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1681

REVIEW ARTICLE

Evidence-Based Cognitive Rehabilitation: Updated Review of


the Literature From 1998 Through 2002
Keith D. Cicerone, PhD, Cynthia Dahlberg, MA, CCC-SLP, James F. Malec, PhD,
Donna M. Langenbahn, PhD, Thomas Felicetti, PhD, Sally Kneipp, PhD, Wendy Ellmo, MS, CCC-SLP,
Kathleen Kalmar, PhD, Joseph T. Giacino, PhD, J. Preston Harley, PhD, Linda Laatsch, PhD,
Philip A. Morse, PhD, Jeanne Catanese, MA, CCC-SLP
ABSTRACT. Cicerone KD, Dahlberg C, Malec JF, Langen- Conclusions: There is substantial evidence to support cog-
bahn DM, Felicetti T, Kneipp S, Ellmo W, Kalmar K, Giacino nitive-linguistic therapies for people with language deficits
JT, Harley JP, Laatsch L, Morse PA, Catanese J. Evidence- after left hemisphere stroke. New evidence supports training
based cognitive rehabilitation: updated review of the literature for apraxia after left hemisphere stroke. The evidence supports
from 1998 through 2002. Arch Phys Med Rehabil 2005;86: visuospatial rehabilitation for deficits associated with visual
1681-92. neglect after right hemisphere stroke. There is substantial ev-
idence to support cognitive rehabilitation for people with TBI,
Objective: To update the previous evidence-based recom- including strategy training for mild memory impairment, strat-
mendations of the Brain Injury Interdisciplinary Special Inter-
egy training for postacute attention deficits, and interventions
est Group of the American Congress of Rehabilitation Medi-
cine for cognitive rehabilitation of people with traumatic brain for functional communication deficits. The overall analysis of
injury (TBI) and stroke, based on a systematic review of the 47 treatment comparisons, based on class I studies included in
literature from 1998 through 2002. the current and previous review, reveals a differential benefit in
Data Sources: PubMed and Infotrieve literature searches favor of cognitive rehabilitation in 37 of 47 (78.7%) compar-
were conducted using the terms attention, awareness, cogni- isons, with no comparison demonstrating a benefit in favor of
tion, communication, executive, language, memory, perception, the alternative treatment condition. Future research should
problem solving, and reasoning combined with each of the move beyond the simple question of whether cognitive reha-
terms rehabilitation, remediation, and training. Reference lists bilitation is effective, and examine the therapy factors and
from identified articles were reviewed and a bibliography list- patient characteristics that optimize the clinical outcomes of
ing 312 articles was compiled. cognitive rehabilitation.
Study Selection: One hundred eighteen articles were ini- Key Words: Brain injuries; Cognition disorders; Practice
tially selected for inclusion. Thirty-one studies were excluded guidelines; Rehabilitation; Stroke.
after detailed review. Excluded articles included 14 studies 2005 by the American Congress of Rehabilitation Medi-
without data, 6 duplicate publications or follow-up studies, 5 cine and the American Academy of Physical Medicine and
nontreatment studies, 4 reviews, and 2 case studies involving Rehabilitation
diagnoses other than TBI or stroke.
Data Extraction: Articles were assigned to 1 of 7 categories
HE BRAIN INJURY interdisciplinary Special Interest
reflecting the primary area of intervention: attention; visual
perception; apraxia; language and communication; memory;
executive functioning, problem solving and awareness; and
T Group (BI-ISIG) of the American Congress of Rehabilita-
tion Medicine (ACRM) previously conducted an evidence-
comprehensive-holistic cognitive rehabilitation. Articles were based review of the literature through 1997 about cognitive
abstracted and levels of evidence determined using specific rehabilitation for people with traumatic brain injury (TBI) or
criteria. stroke.1 That review led the BI-ISIG to make several specific
Data Synthesis: Of the 87 studies evaluated, 17 were rated recommendations concerning the clinical practice of cognitive
as class I, 8 as class II, and 62 as class III. Evidence within each rehabilitation and its effectiveness in TBI and stroke patients.
area of intervention was synthesized and recommendations for Since publication of our initial findings, several additional
practice standards, practice guidelines, and practice options systematic reviews of cognitive rehabilitation have been pub-
were made. lished. A task force under the auspices of the European Fed-
eration 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 evi-
dence to support attention training in the postacute phase after
From JFK-Johnson Rehabilitation Institute, Edison, NJ (Cicerone, Kalmar, Ellmo, TBI (but not during the period of acute recovery) and compen-
Giacino, Catanese); Craig Hospital, Englewood, CO (Dahlberg); Rusk Institute of
Rehabilitation Medicine, New York, NY (Langenbahn); Mayo Medical Center and
satory memory training for subjects with mild memory impair-
Medical School, Rochester, MN (Malec); Beechwood Rehabilitation Services, Lang- ments. Evidence of the effectiveness of pragmatic conversa-
horne, PA (Felicetti); Marianjoy RehabLink, Wheaton, IL (Harley); Community tional therapy after TBI was based on a limited number of
Skills Program, Counseling and Rehabilitation Inc, Marlton, NJ (Kneipp); University studies with small samples, and was in need of confirmation.
of Illinois, Chicago, IL (Laatsch); and Neurobehavioral Services of New England,
Portland, ME (Morse).
Several methods of rehabilitation for spatial neglect were found
No commercial party having a direct financial interest in the results of the research to be effective, as was the treatment of apraxia with compen-
supporting this article has or will confer a benefit upon the authors or upon any satory strategies. As part of a broader effort by the Academy of
organization with which the authors are associated. Neurologic Communication Disorders and Sciences to develop
Reprint requests to Keith D. Cicerone, JFK-Johnson Rehabilitation Institute, 2048
Oak Tree Rd, Edison, NJ 08820, e-mail: kcicerone@solarishs.org.
practice guidelines for treating cognitive-communication dis-
0003-9993/05/8608-9612$30.00/0 orders after TBI, Sohlberg et al3 examined the evidence for the
doi:10.1016/j.apmr.2005.03.024 effectiveness of direct attention training after TBI. They con-

