995) reported a statistically significant difference in the time taken to complete the LOTCA and the LOTCA-G in a group of healthy adults, using two-way ANOVA (F=11.26, P<.0001), with less time taken to complete the LOTCA-G than the LOTCA.

Cooke et al. (2006b) examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the LOTCA (2nd edition) and the LOTCA-G area means with the OT-APST subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
means in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., using Spearman’s rho correlations. Statistically significant correlations were found between the 5 areas of the LOTCA (2nd edition) and LOTCA-G, and the 5 corresponding subscales of the OT-APST (p<0.01). Correlations ranged from adequate (0.33 for OT-APST Apraxia subtest and LOTCA Motor Praxis area/LOTCA-G Praxis area) to excellent (0.80 for OT-APST Constructional skills subtest and LOTCA-G Visuomotor Organization area).

Zwecker et al. (2002) reported adequate correlations between the LOTCA and MMSE (r= 0.588, p<0.001) and between the LOTCA and FIM cognitive subtest (r=0.471, p<0.001) in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (n=66), using Pearson’s CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
.

Su et al. (2000) reported significant correlations between the LOTCA, Rivermead Perceptual Assessment Battery (RPAB), and the Motor-Free Visual Perception Test (MVPT), in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (n=44). Excellent correlations were reported between LOTCA Thinking Operations and MVPT (r = 0.72, p<0.0001); LOTCA Visuomotor Organization and MVPT (r=0.79, p<0.0001); and LOCTA Visuomotor Organisation and RPAB Spatial Awareness (r=0.74, p<0.0001). Adequate correlations were reported between LOTCA Orientation and RPAB Sequencing“The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
(r=0.46, p<0.01) and Object Completion (r=0.38, p<0.01) subtests; LOTCA Perception and RPAB Sequencing“The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
(r=0.38, p<0.01); LOTCA Visuomotor Organization and RPAB Sequencing“The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
(r=0.52, p<0.01); and LOTCA Thinking Operations and RPAB Sequencing“The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
(r=0.56, p<0.0001), Object completion (r=0.36, p<0.05), Figure-ground Discrimination (r=0.51, p<0.01) and Spatial Awareness (r=0.56, p<0.0001) subtests.

Katz et al. (2000) examined correlations between cognitive performance and daily function in two subgroups of adult with right hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (n=40 vs. patients without unilateral spatial neglect, n=21), using Spearman’s correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
analysis. Cognitive skills were measured using the LOTCA at admission to and discharge from inpatient rehabilitation, and only using the Block Design, Puzzle and Clock Drawing subtests at 6-month follow-up. Functional skills were assessed using all or some of the FIM total, motor and cognitive scores, Rabideau Kitchen Evaluation – Revised (RKE-R) (sandwich and drink preparation), and Phone Use tests at these time points. In the neglect group, adequate to excellent correlations were reported between LOTCA Visuomotor Organisation and Thinking Operations areas and functional tests at admission, discharge and follow-up (range r=0.46 to 0.80). Adequate to excellent correlations were reported between LOTCA Perception and functional tests at discharge only (range r=-0.54 to 0.75). Poor correlations were found between LOTCA Orientation and functional tasks in this subgroup. The authors reported a possible confounding effect with this sub-group, given the visual/spatial demands of the LOTCA. In the non-neglect group, poor to excellent correlations were reported between FIM Cognitive and LOTCA Orientation (r=0.05), Perception (r=0.59), Visuomotor Organisation (r=0.67) and Thinking Operations (r=0.58) areas at admission. No significant correlations were reported with FIM total or FIM motor for any LOTCA area on admission. Adequate to excellent correlations were reported between LOTCA Visuomotor Organisation and Thinking Operations subtests and functional tasks at discharge and follow up (range r=0.43 to 0.62).

Known Group:
Katz et al. (1989) examined known group validityThe degree to which an assessment measures what it is supposed to measure.
of the original LOTCA among patients with traumatic brain injury (n=20), patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (n=28), and healthy adults (n=55), using the Wilcoxon testThe Wilcoxon test is a nonparametric test that compares two paired groups. This test calculates and then analyzes the differences between the pairs. The Wilcoxon Rank Sum test is used to determine whether two scores have the same continuous distribution. The Wilcoxon Signed Rank test is suitable to use as an alternative to the paired t-test when the scores are not normally distributed.
. Significant differences among the three subgroups were found on initial assessment at the time of referral (p=0.0001).

