Keith D. Cicerone, PhD, Cynthia Dahlberg, MA-CCC, Kathleen Kalmar, PhD, Donna M. Langenbahn, PhD,
James F. Malec, PhD, Thomas F. Bergquist, PhD, Thomas Felicetti, PhD, Joseph T. Giacino, PhD,
J. Preston Harley, PhD, Douglas E. Harrington, PhD, Jean Herzog, PhD, Sally Kneipp, PhD,
Linda Laatsch, PhD, Philip A. Morse, PhD

ABSTRACT. Cicerone KD, Dahlberg C, Kalmar K, Langenbahn DM, Malec JF, Bergquist TF, Felicetti T, Giacino JT,
Harley JP, Harrington DE, Herzog J, Kneipp S, Laatsch L,
Morse PA. Evidence-based cognitive rehabilitation: recommendations for clinical practice. Arch Phys Med Rehabil 2000;
81:1596-615.
Objective: To establish evidence-based recommendations
for the clinical practice of cognitive rehabilitation, derived
from a methodical review of the scientific literature concerning
the effectiveness of cognitive rehabilitation for persons with
traumatic brain injury (TBI) or stroke.
Data Sources: A MEDLINE literature search using combinations of these key words as search terms: attention, awareness, cognition, communication, executive, language, memory,
perception, problem solving, reasoning, rehabilitation, remediation, and training. Reference lists from identified articles
also were reviewed; a total bibliography of 655 published
articles was compiled.
Study Selection: Studies were initially reviewed according
to the following exclusion criteria: nonintervention studies;
theoretical, descriptive, or review papers; papers without adequate specification of interventions; subjects other than persons
with TBI or stroke; pediatric subjects; pharmacologic interventions; and non-English language papers. After screening, 232
articles were eligible for inclusion. After detailed review, 61 of
these were excluded as single case reports without data, subjects other than TBI and stroke, and nontreatment studies. This
screening yielded 171 articles to be evaluated.
Data Extraction: Articles were assigned to 1 of 7 categories
according to their primary area of intervention: attention, visual
perception and constructional abilities, language and communication, memory, problem solving and executive functioning,
multi-modal interventions, and comprehensive-holistic cognitive rehabilitation. All articles were independently reviewed by
at least 2 committee members and abstracted according to
specified criteria. The 171 studies that passed initial review
were classified according to the strength of their methods.
Class I studies were defined as prospective, randomized controlled trials. Class II studies were defined as prospective
cohort studies, retrospective case-control studies, or clinical
series with well-designed controls. Class III studies were defined as clinical series without concurrent controls, or studies
with appropriate single-subject methodology.
Data Synthesis: Of the 171 studies evaluated, 29 were rated
as Class I, 35 as Class II, and 107 as Class III. The overall
evidence within each predefined area of intervention was then
synthesized and recommendations were derived based on consideration of the relative strengths of the evidence. The resulting practice parameters were organized into 3 types of recommendations: Practice Standards, Practice Guidelines, and
Practice Options.
Conclusions: Overall, support exists for the effectiveness of
several forms of cognitive rehabilitation for persons with stroke
and TBI. Specific recommendations can be made for remediation of language and perception after left and right hemisphere
stroke, respectively, and for the remediation of attention, memory, functional communication, and executive functioning after
TBI. These recommendations may help to establish parameters
of effective treatment, which should be of assistance to practicing clinicians.
Key Words: Practice guidelines; Cognitive disorders; cerebrovascular accident; Brain injuries; Rehabilitation.
© 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and
Rehabilitation
IMPAIRMENTS OF COGNITIVE FUNCTION are a significant cause of disability after traumatic brain injury (TBI)
and stroke. These cognitive impairments are often the most
persistent and prominent sequelae of brain injury in patients
with moderate or good neurologic recovery. Interventions designed to promote the recovery of cognitive function and to
reduce cognitive disability are a standard component of brain
injury rehabilitation: 95% of rehabilitation facilities serving the
needs of persons with brain injury provide some form of
cognitive rehabilitation, including combinations of individual,
group, and community-based therapies.1
Cognition is defined as the process of knowing. It includes
the discrimination between and selection of relevant information, acquisition of information, understanding and retention,
and the expression and application of knowledge in the appropriate situation. Cognitive disability may be seen in reduced
efficiency, pace and persistence of functioning, decreased effectiveness in the performance of routine activities of daily
living (ADLs); or failure to adapt to novel or problematic
situations.
Cognitive rehabilitation is defined as a systematic, functionally oriented service of therapeutic activities that is based on
assessment and understanding of the patient’s brain-behavioral
From JFK-Johnson Rehabilitation Institute, Edison, NJ (Cicerone, Kalmar, Giacino); Craig Hospital, Englewood, CO (Dahlberg); Rusk Institute of Rehabilitation
Medicine, New York, NY (Langenbahn); Mayo Medical Center and Medical School,
Rochester, MN (Malec, Bergquist); Beechwood Rehabilitation Services, Langhorne,
PA (Felicetti); Marianjoy RehabLink, Rehabilitation Medicine Clinic, Wheaton, IL
(Harley); Coastline Community College, Newport Beach, CA (Harrington); Institute
for Rehabilitation and Research, Houston, TX (Herzog); Community Skills Program,
Counseling and Rehabilitation, Inc, Philadelphia, PA (Kneipp); University of IllinoisChicago, Chicago, IL (Laatsch); Neurobehavioral Services of New England, Byfield,
MA (Morse).
Accepted in revised form June 5, 2000.
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.
Reprint requests to Keith D. Cicerone, JFK-Johnson Rehabilitation Institute, 2048
Oak Tree Rd, Edison, NJ 08820, e-mail: kcicerone@jfk.hbocvan.com.
0003-9993/00/8112-6133$3.00/0
doi:10.1053/apmr.2000.19240

deficits. Specific interventions may have various approaches,
including (1) reinforcing, strengthening, or reestablishing previously learned patterns of behavior; (2) establishing new patterns of cognitive activity through compensatory cognitive
mechanisms for impaired neurologic systems; (3) establishing
new patterns of activity through external compensatory mechanisms such as personal orthoses or environmental structuring
and support; and (4) enabling persons to adapt to their cognitive disability, even though it may not be possible to directly
modify or compensate for cognitive impairments, in order to
improve their overall level of functioning and quality of life.
Cognitive rehabilitation may be directed toward many areas of
cognition, including (but not necessarily limited to) attention,
concentration, perception, memory, comprehension, communication, reasoning, problem solving, judgment, initiation, planning, self-monitoring, and awareness. It can be distinguished
from traditional rehabilitation and psychotherapy by its primary focus: alleviation of acquired neurocognitive impairment
and disability. Although cognitive rehabilitation may incorporate interventions directed at the person’s emotional and psychosocial functioning when these issues relate directly to the
acquired neurocognitive dysfunction, they are not the service’s
sole focus. Regardless of the specific approach or area of
intervention, cognitive rehabilitation services should be directed at achieving changes that improve each person’s function in areas that are relevant to their everyday lives.
Given the prevalence, and relevance, of cognitive rehabilitation services for persons with acquired brain injury, a need
exists to establish empirically based recommendations for the
practice of cognitive rehabilitation. Since 1982, this concern
has been formally recognized by a subcommittee of the Brain
Injury–Interdisciplinary Special Interest Group (BI-ISIG) of
the American Congress of Rehabilitation Medicine. The initial
recommendations of the committee were published in 1992 as
the Guidelines for Cognitive Rehabilitation,2 a document that
defined cognitive rehabilitation, set forth the qualifications of
independent practitioners, and established minimal practice
requirements. The recommendations made at that time were
based on “expert opinion” and did not take into account empirical evidence on the effectiveness of cognitive rehabilitation.
Recently, an independent, nonfederal panel presented their
findings before a US National Institutes of Health (NIH) consensus panel regarding the scientific basis of common therapeutic interventions for the cognitive and behavioral sequelae
of TBI.3 This panel reviewed the literature for cognitive rehabilitation published from January 1988 through August 1998,
including 11 randomized, controlled studies.4 Their review
noted that data on the effectiveness of cognitive rehabilitation
programs were limited by the heterogeneity of subjects, interventions, and outcomes studied. Nevertheless, the panel identified several studies, including randomized controlled studies
and case reports, that documented the ability of interventions to
improve specific neuropsychologic processes—predominantly
attention, memory, and executive skills. The panel noted specifically that compensatory devices, such as memory books,
improved particular cognitive functions and compensated for
specific deficits. It was also noted that comprehensive, interdisciplinary programs that included individually tailored interventions for cognitive deficits were commonly used for persons
with TBI. Although this personalized approach made it difficult
to evaluate program effectiveness because of the heterogeneity
of programs and persons served, several uncontrolled studies
and a nonrandomized clinical trial supported the effectiveness
of these approaches.
