Cognitive rehabilitation (CR) can be defined as efforts to promote maximal adaptive cognitive functioning in people with neurologically induced cognitive deficits (Barrett and Gonzalez-Rothi 2002).
The field of CR has grown rapidly over the last few decades, but historically can be traced to the 1800s (Ponsford 2004; Sohlberg and Mateer 2001). For example, Broca administered language rehabilitation in the 1800s, and until the 1980s most rehabilitation programs focused on remediation of language deficits (as reviewed by Ponsford 2004). Many further developments in CR were a result of the confluence of societal influences and scientific and technological advances. During WWI, Goldstein established CR programs for brain-injured soldiers. During WWII, Luria advanced the field of CR through his theoretical model of brain functioning, recovery, and rehabilitation (Ponsford 2004).
Advances in medical practice and an increase in the number of survivors of traumatic brain injury (TBI) led to a greater awareness of the needs of people who sustained TBI and an expansion of the number and focus of CR programs (the “era of proliferation”; Coelho, 1997, as cited by Sohlberg and Mateer 2001). However, current trends in service delivery have resulted in an “era of consolidation,” a term describing the significant downsizing of CR programs. It has been suggested that the reduced length of inpatient stays, outpatient health coverage, and more limited support for CR programs have made evidence and theory-based CR practices increasingly relevant to contemporary practice (Cicerone et al. 2005; Levine and Downey-Lamb 2002; Sohlberg and Mateer 2001).
Rationale or Underlying Theory
CR is multidisciplinary and draws from a range of fields, including neuropsychology, learning theory, cognitive behavioral therapy and psychotherapy, among many others. One main category of theories underlying CR is those specific to the cognitive or behavioral domain of CR focus. For example, attention rehabilitation programs are based on theoretical models of attention, memory rehabilitation programs on theoretical models of memory, and so on. A theory-driven approach provides a rational and empirical basis for intervention and guidance on the structure and delivery of CR (Hart et al. 2014; Sohlberg and Mateer 2001).
Another major theory underlying many forms of CR is neuroplasticity (Kolb and Cioe 2004), the concept that the brain is amenable to change in structure and function. Neuroplasticity has many implications for CR (see Kleim and Jones 2008 for discussion), including the type and timing of CR and the effect of environmental factors on recovery of cognitive function following brain injury (Barrett and Gonzalez-Rothi 2002).
Goals and Objectives
CR aims to foster natural recovery, decrease the development of maladaptive patterns, and increase functional recovery (Sohlberg and Mateer 2001). The primary goal of CR is to help people achieve an optimal level of functioning in the context of impairments, including fostering change in specific neuropsychological deficits and improvement in day-to-day function. CR emphasizes improving function in everyday contexts rather than on specific cognitive tasks per se.
CR has been used with a variety of populations, including but not limited to TBI, stroke, developmental disorders, Alzheimer’s dementia, and schizophrenia. CR has been most commonly used and found effective among people who have sustained TBI and stroke (Cicerone et al. 2011). Recently, there has been significant growth in treatment research aimed at rehabilitation of neurocognitive deficits in schizophrenia (e.g., CR focused on executive functioning deficits; Kluwe-Schiavon et al. 2013).
Variables contributing to the pattern and degree of recovery include demographic (e.g., age, education, gender, culture), injury-related (e.g., time since injury, extent, and severity of injury), and psychological characteristics (e.g., therapeutic alliance, comorbid psychological disorders, awareness).
Age: Younger adults show better levels of recovery than older adults (de la Plata et al. 2008; Green et al. 2008; Teuber, 1975 as cited by Sohlberg and Mateer 2001). Acquired brain injury (ABI) in older adults may be complicated by a number of factors, including the superimposition of effects of ABI on declining cognitive abilities (Richards, 2000 as cited by Sohlberg and Mateer 2001), and psychosocial difficulties more prevalent in the population, including reduced levels of social support and financial resources (Goleburn and Golden 2001). However, it has also been suggested that older adults often have a greater degree of stability, coping skills, fewer life demands, and effective compensatory techniques, which may be helpful in promoting recovery (Sohlberg and Mateer 2001). Older age has been found to be predictive of poorer functional ability (Meyer et al. 2015) and rehabilitation outcome (Koh et al. 2013).
Gender: Some research suggests that women have better recovery following left hemisphere lesions than men (Kimura 1983). Circulating sex hormones have also been shown to have neuroprotective effects; however, future research is needed to better understand these processes (e.g., see Engler-Chiurazzi et al. 2016 for discussion).
