Archives of Physical Medicine and Rehabilitation
Volume 86, Issue 8 , Pages 1681-1692, August 2005

Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 1998 Through 2002

  • Keith D. Cicerone, PhD

      Affiliations

    • JFK-Johnson Rehabilitation Institute, Edison, NJ
    • Corresponding Author InformationReprint requests to Keith D. Cicerone, JFK-Johnson Rehabilitation Institute, 2048 Oak Tree Rd, Edison, NJ 08820
    • ,
  • Cynthia Dahlberg, MA, CCC-SLP

      Affiliations

    • Craig Hospital, Englewood, CO
    • ,
  • James F. Malec, PhD

      Affiliations

    • Mayo Medical Center and Medical School, Rochester, MN
    • ,
  • Donna M. Langenbahn, PhD

      Affiliations

    • Rusk Institute of Rehabilitation Medicine, New York, NY
    • ,
  • Thomas Felicetti, PhD

      Affiliations

    • Beechwood Rehabilitation Services, Langhorne, PA
    • ,
  • Sally Kneipp, PhD

      Affiliations

    • Community Skills Program, Counseling and Rehabilitation Inc, Marlton, NJ
    • ,
  • Wendy Ellmo, MS, CCC-SLP

      Affiliations

    • JFK-Johnson Rehabilitation Institute, Edison, NJ
    • ,
  • Kathleen Kalmar, PhD

      Affiliations

    • JFK-Johnson Rehabilitation Institute, Edison, NJ
    • ,
  • Joseph T. Giacino, PhD

      Affiliations

    • JFK-Johnson Rehabilitation Institute, Edison, NJ
    • ,
  • J. Preston Harley, PhD

      Affiliations

    • Marianjoy RehabLink, Wheaton, IL
    • ,
  • Linda Laatsch, PhD

      Affiliations

    • University of Illinois, Chicago, IL
    • ,
  • Philip A. Morse, PhD

      Affiliations

    • Neurobehavioral Services of New England, Portland, ME
    • ,
  • Jeanne Catanese, MA, CCC-SLP

      Affiliations

    • JFK-Johnson Rehabilitation Institute, Edison, NJ

Article Outline

Abstract 

Cicerone KD, Dahlberg C, Malec JF, Langenbahn DM, Felicetti T, Kneipp S, Ellmo W, Kalmar K, Giacino JT, Harley JP, Laatsch L, Morse PA, Catanese J. Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002.

Objective

To update the previous evidence-based recommendations of the Brain Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 1998 through 2002.

Data Sources

PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, and reasoning combined with each of the terms rehabilitation, remediation, and training. Reference lists from identified articles were reviewed and a bibliography listing 312 articles was compiled.

Study Selection

One hundred eighteen articles were initially selected for inclusion. Thirty-one studies were excluded after detailed review. Excluded articles included 14 studies without data, 6 duplicate publications or follow-up studies, 5 nontreatment studies, 4 reviews, and 2 case studies involving diagnoses other than TBI or stroke.

Data Extraction

Articles were assigned to 1 of 7 categories reflecting the primary area of intervention: attention; visual perception; apraxia; language and communication; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria.

Data Synthesis

Of the 87 studies evaluated, 17 were rated as class I, 8 as class II, and 62 as class III. Evidence within each area of intervention was synthesized and recommendations for practice standards, practice guidelines, and practice options were made.

Conclusions

There is substantial evidence to support cognitive-linguistic therapies for people with language deficits after left hemisphere stroke. New evidence supports training for apraxia after left hemisphere stroke. The evidence supports visuospatial rehabilitation for deficits associated with visual neglect after right hemisphere stroke. There is substantial evidence to support cognitive rehabilitation for people with TBI, including strategy training for mild memory impairment, strategy training for postacute attention deficits, and interventions for functional communication deficits. The overall analysis of 47 treatment comparisons, based on class I studies included in the current and previous review, reveals a differential benefit in favor of cognitive rehabilitation in 37 of 47 (78.7%) comparisons, with no comparison demonstrating a benefit in favor of the alternative treatment condition. Future research should move beyond the simple question of whether cognitive rehabilitation is effective, and examine the therapy factors and patient characteristics that optimize the clinical outcomes of cognitive rehabilitation.

Key Words:  Brain injuries , Cognition disorders , Practice guidelines , Rehabilitation , Stroke

 

THE BRAIN INJURY interdisciplinary Special Interest Group (BI-ISIG) of the American Congress of Rehabilitation Medicine (ACRM) previously conducted an evidence-based review of the literature through 1997 about cognitive rehabilitation for people with traumatic brain injury (TBI) or stroke.1 That review led the BI-ISIG to make several specific recommendations concerning the clinical practice of cognitive rehabilitation and its effectiveness in TBI and stroke patients.

Since publication of our initial findings, several additional systematic reviews of cognitive rehabilitation have been published. A task force under the auspices of the European Federation of Neurological Societies2 used similar methods and reviewed many of the same studies referenced in our initial report. That task force concluded that there is substantial evidence to support attention training in the postacute phase after TBI (but not during the period of acute recovery) and compensatory memory training for subjects with mild memory impairments. Evidence of the effectiveness of pragmatic conversational therapy after TBI was based on a limited number of studies with small samples, and was in need of confirmation. Several methods of rehabilitation for spatial neglect were found to be effective, as was the treatment of apraxia with compensatory strategies. As part of a broader effort by the Academy of Neurologic Communication Disorders and Sciences to develop practice guidelines for treating cognitive-communication disorders after TBI, Sohlberg et al3 examined the evidence for the effectiveness of direct attention training after TBI. They concluded that there was evidence of improvement in attention-based skills with direct training, although the interpretation of studies was limited by factors such as subject heterogeneity and the lack of replications. Two Cochrane reviews have examined cognitive rehabilitation for attention deficits4 or memory deficits5 after stroke, but only class I studies were included. Lincoln et al4 concluded there was some evidence that training improves alertness and sustained attention but insufficient evidence of improved functional independence after stroke. Majid et al5 identified a single study that met their criteria for inclusion and found insufficient evidence to support or refute the effectiveness of cognitive rehabilitation for memory problems after stroke.