Since 1996, the BI-ISIG has been in the process of developing clinical recommendations for the practice of cognitive
rehabilitation, based on an evidence-based review of the existing literature. The recommendations of the Cognitive Rehabilitation Committee, contained in the present report, were based
on an exhaustive review and analysis of existing research. We
reviewed papers addressing interventions for persons with both
TBI and stroke, because they represent the most prevalent
forms of acquired brain injury requiring intervention for cognitive impairments. The selected reports consisted of both
treatment efficacy studies and studies of clinical effectiveness.
Treatment efficacy studies were defined as highly constrained
studies that typically evaluated time-limited interventions of
selected, homogenous samples, primarily for research purposes. Studies of clinical effectiveness were defined as empirical evaluations of treatments within clinical settings, which
may incorporate clinical judgment and strategic modification of
interventions, thus reflecting the actual use of an intervention.
The most widely accepted means of evaluating treatment efficacy are randomized controlled trials that compare the intervention in question with a no-treatment control condition. In
clinical practice, these conditions may be difficult or impossible to establish. Controlled studies of treatment effectiveness
may therefore attempt to determine whether the intervention
offers specific benefits, compared with an alternative treatment,
although this approach may be less useful for initially establishing the effectiveness of an intervention. Ultimately, the
effectiveness of any given treatment should be established by
comparing its benefits with the “best available” treatment with
known effectiveness. Within a typical clinical setting, the best
available treatment may be the combined application of standardized treatment protocols and individualized treatments dictated by clinical experience.4 At present, the closest approximation to such a model is sound, single-subject research
designs or controlled multiple-baseline designs across subjects
or interventions. For this reason, these types of studies were
considered in making the current recommendations.
METHOD
To develop its evidence-based recommendations, the committee identified and refined the questions to be addressed,
identified the relevant literature, reviewed, analyzed, and classified the existing research, and wrote recommendations based
on the strength of available evidence. A MEDLINE literature
search was conducted using the following combinations of
search words: attention, awareness, cognition, communication,
executive, language, memory, perception, problem solving,
reasoning, rehabilitation, remediation, and training. In addition, relevant articles were identified by members of the committee, all of whom are experienced in brain injury rehabilitation and have contributed to the published literature. Reference
lists from identified articles were searched to complete the
initial list of references. This process yielded 655 published
articles. The abstracts or complete reports were reviewed to
eliminate reports according to these exclusion criteria: (1)
reports not addressing intervention; (2) theoretical articles or
descriptions of treatment approaches; (3) review papers; (4)
reports without adequate specification of interventions; (5)
subjects other than persons with TBI or stroke (8 reports were
retained that included diagnoses of “other brain injury” when
these clearly represented a minority of subjects or when it was
possible to distinguish the results for the subjects with TBI and
stroke); (6) pediatric subjects; (7) single case reports without
empirical data; (8) non–peer-reviewed articles and book chapters; (9) pharmacologic interventions; and (10) non-English
language papers. Through this screening process the committee
selected 232 articles for inclusion in the study. Basing their
assignment on the initial review, the committee placed each

article into 1 of 7 categories, reflecting its primary area of
intervention: attention, visual perception and constructional
abilities, language and communication, memory, problem solving and executive functioning, multi-modal interventions, and
comprehensive-holistic cognitive rehabilitation. All articles
were reviewed by at least 2 committee members and abstracted
according to specific criteria: subject characteristics (age, education, gender, nature and injury of severity, time postinjury,
inclusion/exclusion criteria); treatment characteristics (treatment setting, target behavior or function, nature of treatment,
sole treatment or concomitant treatments); methods of monitoring and analyzing change (eg, change on dependent variable
over course of treatment; pretreatment and posttreatment tests
on measures related to target behavior; patient, other, or clinician ratings related to target behaviors; change on functional
measures; global outcome status); maintenance of treatment
effects; statistical analyses performed; and evidence of treatment effectiveness (eg, improvement on cognitive function
being assessed, evidence for generalized improvement on functional outcomes).
Sixty-one additional studies were excluded after detailed
review. They included single case reports without data, subjects with diagnoses primarily other than TBI and stroke, and
nontreatment studies consisting of brief, usually single trial,
experimental manipulations.
For each of the remaining 171 studies, the committee determined the level of evidence, basing their decisions on an
adaptation of previously established criteria5,6 for the development of evidence-based clinical practice parameters. Three
levels of evidence were established. Studies that had well
designed, prospective, randomized controlled trials were considered Class I evidence. Within this category, several studies
featured a prospective design with “quasi-randomized” assignment to treatment conditions, such as prospective assignment
of subjects to alternating conditions. These were designated as
Class Ia studies. Studies were considered Class II evidence if
they consisted of prospective, nonrandomized cohort studies;
retrospective, nonrandomized case-control studies; or clinical
series with well-designed controls that permitted betweensubject comparisons of treatment conditions, such as multiple
baseline across subjects. Clinical series without concurrent
controls, or studies with results from 1 or more single cases that
used appropriate single-subject methods, such as multiple baseline across interventions with adequate quantification and analysis of results, were considered Class III evidence. All classifications were based on the agreement of at least 2 reviewers.
Disagreement between reviewers was resolved through joint
discussion or by obtaining third review. The initial classification of all studies was reviewed by the committee to ensure
consistent application of the criteria and to establish consensus
before the final classification. Of the 171 studies evaluated, 29
were rated as Class I, 35 as Class II, and 107 as Class III.
After the studies were classified, the overall evidence within
each predefined area of intervention was synthesized and recommendations were derived from consideration of the relative
strengths of the evidence. The resulting practice parameters
reflect 3 potential types of recommendations (table 1) from the
best supported, Practice Standards and Practice Guidelines, to
the less evidenced Practice Options.
RESULTS AND DISCUSSION
Remediation of Attention Deficits
Attempts to remediate impairments of attention have generally relied on drill and practice, with exercises designed to
address specific aspects of attention (eg, processing speed,
focused attention, divided attention). Most of the reported
interventions in this area have used stimulus-response paradigms, which required subjects to identify and select among
relevant auditory or visual stimuli, and often used speeded
stimulus presentations. The implicit, if not explicit, rationale
for most of these interventions is to restore basic attentional
abilities through repeated practice. Several studies7-9 have explicitly incorporated and/or evaluated therapeutic interventions
such as feedback, reinforcement, and strategy teaching into the
attention remediation programs. Most studies have relied on
psychometric measures to assess improvements in attention
attributable to treatment, although a few studies have included
behavioral ratings or naturalistic observations.
Thirteen studies were reviewed in this area, including 3
Class I prospective randomized studies,7,8,10 4 Class II controlled studies9,11-13 (of which 2 used a multiple-baseline
method), and 6 Class III studies.14-19 Most controlled studies
compared attention training with an alternative treatment, but
did not include a no-treatment condition.
One Class I and 2 Class II studies evaluated the effectiveness
of attention treatment during the acute period of rehabilitation.
The Class I study7 compared the effectiveness of “focused”
treatment consisting of sequential, hierarchical interventions
directed at specific attention mechanisms versus “unstructured”
intervention consisting of nonsequential, nonhierarchical activities requiring memory or reasoning skills. Forty-four subjects
matched for age, education, and time since injury were randomly assigned to treatment conditions during the acute period
of rehabilitation (average, 6wk postinjury). Subjects received
30-minute treatment sessions 5 times per week throughout their
inpatient rehabilitation, which varied from 1 to 15 weeks. Both
groups received an average of 10 hours of total treatment for
attention. Both groups improved, but no differences existed
between groups on initial or posttreatment neuropsychologic

functioning, ADL status, or staff ratings of cognitive functioning. Because the subjects were in the acute period of rehabilitation, the observed improvements are likely to reflect spontaneous recovery.
One Class II study9 employed a multiple-baseline-acrosssubjects design and evaluated a program for the remediation of
speed of processing deficits in 10 subjects with severe TBI who
were between 6 and 34 weeks postinjury. Treatment was conducted over 6 weeks for a total of 15 hours. The initial 3-week
treatment consisted of the training process alone, whereas in
the second 3 weeks, the training process was combined with
therapist feedback and encouragement. Subjects were also divided into 2 groups according to length of baseline. All subjects showed a gradual improvement across phases, with no
differences in the rate of improvement between groups; thus a
treatment effect was not shown when the effects of spontaneous recovery were controlled. In the second Class II study,11 35
subjects with lateralized stroke (27 left, 8 right) received 7
hours of computer-assisted reaction training over a period of 3
weeks during the acute phase of recovery (4–36wk postonset).