Katz et al. (1995) compared LOTCA scores between healthy adults (n=29) and patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (n=24), using the Wilcoxon testThe Wilcoxon test is a nonparametric test that compares two paired groups. This test calculates and then analyzes the differences between the pairs. The Wilcoxon Rank Sum test is used to determine whether two scores have the same continuous distribution. The Wilcoxon Signed Rank test is suitable to use as an alternative to the paired t-test when the scores are not normally distributed.
. Significant between group differences (range p=0.0002 to p=0.04) were reported for Orientation, Perception, Visuomotor Organization and Thinking Operations areas (excluding the Spatial Perception, Praxis, Coloured Block Design, Plain Block Design, Puzzle, Drawing a Clock, Categorization, Risk Object Classification – ROC -Unstructured and Pictorial Sequence B subtests). The group of healthy adults scored higher on all areas of the LOTCA than the group of patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Katz et al. (1995) reported differences (although no statistical data were provided) between healthy adults and healthy elderly adults on the Visuomotor Organization and Thinking Operation areas of the LOTCA.

Katz et al (1997) compared performance between adults aged 18 – 30 years (n=36) and adults aged 58 – 70 years (n=36) on three versions of the LOTCA puzzle reproduction task (original direct placement version; subplacement version; and LOTCA-G version). Two-way anaylsis of variance (ANOVA) showed significant differences in terms of age (p<0.0001), puzzle version (p<0.0002) and age-by-version interaction (p<0.01). Older adults took significantly longer than younger adults to complete each version of the puzzle. While the younger group of adults took significantly longer to complete the subplacement version as compared to the other two versions (original; LOTCA-G version), the older adults were able to complete the LOTCA-G version at a significantly faster rate than the other two versions (original version; subplacement version).

Katz et al (2000) compared LOTCA performance between two subgroups of adults with right hemisphere strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (patients with unilateral spatial neglect, n=19 vs. patients without unilateral spatial neglect, n=21) on admission to and discharge from inpatient rehabilitation. Patients with neglect were reported to score significantly worse on the Overlapping Figures subtest, Perception area total score, and all Visuomotor Organisation and Thinking Operations subtests and area total scores at admission and discharge (range p=0.02 to p=0.0001; Wilcoxon Rank Sum statistic).

Annes et al. (1996) compared LOTCA maximum scores between healthy young adults aged 17-25 years (n=49) and healthy older adults aged 40-75 years (n=49), using Fisher’s Exact Test or Yate’s chi square as appropriate. No significant differences were reported for Orientation or Perception areas. Younger adults performed significantly better on the Copying Geometric Forms (p=0.01), Plain Block Design (p=0.024) and Pictorial Sequence A (p=0.002) subtests, while older adults were reported to perform significantly better on the Geometric Sequence (p=0.046) subtest. The authors concluded that separate LOTCA norms are not required for the two age groups. While a significant difference was seen for the ROC-Unstructured subtest, it is considered that this difference was due to an error in the administration of the test.
Note: The maximum score was used rather than mean or standard deviations, due to a ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." produced by the consistently high performance of subjects within both groups.

Annes et al. (1996) reported a significant difference in time taken to complete the LOTCA Visuomotor Organization area between healthy young adults aged 17-25 years (n=49) and healthy older adults aged 40-75 years (n=49), with the younger age group completing 6 of 7 subtests more quickly (Copying Geometric Forms, p<0.01; Pegboard Construction, p<0.01; Coloured Block Design, p<0.01; Reproduction of a 2D Model, p<0.05; Reproduction of a Model, p<0.05; and Drawing a Clock p<0.05; but not Plain Block Design).