Several systematic reviews6, 7, 8 found evidence that cognitive rehabilitation, including visual scanning training, improves spatial neglect after right hemisphere stroke, but also found that there is limited or insufficient evidence for the duration of treatment effects or relevance to everyday functioning.6, 8 Systematic reviews of treatment for aphasia have reached conflicting conclusions. Robey9 conducted a meta-analytic review of 55 studies of clinical outcomes after aphasia rehabilitation. These were generally observational studies, rather than randomized controlled trials (RCTs). Outcomes for treated subjects were superior to outcomes for untreated subjects in all stages of recovery, particularly when treatment was begun in the acute stage of recovery, and the extent of treatment effects was positively associated with the amount of treatment. There were too few studies to permit an examination of the differential effects of treatments for different types of aphasia. Cappa et al2 found some evidence for the effectiveness of aphasia therapy, again based largely on class II and III studies. In contrast, a Cochrane review10 of aphasia rehabilitation identified only 12 RCTs suitable for the authors’ review, none of which were considered of adequate methodologic quality to warrant complete description and analysis. The main conclusion reached in that review was that aphasia therapy after stroke has not been shown to be clearly effective or ineffective within an RCT.

These systematic reviews have generally found some evidence to support the effectiveness of cognitive rehabilitation after TBI or stroke, but have also recognized the need for better specification of treatment effects and increased methodologic rigor, and have sometimes limited their conclusions on these grounds. We recognize that clinical guideline development is an ongoing process that should include an updated review of the literature within 5 years of the initial recommendations. The BI-ISIG recently completed an updated evidence-based review and made recommendations that incorporate the literature published from 1998 through 2002. This article summarizes those findings and recommendations. In this article, we concentrate on describing class I studies. Class II and III studies are discussed when they provide unique or contradictory information. A more complete discussion of these studies is in the full report of the BI-ISIG committee (online at http://www.acrm.org).

Back to Article Outline

Methods 

We followed prior methodology for identifying relevant literature, reviewing, and classifying, and developing recommendations. These methods are described in more detail in our initial publication.1 For the current review, we searched PubMed and Infotrieve for articles published between 1998 and 2002, using the terms attention, awareness, cognitive, communication, executive, language, memory, perception, problem solving, and reasoning combined with each of the terms rehabilitation, remediation, and training. We elected to include RCTs published before 1998 that were not included in our first review, but not other studies. Two such articles were identified and included in this review. This resulted in the identification of 312 articles. The abstracts or complete articles were reviewed to eliminate articles according to the following exclusion criteria: (1) articles not addressing intervention, (2) theoretical articles or descriptions of treatment approaches, (3) review articles, (4) articles without adequate specification of interventions, (5) articles that did not include participants primarily with a diagnosis of TBI or stroke, (6) studies of pediatric subjects, (7) single-case reports without empirical data, (8) non-peer-reviewed articles and book chapters, (9) articles describing pharmacologic interventions, and (10) articles not written in English. One hundred eighteen articles were included this screening process. Thirty-one studies were excluded after further detailed review (14 studies without data, 6 articles representing duplicate publications or follow-up studies, 5 articles that were nontreatment studies or experimental manipulations, 4 reviews, and 2 single-case studies of subjects with diagnoses other than TBI or stroke). Studies providing follow-up to previously reviewed treatment studies were not fully evaluated or classified as new treatment studies, but findings from these studies were reviewed and are discussed here when appropriate.

Eighty-seven studies were fully reviewed and evaluated, with the level of evidence determined based on criteria used in our prior review.1 Well-designed, prospective RCTs were considered class I evidence; studies using a prospective design with “quasirandomized” assignment to treatment conditions were designated as class Ia studies. Given the inherent difficulty in blinding rehabilitation interventions, we did not consider this as criterion for class I or Ia studies. Class II studies consisted of prospective, nonrandomized cohort studies; retrospective, nonrandomized case-control studies; or multiple-baseline studies that permitted a direct comparison of treatment conditions. Clinical series without concurrent controls, or single-subject designs with adequate quantification and analysis were considered class III evidence. Articles were reviewed and classified by at least 2 committee members. Disagreements between the 2 primary reviewers (as happened with 7 articles) were first addressed by discussion between reviewers to correct minor sources of disagreement, ant then by obtaining a third review.

Of the 87 studies, 17 were rated as class I, 8 as class II, and 62 as class III. The overall evidence within each predefined area of intervention was synthesized and recommendations were derived from the relative strengths of the evidence. The level of evidence required to determine practice standards, practice guidelines, or practice options was based on the decision rules applied in our initial review (appendix 1). All recommendations were reviewed by the entire committee to ensure consensus.

Remediation of Attention Deficits 

We identified 5 studies on remediation of attention deficits after TBI. Two were class I prospective randomized studies11, 12 comparing attention treatment with alternative treatments; 1 was a class II study13 that compared attention treatment with no treatment; and 2 were class III studies.14, 15

Sohlberg et al11 used a crossover design to compare the effectiveness of “attention process training” (APT) brain injury education and support for 14 patients with acquired brain injury. Self-reported changes in attention and memory functioning, as well as improvement on neuropsychologic measures of attention-executive functioning, were greater after APT than after therapeutic support. The second class I study12 taught 22 patients with severe TBI to compensate for slowed information processing and the experience of “information overload” in daily tasks. Participants were randomly assigned to receive either time pressure management (TPM) or an alternative treatment of generic “concentration” training. Participants receiving TPM showed significantly greater use of self-management strategies and greater improvement of attention and memory functioning than did participants who received the alternative treatment.