Beneficial effects of attention training beyond the effects of
practice and spontaneous recovery were reported on 5 of 14
outcome measures. These benefits were apparent on measures
of perceptual speed and selective attention, 4 of which resembled the training tasks, with no effect shown on measures of
vigilance or general cognitive functioning. The treatment effect
was primarily apparent for subjects with left hemisphere lesions (most of whom were also aphasic) rather than for subjects
with right hemisphere lesions.
Two Class I and 2 Class II studies evaluated the effectiveness of attention treatment during the postacute period of
rehabilitation. Gray et al10 treated 31 subjects with attention
dysfunction as identified by subjective report and impaired
performance on a screening measure of attention. Subjects
were randomly assigned to receive either computerized attention retraining or an equivalent amount of recreational computer use to control for any nonspecific effects of using microcomputers. The subjects were stratified into TBI versus other
diagnoses (including stroke) and mild/moderate versus severe
attentional dysfunction. Neither variable influenced treatment
results. Time postinjury varied widely from 7 weeks for 1 mild
stroke subject to 10 years. Subjects received approximately 16
hours of treatment over 3 to 9 weeks. The selection of microcomputer-based attention training tasks was based on the demands placed on control processes in the brain involved in
alerting (defined as increasing reaction times), manipulating
information in working memory, or dividing attention. Specific
training included practice on simple and discrimination reaction time with feedback and reinforcement, as well as simultaneous dual tasks with training in verbal regulation and allocation of attention in complex situations. Externally paced
tasks, masked stimuli, or short stimulus displays were excluded
from the recreational computing games used in the control
condition. Immediately after training, the experimental group
showed marked improvement relative to the control group on 2
measures of attention, although, when premorbid intelligence
score and time since injury were added as covariates, the
treatment effect was no longer significant. At 6-month followup, the treatment group showed continued improvement and
superior performance compared with the control group on tests
involving auditory-verbal working memory. In some cases, the
performance of the control group deteriorated from posttreatment to follow-up. The researchers suggest that the initial
improvement in the control group was compatible with a nonspecific effect of increased attention and activity levels during
the treatment period. In contrast, the treatment group’s pattern
of initial improvement during training, which continued over
the follow-up period, was consistent with a strategy training
model, with “some benefit as the strategy is implemented, but
increasing benefit as it becomes increasingly automated and
integrated into a wider range of behaviors.”10
In the second postacute Class I study,8 community-dwelling
subjects with moderate to severe brain injury and time postinjury between 12 and 72 months were screened for orientation,
vision, aphasia, and psychiatric illness. Twenty-six subjects
were randomly assigned to receive either attention training or
a comparison treatment condition consisting of memory training over a 9-week period. A total of 36 hours of individual
treatment was received. The attention treatment consisted primarily of computerized tasks directed at improving focused
and alternating attention to visual and auditory stimuli and
divided-attention tasks intended to improve the allocation of
attentional resources. Comprehensive feedback and strategy
teaching was provided within each session. The effects of
training were evaluated through repeated measures administered throughout training, as well as pretreament and posttreatment neuropsychologic assessment of attention and memory.
The attention measures were chosen to have “predictive validity for daily activities,” although no direct measures of functional outcome were employed. Several additional measures
were administered only before and after treatment to assess
near generalization of treatment effects. After treatment, the
experimental attention training group improved significantly
more than the alternative treatment group on 4 attention measures administered throughout the treatment period, although
the effects did not generalize to the second set of neuropsychologic measures. Both treatment groups exhibited some improvement on all measures, but the effects on specific measures
were weak.
Sohlberg and Mateer12 employed a (Class II) multiple-baseline design with 4 subjects, 12 to 72 months postinjury, to
evaluate the effectiveness of a specific, hierarchical attention
training program. Treatment was provided for 7 to 9 sessions
weekly and lasted from 4 to 8 weeks. All 4 subjects showed
gains on a single attentional-outcome measure administered
after the start of attention training but not after training on
visuospatial processing. Several components of the attention
training tasks closely reflected aspects of the outcome measure,
suggesting the possibility of a relatively task-specific treatment
effect. Strache13 conducted a prospective (Class II) study of 45
subjects with mixed trauma and vascular etiologies, most of
whom were more than 6 months postinjury, and compared 2
closely related interventions for concentration with subjects in
an “untreated” control group who were receiving general rehabilitation. After 20 treatment sessions, both attention treatments resulted in significant improvement on attention measures relative to control subjects, with some generalization to
memory and intelligence measures. No attempt was made to
control for the large number of variables measured. The interpretation of these 3 studies is tempered by the limited range of
relevant outcome measures and, in some cases, the relatively
small effects of treatment.
Within the attention domain, several attempts were made to
establish the differential effectiveness of training for specific
components of attention. Improvements in speed of processing
appear to be less robust than improvements on nonspeeded
tasks.9,14,15 Consistent with this finding, several studies also
suggest greater benefits of attention training on more complex
tasks that require selective or divided attention than on basic
tasks of reaction time or vigilance.10,11,14
Limited direct evidence exists for the generalization of benefits attributable to attention remediation, with a tendency to

observe gains on tasks most closely related to the training
tasks. However, evidence from a well-designed (Class III)
single-subject study suggests that attention training may be
related to improvements in daily functioning and generalized
outcomes. Wilson and Robertson,16 implementing a series of
individualized interventions intended to facilitate voluntary
control over attention during functional activities, effectively
decreased the attentional lapses that the subject experienced
when reading novels and texts.
The studies conducted to date have concentrated on providing subjects with practice on training tasks related to specific
aspects of attention. Evidence suggests that the quality of
therapeutic intervention beyond the specific training tasks employed may be an important variable in the effectiveness of
treatment. For example, in the Ponsford and Kinsella9 study, 3
of the 10 subjects appeared to gain significant clinical benefit
from the addition of feedback and reinforcement to the computer-mediated training. The study by Wilson and Robertson16
incorporated highly personalized treatment procedures, including therapist feedback and “confidence building” by monitoring the subject’s emotional reactions to deficits. In the study by
Niemann et al,8 at least 30 to 40 minutes of each 2-hour session
were devoted to specific training tasks, whereas the remaining
time was allocated to providing the subjects with feedback on
their performance and actively teaching strategies to improve
their functioning.
Recommendations. Evidence from 2 Class I8,10 studies
with a total of 57 subjects and 2 Class II studies12,13 with a total
of 49 subjects supports the effectiveness of attention training
beyond the effects of nonspecific cognitive stimulation for
subjects with TBI or stroke during the postacute phase of
recovery and rehabilitation. This form of intervention is recommended as a Practice Guideline for these persons. Interventions should include training with different stimulus modalities,
levels of complexity, and response demands. The intervention
should include therapist activities such as monitoring subjects’
performance, providing feedback, and teaching strategies. Attention training appears to be more effective when directed at
improving the subject’s performance on more complex, functional tasks. However, the effects of treatment may be relatively small or task-specific, and an additional need exists to
examine the impact of attention treatment on ADLs or functional outcomes.
Evidence is insufficient to distinguish the effects of specific
attention training from spontaneous recovery or more general
cognitive interventions for subjects with moderate-to-severe
TBI and stroke during the acute period of recovery and inpatient rehabilitation. Thus, specific interventions for attention
during the period of acute recovery are not recommended.
Although improvements in attention and functional status appear to occur in these subjects, this finding may be attributable
to the effects of spontaneous recovery or the more general
effects of acute brain injury rehabilitation. In the studies reviewed, all subjects were receiving inpatient brain injury rehabilitation that included interventions directed at orientation,
memory, or general cognitive skills. No studies were found that
directly compared recovery of attention between treated and
untreated subjects; therefore, improvements attributable to the
natural course of recovery and those attributable to cognitive
interventions within the context of comprehensive acute brain
injury rehabilitation programs are confounded.
