The combined intervention of therapy and bromocriptine mesylate to improve functional performance after brain injury.

The American Journal of Occupational Therapy Survivors of brain injuries often experience multiple cognitive, behaVioral, and motor deficits that they must learn to remediate or compensate for to become functional in daily self-care tasks as well as mobility tasks, Executive dysfunction is a generalized term used to indicate the ability to integrate higher level cognitive skills, Executive dysfunction is often present in persons with brain injury, especially those whose frontal lobes have been directly or indirectly injured, The frontal lobes perform two major tasks: they help a person decide what is important to pay attention to and what is worth doing, and they provide continuity and coherence of behavior over time (Hart & Jacobs, 1993) Persons with frontal lobe deficits are described as knowing what to do but unable to do it (Hart &Jacobs, 1993). This inability to use knowledge to guide behavior may often be interpreted as resistance or poor motivation. According to Fuster (1991), short-term or working memory also is involved in the ability to adjust behavior to incoming information as well as in the ability to create a preparatory motor set that allows for the execution of behavior according to perceived needs. Lezak (1993) suggested that executive functions consist in part of a volitional or motivational aspect as well as purposive action. Stuss (1993) separated executive function into routine or automatic functions (also referred to as the basal ganglia) and nonroutine or control functions, He stated that a disruption at the routine or automatic level can result in a deficit at the control or nonroutine level. Initiation deficits, for example, in the kinetic or movement system can be connected to initiation deficits in the cognitive system, Often patients may be able to verbalize what they need to do if asked or cued in some manner, but may be unable to initiate the activity itseJE. For this case study, we refer to this inability as an initiation dejlcit Poor initiation can severely impair or interfere with a patient's ability to regain or achieve independence in daily functional activities, After brain injury, patients must often learn new ways of completing basic activities, Giles and Shore (1989) stated that new physical routines may be the hardest tasks to learn, Patients with initiation deficits may nor require physical assistance, but they generally require verbal cues. A patient who can complete a functional task, such as bathing or dressing, only with step-by-step verbal cues is not truly independent. Therapists who provide rehabilitation services for patients with brain injury resulting in poor initiation must find a way to address this deficit to ensure optimum return to independent functioning. The occupational therapy literature provides little information on how to retrain patients specifically for functional tasks if they have cognitive deficits in general (Giles & Clark-Wilson, 1988; Giles & Shore, 1989) or cognitive deficits in conjunction with motor deficits, There is even less information on retraining patients with specific initiation deficits. Traditional approaches to retraining