Although the precise nature of the interventions in these 2 class I studies differ, they share a common emphasis on the development of strategies to compensate for residual cognitive deficits (“strategy training”) rather than attempting to directly restore the underlying impaired function (“restitution training”). The results of these 2 studies and of an additional small class II study13 are therefore consistent with a strategy training model for attention deficits after TBI, and reinforce the conclusions made in our initial review.1

Clinical recommendations 

In the current review, there is evidence from 2 class I studies11, 12 with 36 subjects that supports the effectiveness of attention training for subjects with TBI during the postacute period of rehabilitation. Considering this evidence, along with our previous recommendation based on 2 class I studies with 57 subjects,1 the committee recommends that strategy training for attention deficits exhibited by subjects with TBI be considered as a practice standard during the postacute period of rehabilitation. Results of studies in this area suggest greater benefits on complex tasks requiring the regulation of attention, rather than on basic aspects of attention (eg, reaction time or vigilance). These results are consistent with the emphasis on strategy training to compensate for attention deficits in functional situations. There is insufficient evidence to support the use of specific interventions for attention deficits during acute rehabilitation.

Recommendations for future research 

Evidence from 1 class I study11 suggests that cognitive remediation has differential effects on various components of attention; therefore, more research is needed to clarify the differential effects of interventions. The finding that cognitive interventions influence the regulation of attention can be contrasted with pharmacologic treatment, which may exert its primary effect on basic processing speed.16 This suggests that a combination of cognitive and pharmacologic interventions may produce the greatest overall improvement in attention deficits after TBI, although this has not been evaluated through controlled research.

Remediation of Visuospatial Deficits 

We reviewed 11 studies in the area of rehabilitation of visuoperceptual deficits. The majority of these involved rehabilitation of unilateral visual neglect, and 1 involved the restitution of visual fields. The 13 studies included 3 class I17, 18 or Ia19 studies, 3 class II studies,20, 21, 22 and 5 class III studies.23, 24, 25, 26, 27

Two class I or Ia studies involved the rehabilitation of visual neglect after stroke. The class Ia study19 was a prospective controlled trial that replicated a prior class II study.28 Training for neglect produced improvement on standard neglect tests and a functional measure evaluating generalization, compared with general cognitive stimulation. Niemeier18 found systematic cueing of visual scanning to be superior to conventional rehabilitation (which did not produce improvement).

Kasten et al17 examined computer-based treatment of partial blindness resulting from optic nerve damage or postchiasmal lesions. The training was intended to restore the underlying neurologic and visual functions and reduce the extent of the damaged visual fields (ie, “restitution training”). The training resulted in significant enlargement of the visual field in 95% of the subjects, which remained stable 2 years later.29

One class II22 and 1 class III25 study replicated class I demonstrations that visual scanning is an effective treatment for visual neglect. Additional class II20 and class III23, 24, 26, 27 studies introduced forced activation of the affected limb in conjunction with visual scanning training as a treatment for visual, and possibly sensory, neglect.

Clinical recommendations 

Two class I18 or Ia19 studies of 41 subjects with cerebral stroke replicated the effectiveness of visual scanning in treating unilateral neglect, consistent with the 6 class I studies involving 286 subjects from our prior review.1 These class I studies demonstrating the efficacy of visual scanning training for visual neglect strongly support that this type of intervention as a practice standard. Inclusion of limb activation or electronic technologies for visual scanning training is recommended as a new practice option, pending confirmation of efficacy through more rigorous investigation.

A class I study17 provided evidence that computer-based restitution training can reduce the extent of damaged visual fields due to postchiasmal lesions, and produce subjective improvements in visual functioning. We previously noted1 that the observed reductions in visual field defects were insufficient to explain the associated reduction in functional impairments, and that functional improvement was associated with increased compensation rather than change in the underlying visual field deficit. We recommend that interventions intended to reduce the extent of damaged visual fields be considered a practice option, pending replication by independent investigators.

Recommendations for future research 

Class I studies verifying the usefulness of technologies that might increase the availability of visual scanning treatment, such as computer projection22 and the Useful Field of View test25 introduced in class II and III studies, should be conducted. Class II and III studies demonstrating positive results for limb activation in conjunction with visual scanning treatment for neglect merit verification through class I research.

The evidence that visual restitution training may actually result in regeneration of the visual fields makes it increasingly difficult to dismiss this possibility, even though it runs counter to conventional neurologic wisdom. This method merits further independent and rigorous investigation in other centers. Such studies should attempt to differentiate between the contribution of visual restitution training intended to have an impact directly on visual field restrictions and the contribution of compensatory mechanisms (eg, improved scanning) to improved functioning.

Prospective, controlled (class I) studies of interventions to improve more complex visuospatial abilities required for functional activities (eg, meal preparation, driving) are recommended. Such interventions were explored through class II and III studies with positive results in our previous review, but further investigation of such interventions is noticeably absent in this update.

Remediation of Apraxia 

There was a new area of focus with 2 class I30 or Ia31 studies of rehabilitation for apraxia. Apraxia, the inability to do learned and purposeful activities such as dressing, can result in self-care deficits and dependence on caregivers. Smania et al31 compared the effectiveness of gestural training and object use in 13 subjects with limb apraxia after left hemisphere stroke with conventional aphasia therapy. Despite an equal amount of treatment, the group receiving conventional therapies showed no improvement, while the apraxia treatment produced improvement in both ideational and ideomotor apraxia. Donkervoort et al30 conducted a multisite study of subjects with apraxia from left hemisphere stroke. Subjects were randomized to receive either “strategy” training integrated into occupational therapy (OT) or conventional OT. The main principle of the strategy training program was the use of internal or external compensations for the apraxic impairment during the performance of activities of daily living (ADLs).32 The emphasis of conventional treatment was on sensorimotor impairments. During the first 8 weeks of their inpatient stay, all subjects received 15 to 19 hours of treatment, with no difference in the amount of treatment provided in the 2 conditions. Strategy training was more effective in improving ADL function than the conventional OT at the conclusion of the 8 weeks of training. At 5-month follow-up, there were no differences between the 2 groups; apparently because of the continued improvement in the subjects who had received (and in some cases were still receiving) conventional treatment. The investigators suggested that patients receiving conventional therapy needed more therapy to improve their ADL functioning.