Remediation of Visuospatial Deficits
Within the area of remediation of visuoperceptual and constructional deficits, 1 group of studies focused on the remediation of basic abilities and behaviors such as visual scanning or
visual perception. Another group of studies addressed the remediation of complex, high-level skills involved in constructional or functional activities that require spatial relationships
for assembly, arrangement, or mobile interaction with the environment. Of the 40 articles considered for final review in this
area, there were 12 Class I studies,20-31 12 Class II studies,32-43
and 11 Class III studies.44-59
Five Class I or Ia studies assessed the effectiveness of
interventions for visual scanning or visual neglect. In an early
study of cognitive remediation, Weinberg et al20 compared
standard rehabilitation with an intervention designed to train
subjects to compensate for impaired scanning habits after right
hemisphere stroke. Subjects in the standard rehabilitation sample (n
32) and the experimental group (n
25) were at least
4 weeks postinsult. The experimental treatment group received
20 hours of training in which graded visual material was used
to promote left-sided scanning. The treatment group gained
significant benefits on both specific measures of scanning and
academic reading tests that were hypothesized to depend on
intact visual scanning. Young et al22 also compared standard
occupational therapy with experimental training in visual scanning in 27 subjects with right hemisphere stroke and left-sided
neglect. The experimental groups not only significantly improved on several measures closely related to the training
procedures but also significantly improved on academic measures of reading and writing. In contrast with these 2 studies, a
Class Ia study by Robertson et al23 did not show any benefit of
microcomputer-based visual scanning training. The visual
scanning intervention was based, in part, on tasks used by
Weinberg20 and was compared with recreational computing
(which excluded tasks requiring visual scanning or timed presentations). Thirty-five subjects were selected on the basis of
impaired performance on a measure of behavioral inattention;
32 of them had sustained a stroke (of unspecified laterality) and
several were diagnosed with head trauma or meningioma. Less
than one third of the subjects showed improvement on behavioral measures of inattention, with no differences between the
groups immediately after treatment or 6 months later.
Two of these studies of visual neglect used functional outcome measures.24,25 Wiart et al24 showed greater resolution of
unilateral neglect and reduced functional impairments for 11
subjects who received a combination of visual scanning and
voluntary trunk rotation compared with 11 subjects who received traditional rehabilitation for acute stroke. Kalra et al25
compared conventional stroke rehabilitation directed at restoration of normal tone and motor activity with an experimental
treatment that involved “spatiomotor cuing during limb activation” in the affected hemispace. The experimental intervention
produced significant improvements on specific measures of
body image and spatial exploration. In addition, the visual
neglect subjects who received the active intervention had significantly shorter lengths of hospital stay. The latter finding
may be particularly noteworthy, given that the presence of
unilateral neglect in subjects with right hemisphere stroke is
associated with greater functional disability and prolonged
hospitalization.60
Seven Class I and Ia studies incorporated training of complex visuospatial skills for subjects with acquired brain damage. Two of these studies featured a hierarchical approach to
treating subjects with right hemisphere stroke who exhibited
visuospatial deficits, including unilateral visual neglect. Weinberg’s group21 built on their earlier study of scanning and
academic skill performance to evaluate training effects on more
complex sensory and spatial skills for 53 subjects with right
hemisphere stroke. The 30 subjects in the experimental condition received 20 hours of training in sensory awareness and

spatial organization in addition to a condensed version of the
original visual scanning training. The 20 subjects in the control
condition received an equivalent amount of occupational or
physical therapy. The subjects receiving the visuoperceptual
remediation benefited significantly on visuospatial and academic tasks relative to the control subjects. As in the earlier
study, the benefits were most apparent among subjects with
more severe perceptual disturbance. Weinberg21 suggested that
the training that incorporated multiple treatment levels produced more robust benefits and greater generalization than the
original single treatment program. In another study,26 this
group further evaluated the claim for the effectiveness of
systematic treatment directed at multiple levels of visuospatial
impairment. A comprehensive program of treatment for visuoperceptual disturbances associated with right hemisphere
stroke was developed by integrating 3 types of previously
evaluated perceptual remediation techniques in a sequentially
administered intervention: basic visual scanning, somatosensory awareness and size estimation, and complex visuoperceptual organization. Among 77 subjects with right hemisphere
stroke receiving inpatient rehabilitation at least 4 weeks postinsult, 48 received the experimental treatment and 29 received
conventional rehabilitation. At rehabilitation discharge, the experimental group showed greater gains than the control group
in all 3 areas of visuospatial functioning. Evidence for generalization of these gains to functional outcome was shown by
the increased time that the experimental subjects spent reading.
However, these gains were less apparent at 4-months’ followup, both because of the continued improvement seen in the
control subjects and the plateau or decline seen in the performance of the experimental subjects.
The remaining 5 Class I studies27-31 compared the effectiveness of visuospatial remediation with conventional rehabilitation therapies for subjects without specific evidence of unilateral neglect and in some cases included subjects who had left
hemisphere stroke or TBI. One of these studies27 provided
training in visual scanning, visuospatial orientation, and time
judgment to subjects within the first week after right or left
hemisphere stroke. The subjects who received the perceptualcognitive training had significantly greater improvement after 3
to 4 weeks of treatment than did subjects who received “conventional” stroke rehabilitation. The results do not allow one to
determine the possible differential benefits for subjects with
left and right hemisphere stroke. Another study28 provided
training designed to establish a systematic strategy for organizing visual material. The study was for patients with perceptual organization deficits without visual neglect after right
hemisphere stroke, most of whom were more than 3 months
postonset. Compared with conventional rehabilitation, the experimental treatment produced benefits on measures of visual
analysis and organization, with no differential improvement in
general cognitive functioning. The researchers noted that the
treatment effect was less dramatic than previous studies that
treated patients with neglect, perhaps because of the attempt to
treat a general cognitive domain rather than a specific behavioral anomaly. In 2 studies,29,30 no differential improvements in
perceptual functioning or ADLs occurred as a result of the
experimental treatment, compared with conventional occupational or physical therapies that did not directly address visuoperceptual functioning.
Only 1 study specifically addressed the treatment of visuoconstructional deficits in subjects with TBI.31 Treatment was
provided for 45 male TBI subjects who were at least 6 months
postinjury and none of whom exhibited signs of unilateral
neglect. Researchers compared visuospatial training on a parquetry task with functional activity training in meal preparation, while controlling for the level and type of cuing. Each
treatment produced highly task-specific improvement on a
measure of constructional ability and kitchen evaluation, respectively.
Of the 12 Class II studies, 8 addressed the remediation of
unilateral visual neglect.32-39 All these studies showed significant benefits of cognitive remediation, as did an additional 8
Class III studies,44-51 including evidence of generalization to
functional tasks.34,36,37 As was seen among the Class I studies,
the Class II32,40,41 and Class III52-56 studies that addressed
visuospatial deficits other than neglect generally produced less
dramatic or equivocal effects of treatment. However, it is worth
noting that several of these interventions did result in improvements that generalized to complex, functional ADLs.40,53
Two Class II34,35 and 2 Class III studies54,57 reported decrements in visual field defects in nonrandomized studies of
specific remediation procedures. However, these results are
discrepant with the conclusion based on a randomized study20
that functional improvements are associated with increased
compensation through improved scanning and not with any
appreciable change in the underlying neurologic deficit. Kekhoff et al35 also commented that the observed reduction in
visual field defects that his group recorded was insufficient to
explain the associated reduction in functional impairments in
visual scanning and reading. Most of the studies reporting
positive results indicate that training in compensation through
visual scanning is required to reduce functional impairments in
activities such as reading and perception of the visual environment.
Recommendations. Evidence from 6 Class I20-22,24-26 studies with a total of 286 subjects and 8 Class II32-39 studies
totaling 248 subjects shows that visuospatial rehabilitation that
includes practice in visual scanning improves compensation for
visual neglect after right hemisphere stroke and is superior to
“conventional” occupational or physical therapies. Only 1
Class I study23 of 36 subjects in which the treatment was
limited to microcomputer-based remediation failed to confirm
this finding. Visuospatial rehabilitation with training in visuospatial scanning is recommended by the committee as a Practice Standard for persons with visuoperceptual deficits associated with visual neglect after right hemisphere stroke. For these
subjects, additional training on more complex visuospatial
tasks appears to enhance the benefits of treatment and facilitate
generalization to other visuospatial, academic, and everyday
activities that require visual scanning (eg, reading, working
written arithmetic problems).20,21,26 Treatment effects also generalize to more effective performance in rehabilitation and
everyday living activities,24,32,39,40 as evidenced by improved
driving ability,43 and greater gains and shorter lengths of stay in
acute rehabilitation.25 Treatment effects appear to be maintained in the long term (ie, up to 1yr).24
Additional evidence from nonrandomized, controlled (Class
II) studies suggested several specific factors that should be
considered in developing clinical visuospatial rehabilitation
programs. Training appears to be most effective in subjects
who have more severe visuoperceptual impairment that includes visual neglect.20,21 With this subject group, scanning
training appears to be an important, even critical, element of
the intervention. Thus, the committee recommends as a Practice Guideline scanning training for persons with visual neglect. Comparisons across the few studies finding negative
results and those studies producing positive effects suggest that
effective training generally needs to be relatively intense (ie,
daily). Effective treatment typically involved 20 1-hour sessions delivered over the course of 4 weeks. Scanning training
may be most effective when the intervention features a large

apparatus that challenges peripheral vision. A nonrandomized
study35 suggests that scanning training may be more effective
if done without head rotation. However, another study24 suggests that training to improve trunk rotation may enhance the
effects of scanning training. Because most studies had relatively acute stroke subjects (ie, onset 6mo before start of
treatment), the effectiveness of similar interventions with a
more chronic or diagnostically diverse group is uncertain.