Arch Phys Med Rehabil Vol 86, August 2005


1682 UPDATE ON COGNITIVE REHABILITATION, Cicerone

cluded that there was evidence of improvement in attention- RCTs published before 1998 that were not included in our first
based skills with direct training, although the interpretation of review, but not other studies. Two such articles were identified
studies was limited by factors such as subject heterogeneity and and included in this review. This resulted in the identification
the lack of replications. Two Cochrane reviews have examined of 312 articles. The abstracts or complete articles were re-
cognitive rehabilitation for attention deficits4 or memory defi- viewed to eliminate articles according to the following exclu-
cits5 after stroke, but only class I studies were included. Lin- sion criteria: (1) articles not addressing intervention, (2) theo-
coln et al4 concluded there was some evidence that training retical articles or descriptions of treatment approaches, (3)
improves alertness and sustained attention but insufficient ev- review articles, (4) articles without adequate specification of
idence of improved functional independence after stroke. Ma- interventions, (5) articles that did not include participants pri-
jid et al5 identified a single study that met their criteria for marily with a diagnosis of TBI or stroke, (6) studies of pedi-
inclusion and found insufficient evidence to support or refute atric subjects, (7) single-case reports without empirical data,
the effectiveness of cognitive rehabilitation for memory prob- (8) nonpeer-reviewed articles and book chapters, (9) articles
lems after stroke. describing pharmacologic interventions, and (10) articles not
Several systematic reviews6-8 found evidence that cognitive written in English. One hundred eighteen articles were in-
rehabilitation, including visual scanning training, improves cluded this screening process. Thirty-one studies were ex-
spatial neglect after right hemisphere stroke, but also found that cluded after further detailed review (14 studies without data, 6
there is limited or insufficient evidence for the duration of articles representing duplicate publications or follow-up stud-
treatment effects or relevance to everyday functioning.6,8 Sys- ies, 5 articles that were nontreatment studies or experimental
tematic reviews of treatment for aphasia have reached conflict- manipulations, 4 reviews, and 2 single-case studies of subjects
ing conclusions. Robey9 conducted a meta-analytic review of with diagnoses other than TBI or stroke). Studies providing
55 studies of clinical outcomes after aphasia rehabilitation. follow-up to previously reviewed treatment studies were not
These were generally observational studies, rather than ran- fully evaluated or classified as new treatment studies, but
domized controlled trials (RCTs). Outcomes for treated sub- findings from these studies were reviewed and are discussed
jects were superior to outcomes for untreated subjects in all here when appropriate.
stages of recovery, particularly when treatment was begun in Eighty-seven studies were fully reviewed and evaluated,
the acute stage of recovery, and the extent of treatment effects with the level of evidence determined based on criteria used in
was positively associated with the amount of treatment. There our prior review.1 Well-designed, prospective RCTs were con-
were too few studies to permit an examination of the differen- sidered class I evidence; studies using a prospective design
tial effects of treatments for different types of aphasia. Cappa with quasirandomized assignment to treatment conditions
et al2 found some evidence for the effectiveness of aphasia were designated as class Ia studies. Given the inherent diffi-
therapy, again based largely on class II and III studies. In culty in blinding rehabilitation interventions, we did not con-
contrast, a Cochrane review10 of aphasia rehabilitation identi- sider this as criterion for class I or Ia studies. Class II studies
fied only 12 RCTs suitable for the authors review, none of consisted of prospective, nonrandomized cohort studies; retro-
which were considered of adequate methodologic quality to spective, nonrandomized case-control studies; or multiple-
warrant complete description and analysis. The main conclu- baseline studies that permitted a direct comparison of treatment
sion reached in that review was that aphasia therapy after conditions. Clinical series without concurrent controls, or sin-
stroke has not been shown to be clearly effective or ineffective gle-subject designs with adequate quantification and analysis
within an RCT. were considered class III evidence. Articles were reviewed and
These systematic reviews have generally found some evi- classified by at least 2 committee members. Disagreements
dence to support the effectiveness of cognitive rehabilitation between the 2 primary reviewers (as happened with 7 articles)
after TBI or stroke, but have also recognized the need for better were first addressed by discussion between reviewers to correct
specification of treatment effects and increased methodologic minor sources of disagreement, ant then by obtaining a third
rigor, and have sometimes limited their conclusions on these review.
grounds. We recognize that clinical guideline development is Of the 87 studies, 17 were rated as class I, 8 as class II, and
an ongoing process that should include an updated review of 62 as class III. The overall evidence within each predefined
the literature within 5 years of the initial recommendations. area of intervention was synthesized and recommendations
The BI-ISIG recently completed an updated evidence-based were derived from the relative strengths of the evidence. The
review and made recommendations that incorporate the litera- level of evidence required to determine practice standards,
ture published from 1998 through 2002. This article summa- practice guidelines, or practice options was based on the
rizes those findings and recommendations. In this article, we decision rules applied in our initial review (appendix 1). All
concentrate on describing class I studies. Class II and III recommendations were reviewed by the entire committee to
studies are discussed when they provide unique or contradic- ensure consensus.
tory information. A more complete discussion of these studies
is in the full report of the BI-ISIG committee (online at http:// Remediation of Attention Deficits
www.acrm.org). We identified 5 studies on remediation of attention deficits
after TBI. Two were class I prospective randomized stud-
METHODS ies11,12 comparing attention treatment with alternative treat-
We followed prior methodology for identifying relevant ments; 1 was a class II study13 that compared attention treat-
literature, reviewing, and classifying, and developing recom- ment with no treatment; and 2 were class III studies.14,15
mendations. These methods are described in more detail in our Sohlberg et al11 used a crossover design to compare the
initial publication.1 For the current review, we searched effectiveness of attention process training (APT) brain injury
PubMed and Infotrieve for articles published between 1998 and education and support for 14 patients with acquired brain
2002, using the terms attention, awareness, cognitive, commu- injury. Self-reported changes in attention and memory func-
nication, executive, language, memory, perception, problem tioning, as well as improvement on neuropsychologic measures
solving, and reasoning combined with each of the terms reha- of attention-executive functioning, were greater after APT than
bilitation, remediation, and training. We elected to include after therapeutic support. The second class I study12 taught 22