Clinical recommendations 

Two class I30 or class Ia31 studies of 126 subjects with left hemisphere stroke provide evidence that apraxia can be treated effectively and may facilitate improvement in functional ADLs during the initial period of inpatient rehabilitation, compared with conventional sensorimotor or aphasia therapies. Specific gestural or strategy training for apraxia after left hemisphere stroke is therefore recommended as a new practice standard during acute rehabilitation.

Remediation of Language and Communication Deficits 

The remediation of neurogenic communication disorders is an active area of research, with 40 studies identified in the current review that addressed a range of language-related impairments. There were 3 class I studies,33, 34, 35 1 class Ia study,36 1 class II study,37 and 35 class III studies.38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72 Most of this research involved subjects with left hemisphere stroke (35 articles with a total of 253 stroke subjects). Three studies in which the subjects were primarily people with stroke also included subjects with TBI.38, 39, 40 There were also 4 single-subject studies of people with TBI.42, 43, 44, 45 There was 1 study41 of 6 subjects with TBI for a total of 16 subjects with TBI in 8 research articles during this review period.

Denes et al33 evaluated the effect of intensity of treatment for 17 subjects with global aphasia at an average of 3 months postonset, using a functional stimulation approach to therapy. More subjects with intensive treatment reached significant improvement in all language modalities. This concept was supported by 3 class III articles reporting improved functional communication after chronic stroke46 and improved naming ability of subjects with stroke or TBI40, 43 with increased intensity of treatment. Constraint-induced movement therapy (CIMT) to improve language skills after left hemisphere stroke was evaluated in a class I study of 17 subjects with chronic aphasia.35 CIMT was described as massed practice of verbal responses that was designed to constrain patients to the systematic practice of speech acts with which they had difficulty. The results demonstrated significant benefit of CIMT compared with conventional aphasia therapy.

Elman and Bernstein-Ellis34 evaluated the effectiveness of group communication treatment after left hemisphere stroke. All participants were at least 6 months postinjury and were stratified according to their initial aphasia severity. They were randomly assigned to receive either group communication treatment or deferred treatment. Group communication treatment focused on initiating conversations and conveying a message, understanding the communication disorder, being aware of personal goals and progress, and having confidence in being able to communicate in personally relevant situations. To control for the effect of social contact, the control subjects participated in social activities (eg, movement classes, church activities) while their group communication treatment was deferred. Participants who received the group communication treatment showed significantly more improvement in functional communication. In an effort to evaluate a cost-effective and functional treatment program, Worrall and Yiu36 compared a home-based, functional communication program provided by trained volunteers with non-language-based recreational treatment and no treatment conditions, for people with chronic aphasia. Between-group comparisons revealed significant improvement from the functional communication program compared with no treatment, but not compared with recreational activities.

There is evidence supporting the use of cuing techniques and semantic analysis to improve naming ability by people with aphasia and TBI,43, 44, 46, 52, 53, 56, 57, 65, 69, 71 to improve writing skills in patients with chronic aphasia,46, 47, 48, 49, 50, 51, 61, 67, 68 and to improve sentence production in patients with agrammatic aphasia.39, 59, 64, 70 These studies, along with the studies from the last review,1 support the efficacy of treating naming disorders in people with chronic aphasia, but there is still no clear evidence that one method is more effective than another.

A class III study by Wiseman-Hakes et al41 supported the effectiveness of group treatment to improve pragmatic communication skills for 6 subjects with TBI. However, 1 class III single-subject study42 failed to demonstrate the effectiveness of pragmatic training, primarily because of the limited contextual aspects of the treatment.

Clinical recommendations 

The results from 3 class I studies33, 34, 35 of treatment of language deficits in 58 subjects after left hemisphere stroke are consistent with the results from 3 class I studies with 169 subjects from our prior review,1 and provide additional support for the practice standard recommending cognitive linguistic therapies during acute and postacute rehabilitation for such subjects. There is evidence that group communication treatment can produce clinically meaningful improvements in language functioning, including improved functional communication, beyond the effects of social contact alone.34, 41

Two class I studies with 34 subjects33, 35 and 3 class III studies40, 43, 46 with 44 subjects support the concept that increased intensity of treatment for subjects with aphasia results in improved communication skills. We recommend that treatment intensity be considered as a key factor in the rehabilitation of language skills after left hemisphere stroke, as a new practice guideline.

Several class III studies provide additional support for the established practice guideline that interventions for specific language impairments, such as reading comprehension and language formulation, are effective after left hemisphere stroke or TBI.

Two class III studies53, 65 suggest that independent computer use may serve as an adjunct to clinician-directed treatment of word retrieval. Based on these findings, the committee recommends as a practice option that computer-based interventions be considered as an adjunct to treatment when there is therapist involvement; sole reliance on repeated exposure and practice on computer-based tasks without some involvement and intervention by a therapist is not recommended.

Recommendations for future research 

Given the overall evidence to support the effectiveness of language interventions after left hemisphere stroke, additional research should be directed at specific parameters of treatment related to effectiveness. Several studies suggest that more intense treatment, including massed practice, produces significant benefits; this area merits further controlled investigation.

Several studies from this and our prior review suggest that intervention provided in the home or community by trained volunteers can improve language functioning.36, 73, 74 We identified several additional studies that addressed training for volunteers75 or caretakers76 to support the conversation of partners with aphasia; however, we excluded those studied from formal review because they did not directly treat the people with aphasia. This may represent a valuable adjunct or alternative to traditional treatments, particularly for chronic aphasia, that merits further controlled investigation.

There remains a compelling need for controlled studies of interventions to improve pragmatic communication in people with TBI.