The benefits of cognitive rehabilitation for persons with
visuoperceptual deficits but without visual neglect have not
been clearly shown. Evidence from 2 Class I studies27,28 suggests that visuospatial rehabilitation is superior to conventional
therapies, whereas the results of 3 additional Class I studies are
equivocal.29-31 Basing its observation on these studies, the
committee recommended as a Practice Option that persons with
visuoperceptual deficits without neglect after right hemisphere
stroke may benefit from systematic training of visuospatial and
organizational skills as part of their acute rehabilitation. No
consistent evidence exists to support the specific effectiveness
of visuospatial remediation for persons with left hemisphere
stroke or TBI who do not exhibit unilateral spatial inattention,
and this intervention cannot be recommended in these cases.
Although several studies have reported decrements in visual
field defects as a result of specific perceptual remediation
procedures, the effects appear related to compensation through
improved visual scanning and not to any appreciable change in
the underlying neurologic deficit. Basing its decision on the
available research and conflicting evidence, the committee
does not recommend clinical interventions to directly increase
visual fields.
Based on the results of a single Class I study,23 the treatment
of unilateral left behavioral inattention through the isolated use
of microcomputer-based exercises is not effective and is not
recommended.
Remediation of Language and Communication Deficits
A dynamic interaction exists between language and cognition in that linguistic processes are critical to the acquisition of
knowledge and mediation of cognitive processes, and cognitive
impairments often produce related communication impairments.61 Language deficits after TBI and stroke include specific
language disorders (ie, aphasia), functional disorders such as
impaired reading comprehension, and impairments in communication pragmatics. Recognizing the interrelatedness of cognitive and linguistic processes, the committee reviewed treatment studies that addressed a broad scope of language-related
impairments. As a result, the review of research in the area of
language and communication revealed a wide range of treatment approaches. The majority (84%) of the studies that the
committee reviewed researched subjects with stroke, with 16%
of studies addressing communication disorders from TBI. This
distribution seems to reflect the recent focus on TBI treatment
and the availability of larger homogeneous samples of subjects
with left hemisphere stroke. Of the 41 studies identified to
review in this area, 8 were Class I studies,62-69 7 were Class II
studies,70-76 and 26 were Class III studies.77-102 Of the Class I
studies, 6 were conducted using subjects with left hemisphere
stroke and 2 involved subjects with TBI.
Two Class I studies of language remediation included an
untreated control group. Wertz et al62 evaluated the effectiveness of language treatment for aphasia among 94 subjects that
had left hemisphere stroke. These subjects were randomly
assigned to 3 groups: treatment in a clinic, treatment at home,
and deferred treatment. Treatment was designed to reduce
deficits in comprehension, expressive language, reading, and
writing. General treatment protocols were specified and consisted of traditional facilitation techniques and specific language programs, although specific techniques were individualized and designed to meet each subject’s needs. Treatment was
administered for 8 hours weekly throughout each 12-week
study period. The home treatment condition was designed and
monitored by speech-language pathologists, but was administered by trained volunteers. After the initial 12 weeks, the clinic
treatment group showed a significant treatment effect over the
deferred (no treatment) group. After an additional 12 weeks,
during which clinic treatment was provided to the deferred
treatment subjects, the differences between the groups were
eliminated, a result that indicated treatment effectiveness past
the period of expected spontaneous recovery. This study also
addressed the specific effectiveness of clinic-based treatment in
comparison with a home-based program of structured language
stimulation. The home treatment group improved more than the
untreated group but less than the clinic treatment group; however, neither of these differences was significant.
In a prospective (Class Ia) study, Hagen69 evaluated a homogeneous sample of 20 subjects with posterior left hemisphere stroke who were sequentially assigned to treatment or
no treatment conditions at 6 months postinjury. Both groups
were in the same chronic care environment, with the only
reported difference being the intensive communication therapy
provided for the experimental group. The treatment consisted
of individual, group, and programmed independent therapies
focused on each subject’s specific level of language abilities
and deficits, which were identified and remediated by speech/
language pathologists. The study showed a significant treatment effect at 1 year in 5 areas: reading comprehension,
spelling, arithmetic, language formulation, and speech production. No difference was found in auditory and visual comprehension skills. This finding was attributed to spontaneous recovery before the start of the treatment. Because treatments
were individualized according to specific deficits, and personally meaningful and useful material was developed for each
subject, the strict comparability of interventions among the
subjects in the treatment group is limited. However, this situation also approximates the typical clinical situation and may
support the generalizability of treatment effectiveness. These 2
studies provide evidence that language remediation after a
single left hemisphere stroke is effective.
Three Class I studies compared the effectiveness of language
remediation and alternative forms of treatment for communication impairments after left hemisphere stroke.63-65 Wertz et
al63 conducted a (Class I) multi-center study that compared the
effectiveness of individual treatment of specific language deficits versus group treatment designed to improve communication without direct treatment of specific language deficits. All
subjects received 8 hours of weekly therapy, beginning at 4
weeks postonset and continuing up to 48 weeks postonset.
Individual treatment of specific language deficits resulted in
significantly greater improvement on the Porch Index of Communication Ability, although there was evidence of significant
improvement for both groups, with no other differences between groups on specific language measures. David et al64
reported the results of another (Class I) multi-center, randomized controlled trial, with 96 subjects with aphasia due to stroke
assigned to either 30 hours of individualized, “conventional
speech therapy” over 15 to 20 weeks or an equal amount of
stimulation and support from volunteers. Volunteers were
given a detailed description of each subject’s communication
problems and were asked to encourage the subject to communicate as well as possible, but they were given no instruction in
speech therapy techniques. Improvement of functional communication was apparent for both groups, with no significant
difference between the groups. It was also noted that subjects
referred for treatment more than 20 weeks postonset showed a
similar pattern of improvement, suggesting that the effects
were not due to spontaneous recovery, although again no
differences were found between treatment conditions. In this
study, the volunteers were informed of each subject’s deficit
areas and were asked to focus on these areas and encourage
communication. A related study by Hartman and Landau65
compared 6 months of formal language therapy for acute
stroke-induced aphasia with an equal amount of emotionally
supportive counseling therapy. Both interventions were provided by speech-language therapists. The alternative treatment
(counseling) was unstructured and conversationally based;
however, therapists were trained specifically not to provide
instruction or specific suggestions for language practice. Both
groups showed small improvements, and conventional speech
was no more effective than emotional support without formal
language instruction. These studies suggest that nonspecific
treatment factors such as therapist interest, support and encouragement, and stimulation may contribute to the effectiveness of
treatment for communication deficits after stroke.
Four Class II studies provide evidence directly related to the
effectiveness of language remediation compared with no treatment; 3 provide support for language remediation70-72 and 173
provides negative evidence. Basso et al70 evaluated the effect
of language remediation on specific skills of comprehension,
expression, reading, and writing among 281 subjects who were
aphasic because of stroke (85%) or TBI (1%). Treatment had a
significant effect on all language skills. Time postonset and
aphasia severity were inversely related to amount of improvement, although subjects who entered treatment several months
or even years postonset showed improvement. Shewan and
Kertesz71 compared 2 forms of language remediation (“language therapy” or group facilitation by speech-language therapists) versus alternative treatment (group stimulation by
nurses) or no treatment among 100 subjects with aphasia due to
stroke. Significant improvement occurred only in the 2 language remediation conditions. Poeck et al72 compared the
treatment of 68 aphasic stroke subjects with 92 untreated,
historical controls. Significant benefits of treatment were observed beyond the effects of spontaneous recovery, even in
subjects in late (4–12mo) or chronic (12mo) stages of recovery. Prins et al73 compared 2 forms of language remediation
consisting of either conventional therapy or a systematic program of remediation for auditory comprehension, with a no
treatment control condition. The sample consisted of 32 aphasic stroke subjects averaging 3 years postonset and as long as
17 years postonset. Groups were not matched for age, severity,
or chronicity. No clear effect was found on the recovery
process for either form of language remediation.