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UPDATE ON COGNITIVE REHABILITATION, Cicerone 1683

patients with severe TBI to compensate for slowed information resulted in significant enlargement of the visual field in 95% of
processing and the experience of information overload in the subjects, which remained stable 2 years later.29
daily tasks. Participants were randomly assigned to receive One class II22 and 1 class III25 study replicated class I
either time pressure management (TPM) or an alternative treat- demonstrations that visual scanning is an effective treatment
ment of generic concentration training. Participants receiving for visual neglect. Additional class II20 and class III23,24,26,27
TPM showed significantly greater use of self-management studies introduced forced activation of the affected limb in
strategies and greater improvement of attention and memory conjunction with visual scanning training as a treatment for
functioning than did participants who received the alternative visual, and possibly sensory, neglect.
treatment. Clinical recommendations. Two class I18 or Ia19 studies of
Although the precise nature of the interventions in these 2 41 subjects with cerebral stroke replicated the effectiveness of
class I studies differ, they share a common emphasis on the visual scanning in treating unilateral neglect, consistent with
development of strategies to compensate for residual cognitive the 6 class I studies involving 286 subjects from our prior
deficits (strategy training) rather than attempting to directly review.1 These class I studies demonstrating the efficacy of
restore the underlying impaired function (restitution train- visual scanning training for visual neglect strongly support that
ing). The results of these 2 studies and of an additional small this type of intervention as a practice standard. Inclusion of
class II study13 are therefore consistent with a strategy training limb activation or electronic technologies for visual scanning
model for attention deficits after TBI, and reinforce the con- training is recommended as a new practice option, pending
clusions made in our initial review.1 confirmation of efficacy through more rigorous investigation.
Clinical recommendations. In the current review, there is A class I study17 provided evidence that computer-based
evidence from 2 class I studies11,12 with 36 subjects that restitution training can reduce the extent of damaged visual
supports the effectiveness of attention training for subjects with fields due to postchiasmal lesions, and produce subjective
TBI during the postacute period of rehabilitation. Considering improvements in visual functioning. We previously noted1 that
this evidence, along with our previous recommendation based the observed reductions in visual field defects were insufficient
on 2 class I studies with 57 subjects,1 the committee recom- to explain the associated reduction in functional impairments,
mends that strategy training for attention deficits exhibited by and that functional improvement was associated with increased
subjects with TBI be considered as a practice standard during compensation rather than change in the underlying visual field
the postacute period of rehabilitation. Results of studies in this deficit. We recommend that interventions intended to reduce
area suggest greater benefits on complex tasks requiring the the extent of damaged visual fields be considered a practice
regulation of attention, rather than on basic aspects of attention option, pending replication by independent investigators.
(eg, reaction time or vigilance). These results are consistent Recommendations for future research. Class I studies
with the emphasis on strategy training to compensate for at- verifying the usefulness of technologies that might increase the
tention deficits in functional situations. There is insufficient availability of visual scanning treatment, such as computer
evidence to support the use of specific interventions for atten- projection22 and the Useful Field of View test25 introduced in
tion deficits during acute rehabilitation. class II and III studies, should be conducted. Class II and III
Recommendations for future research. Evidence from 1 studies demonstrating positive results for limb activation in
class I study11 suggests that cognitive remediation has differ- conjunction with visual scanning treatment for neglect merit
ential effects on various components of attention; therefore, verification through class I research.
more research is needed to clarify the differential effects of The evidence that visual restitution training may actually
interventions. The finding that cognitive interventions influ- result in regeneration of the visual fields makes it increasingly
ence the regulation of attention can be contrasted with phar- difficult to dismiss this possibility, even though it runs counter
macologic treatment, which may exert its primary effect on to conventional neurologic wisdom. This method merits further
basic processing speed.16 This suggests that a combination of independent and rigorous investigation in other centers. Such
cognitive and pharmacologic interventions may produce the studies should attempt to differentiate between the contribution
greatest overall improvement in attention deficits after TBI, of visual restitution training intended to have an impact directly
although this has not been evaluated through controlled on visual field restrictions and the contribution of compensa-
research. tory mechanisms (eg, improved scanning) to improved
functioning.
Remediation of Visuospatial Deficits Prospective, controlled (class I) studies of interventions to
We reviewed 11 studies in the area of rehabilitation of improve more complex visuospatial abilities required for func-
visuoperceptual deficits. The majority of these involved reha- tional activities (eg, meal preparation, driving) are recom-
bilitation of unilateral visual neglect, and 1 involved the resti- mended. Such interventions were explored through class II and
tution of visual fields. The 13 studies included 3 class I17,18 or III studies with positive results in our previous review, but
Ia19 studies, 3 class II studies,20-22 and 5 class III studies.23-27 further investigation of such interventions is noticeably absent
Two class I or Ia studies involved the rehabilitation of visual in this update.
neglect after stroke. The class Ia study19 was a prospective
controlled trial that replicated a prior class II study.28 Training Remediation of Apraxia
for neglect produced improvement on standard neglect tests There was a new area of focus with 2 class I30 or Ia31 studies
and a functional measure evaluating generalization, compared of rehabilitation for apraxia. Apraxia, the inability to do learned
with general cognitive stimulation. Niemeier18 found system- and purposeful activities such as dressing, can result in self-
atic cueing of visual scanning to be superior to conventional care deficits and dependence on caregivers. Smania et al31
rehabilitation (which did not produce improvement). compared the effectiveness of gestural training and object use
Kasten et al17 examined computer-based treatment of partial in 13 subjects with limb apraxia after left hemisphere stroke
blindness resulting from optic nerve damage or postchiasmal with conventional aphasia therapy. Despite an equal amount of
lesions. The training was intended to restore the underlying treatment, the group receiving conventional therapies showed
neurologic and visual functions and reduce the extent of the no improvement, while the apraxia treatment produced im-
damaged visual fields (ie, restitution training). The training provement in both ideational and ideomotor apraxia. Donker-