Remediation of Memory Deficits 

Studies of the remediation of memory deficits have continued to address the use of compensatory strategies, as well as a growing interest in evaluating the application of assistive technology. We reviewed 13 studies in this area, including 3 class I77, 78 or Ia79 studies, 2 class II studies,80, 81 and 8 class III studies.82, 83, 84, 85, 86, 87, 88, 89

Two class I studies77, 78 addressed the effectiveness of training strategies in memory rehabilitation. Kaschel et al77 evaluated the use of a simple visual imagery technique for the rehabilitation of participants with mild memory impairment after acquired brain injury. Visual imagery was compared with the “standard” approach to memory treatment in 7 different rehabilitation centers (eg, practical guidelines to improve memory, use of notebooks and calendars). Both the visual imagery and standard conditions were preceded by 3 months of no-treatment baseline; this was followed by memory training for 30 sessions over 10 weeks, with follow-up assessment 3 months later. Significant improvement was apparent for the imagery condition, and was restricted to the therapeutic interval and recall of verbal material, consistent with predictions. The improvements associated with visual imagery training were paralleled by positive changes in relatives’ ratings of patients’ memory functioning and were maintained at 3-month follow-up.

Ownsworth and McFarland78 investigated the remediation of “everyday memory impairment” using a diary combined with self-instructional training. The addition of the self-management strategy to diary use was associated with better maintenance of strategy use and greater decline in memory problems. The results are consistent with a previous single-subject study90 and also suggest that some forms of compensatory strategy training may be beneficial to patients who are many years postinjury. These class I studies from this review are consistent with the conclusions from our prior review, indicating that compensatory memory strategy training is effective for patients with relatively mild memory impairment.

One class Ia study79 extended the results of a previous class II study91 investigating the effectiveness of a portable pager (NeuroPage) to improve independence in people with memory and planning problems. During the intervention period, the pager was used to address specific problems in daily functioning that were identified by patients or relatives. Significant improvements in participants’ completion of everyday tasks resulted, compared with no-treatment and baseline conditions. Use of a pager appears to be particularly beneficial for people who must complete certain tasks on a regular basis, and is facilitated by its ease of use and relevance to patients’ self-identified needs.87 Five additional class III studies84, 85, 86, 88, 89 investigated the application of some form of external compensation for memory impairments using assistive technology (eg, voice organizers).84, 85, 89

Clinical recommendations 

Two class I studies77, 78 with 41 participants demonstrated the effectiveness of memory strategies for subjects with mild memory impairments after TBI or stroke, including reducing memory failures. These findings are consistent with the previous 4 class I studies1 with 91 subjects and support the use of strategy training for subjects with mild memory impairment as a practice standard. These interventions may consist of internal strategies (eg, visual imagery) as well as compensation through the use of notebooks or diaries. The benefits of specific intervention strategies may be evident in discrete aspects of memory performance, for example, visual imagery to facilitate verbal recall.77 There is evidence that the incorporation of self-management techniques enhances the use, maintenance, and perceived helpfulness of a memory notebook.78 There is also evidence that interventions to promote the use of external memory aids can benefit people with TBI who are many years postinjury.78

The use of externally directed assistive devices such as pagers and voice organizers appears to benefit people with moderate to severe memory impairments, including evidence from 1 class Ia79 study that included subjects for whom previous interventions were ineffective. These interventions facilitate completion of everyday activities that subjects have self-identified as relevant. The use of external memory aids and assistive devices may require extensive training,1 or may need to remain under the direction of someone other than the person with memory impairment.79, 86 As with our previous recommendation on the use of interventions directed at the acquisition of specific skills, these interventions appear effective for increasing specific behaviors rather than improving memory function. Based on current evidence and in conjunction with the evidence from our previous review, training in the use of external compensations (including assistive technology) with direct application to functional activities is recommended as a practice guideline in subjects with moderate or severe memory impairment after TBI or stroke.

Recommendations for future research 

Findings from 1 class I study77 are notable for suggesting that a specific intervention has a differential impact on different aspects of memory functioning. This finding requires replication. The effectiveness of various assistive technologies to compensate for severe memory impairment should be investigated through additional prospective, controlled studies.

Remediation of Executive Functioning, Problem-Solving, and Awareness 

The area of executive functioning includes several integrative cognitive processes by which people monitor, manage, and regulate the orderly “execution” of goal-directed ADLs. We reviewed 9 studies concerned with executive functioning, problem solving, and awareness, including 1 class I study,92 1 class Ia study,93 and 7 class III studies.94, 95, 96, 97, 98, 99, 100

The class I study92 evaluated the effectiveness of a problem-solving intervention, goal management training (GMT), on successful task completion. Participants received either 1 hour of GMT or 1 hour of motor skills training. GMT was associated with improved performance on paper-and-pencil measures intended to simulate everyday activities. The fact that the entire treatment in this trial was limited to a single hour of instruction limits the translation of these findings in terms of the clinical application and effectiveness of the intervention.

One class Ia study addressed the internalization of self-regulation strategies. Medd and Tate93 examined the effectiveness of a cognitive-behavioral program of anger management that involved self-awareness and self-instructional training. Efforts were made to increase participants’ awareness of anger via training to recognize their cognitive, physical, and emotional reactions. Results showed a significant decrease in the outward expression of anger for the treatment group compared with controls, suggesting improved emotional self-regulation as a result of treatment. One class III study95 evaluated a group treatment program developed to enhance self-regulation skills and self-awareness in 21 patients with acquired brain injury. After treatment, participants reported greater awareness of deficits and increased use and effectiveness of strategies in their daily life.