Cermak et al. (1995) compared LOTCA performance between American (n=25) and Israeli (n=56) patients with CVA. Using the total sample group, they also compared performance between patients with right CVA (n=45) and patients with left CVA (n=36), using t-tests. Israeli participants were found to perform significantly better than American participants on the Orientation to Time subtest (p<0.01) in both subgroups (right CVA and left CVA); the Drawing a Clock (p<0.01) and Risk Object Classification – structured (p<0.05) subtests in the right CVA subgroup; and the Object Constancy (p<0.01) subtest in the left CVA subgroup. Comparison according to side of lesion showed that patients with right CVA performed significantly better (p<0.05) than those with left CVA on the Orientation to Time, Object Constancy and Spatial Perception subtests within the American subgroup; and on the Praxis subtest within the Israeli subgroup (p<0.01). However, patients with left CVA performed significantly better (p<0.05) than patients with right CVA on the Pegboard Construction subtest amongst both American and Israeli participants. It should be noted that Israeli participants were significantly younger than American participants in both the right CVA (mean age 58.5 vs 64.3, t = 2.25, p < 0.05) and left CVA (mean age 55.0 vs. 69.0, t=3.09, p<0.01) groups. The correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between LOTCA subtests and age were low to moderate for most subtests, but was moderate for the Orientation to Time subtest, in which the Israeli group performed significantly better than the American group.

Su et al. (2000) compared the perceptual performance of patients with intracerebral hemorrhage (n=22) to patients with ischemia (n=22) early after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and found that patients with intracerebral hemorrhage performed significantly worse on the LOTCA Thinking Operations area (p=0.007). No significant differences were reported between subjects with right-sided lesions and subjects with left-sided lesions for any LOTCA area.

Josman and Katz (2006) examined the relationship between formal categorization-sorting tests and functional sorting tasks among individuals with schizophrenia (n=37), patients post strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (n=18) and healthy adults (n=15), using the LOTCA Picture Sort subtest, Wisconsin Card Sorting Test, Short Category Test, Risk Object Classification and five functional daily tasks (sorting laundry, utensils, invoices, and two shopping lists). One way ANCOVA revealed a significant difference in the mean performance of the LOTCA Picture Sort subtest (F= 7.57, P=0.001). Post hoc Scheffe tests revealed that patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. performed worse than individuals with schizophrenia (P<0.05) and healthy adults (P<0.05).

Katz et al (1995) compared LOTCA-G scores between healthy older adults (n=43) and patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (n=33), using the Wilcoxon sign test. Healthy older adults performed significantly better than patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. for the Orientation, Perception, Visuomotor Organization and Thinking Operations areas (range p=0.0001 to p=0.05), excluding the Praxis and Coloured Blocks Design subtests. Significant differences in the time taken to complete the LOTCA-G were also found between the 2 groups (P<0.0001), with the healthy older adults completing the assessment more quickly than patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Bar-Haim Erez & Katz (2003) compared LOTCA-G scores between healthy adults (n=43) and individuals with dementia (n=30). Healthy adults performed significantly better than individuals with dementia on all subtests (p=0.000), except for the Object Identification and Shape Identification subtests. Health adults completed the test significantly quicker than individuals with dementia (p<0.000). Comparison of healthy adults and two subgroups of individuals with dementia (mild dementia, n=13; moderate dementia, n=17) by one way ANOVA showed significant F tests for all areas (p<0.000, except visual perception p<0.05). Post hoc Scheffe testing showed that individuals with mild dementia performed better than individuals with moderate dementia in the areas of Orientation, Visual Perception, Visuomotor Organisation, Thinking Operations and Memory. Mann-Whitney analysis of subtest mean scores from the two dementia subgroups further showed that individuals with mild dementia performed significantly better than individuals with moderate dementia on 10 subtests (Orientation to Place, Orientation to Time, Spatial Perception-Self and Surrounding, Motor Imitation, Utilisation of Objects, Copying Geometric Forms, Pegboard Construction, Block Design (Colour), Categorisation, Memory of a Famous Personality), indicating that the LOTCA-G is sensitive to degree of dementia.

Responsiveness

No studies have reported on the responsivenessThe ability of an instrument to detect clinically important change over time.
of the LOTCA.