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1684 UPDATE ON COGNITIVE REHABILITATION, Cicerone

voort et al30 conducted a multisite study of subjects with able to communicate in personally relevant situations. To con-
apraxia from left hemisphere stroke. Subjects were randomized trol for the effect of social contact, the control subjects partic-
to receive either strategy training integrated into occupa- ipated in social activities (eg, movement classes, church activ-
tional therapy (OT) or conventional OT. The main principle of ities) while their group communication treatment was deferred.
the strategy training program was the use of internal or external Participants who received the group communication treatment
compensations for the apraxic impairment during the perfor- showed significantly more improvement in functional commu-
mance of activities of daily living (ADLs).32 The emphasis of nication. In an effort to evaluate a cost-effective and functional
conventional treatment was on sensorimotor impairments. Dur- treatment program, Worrall and Yiu36 compared a home-based,
ing the first 8 weeks of their inpatient stay, all subjects received functional communication program provided by trained volun-
15 to 19 hours of treatment, with no difference in the amount teers with non-language-based recreational treatment and no
of treatment provided in the 2 conditions. Strategy training was
treatment conditions, for people with chronic aphasia. Be-
more effective in improving ADL function than the conven-
tional OT at the conclusion of the 8 weeks of training. At tween-group comparisons revealed significant improvement
5-month follow-up, there were no differences between the 2 from the functional communication program compared with no
groups; apparently because of the continued improvement in treatment, but not compared with recreational activities.
the subjects who had received (and in some cases were still There is evidence supporting the use of cuing techniques and
receiving) conventional treatment. The investigators suggested semantic analysis to improve naming ability by people with
that patients receiving conventional therapy needed more ther- aphasia and TBI,43,44,46,52,53,56,57,65,69,71 to improve writing
apy to improve their ADL functioning. skills in patients with chronic aphasia,46-51,61,67,68 and to im-
Clinical recommendations. Two class I30 or class Ia31 prove sentence production in patients with agrammatic apha-
studies of 126 subjects with left hemisphere stroke provide sia.39,59,64,70 These studies, along with the studies from the last
evidence that apraxia can be treated effectively and may facil- review,1 support the efficacy of treating naming disorders in
itate improvement in functional ADLs during the initial period people with chronic aphasia, but there is still no clear evidence
of inpatient rehabilitation, compared with conventional senso- that one method is more effective than another.
rimotor or aphasia therapies. Specific gestural or strategy train- A class III study by Wiseman-Hakes et al41 supported the
ing for apraxia after left hemisphere stroke is therefore recom- effectiveness of group treatment to improve pragmatic com-
mended as a new practice standard during acute rehabilitation. munication skills for 6 subjects with TBI. However, 1 class III
single-subject study42 failed to demonstrate the effectiveness of
Remediation of Language and Communication Deficits pragmatic training, primarily because of the limited contextual
The remediation of neurogenic communication disorders is aspects of the treatment.
an active area of research, with 40 studies identified in the Clinical recommendations. The results from 3 class I stud-
current review that addressed a range of language-related im- ies33-35 of treatment of language deficits in 58 subjects after left
pairments. There were 3 class I studies,33-35 1 class Ia study,36 hemisphere stroke are consistent with the results from 3 class
1 class II study,37 and 35 class III studies.38-72 Most of this I studies with 169 subjects from our prior review,1 and provide
research involved subjects with left hemisphere stroke (35 additional support for the practice standard recommending
articles with a total of 253 stroke subjects). Three studies in cognitive linguistic therapies during acute and postacute reha-
which the subjects were primarily people with stroke also bilitation for such subjects. There is evidence that group com-
included subjects with TBI.38-40 There were also 4 single- munication treatment can produce clinically meaningful im-
subject studies of people with TBI.42-45 There was 1 study41 of provements in language functioning, including improved
6 subjects with TBI for a total of 16 subjects with TBI in 8 functional communication, beyond the effects of social contact
research articles during this review period. alone.34,41
Denes et al33 evaluated the effect of intensity of treatment for Two class I studies with 34 subjects33,35 and 3 class III
17 subjects with global aphasia at an average of 3 months studies40,43,46 with 44 subjects support the concept that in-
postonset, using a functional stimulation approach to therapy. creased intensity of treatment for subjects with aphasia results
More subjects with intensive treatment reached significant im- in improved communication skills. We recommend that treat-
provement in all language modalities. This concept was sup- ment intensity be considered as a key factor in the rehabilita-
ported by 3 class III articles reporting improved functional tion of language skills after left hemisphere stroke, as a new
communication after chronic stroke46 and improved naming practice guideline.
ability of subjects with stroke or TBI40,43 with increased inten- Several class III studies provide additional support for the
sity of treatment. Constraint-induced movement therapy established practice guideline that interventions for specific
(CIMT) to improve language skills after left hemisphere stroke language impairments, such as reading comprehension and
was evaluated in a class I study of 17 subjects with chronic language formulation, are effective after left hemisphere stroke
aphasia.35 CIMT was described as massed practice of verbal or TBI.
responses that was designed to constrain patients to the sys- Two class III studies53,65 suggest that independent computer
tematic practice of speech acts with which they had difficulty. use may serve as an adjunct to clinician-directed treatment of
The results demonstrated significant benefit of CIMT compared word retrieval. Based on these findings, the committee recom-
with conventional aphasia therapy. mends as a practice option that computer-based interventions
Elman and Bernstein-Ellis34 evaluated the effectiveness of be considered as an adjunct to treatment when there is therapist
group communication treatment after left hemisphere stroke. involvement; sole reliance on repeated exposure and practice
All participants were at least 6 months postinjury and were on computer-based tasks without some involvement and inter-
stratified according to their initial aphasia severity. They were vention by a therapist is not recommended.
randomly assigned to receive either group communication Recommendations for future research. Given the overall
treatment or deferred treatment. Group communication treat- evidence to support the effectiveness of language interventions
ment focused on initiating conversations and conveying a mes- after left hemisphere stroke, additional research should be
sage, understanding the communication disorder, being aware directed at specific parameters of treatment related to effective-
of personal goals and progress, and having confidence in being ness. Several studies suggest that more intense treatment, in-

