Loewenstein Occupational Therapy Cognitive Assessment (LOTCA)

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 Consistency:
Katz, Itzkovich and Averbuch (1989) examined the internal consistency of the original LOTCA with patients with traumatic head injury (n=20), patients with stroke (n=28) and health adults (n=55), and reported excellent 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 reliability of the LOTCA when used with patients with stroke.

Intra-rater:
No studies have examined the intra-rater reliability of the LOTCA.

Inter-rater:
Katz et al (1989) reported excellent inter-rater reliability for subtests of the LOTCA, with Spearman’s rank 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 stroke.

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 validity of the original LOTCA, using two groups of patients with traumatic head injury or stroke (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. 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 stroke (n=44), using Pearson 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 correlation analysis.

Cooke et al. (2006a) examined the concurrent validity of the OT-APST in patients with stroke (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 stroke (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 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 validity of the LOTCA with patients with stroke.

Construct:
Katz et al. (1989) conducted factor analysis of the original LOTCA and reported suitable construct validity for the Perception, Visuomotor Organization and Thinking Operations areas.

Su et al. (2000) reported that the LOTCA Orientation and Perception areas demonstrate suitable construct validity 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 validity of the LOTCA (2nd edition) and the LOTCA-G area means with the OT-APST subscale means in patients with stroke, 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 stroke (n=66), using Pearson’s 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 stroke (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 (r=0.46, p<0.01) and Object Completion (r=0.38, p<0.01) subtests; LOTCA Perception and RPAB Sequencing (r=0.38, p<0.01); LOTCA Visuomotor Organization and RPAB Sequencing (r=0.52, p<0.01); and LOTCA Thinking Operations and RPAB Sequencing (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 stroke (n=40 vs. patients without unilateral spatial neglect, n=21), using Spearman’s 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 validity of the original LOTCA among patients with traumatic brain injury (n=20), patients with stroke (n=28), and healthy adults (n=55), using the Wilcoxon test. 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 stroke (n=24), using the Wilcoxon test. 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 stroke.

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 stroke (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 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 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 stroke 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 stroke (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 stroke 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 stroke (n=33), using the Wilcoxon sign test. Healthy older adults performed significantly better than patients with stroke 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 stroke.

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 responsiveness 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.