In addition to the relatively broad-based interventions already discussed, another Class I study refined treatment focus
and examined the efficacy of a computer-based program to
improve reading comprehension after left hemisphere stroke.66
Fifty-five aphasic subjects were randomly assigned to receive
either treatment for reading comprehension, generalized computer stimulation for the same time period, or no treatment.
Significant treatment effect existed for the computer reading
treatment, with improved functioning in reading comprehension and generalization to other language functions. The
strength of this study lies in the focused nature of the intervention on a specific language function, with each subject
exposed to a systematic hierarchy of language-based treatment
stimuli. This study more closely analyzed the efficacy of what
is currently considered a cognitive-linguistic remediation technique, with strong evidence for efficacy given the time elapsed
postinjury and the lack of change with computer stimulation
alone or no treatment. Three small Class II studies have provided evidence for the effectiveness of specific language interventions directed at sentence production74,75 or sentence comprehension,76 with no negative findings in Class II studies of
specific interventions. Several Class III studies have evaluated
interventions for specific language deficits, including naming
and word retrieval,77-82 sentence production,83-86 alexia,87 and
verbal perseveration.88 These studies support the effectiveness
of individualized treatment for cognitive-linguistic deficits after left hemisphere stroke.
Two Class I studies evaluated the effectiveness of cognitive
remediation for functional communication deficits after TBI.
Helffenstein and Wechsler67 evaluated the effectiveness of a
group intervention designed to improve interpersonal communication skills compared with nontherapeutic attention. Treatment involved systematic feedback on videotaped communication interactions for 20 hours total for the therapy group. The
control group received an equivalent amount of treatment in
individual sessions with no feedback on interpersonal communication skills. Although group size was small (n
16), a
significant treatment effect was found, with the experimental
subjects showing improvements on measures of self-concept,
others’ ratings of interpersonal and communications skills, and
the observed frequency of specific behaviors related to effective interpersonal communication in nontherapeutic, social settings.
Thomas-Stonell et al68 evaluated the effectiveness of a computer-based program for the remediation of “higher level cognitive-communication deficits (i.e., those that require the interplay of cognitive, memory, and language processes)” in 12
young adults with TBI. The computer-based intervention
(TEACHwarea
) addressed 5 skill areas: attention, memory and
word retrieval, comprehension of abstract language, organization, and problem solving. The subjects were selected on the
basis of demonstrated cognitive-linguistic impairments on standardized neuropsychologic tests and randomly assigned to receive the 16-hour program of the computer-based cognitive
remediation or control treatment. The cognitive remediation
was conducted by a speech therapist, occupational therapist, or
teacher who also provided insight into cognitive strengths and
weaknesses, provided training in the use of compensatory
strategies, and facilitated transfer of skills from the treatment
tasks to real-life situations. The 6 subjects in the control group
were already receiving either intensive rehabilitation or were in
community school programs. Although some remediation of
cognitive deficits was apparently included in the control subjects’ program, the nature of these interventions was not specified and skill transfer to real-world situations was reported as
a focus of the control groups’ treatment. The computer-based
remediation group showed significant improvements on several
standardized language measures, whereas the control group did
not. It was also noted that unsolicited reports of improved
concentration, memory, and classroom performance were received from classroom teachers of students in the experimental
group but not for the control group.
Five small Class III studies have also reported benefits
related to remediation for social and pragmatic communication
abilities after TBI.98-102 Ehrlich and Sipes98 showed improved
social and conversational skills in 6 TBI subjects after 12
weeks of group treatment. Gajar et al99 provided feedback and
self-monitoring training to improve conversational interactions
for 2 TBI subjects who were at 18 months postinjury. Conversational skills improved to a normal range with generalization
observed to less structured situations. Similarly, Giles et al100
found improved pragmatic communication skills in 1 TBI
subject, with maintenance of gains at least 2 months posttreatment. Although limited by small sample size, these studies
show the effectiveness of focused cognitive interventions to
improve interpersonal and functional communication skills after TBI.
Recommendations. Because good evidence exists to support the effectiveness of cognitive-linguistic therapies beyond
the period of spontaneous recovery for the treatment of subjects
with language deficits from left hemisphere stroke, the committee recommends this approach as a Practice Standard.
Among the 3 Class I studies62,66,69 and 4 Class II studies70-73
comparing language remediation with no treatment, 6 studies
with 676 subjects report significant benefits of language remediation and 1 Class II study73 with 38 subjects reported no clear
effect.
Because the results of a controlled prospective study,67 supported by several Class III studies, indicate that significant
benefits may be derived from interventions directed at improving pragmatic communication and conversational skills after
TBI, the committee also recommends these interventions as a
Practice Standard.
With evidence from 2 well-controlled, prospective (Class I)
studies to support the use of cognitive interventions for specific
areas of language impairment (eg, reading comprehension,
language formulation) after left hemisphere stroke66 or TBI,68
the committee recommends this approach as a Practice Guideline.
Remediation of Memory Deficits
Studies of the remediation of memory deficits have addressed a range of memory-related issues including general
concerns (“everyday memory problems,” impaired learning,
capacity to learn during posttraumatic amnesia), specific memory problems (remembering names, dates, routes, lists, faces,
appointments, routines), the capacity to use effectively compensatory aids (computers, memory books), and individual
subjective memory complaints. Interventions to address these
problems have included use of external compensatory aids such
as computers, pagers, or notebooks; individualized remediation
programs with heavy involvement of client input, family/social/therapist support, and environmental adaptations; didactic
lessons and homework assignments; training in compensatory
strategies such as rehearsal, organizational strategies, visual
imagery, verbal labeling, and use of mnemonics; and implicit
memory tasks.
Among the 42 studies reviewed in this area, 4 were prospective, randomized controlled studies of subjects with TBIs.103-106
Four studies were considered Class II designs107-110 and 34
were Class III studies.111-144
The 4 Class I studies addressed the effectiveness of training
compensatory strategies in memory rehabilitation. Berg et al103
compared memory strategy training with a “pseudotreatment”
(drill and repetitive practice on memory tasks) and a notreatment condition. Most of the 39 subjects were at least 1
year postinjury, although the range extended up to 24 years. All
of the subjects were living independently, and about one half
were working either full- or part-time in their previous vocation, although at a reduced level, which suggested that most
subjects exhibited a relatively mild degree of memory impairment. The memory strategy training consisted of teaching the
subjects to apply “well known principles of memory functioning” to daily functioning. Subjects in the strategy training
group identified 3 personal functional memory problems they
were experiencing as target behaviors for treatment, and the
interventions were highly individualized. The “pseudotreatment” consisted of practice with various memory tasks and
games. Objective pretreatment and posttreatment assessments
of memory function were conducted, and subjective ratings of
improvement were obtained. Results of objective memory testing showed improved memory function in the strategy training
group only, although subjects in both treatment groups reported
that they found the training beneficial in terms of their everyday memory function. The largest effect of strategy training
was found at follow-up 4 months after therapy, suggesting that
subjects continued to practice the strategies learned.
Ryan and Ruff104 combined “empirically proven” mnemonic
techniques into a comprehensive treatment program with the
goal of improving verbal and nonverbal memory capacities.
Twenty TBI subjects with mild to moderate memory impairments from 1.5 to 7.5 years postinjury were matched for age,
education, gender, and time postinjury before being randomly
assigned to the treatment group. The experimental group received memory retraining employing rehearsal and visual imagery strategies on associational and chaining tasks. The control group received alternative treatment, including computer
games and psychosocial support. Both groups followed the
same schedule in terms of intensity and duration of treatment,
which lasted for 6 weeks. After treatment, both groups improved on neuropsychologic measures of memory functioning,
no matter which treatment they received. Post hoc, the groups
were divided based on severity of initial neuropsychologic
functioning, and the data were reanalyzed. Differential benefit
of the memory retraining was observed only in those subjects
who had mild memory impairment before treatment. Kerner
and Acker105 evaluated the effectiveness of using memory
retraining software and a computer for remediation of “mild to
moderate” memory impairment at least 3 months postinjury.
Significant improvement was observed on psychometric memory performance after 12 training sessions, suggesting that
memory skills were enhanced by using computer-based memory retraining software. However, these gains were not maintained when the subjects were tested again 15 days later, so
there was little evidence of lasting benefits of treatment beyond
what would be expected from spontaneous memory improvement.
Schmitter-Edgecombe et al106 evaluated the efficacy of a
9-week, notebook training treatment relative to supportive therapy for rehabilitation of memory disturbance in 8 TBI subjects
more than 2 years postinjury. The degree of memory impairment in all subjects appeared to be relatively mild. The treatment consisted of teaching a specific protocol for use of a
memory notebook and individualized modifications to address
the subjects’ personal needs and application to novel settings.