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UPDATE ON COGNITIVE REHABILITATION, Cicerone 1685

cluding massed practice, produces significant benefits; this area sation for memory impairments using assistive technology (eg,
merits further controlled investigation. voice organizers).84,85,89
Several studies from this and our prior review suggest that Clinical recommendations. Two class I studies77,78 with
intervention provided in the home or community by trained 41 participants demonstrated the effectiveness of memory strat-
volunteers can improve language functioning.36,73,74 We iden- egies for subjects with mild memory impairments after TBI or
tified several additional studies that addressed training for stroke, including reducing memory failures. These findings are
volunteers75 or caretakers76 to support the conversation of consistent with the previous 4 class I studies1 with 91 subjects
partners with aphasia; however, we excluded those studied and support the use of strategy training for subjects with mild
from formal review because they did not directly treat the memory impairment as a practice standard. These interventions
people with aphasia. This may represent a valuable adjunct or may consist of internal strategies (eg, visual imagery) as well
alternative to traditional treatments, particularly for chronic as compensation through the use of notebooks or diaries. The
aphasia, that merits further controlled investigation. benefits of specific intervention strategies may be evident in
There remains a compelling need for controlled studies of discrete aspects of memory performance, for example, visual
interventions to improve pragmatic communication in people imagery to facilitate verbal recall.77 There is evidence that the
with TBI. incorporation of self-management techniques enhances the use,
maintenance, and perceived helpfulness of a memory note-
Remediation of Memory Deficits book.78 There is also evidence that interventions to promote the
Studies of the remediation of memory deficits have contin- use of external memory aids can benefit people with TBI who
ued to address the use of compensatory strategies, as well as a are many years postinjury.78
growing interest in evaluating the application of assistive tech- The use of externally directed assistive devices such as
nology. We reviewed 13 studies in this area, including 3 class pagers and voice organizers appears to benefit people with
I77,78 or Ia79 studies, 2 class II studies,80,81 and 8 class III moderate to severe memory impairments, including evidence
studies.82-89 from 1 class Ia79 study that included subjects for whom previ-
Two class I studies77,78 addressed the effectiveness of train- ous interventions were ineffective. These interventions facili-
ing strategies in memory rehabilitation. Kaschel et al77 evalu- tate completion of everyday activities that subjects have self-
ated the use of a simple visual imagery technique for the identified as relevant. The use of external memory aids and
rehabilitation of participants with mild memory impairment assistive devices may require extensive training,1 or may need
after acquired brain injury. Visual imagery was compared with to remain under the direction of someone other than the person
the standard approach to memory treatment in 7 different with memory impairment.79,86 As with our previous recom-
rehabilitation centers (eg, practical guidelines to improve mem- mendation on the use of interventions directed at the acquisi-
ory, use of notebooks and calendars). Both the visual imagery tion of specific skills, these interventions appear effective for
and standard conditions were preceded by 3 months of no- increasing specific behaviors rather than improving memory
treatment baseline; this was followed by memory training for function. Based on current evidence and in conjunction with
30 sessions over 10 weeks, with follow-up assessment 3 the evidence from our previous review, training in the use of
months later. Significant improvement was apparent for the external compensations (including assistive technology) with
imagery condition, and was restricted to the therapeutic inter- direct application to functional activities is recommended as a
val and recall of verbal material, consistent with predictions. practice guideline in subjects with moderate or severe memory
The improvements associated with visual imagery training impairment after TBI or stroke.
were paralleled by positive changes in relatives ratings of Recommendations for future research. Findings from 1
patients memory functioning and were maintained at 3-month class I study77 are notable for suggesting that a specific inter-
follow-up. vention has a differential impact on different aspects of mem-
Ownsworth and McFarland78 investigated the remediation of ory functioning. This finding requires replication. The effec-
everyday memory impairment using a diary combined with tiveness of various assistive technologies to compensate for
self-instructional training. The addition of the self-management severe memory impairment should be investigated through
strategy to diary use was associated with better maintenance of additional prospective, controlled studies.
strategy use and greater decline in memory problems. The
results are consistent with a previous single-subject study90 and Remediation of Executive Functioning, Problem-Solving,
also suggest that some forms of compensatory strategy training and Awareness
may be beneficial to patients who are many years postinjury. The area of executive functioning includes several integra-
These class I studies from this review are consistent with the tive cognitive processes by which people monitor, manage, and
conclusions from our prior review, indicating that compensa- regulate the orderly execution of goal-directed ADLs. We
tory memory strategy training is effective for patients with reviewed 9 studies concerned with executive functioning, prob-
relatively mild memory impairment. lem solving, and awareness, including 1 class I study,92 1 class
One class Ia study79 extended the results of a previous class Ia study,93 and 7 class III studies.94-100
II study91 investigating the effectiveness of a portable pager The class I study92 evaluated the effectiveness of a problem-
(NeuroPage) to improve independence in people with memory solving intervention, goal management training (GMT), on
and planning problems. During the intervention period, the successful task completion. Participants received either 1 hour
pager was used to address specific problems in daily function- of GMT or 1 hour of motor skills training. GMT was associated
ing that were identified by patients or relatives. Significant with improved performance on paper-and-pencil measures in-
improvements in participants completion of everyday tasks tended to simulate everyday activities. The fact that the entire
resulted, compared with no-treatment and baseline conditions. treatment in this trial was limited to a single hour of instruction
Use of a pager appears to be particularly beneficial for people limits the translation of these findings in terms of the clinical
who must complete certain tasks on a regular basis, and is application and effectiveness of the intervention.
facilitated by its ease of use and relevance to patients self- One class Ia study addressed the internalization of self-
identified needs.87 Five additional class III studies84-86,88,89 regulation strategies. Medd and Tate93 examined the effective-
investigated the application of some form of external compen- ness of a cognitive-behavioral program of anger management