In the Medd and Tate study,93 there was no change in participants’ awareness of anger problems with the treatment. Three class III case studies specifically addressed techniques for improving awareness by promoting internal control of behavior: one via self-monitoring techniques96 and the others using observer feedback and self-evaluation.97, 98 Several of these studies suggest that behavioral improvement is not contingent on increased self-awareness.93, 99, 100

Clinical recommendations 

One class I study with 30 participants supports the effectiveness of interventions for problem-solving deficits,92 although the direct application to clinical practice is constrained by the limited extent of the intervention. A class III study95 demonstrated improved strategy application and psychosocial functioning after training in problem solving. These findings are consistent with a class Ia study with 37 participants from our prior review,1 and reinforce the practice guideline recommending the training of formal problem-solving strategies and their application to everyday situations and functional activities of people with TBI.

Our previous review recommended that cognitive interventions that promote internalization of self-regulation strategies through self-instruction and self-monitoring, be considered a practice option for the remediation of deficits in executive functioning.1 Two class III studies94, 95 support this recommendation and 1 class Ia study93 suggests that these techniques may be used to improve emotional self-regulation in patients with TBI. In addition, 3 class I studies indicate that self-instructional training is an effective component of interventions for the remediation of deficits in attention,12 visual neglect,18 or memory.78

The effectiveness of interventions directed at patients’ poor awareness of deficits has been addressed by 1 class Ia study93 and 6 class III studies.95, 96, 97, 98, 99, 100 Given the small number of uncontrolled studies and inconsistency of methods and results in this area, there is insufficient evidence to make specific recommendations regarding interventions to improve self-awareness after TBI or stroke.

Recommendations for future research 

Future studies may incorporate treatment for problems of emotional control and psychosocial skills, particularly as these reflect components of problem-solving and self-regulation interventions. The effectiveness of interventions that attempt to promote the internalization of strategies needs to be addressed through prospective, controlled studies. Our previous review noted the potential use of external strategies for the rehabilitation of executive problems,101 and this approach might have promise in the treatment of patients with marked difficulties in their planning and organization of everyday activities.79 Despite the importance that is commonly attributed to awareness as a mediator of rehabilitation outcomes, there continue to be few studies of interventions in this area.

Comprehensive-Holistic Cognitive Rehabilitation 

In comprehensive-holistic cognitive rehabilitation, we included studies that investigated interventions directed at multiple aspects of dysfunction, often addressing a combination of cognitive, emotional, motivational, and interpersonal impairments, in the context of an integrated and programmatic treatment approach. We reviewed 1 class I,102 1 class II,103 and 5 class III studies104, 105, 106, 107, 108 of comprehensive-holistic programs of cognitive rehabilitation. The class I study by Salazar et al102 evaluated the efficacy of cognitive rehabilitation for 120 people with moderate to severe TBI within a single, military medical referral center. Of 273 consecutively hospitalized patients, 120 patients met eligibility criteria and participated in the study. They were, on average, about 38 days postinjury. Patients were randomly assigned to receive either multidisciplinary, in-hospital cognitive rehabilitation109 or a limited home program110 consisting of individual education and encouragement from a psychiatric nurse. Return to work rates were 90% for the cognitive rehabilitation group and 94% for the home group; the authors noted these “extraordinarily high return-to-work rates” and suggested that participants’ high preinjury education and level of functioning, significant degree of spontaneous recovery, and ready availability of (military) employment after injury might have limited the ability to detect any differential benefits from the cognitive rehabilitation program. A subgroup analysis of 75 participants with more severe injuries (those unconscious for >1h) showed a significant benefit from the cognitive rehabilitation program. While this study does not provide strong support for comprehensive-holistic cognitive rehabilitation, the significant subject selection bias and restricted setting markedly limit the ability to generalize these findings to most areas of rehabilitation practice.

A principle contribution of the class III studies is their relevance to understanding the impact of comprehensive-holistic cognitive rehabilitation on social participation and community integration after TBI. Four studies104, 105, 106, 107 with a total of 270 patients evaluated programs based on the principles of neuropsychologic rehabilitation. Most of the participants were people with severe TBI who had received clinical treatment for at least 3 months-in many cases, several years-after injury. Between 39%104 and 62%107of patients were engaged in community-based employment after treatment, and 49% made clinically significant gains in community integration.106

Clinical recommendations 

The single class I study102 of 120 subjects with TBI did not provide support for comprehensive cognitive rehabilitation compared with basic education and reassurance in the early stages of recovery from TBI; patients with more severe injuries, however, did show greater benefit with the more intense, structured treatment program. However, the ability to generalize from the results of this study is severely constrained by the restricted nature of the population, unique (military) setting, and limited course of treatment.

Four class III studies104, 105, 106, 107 with 265 subjects support the clinical effectiveness of comprehensive-holistic programs of cognitive rehabilitation for improving community integration, social participation, and productivity after TBI or stroke. There is also evidence that gains in community functioning can be achieved by patients 1 or more years postinjury,106 and that gains from treatment are maintained for several years after rehabilitation.105, 111, 112 These studies support our previous conclusion1 that treatment in postacute programs of comprehensive-holistic cognitive rehabilitation is recommended as a practice guideline in treating people with moderate to severe TBI. The integration of cognitive and interpersonal interventions is characteristic of comprehensive-holistic cognitive rehabilitation programs. There is also evidence that psychosocial interventions may facilitate the effectiveness of treatments directed at specific cognitive impairments after TBI11 or stroke.64 These findings are consistent with our prior recommendation that the integration of individualized cognitive and interpersonal therapies be considered a practice option.