Culture: Culture influences beliefs regarding the nature and cause of loss, service utilization, degree of personal responsibility for health, role of family, and many other facets of psychological and behavioral functioning relevant to recovery and participation in CR (Sohlberg and Mateer 2001).
Time Since Injury: Time since injury has been found to be an important predictor of cognitive sequelae following mild TBI, with litigation identified as a factor that may be associated with an atypical trajectory of recovery (see Belanger et al. 2005). Spontaneous recovery typically occurs at a faster rate immediately following brain injury, particularly within the first 6 months, with significant recovery also occurring up to 2 years following injury (Sohlberg and Mateer 2001). However, it is important to note that compensatory techniques can be implemented and underlying motor and cognitive skills improved years after injury (e.g., Shaw et al. 2005).
Extent and Severity of Injury: In general, relatively mild injuries are associated with faster recovery rate and better outcomes. Focal injuries are often associated with more rapid recovery than diffuse injury (Sohlberg and Mateer 2001). TBI severity is related to greater impairment in subsequent functional outcome (Husson et al. 2010; Rassovsky et al. 2015).
Therapeutic Alliance: CR should be an interactive partnership between the client, therapist, and significant others (if indicated). Cultivating a relationship characterized by attentiveness, respect, trust, commitment, and rapport is a critical component of CR. Open communication and involvement of the client and family in goal setting can also enhance engagement in rehabilitation (Sohlberg and Mateer 2001).
Comorbid Psychological Disorders: Depression and anxiety are frequently associated with brain injury (e.g., Anson and Ponsford 2006). These can impede CR and adjustment following injury due to their propensity to decrease motivation and contribute to a feeling of hopelessness (Sohlberg and Mateer 2001).
Awareness: Greater awareness of deficits following TBI may be associated with better treatment outcomes (see Ownsworth and Clare 2006 for discussion). Methodological limitations have been noted in the awareness literature, and further research is required.
Examples of domains that have been a focus of CR include attention, memory, language, visuoperceptual difficulties, executive functions, and socioemotional and behavioral disturbances. CR encompasses a range of interventions. These can be broadly divided into two types of techniques.
The first are those that aim to restore or enhance function, by targeting the underlying impairment (Glisky and Glisky 2002; Sohlberg and Mateer 2001). For example, Attention Process Training (APT) is a theoretically driven program that contends that attention can be improved through repeated activation of attentional systems (Sohlberg and Mateer 1987, 2001). APT consists of a group of hierarchically organized tasks that exercise different components of attention (e.g., sustained, selective, alternating, divided attention). In CR of memory deficits, restorative/generalized memory approaches aim to improve specific memory systems (e.g., Raskin & Sohlberg, 1996, as cited by Sohlberg and Mateer 2001; Spreij et al. 2014). Various approaches to executive function rehabilitation focus on training in formal problem-solving strategies as well as how these strategies can be applied to activities of daily living (Cicerone et al. 2011).
The second category of CR interventions is compensatory techniques, which aim to compensate for or bypass deficits (Sohlberg and Mateer 2001; Wilson and Zangwill 2003). These include environmental supports (e.g., organization of physical space, manipulation of physiological factors such as sleep, nutrition, etc.) and external aids (e.g., calendars, checklists, etc.; Manly et al. 2002; Wilson and Zangwill 2003). Compensatory techniques can be helpful in managing diverse types of cognitive difficulties, including memory deficits (McDonald et al. 2011 ; Sohlberg and Mateer 2001).
Another method is the use of specialized approaches to teaching and stabilizing new behaviors and knowledge in people with memory difficulties. These include instructional techniques such as errorless learning, in which mistakes are minimized (Wilson et al. 1994), the method of vanishing cues (e.g., Kessels and Haan 2003), and traditional behavioral shaping and training techniques.
Psychosocial support or psychotherapy (e.g., supported listening, brain injury education, relaxation training) can also be an integral part of a rehabilitation program, depending on the needs of the client (Sohlberg and Mateer 2001). For instance, a range of psychological interventions have been shown to be effective in addressing depressive symptoms in long-term rehabilitation after ABI (Stalder-Lüthy et al. 2013). Comprehensive-holistic rehabilitation programs have been found to be efficacious for addressing behavioral and psychosocial disorders following ABI (Cattelani et al. 2010).
Computer programs can be used as an adjunct to CR but should not be the sole form of CR (Cicerone et al. 2005). A recent systematic review highlighted the insufficient evidence of computer-based CR and the critical need for future research in this area (Politis and Norman 2016). A successful rehabilitation program typically involves a combination of interventions, specifically tailored to the individual’s level of disability and personal goals (Manly et al. 2002; Sohlberg and Mateer 2001).