References

• Annes, G., Katz, N., & Cermak, S. (1996). Comparison of younger and older healthy American adults on the Loewenstein Occupational Therapy Cognitive Assessment. Occupational Therapy International, 3, 157-173.
• Bar-Haim Erez, A., & Katz, N. (2003). Cognitive profiles of individuals with dementia and healthy elderly: The Loewenstein Occupational Therapy Cognitive Assessment (LOTCA-G). Physical and Occupational Therapy in Geriatrics, 22, 29-42.
• Cermak, S. A., Katz, N., McGuire, E., Greenbaum, S., Peralta, C., & Flanagan, V.M. (1995). Performance of Americans and Israelis with cerebrovascular accident on the Loewenstein Occupational Therapy Cognitive Assessment. American Journal of Occupational Therapy, 49, 500-506.
• Cooke, D. M., McKenna, K., Fleming, J. & Darnell, R. (2006a). Criterion validity of the Occupational Therapy Adult Percepetual Screening Test (OT-APST). Scandinavian Journal of Occupational Therapy, 13, 38-48.
• Cooke, D. M., McKenna, K., Fleming, J. & Darnell, R. (2006b). Construct and ecological validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST). Scandinavian Journal of Occupational Therapy, 13, 49-61.
• Jang, Y., Chern, J-S., & Lin, K-C. (2009). Validity of the Loewenstein Occupational Therapy Cognitive Assessment in people with intellectual disabilities. American Journal of Occupational Therapy, 63, 414-244.
• Josman, N., Abdallah, T. M., & Engel-Yeger, B. (2010). Cultural factors affecting the differential performance of Israeli and Palestinian children on the Loewenstein Occupational Therapy Cognitive Assessment. Research in Developmental Disabilities, 31, 656-663.
• Josman, N., & Katz, N. (2006). Relationships of categorization on tests and daily tasks in patients with schizophrenia, post-stroke patients and healthy controls. Psychiatry Research, 141, 15-28.
• Katz, N., Champagne, D., & Cermak, S. (1997). Comparison of the performance of younger and older adults on three versions of a puzzle reproduction task. American Journal of Occupational Therapy, 51, 562-568.
• Katz, N., Elazar, B., & Itzkovich, M. (1995). Construct validity of a geriatric version of the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) battery. Physical and Occupational Therapy in Geriatrics, 13, 31-46.
• Katz, N., Hartman-Maeir, A., Ring, H., & Soroker, N. (2000). Relationships of cognitive performance and daily function of clients following right hemisphere stroke: Predictive and ecological validity of the LOTCA battery. Occupational Therapy Journal of Research, 20, 3-17.
• Katz, N., Itzkovich, M., & Averbuch, S. (2002). The Loewenstein Occupational Therapy Cognitive Assessment. Archives of Physical Medicine and Rehabilitation, 83, 1179.
• Katz, N., Itzkovich, M., Averbuch, S., & Elazar, B. (1989). Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) battery for brain-injured patients: Reliability and validity. American Journal of Occupational Therapy, 43, 184-192.
• Su, C-Y., Chang, J-J., Chen, H-M., Su, C-J., Chien, T-H., & Huang, M-H. (2000). Perceptual differences between stroke patients with cerebral infarction and intracerebral hemorrhage. Archives of Physical Medicine and Rehabilitation, 81, 706-714.
• Su, C-Y., Chen, W-L., Tsai, P-C., Tsai, C-Y., & Su, W-L. (2007). Psychometric properties of the Loewenstein Occupational Therapy Cognitive Assessment-Second Edition in Taiwanese persons with schizophrenia. American Journal of Occupational Therapy, 61, 108-118.
• Su, C-Y., Lin, Y-H., Chen-Sea, M-J., & Yang, M-J. (2007). A confirmatory factor analysis of the Chinese version of the Loewenstein Occupational Therapy Cognitive Assessment-second edition in a Taiwanese mixed clinical sample. Occupational Therapy Journal of Research, 27, 71-80.
• Zwecker, M., Levenkrohn, S., Fleisig, Y., Zeilig, G., Ohry, A., & Adunsky, A. (2002). Mini-Mental State Examination, cognitive FIM instrument, and the Loewenstein Occupational Therapy Cognitive Assessment: Relation to functional outcome of stroke patients. Archives of Physical Medicine and Rehabilitation, 83, 342-5.

See the measure

How to obtain the LOTCA?

The LOTCA can be purchased online from http://store.grovergear.com/, http://www.ot-innovations.com, or http://therapro.com.