Recommendations for future research 

There is a particular need in this area to confirm the positive findings from class III studies using controlled trials. This might best be addressed through practical clinical trials that select clinically relevant, alternative interventions for comparison, represent a diverse population of study participants, and use a broad range of relevant health outcomes.113 The continued use of observational methods is also encouraged, particularly to identify the types of patients who are most appropriate for, and likely to benefit from, comprehensive-integrated cognitive rehabilitation.114

Comparison of Cognitive Rehabilitation and Alternative Interventions 

The question of effectiveness of cognitive rehabilitation must be answered in relation to available alternative treatments. For each of the 46 class I studies included in this and our prior review, we examined the nature of the alternative treatment conditions and classified them as no treatment, conventional rehabilitation, pseudotreatment, a psychosocial intervention, or an alternative cognitive intervention. We defined conventional rehabilitation as the provision of standard physical, OT, and/or speech therapy in accordance with routine procedures in a traditional rehabilitation setting. We defined pseudotreatment as providing participants with mental or social stimulation without specific therapeutic intent (eg, recreational computing, leisure activities, repetitive mental exercises). Psychosocial interventions were defined as individual or group psychotherapy or emotional support. Studies that compared different types of specific cognitive interventions (eg, attention training compared with memory training) were considered to provide an alternative cognitive intervention in comparison with the intervention under investigation. We relied on the original authors’ description of the alternative treatment to make these classifications, although on several occasions we had to rely on our judgment regarding the nature of the comparison. We used only studies that reported direct statistical comparisons between treatments in this analysis. For studies that compared cognitive rehabilitation with more than 1 alternative treatment, cognitive rehabilitation was compared separately with each of the alternatives. For the purpose of this analysis, we collapsed studies using psychosocial or “other cognitive” interventions as the alternative treatment. This resulted in the comparison of 47 treatment conditions, representing 1801 patients (table 1).

Table 1. Differential Treatment Effects of Cognitive Rehabilitation (CR) Compared With Alternative Treatment or Control Conditions Based on All Class I Studies
Nature of Treatment ComparisonNo. of ComparisonsNo. of PatientsPercentage of Comparisons Showing Differential Benefit in Favor of CR
CR vs other cognitive or psychosocial treatment1029060.0
CR vs pseudotreatment1558266.7
CR vs conventional rehabil1458792.9
CR vs no treatment8342100.0
Total47180178.7

It is clear that cognitive rehabilitation provides clinical benefits, compared with not receiving any treatment, and substantial benefits compared with conventional rehabilitation. Cognitive rehabilitation produced greater improvement than pseudotreatment, psychosocial treatment, or an alternative cognitive intervention in about two thirds (64%) of the study comparisons. Overall, cognitive remediation resulted in a significant benefit compared with the alternative condition in about 79% of all treatment comparisons (see table 1). There were 22 treatment comparisons involving 616 patients primarily with TBI. In those studies, 18 of the 22 (81.8%) comparisons demonstrated a differential benefit in favor of cognitive remediation. Among the 25 treatment comparisons involving 1185 patients primarily with stroke, 19 (76%) demonstrated a differential benefit favoring cognitive remediation. In no case was there evidence that the alternative condition was superior to cognitive rehabilitation.

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Discussion 

This updated review of the literature regarding cognitive rehabilitation included 17 class I studies of 291 patients with TBI and 247 patients with stroke, with 16 of the 17 studies providing evidence for the effectiveness of cognitive rehabilitation. Five class I studies provide evidence for the effectiveness of remediation for visual inattention17, 18, 19 or apraxia30, 31 in patients with stroke, and 4 studies support the effectiveness of interventions for communication deficits after stroke.33, 34, 35, 36 One of these studies36 supported the use of volunteers to improve communication skills after chronic aphasia, compared with no treatment, but failed to demonstrate benefits when compared with social recreation.

Among studies addressing the remediation of cognitive impairments after TBI, 2 class I studies11, 12 support the training of compensatory strategies to improve attention during the postacute period of rehabilitation. Two class I studies support the use of memory strategy training, including the development of internalized strategies77 and use of a memory notebook or diary,78 for patients with mild memory deficits resulting from TBI. An additional class I study79 indicated that an external cueing system may benefit patients with persistent, severe impairments of memory and planning as a result of TBI or stroke. A class I study92 supports the use of interventions to improve problem-solving abilities. An additional class Ia study93 suggests that treatment to improve emotional self-regulation may benefit TBI patients; this study contributes to the evidence supporting the internalization of self-regulatory strategies after TBI. The studies that have demonstrated effective rehabilitation of attention, memory, and executive functioning deficits after TBI used different interventions, but they all emphasized strategy training as a general principle (ie, training patients to compensate for residual deficits, rather than attempting to eliminate the underlying neurocognitive impairment), and this is reflected in our recommendations. One class I study102 failed to demonstrate the effectiveness of comprehensive-integrated cognitive rehabilitation after TBI compared with limited home-based treatment, although methodologic concerns limit the generalization of these results.

Integrating the results from our previous and current reviews, the committee found evidence to support several of our initial recommendations, made several new recommendations, and modified several recommendations (Table 2, Table 3, Table 4). There is now a substantial body of evidence demonstrating that patients with TBI or stroke benefit from cognitive rehabilitation. It is time to move beyond the simple question of whether cognitive rehabilitation is effective, and to look more precisely at the therapy factors and patient characteristics that optimize the clinical outcomes of cognitive rehabilitation.