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1686 UPDATE ON COGNITIVE REHABILITATION, Cicerone

that involved self-awareness and self-instructional training. Comprehensive-Holistic Cognitive Rehabilitation


Efforts were made to increase participants awareness of anger In comprehensive-holistic cognitive rehabilitation, we in-
via training to recognize their cognitive, physical, and emo- cluded studies that investigated interventions directed at mul-
tional reactions. Results showed a significant decrease in the tiple aspects of dysfunction, often addressing a combination of
outward expression of anger for the treatment group compared cognitive, emotional, motivational, and interpersonal impair-
with controls, suggesting improved emotional self-regulation ments, in the context of an integrated and programmatic treat-
as a result of treatment. One class III study95 evaluated a group ment approach. We reviewed 1 class I,102 1 class II,103 and 5
treatment program developed to enhance self-regulation skills class III studies104-108 of comprehensive-holistic programs of
and self-awareness in 21 patients with acquired brain injury. cognitive rehabilitation. The class I study by Salazar et al102
After treatment, participants reported greater awareness of def- evaluated the efficacy of cognitive rehabilitation for 120 people
icits and increased use and effectiveness of strategies in their with moderate to severe TBI within a single, military medical
daily life. referral center. Of 273 consecutively hospitalized patients, 120
In the Medd and Tate study,93 there was no change in patients met eligibility criteria and participated in the study.
participants awareness of anger problems with the treatment. They were, on average, about 38 days postinjury. Patients were
Three class III case studies specifically addressed techniques randomly assigned to receive either multidisciplinary, in-hos-
for improving awareness by promoting internal control of pital cognitive rehabilitation109 or a limited home program110
behavior: one via self-monitoring techniques96 and the others consisting of individual education and encouragement from a
using observer feedback and self-evaluation.97,98 Several of psychiatric nurse. Return to work rates were 90% for the
these studies suggest that behavioral improvement is not con- cognitive rehabilitation group and 94% for the home group; the
tingent on increased self-awareness.93,99,100 authors noted these extraordinarily high return-to-work rates
Clinical recommendations. One class I study with 30 par- and suggested that participants high preinjury education and
ticipants supports the effectiveness of interventions for prob- level of functioning, significant degree of spontaneous recov-
lem-solving deficits,92 although the direct application to clini- ery, and ready availability of (military) employment after in-
cal practice is constrained by the limited extent of the jury might have limited the ability to detect any differential
intervention. A class III study95 demonstrated improved strat- benefits from the cognitive rehabilitation program. A subgroup
egy application and psychosocial functioning after training in analysis of 75 participants with more severe injuries (those
problem solving. These findings are consistent with a class Ia unconscious for 1h) showed a significant benefit from the
study with 37 participants from our prior review,1 and reinforce cognitive rehabilitation program. While this study does not
the practice guideline recommending the training of formal provide strong support for comprehensive-holistic cognitive
problem-solving strategies and their application to everyday rehabilitation, the significant subject selection bias and re-
stricted setting markedly limit the ability to generalize these
situations and functional activities of people with TBI.
findings to most areas of rehabilitation practice.
Our previous review recommended that cognitive interven- A principle contribution of the class III studies is their
tions that promote internalization of self-regulation strategies relevance to understanding the impact of comprehensive-holis-
through self-instruction and self-monitoring, be considered a tic cognitive rehabilitation on social participation and commu-
practice option for the remediation of deficits in executive nity integration after TBI. Four studies104-107 with a total of 270
functioning.1 Two class III studies94,95 support this recommen- patients evaluated programs based on the principles of neuro-
dation and 1 class Ia study93 suggests that these techniques may psychologic rehabilitation. Most of the participants were peo-
be used to improve emotional self-regulation in patients with ple with severe TBI who had received clinical treatment for at
TBI. In addition, 3 class I studies indicate that self-instructional least 3 months-in many cases, several years-after injury. Be-
training is an effective component of interventions for the tween 39%104 and 62%107of patients were engaged in commu-
remediation of deficits in attention,12 visual neglect,18 or nity-based employment after treatment, and 49% made clini-
memory.78 cally significant gains in community integration.106
The effectiveness of interventions directed at patients poor Clinical recommendations. The single class I study102 of
awareness of deficits has been addressed by 1 class Ia study93 120 subjects with TBI did not provide support for comprehen-
and 6 class III studies.95-100 Given the small number of uncon- sive cognitive rehabilitation compared with basic education
trolled studies and inconsistency of methods and results in this and reassurance in the early stages of recovery from TBI;
area, there is insufficient evidence to make specific recommen- patients with more severe injuries, however, did show greater
dations regarding interventions to improve self-awareness after benefit with the more intense, structured treatment program.
TBI or stroke. However, the ability to generalize from the results of this study
Recommendations for future research. Future studies is severely constrained by the restricted nature of the popula-
tion, unique (military) setting, and limited course of treatment.
may incorporate treatment for problems of emotional control
Four class III studies104-107 with 265 subjects support the
and psychosocial skills, particularly as these reflect compo- clinical effectiveness of comprehensive-holistic programs of
nents of problem-solving and self-regulation interventions. The cognitive rehabilitation for improving community integra-
effectiveness of interventions that attempt to promote the in- tion, social participation, and productivity after TBI or
ternalization of strategies needs to be addressed through pro- stroke. There is also evidence that gains in community
spective, controlled studies. Our previous review noted the functioning can be achieved by patients 1 or more years
potential use of external strategies for the rehabilitation of postinjury,106 and that gains from treatment are maintained
executive problems,101 and this approach might have promise for several years after rehabilitation.105,111,112 These studies
in the treatment of patients with marked difficulties in their support our previous conclusion1 that treatment in postacute
planning and organization of everyday activities.79 Despite the programs of comprehensive-holistic cognitive rehabilitation
importance that is commonly attributed to awareness as a is recommended as a practice guideline in treating people
mediator of rehabilitation outcomes, there continue to be few with moderate to severe TBI. The integration of cognitive
studies of interventions in this area. and interpersonal interventions is characteristic of compre-