The duration and frequency of CR varies widely (e.g., Geusgens et al. 2007; Kurtz and Nichols 2007). CR has been delivered both on an individual and on a group basis. Significant others (e.g., family) are viewed as an integral part of treatment (Sohlberg and Mateer 2001). Family and caregiver characteristics (e.g., family functioning, caregiver distress, social support) are associated with better community integration following mild/moderate TBI (Sady et al. 2010).
Evidence-based standards of CR are frequently identified as important in advancing the field of CR, both in terms of quality of treatment and for fiscal support at an organizational level (e.g., Sohlberg and Mateer 2001). Cicerone et al. (2000, 2005, 2011) conducted reviews on outcomes of CR for people with TBI or stroke. Across studies, a total of 370 interventions (65 Class I or Ia, 54 Class II, and 251 Class III studies) were reviewed. Interventions were classified as practice standards, practice guidelines, or practice options, based on quality of evidence (see Cicerone et al. 2011 for details).
Although implementation of CR programs frequently results in positive change, a number of methodological problems have been identified in the CR literature, including sample characteristics (e.g., client variability, insufficient information provided, small sample sizes) and treatment characteristics (e.g., variability of settings, insufficient description of interventions, lack of standardized treatment protocols, absence of control conditions).
The results of Cicerone and colleagues’ reviews provide insight into the research support for various CR methods. Specifically, remediation of attention focused on direct attention training and metacognitive training was supported. Strong empirical support was found for visuospatial rehabilitation after right hemisphere stroke (e.g., visual scanning) and interventions for apraxia after left hemisphere stroke (e.g., specific gestural or strategy training). A number of language interventions were shown to have empirical support, including cognitive linguistic therapies, pragmatic conversational skills, and interventions for specific language impairments (e.g., reading comprehension).
Memory strategy training, such as internalized strategies (e.g., visual imagery) and external memory compensations (e.g., notebooks), had strong empirical support for mild memory impairments from TBI. Metacognitive strategy training (e.g., self-monitoring and self-regulation) for deficits in executive functioning after TBI was supported, as was comprehensive-holistic CR programs (which address multiple aspects of impairment).
Although CR has found to be efficacious, there are still limitations. Further guidelines and standards are required to evaluate the quality of methods used in cognitive rehabilitation research in order to inform best practices (e.g., see Cicerone et al. 2009).
There is less empirical study of CR with populations beside TBI and stroke. A Cochrane review reported cognitive training was of limited benefit for dementia, but quality of studies was low to moderate (Bahar-Fuchs et al. 2013). Cognitive remediation in early schizophrenia may improve verbal memory and social cognition (Revell et al. 2015). A review of CR for people with multiple sclerosis suggested some promise for CR, but methodological weaknesses limited conclusions (Mitolo et al. 2015).
Hart and Ehde (2015) recommend that rehabilitation programs should explicitly include targets of the intervention (i.e., the desired outcome), active ingredients of the CR program (i.e., specific aspects of the program that exert the greatest impact on the desired outcome), and finally, the mechanisms by which the outcomes are achieved. Measures should include specific outcome measures related to the construct addressed by the intervention and general measures of functional outcome (i.e., work/school return, interpersonal relationships; Levine and Downey-Lamb 2002). When possible, measures should have established psychometric properties and be completed by both the client and significant others.
Neuropsychological assessment can be a valuable tool at various points to predict outcome, guide appropriate rehabilitation strategies, guide vocational and educational planning, interpret behavior, and help evaluate the extent of injury in conjunction with other information (Bergquist and Malec 2002).
Measurement of transfer of training to everyday life has been measured through assessment of performance on tasks similar to tasks used during training, standardized observations of simulated performance of daily tasks in a laboratory environment, and standardized and non-standardized reports of transfer to daily functioning (Geusgens et al. 2007). There is a need for further development of standardized measures of transfer with good psychometric properties (Geusgens et al. 2007). It has been recommended that generalization should not be “expected” but should be “programmed” throughout the CR program (Sohlberg and Mateer 2001).
Qualifications of Treatment Providers
CR is typically provided by registered psychologists and occupational therapists. Speech and language therapists typically provide rehabilitation for language and communication deficits. Neuropsychologists have a key role in CR, in terms of providing neuropsychological assessment (see above), matching theoretical foundations with practice, and guiding empirically informed practice.
References and Readings
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