Table 2. Evidence-Based Recommendations for Cognitive Rehabilitation: Practice Standards
InterventionRecommendations
Visuospatial rehabilitationRecommended for persons with visuoperceptual deficits associated with visual neglect after right hemisphere stroke
Cognitive-linguistic therapiesRecommended during acute and postacute rehabilitation for persons with language deficits secondary to left hemisphere stroke
Specific interventions for functional communication deficits, including pragmatic conversational skillsRecommended for persons with TBI
Specific gestural or strategy training for apraxiaRecommended for persons with apraxia after left hemisphere stroke during acute rehabilitation
Memory strategy trainingRecommended for persons with mild memory impairments from TBI, including the use of internalized strategies (eg, visual imagery) and external memory compensations (eg, notebooks)
Strategy training for attention deficitsRecommended during postacute rehabilitation for persons with TBI. Insufficient evidence exists to distinguish the effects of specific attention training during acute recovery and rehabilitation from spontaneous recovery or from more general cognitive interventions.
Table 3. Evidence-Based Recommendations for Cognitive Rehabilitation: Practice Guidelines
InterventionRecommendations
Scanning trainingRecommended as an important, even critical, element for persons with severe visuoperceptual impairment that includes visual neglect after right hemisphere stroke
Cognitive interventions for specific language impairments such as reading comprehension and language formulationRecommended after left hemisphere stroke or TBI
Treatment intensityShould be considered as a key factor in the rehabilitation of language skills after left hemisphere stroke
Use of external compensations with direct application to functional activitiesRecommended for persons with severe memory impairment after TBI or stroke
Training in formal problem-solving strategies and their application to everyday situations and functional activitiesRecommended during postacute rehabilitation for persons with stroke or TBI
Comprehensive-holistic neuropsychologic rehabilitationRecommended during postacute rehabilitation to reduce cognitive and functional disability for persons with moderate to severe TBI or stroke
Isolated microcomputer exercises to treat unilateral left neglectNOT recommended; does not appear effective
Table 4. Evidence-Based Recommendations for Cognitive Rehabilitation: Practice Options
InterventionRecommendations
Systematic training of visuospatial and organizational skillsMay be considered for persons with visual perceptual deficits, without visual neglect, after right hemisphere stroke as part of acute rehabilitation. NOT recommended for persons with left hemisphere stroke or TBI who do not exhibit unilateral spatial inattention.
Inclusion of limb activation or electronic technologies for visual scanning trainingMay be included in treatment of visual neglect after right hemisphere stroke
Computer-based interventions intended to produce extension of damaged visual fieldsMay be considered for persons with TBI or stroke
Computer-based interventions as an adjunct to clinician-guided treatmentMay be considered for cognitive and linguistic impairments
Sole reliance on repeated exposure and practice on computer-based tasks without some involvement and intervention by a therapistNOT recommended
Interventions that promote internalization of self-regulation strategies through self-instruction and self-monitoringMay be considered for persons with deficits in executive functioning after TBI, including impairments of emotional self-regulation, and as a component of interventions for deficits in attention, neglect, and memory
Integrated treatment of individualized cognitive and interpersonal therapiesMay improve functioning within the context of a comprehensive neuropsychologic rehabilitation program, and facilitate effectiveness of specific interventions

General Recommendations for Future Research 

Future research on the therapeutic factors that contribute to successful outcomes will require standardized interventions and identification of the various components of complex interventions. Considerable heterogeneity exists among treatment methods reported in the literature, and it is difficult to compare interventions even when these are purported to represent the same type of treatment. The need to provide greater specification of the theoretical basis, design, and components of interventions has received increased attention, as a prerequisite to investigating the effectiveness of rehabilitation.115, 116

There is a need to replicate interventions that have already demonstrated effectiveness, to make increasingly specific predictions about the effects of interventions, and to compare different techniques for specific deficits. This requires the ability to compare the size of treatment effects across different studies and types of treatment. Much of the literature has failed to provide information that would allow for a determination of effect sizes. This also makes it difficult to determine whether the statistical improvements associated with specific interventions are clinically significant. We recommend the routine reporting of effect sizes and related statistics (eg, odds ratios, reliable change indices) that provide some estimate of the clinical relevance of changes associated with the interventions in question.

Clinically, there is consensus that cognitive rehabilitation should not be focused exclusively on the remediation of impairments, but should reduce disability and help restore social role functioning. However, most studies have evaluated the outcome of interventions at the impairment level rather than their effect on the performance of activities or changes in social participation. Even when interventions are directed at the remediation of impairments, this is presumably based on the (implicit or explicit) belief that this will ultimately result in more effective functioning in meaningful contexts. There is a persistent need to evaluate the effects of cognitive rehabilitation on relevant, functional outcomes. The selection of outcome measures will also vary, depending on level of analysis and rationale for specific interventions. We recommend that primary outcome measures be identified in relation to specific hypotheses and directly related to the intended effects of treatment.

We recognize that the practice of cognitive rehabilitation must rely on clinical judgment and the accommodation of treatment approaches to patients’ unique presentations and needs.117 Increased specifications of patient characteristics, interventions, outcomes, and their relationships should facilitate the translation of research into clinical practice and allow clinicians to better tailor specific interventions to different aspects of cognitive dysfunction and patients’ functional goals.

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Conclusions 

We have now systematically reviewed 46 class I studies, 43 class II studies, and 169 class III studies of cognitive rehabilitation for people with TBI or stroke. Our overall analysis of 47 treatment comparisons from class I studies, representing 1801 patients, indicates that cognitive rehabilitation is of significant benefit when compared with alternative treatments. The resulting recommendations should help guide clinical treatment and facilitate additional research.

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Acknowledgments 

The Cognitive Rehabilitation Task Force of the BI-ISIG of ACRM conducted this work. We would like to acknowledge Joanne Azulay, PhD, Thomas Bergquist, PhD, Douglas Katz, MD, and Virginia Mills, RPT, for their contributions to the review and classification of the literature.

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Appendix 1. Definition of levels of recommendations 

Practice standardsBased on at least 1 well-designed class I study with an adequate sample, with support from class II or class III evidence, that directly addresses the effectiveness of the treatment in question, providing substantive evidence of effectiveness to support a recommendation that the treatment be specifically considered for people with acquired neurocognitive impairments and disability.
Practice guidelinesBased on 1 or more class I studies with methodologic limitations, or well-designed class II studies with adequate samples, that directly address the effectiveness of the treatment in question, providing evidence of probable effectiveness to support a recommendation that the treatment be specifically considered for people with acquired neurocognitive impairments and disability.
Practice optionsBased on class II or class III studies that directly address the effectiveness of the treatment in question, providing evidence of possible effectiveness to support a recommendation that the treatment be specifically considered for people with acquired neurocognitive impairments and disability.

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 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.

PII: S0003-9993(05)00330-8

doi:10.1016/j.apmr.2005.03.024

Archives of Physical Medicine and Rehabilitation
Volume 86, Issue 8 , Pages 1681-1692, August 2005

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