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UPDATE ON COGNITIVE REHABILITATION, Cicerone 1687

Table 1: Differential Treatment Effects of Cognitive Rehabilitation We defined conventional rehabilitation as the provision of
(CR) Compared With Alternative Treatment or Control Conditions
Based on All Class I Studies
standard physical, OT, and/or speech therapy in accordance
with routine procedures in a traditional rehabilitation set-
Percentage of ting. We defined pseudotreatment as providing participants
Comparisons
Showing with mental or social stimulation without specific therapeu-
Differential tic intent (eg, recreational computing, leisure activities, re-
Nature of Treatment No. of No. of Benefit in Favor petitive mental exercises). Psychosocial interventions were
Comparison Comparisons Patients of CR
defined as individual or group psychotherapy or emotional
CR vs other cognitive or support. Studies that compared different types of specific
psychosocial treatment 10 290 60.0 cognitive interventions (eg, attention training compared
CR vs pseudotreatment 15 582 66.7 with memory training) were considered to provide an alter-
CR vs conventional rehabil 14 587 92.9 native cognitive intervention in comparison with the inter-
CR vs no treatment 8 342 100.0 vention under investigation. We relied on the original au-
Total 47 1801 78.7 thors 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
hensive-holistic cognitive rehabilitation programs. There is used only studies that reported direct statistical comparisons
also evidence that psychosocial interventions may facilitate between treatments in this analysis. For studies that com-
the effectiveness of treatments directed at specific cognitive pared cognitive rehabilitation with more than 1 alternative
impairments after TBI11 or stroke.64 These findings are treatment, cognitive rehabilitation was compared separately
consistent with our prior recommendation that the integra- with each of the alternatives. For the purpose of this anal-
tion of individualized cognitive and interpersonal therapies ysis, we collapsed studies using psychosocial or other
be considered a practice option. cognitive interventions as the alternative treatment. This
Recommendations for future research. There is a particu- resulted in the comparison of 47 treatment conditions, rep-
lar need in this area to confirm the positive findings from class III resenting 1801 patients (table 1).
studies using controlled trials. This might best be addressed It is clear that cognitive rehabilitation provides clinical
through practical clinical trials that select clinically relevant, al- benefits, compared with not receiving any treatment, and
ternative interventions for comparison, represent a diverse popu- substantial benefits compared with conventional rehabilita-
lation of study participants, and use a broad range of relevant tion. Cognitive rehabilitation produced greater improvement
health outcomes.113 The continued use of observational methods than pseudotreatment, psychosocial treatment, or an alter-
is also encouraged, particularly to identify the types of patients native cognitive intervention in about two thirds (64%) of
who are most appropriate for, and likely to benefit from, compre- the study comparisons. Overall, cognitive remediation re-
hensive-integrated cognitive rehabilitation.114 sulted in a significant benefit compared with the alternative
condition in about 79% of all treatment comparisons (see
Comparison of Cognitive Rehabilitation and Alternative table 1). There were 22 treatment comparisons involving
Interventions 616 patients primarily with TBI. In those studies, 18 of the
The question of effectiveness of cognitive rehabilitation 22 (81.8%) comparisons demonstrated a differential benefit
must be answered in relation to available alternative treat- in favor of cognitive remediation. Among the 25 treatment
ments. For each of the 46 class I studies included in this and comparisons involving 1185 patients primarily with stroke,
our prior review, we examined the nature of the alternative 19 (76%) demonstrated a differential benefit favoring cog-
treatment conditions and classified them as no treatment, nitive remediation. In no case was there evidence that the
conventional rehabilitation, pseudotreatment, a psychoso- alternative condition was superior to cognitive rehabilita-
cial intervention, or an alternative cognitive intervention. tion.

Table 2: Evidence-Based Recommendations for Cognitive Rehabilitation: Practice Standards


Intervention Recommendations

Visuospatial rehabilitation Recommended for persons with visuoperceptual deficits associated with visual
neglect after right hemisphere stroke
Cognitive-linguistic therapies Recommended during acute and postacute rehabilitation for persons with language
deficits secondary to left hemisphere stroke
Specific interventions for functional Recommended for persons with TBI
communication deficits, including pragmatic
conversational skills
Specific gestural or strategy training for apraxia Recommended for persons with apraxia after left hemisphere stroke during acute
rehabilitation
Memory strategy training Recommended 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 deficits Recommended 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.

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1688 UPDATE ON COGNITIVE REHABILITATION, Cicerone

Table 3: Evidence-Based Recommendations for Cognitive Rehabilitation: Practice Guidelines


Intervention Recommendations

Scanning training Recommended 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 Recommended after left hemisphere stroke or TBI
impairments such as reading comprehension and
language formulation
Treatment intensity Should be considered as a key factor in the rehabilitation of language
skills after left hemisphere stroke
Use of external compensations with direct application Recommended for persons with severe memory impairment after TBI
to functional activities or stroke
Training in formal problem-solving strategies and their Recommended during postacute rehabilitation for persons with stroke
application to everyday situations and functional or TBI
activities
Comprehensive-holistic neuropsychologic rehabilitation Recommended 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 NOT recommended; does not appear effective
neglect