The control subjects received supportive therapy that allowed
them to express frustrations about their cognitive and psychosocial functioning. After treatment, subjects who received the
notebook training reported fewer observed, everyday memory
failures than the supportive therapy subjects. Of the subjects
who received the memory remediation, 3 were still actively
using the memory notebook to assist with their daily activities
at 6-month follow-up. The memory remediation group reported
fewer retrospective memory failures and continued to report a
reduction of observed everyday memory failures 6 months after
treatment, although the difference from control subjects was no
longer significant.
One Class II study107 supported the findings related to the
effectiveness of training compensatory strategies, although,
again, evidence from several Class III studies indicates that this
form of memory remediation is effective for subjects with mild
impairments but not subjects with severe memory impairment.111-113 The remaining Class III studies addressing compensatory memory retraining included training in the use of
rehearsal, semantic elaboration, visual imagery, prospective
memory, and specific mnemonics. Several of these studies
addressed highly specific behaviors such as learning name-face
associations.114 In 1 (Class III) study,115 visual imagery and
verbal elaboration were effective in teaching name-face associations in subjects with severe memory impairment. However,
the learning strategy was externally imposed on the subjects to
reduce the cognitive demands of strategy use, with no attempt
to teach them to use any of the strategies independently or to
apply the strategies to new situations. The authors noted that
the effectiveness of such training may therefore be specific to
the nature of the memory task and the material to be learned.
One Class III study116 compared the effectiveness of 3
memory retraining strategies (verbal rehearsal, written rehearsal, acronym formation) with memory notebook logging to
improve recall of specific, functional material over a 24-hour
period. The memory notebook (which was available to subjects
at the time of recall) was superior to all of the retraining
techniques. The differential benefits of using the memory notebook was most apparent for the subjects with more severe
memory difficulties, for whom the retraining techniques were
largely ineffective. Three single-case (Class III) reports supported the effectiveness of training subjects who had severe
memory impairment from TBI117,118 or stroke119 to use a memory notebook to facilitate performance of daily activities.
These studies suggest that the use of a memory notebook as
an external, compensatory aid should be distinguished from
interventions that attempt to promote the use of internalized,
compensatory memory strategies. Of note, the effective use of
memory notebooks may require extensive, structured training118 and attention to subjects’ emotional and social acceptance of such use.117
One Class II study109 showed the effectiveness of a portable
paging system to circumvent specific, everyday memory failures such as remembering to take medication on time or remembering to shut off appliances. All 15 subjects in this study
benefited from the introduction of the external memory aid to
varying degrees, and two thirds of the subjects were able to
establish a stable routine after 3 months of treatment. Several
additional Class III studies have addressed the effectiveness of
specific learning interventions120,121 or external memory
aids122,123 for subjects with moderate to severe memory disorders. These studies have generally shown the effectiveness of
techniques for teaching subjects highly specific information,
including the application of specific learning techniques and
external memory aids to assist with the acquisition and performance of functional work skills.123
Recommendations. Four prospective, controlled (Class I)
studies103-106 with a total of 91 subjects have evaluated the
effectiveness of training compensatory memory strategies for
subjects with TBI. All of these studies compared memory
remediation with an alternative treatment condition, and 2
studies included untreated controls. Three of these studies103,105,106 showed beneficial effects of memory remediation
on neuropsychologic indices of memory functioning or reductions in subjective reports of everyday memory failures. In the
fourth study,104 differential benefits of memory remediation in
comparison with the alternative treatment were apparent when
the subjects were stratified according to the severity of their
initial memory impairment. Basing their decision on these
results, the committee found the evidence for the effectiveness
of compensatory memory training for subjects with mild memory impairments compelling enough to recommend it as a
Practice Standard. The evidence also suggests that memory
remediation is most effective when subjects are fairly independent in daily function, are actively involved in identifying the
memory problem to be treated, and are capable and motivated
to continue active, independent strategy use. Efforts should be
taken to ensure that subjects continue to use compensations
through appropriate preparation and follow-up.
Specific interventions directed at facilitating the acquisition of specific skills and domain-specific knowledge rather
than improving memory functioning per se, can be effective
for subjects with moderate to severe memory impairments,109,116-123 with evidence of their potential direct application to functional activities, and are thus recommended by
the committee as a Practice Option. No evidence exists to
support the effectiveness of cognitive remediation to restore
memory function in subjects with severe memory impairment.
Remediation of Executive Functioning and
Problem Solving
The term executive functioning refers to those integrative
cognitive processes that determine goal-directed and purposeful behavior and are superordinate in the orderly execution of
daily life functions. This term encompasses a broad array of
cognitive function and dysfunction and is commonly used to
characterize difficulties resulting from injury to the frontal
lobes, although it is important that the anatomic and behavioral
referents of this term remain distinct. These integrative functions include the ability to formulate goals; to initiate behavior;
to anticipate the consequences of actions; to plan and organize
behavior according to spatial, temporal, topical, or logical
sequences; and to monitor and adapt behavior to fit a particular
task or context. Disturbances of these executive functions also
appear related to impaired emotional and behavioral self-regulation, reduced capacity for insight, and neurologically based
disorders of awareness. These processes are often conceptualized to reflect the associated difficulties with everyday problem
solving, reasoning, and decision making. Deficits in these areas
are often difficult to operationalize because they deal not only
with discrete skills but also with the cognitive structures and
processes that control the use of these skills. Thus, although the
scope of problems or target behaviors encompassed in this
section ranges widely, even those studies that sought to train
relatively discrete actions generally designed their interventions with the goal of establishing external structure and/or
internalization of control over these actions.
Based on the final review of the literature, the committee
evaluated 14 studies in this area. They included 1 Class Ia
study,145 2 Class II studies,146,147 and 11 Class III148-158 studies
that employed single-subject designs. The choice of interventions reflected a range of approaches that were primarily cognitive, behavioral, or combined cognitive-behavioral techniques. Often, behavioral techniques were used for specific
skill training, whereas more cognitively based methods were
employed to achieve greater internalization of strategies for
initiation and self-monitoring of these skills.
The single Class Ia study in this area was conducted by von
Cramen et al,145 with alternating assignment to 1 of 2 groups,
either problem-solving training or an alternative memory training control, and without a no-treatment control group. Training
was provided to 37 subjects (from 61 consecutive inpatient
rehabilitation admissions) who were classified as “poor” problem-solvers by virtue of obtaining 2 of 3 scores below the
median on formal tests of problem solving. The study primarily
included subjects with TBI or stroke, although 6 subjects had
“other” brain injury diagnoses, with the average time postonset
for the entire group being 7 months. The training in problem
solving provided subjects with techniques to analyze complex
problems into manageable steps based on a social problem
solving model that emphasized training in problem orientation,
problem definition and formulation, generation of alternatives,
decision making, and solution verification. Subjects in the
memory training group were taught to use internal memory
strategies, with the rationale that memory-strategy training
might have implicit effects on problem-solving abilities. Problem solving and memory training were carried out with equivalent intensity and duration by 2 therapists. The problemsolving training was done on a group basis, although subjects
with arousal difficulties were also treated individually, to allow
prompting to maintain mental effort. Treatment outcomes were
assessed with pre- and posttraining comparisons on neuropsychologic measures of intelligence and planning, with predefined improvement criteria and with behavioral ratings by
clinicians on 9 aspects of impaired functional problem solving.
Results of pre- and posttraining comparisons showed significant improvement for the problem-solving treatment on 3 of 5
intelligence subtests and on both measures of planning ability.
Behavioral ratings revealed significantly greater improvement
in the problem-solving treatment group than for subjects in the
memory treatment group in awareness of deficits, goal-directed
ideas, problem-solving ability, and premature actions. The behavioral ratings were interpreted as evidence for generalization
of treatment effects to everyday ward activities.
The evidence for effectiveness of problem-solving interventions for subjects with TBI is supported by a Class II study146
that developed and evaluated a program for teaching problemsolving strategies by using verbal analogs of problem situations
in 4 general areas of everyday life relevant to community
placement and adjustment: (1) community awareness and
transportation; (2) medication, alcohol, and drugs; (3) stating
one’s rights; and (4) emergencies, injuries, and safety. The
training of problem-solving strategies was based on the generation of alternatives and choice of a single solution. The
training methods included the use of cue cards, responsespecific feedback, modeling, self-monitoring, positive reinforcement, response practice, self-correction, and individualized performance criterion levels. Specific criterion questions
were used for scoring, providing feedback, and providing cues
during training. Training was provided to 3 subjects with TBI
within a residential rehabilitation facility. Three individuals
within the same facility served as untreated control subjects.