DISCUSSION compensatory strategies to improve attention during the post-


This updated review of the literature regarding cognitive acute period of rehabilitation. Two class I studies support the
rehabilitation included 17 class I studies of 291 patients with use of memory strategy training, including the development of
TBI and 247 patients with stroke, with 16 of the 17 studies internalized strategies77 and use of a memory notebook or
providing evidence for the effectiveness of cognitive rehabili- diary,78 for patients with mild memory deficits resulting from
tation. Five class I studies provide evidence for the effective- TBI. An additional class I study79 indicated that an external
ness of remediation for visual inattention17-19 or apraxia30,31 in cueing system may benefit patients with persistent, severe
patients with stroke, and 4 studies support the effectiveness of impairments of memory and planning as a result of TBI or
interventions for communication deficits after stroke.33-36 One stroke. A class I study92 supports the use of interventions to
of these studies36 supported the use of volunteers to improve improve problem-solving abilities. An additional class Ia
communication skills after chronic aphasia, compared with no study93 suggests that treatment to improve emotional self-
treatment, but failed to demonstrate benefits when compared regulation may benefit TBI patients; this study contributes to
with social recreation. the evidence supporting the internalization of self-regulatory
Among studies addressing the remediation of cognitive im- strategies after TBI. The studies that have demonstrated effec-
pairments after TBI, 2 class I studies11,12 support the training of tive rehabilitation of attention, memory, and executive func-

Table 4: Evidence-Based Recommendations for Cognitive Rehabilitation: Practice Options


Intervention Recommendations

Systematic training of visuospatial and organizational skills May 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 May be included in treatment of visual neglect after right
visual scanning training hemisphere stroke
Computer-based interventions intended to produce extension May be considered for persons with TBI or stroke
of damaged visual fields
Computer-based interventions as an adjunct to clinician- May be considered for cognitive and linguistic impairments
guided treatment
Sole reliance on repeated exposure and practice on NOT recommended
computer-based tasks without some involvement and
intervention by a therapist
Interventions that promote internalization of self-regulation May be considered for persons with deficits in executive
strategies through self-instruction and self-monitoring 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 May improve functioning within the context of a comprehensive
interpersonal therapies neuropsychologic rehabilitation program, and facilitate
effectiveness of specific interventions

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UPDATE ON COGNITIVE REHABILITATION, Cicerone 1689

tioning deficits after TBI used different interventions, but they terventions, outcomes, and their relationships should facilitate
all emphasized strategy training as a general principle (ie, the translation of research into clinical practice and allow
training patients to compensate for residual deficits, rather than clinicians to better tailor specific interventions to different
attempting to eliminate the underlying neurocognitive impair- aspects of cognitive dysfunction and patients functional goals.
ment), and this is reflected in our recommendations. One class
I study102 failed to demonstrate the effectiveness of compre- CONCLUSIONS
hensive-integrated cognitive rehabilitation after TBI compared We have now systematically reviewed 46 class I studies, 43
with limited home-based treatment, although methodologic class II studies, and 169 class III studies of cognitive rehabil-
concerns limit the generalization of these results. itation for people with TBI or stroke. Our overall analysis of 47
Integrating the results from our previous and current re- treatment comparisons from class I studies, representing 1801
views, the committee found evidence to support several of our patients, indicates that cognitive rehabilitation is of significant
initial recommendations, made several new recommendations, benefit when compared with alternative treatments. The result-
and modified several recommendations (tables 2 4). There is ing recommendations should help guide clinical treatment and
now a substantial body of evidence demonstrating that patients facilitate additional research.
with TBI or stroke benefit from cognitive rehabilitation. It is
time to move beyond the simple question of whether cognitive Acknowledgments: The Cognitive Rehabilitation Task Force of
rehabilitation is effective, and to look more precisely at the the BI-ISIG of ACRM conducted this work. We would like to ac-
therapy factors and patient characteristics that optimize the knowledge Joanne Azulay, PhD, Thomas Bergquist, PhD, Douglas
clinical outcomes of cognitive rehabilitation. Katz, MD, and Virginia Mills, RPT, for their contributions to the
review and classification of the literature.
General Recommendations for Future Research
APPENDIX 1: DEFINITION OF LEVELS OF
Future research on the therapeutic factors that contribute to RECOMMENDATIONS
successful outcomes will require standardized interventions
and identification of the various components of complex inter-
ventions. Considerable heterogeneity exists among treatment Practice standards Based on at least 1 well-designed class I
methods reported in the literature, and it is difficult to compare study with an adequate sample, with
interventions even when these are purported to represent the support from class II or class III evidence,
same type of treatment. The need to provide greater specifica- that directly addresses the effectiveness
tion of the theoretical basis, design, and components of inter- of the treatment in question, providing
ventions has received increased attention, as a prerequisite to substantive evidence of effectiveness to
investigating the effectiveness of rehabilitation.115,116 support a recommendation that the
There is a need to replicate interventions that have already treatment be specifically considered for
demonstrated effectiveness, to make increasingly specific pre- people with acquired neurocognitive
dictions about the effects of interventions, and to compare impairments and disability.
different techniques for specific deficits. This requires the abil- Practice guidelines Based on 1 or more class I studies with
ity to compare the size of treatment effects across different methodologic limitations, or well-
studies and types of treatment. Much of the literature has failed designed class II studies with adequate
to provide information that would allow for a determination of samples, that directly address the
effect sizes. This also makes it difficult to determine whether effectiveness of the treatment in
the statistical improvements associated with specific interven- question, providing evidence of probable
tions are clinically significant. We recommend the routine effectiveness to support a recommendation
reporting of effect sizes and related statistics (eg, odds ratios, that the treatment be specifically
reliable change indices) that provide some estimate of the considered for people with acquired
clinical relevance of changes associated with the interventions neurocognitive impairments and disability.
in question. Practice options Based on class II or class III studies that
Clinically, there is consensus that cognitive rehabilitation directly address the effectiveness of
should not be focused exclusively on the remediation of im- the treatment in question, providing
pairments, but should reduce disability and help restore social evidence of possible effectiveness to
role functioning. However, most studies have evaluated the support a recommendation that the
outcome of interventions at the impairment level rather than treatment be specifically considered
their effect on the performance of activities or changes in social for people with acquired neurocognitive
participation. Even when interventions are directed at the re- impairments and disability.
mediation of impairments, this is presumably based on the
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