Throughout the course of training, the percentages of criterion
questions answered correctly by the experimental subjects increased from 29% to 96% correct. Performance on probes in
which analogous problem situations were used increased from
26% during baseline to 93% after training. Generalization of
training was measured by interview and simulated interactions
conducted in the natural environment by facility staff. The
experimental subjects showed significant improvements in
problem solving after treatment, whereas the performance of
the untreated subjects was essentially unchanged. The improvements in problem solving by the experimental subjects
were maintained at a 6-month follow-up. The use of ecologically relevant problems and situational simulations is relatively
unique, although the outcome measures largely represented
only the subjects’ verbal responses rather than measuring their
actual performance in problem-solving situations. Despite the
small number of subjects, the comparison with untreated control subjects and the attempt to address problem solving in
relevant, everyday situations increase the value of this study in
support of the effectiveness of problem-solving interventions.
One (Class II) study with multiple-baseline controls directly
addressed the remediation of executive functioning. Cicerone
and Giacino147 adapted a self-instructional procedure to train
executive functioning deficits in 6 subjects (5 with TBI, 1 with
a benign tumor) by using a multiple-baseline-across-subjects
design. All subjects had planning and self-monitoring difficulties, which were revealed by scores on frontal lobe measures
and by reports from family and rehabilitation staff. Subjects
received baseline pretesting on the Tower of London, which
was also used as the training task. Training consisted of 10 to
20 hours of individualized treatment over 5 to 9 weeks to
complete 3 phases of self-instruction. The graphic representation of results suggested that 5 of the 6 subjects showed
dramatic decreases in task-specific errors, although some
downward trend in errors was present before the start of treatment. Pre- and posttreatment analyses of neuropsychologic
measures indicated significant reductions in maze errors and
perseverative responses, which were interpreted as evidence of
enhanced performance on tasks that required novel problem
solving and inhibition of irrelevant responses. Additionally,
generalization of training to the reduction in off-task, disinhibited behaviors was found during treatment and follow-up assessment. This finding was consistent with an earlier singlesubject study of treatment protocol that showed application to
everyday behaviors with extended training promoted generalization.148 The effectiveness of verbally mediated, self-instructional training for executive function deficits receives some
support from additional single-subject studies.148-152 In a related form of intervention, Sohlberg et al153 used external cuing
to train the self-monitoring of verbal initiation and response
acknowledgment in a subject who showed restricted affect and
motivation after severe TBI. These studies have typically emphasized a program of treatment aimed at internalization of
control of the skill to be learned, whether by saturated cuing,
self-instruction, self-questioning, or self-monitoring. They
have frequently used a combination of cognitive and behavioral
interventions and have relied on detailed neuropsychologic and
clinical assessment of subjects to identify specific target behaviors and to develop individually tailored interventions.
One (Class III) study154 evaluated the use of an external
cuing-monitoring system (NeuroPageb
) and paper-and-pencil
checklist in the rehabilitation of executive problems following
anterior stroke. The subject had difficulty with timely initiation
of intended actions, despite relatively preserved memory functioning. External cuing and monitoring were useful in increasing the probability that she would successfully initiate and
complete specific tasks as part of her daily routine, with no
attempt to remediate her executive functioning per se.
Unawareness of deficits after brain injury is often observed
following TBI or stroke and may be associated with deficits of
executive functioning. Several studies of executive functioning
incorporated techniques such as formal feedback and selfmonitoring of deficits148,153,155 in an attempt to address subjects’ self-awareness. However, we found very few empirical
studies, and no controlled studies, of treatment to improve
directly subjects’ awareness of deficits. Two Class III studies
suggest that having subjects predict their performance on tasks
and providing them with tangible feedback may reduce discrepancies between their predicted and actual performance.157,158
Recommendations. Practice recommendations regarding
interventions for problem-solving and executive functioning
deficits are constrained by the small number of studies comprising Class I and Class II research in this area. Only 3 Class
I or Class II studies were identified,145-147 reporting results for
a total of 43 subjects. Basing its decision on the studies that
support the effectiveness of programmatic interventions for
problem-solving deficits, the committee recommends training
of formal problem-solving strategies and their application to
everyday situations and functional activities145,146 as a Practice
Guideline.
Cognitive interventions that promote internalization of selfregulation strategies through use of verbal self-instruction,
self-questioning, and self-monitoring may be considered a
Practice Option for the remediation of deficits in executive
functioning, including the reduction of problem behaviors in
everyday situations.147-152 Such interventions should incorporate detailed neuropsychologic and clinical assessment data to
identify relevant behaviors for intervention and to make modifications in treatment interventions on the basis of individual
patterns of strengths and limitations. Some persons, especially
those with multiple cognitive impairments or severe impairments of executive functioning, may require consistent external
structure and environmental management to achieve discrete
improvements in skills or behaviors within limited contexts.153,154 Interventions for cognitive deficits after acquired
brain injury may also include efforts to assess subjects’ awareness of their deficits and to improve the accuracy of subjects’
self-appraisal of their performance. However, these interventions have not been adequately addressed through controlled
studies.
Multi-Modal Interventions for Cognitive Deficits
In clinical practice, it is not uncommon for treatment to
address multiple areas of cognitive functioning by providing
specific interventions for each deficit (eg, attention, memory,
problem solving). The specific interventions are typically administered sequentially, although some deficits may be addressed concurrently. For example, the study by ThomasStonell68 incorporated interventions for attention, memory and
word retrieval, comprehension of abstract language, organization, and problem solving to address “higher level cognitive
impairments.”
We evaluated 6 studies that provided multi-modal intervention for 1 or more deficits, including 2 Class II studies comparing the effectiveness of computer-assisted and noncomputerized cognitive remediation techniques159,160 and 4 Class III
studies.161-164 The 2 controlled (Class II) studies159,160 did not
reveal any differential effectiveness of computer-assisted versus noncomputerized intervention techniques. In both studies,
investigators compared computer-based cognitive remediation
directed at attention, memory, visuospatial functioning, and
problem-solving abilities with non-computer-based cognitive
remediation. In the study by Batchelor et al,159 both groups
received similar training consisting of repeated practice and
strategy training directed at memory, organization, planning
and flexibility, reasoning, and problem-solving abilities. In the
study by Chen et al,160 the experimental group received a
structured, hierarchical computer-based treatment, whereas the
comparison group received other therapies, including speech
and occupational therapies, in a postacute, brain injury rehabilitation program. It is likely that this group also received
cognitive rehabilitation, although it was not specified by the
authors. In these 2 studies, experimental and comparison
groups both improved significantly on neuropsychologic measures, with no significant difference between treatment conditions.
Recommendations. The studies in this area, although few,
suggest that cognitive rehabilitation therapies directed at multiple areas of cognitive impairment can significantly improve
neuropsychologic performance in those skill areas. Multimodal intervention may be considered for persons who have
multiple areas of cognitive impairment, with specific interventions based on recommendations provided in the preceding
sections. No evidence exists that computer-based cognitive
remediation provides specific benefits or effectiveness, compared with other forms of cognitive rehabilitation. From the
evidence of 2 Class II studies,159,160 the committee recommends as a Practice Option that computer-based interventions
may be used within a multi-modal intervention for cognitive
deficits, as long as a therapist is actively involved to foster
insight into cognitive strengths and weaknesses, to develop
compensatory strategies, and to facilitate the transfer of skills
from the treatment tasks to real-life situations. Rehabilitation
for cognitive deficits that relies solely on repeated exposure and
practice on computer-based treatment tasks without extensive
involvement and intervention by a therapist is not recommended.
Comprehensive-Holistic Cognitive Rehabilitation
Given the interaction of neurophysical, cognitive, and psychologic factors resulting from acquired brain injury, a persuasive argument can be made that persons with acquired brain
injury are best served by a comprehensive, integrated, and
holistic program of neuropsychologically oriented rehabilitation. These programs frequently provide intensive individual
and group therapies that address both cognitive and interpersonal-emotional impairments within the context of an organized therapeutic environment, with explicit attention to establishing an effective therapeutic relationship, to increasing
subjects’ self-awareness, and to optimizing adjustment through
realistic goals. The program may include psychosocial and
vocationally oriented interventions as well as specific efforts to
improve cognitive functioning. Improved function may be accomplished by patients’ using their residual cognitive abilities
more effectively, rather than by restoring the underlying cognitive deficits.165,166
The committee reviewed 15 studies that reflected a comprehensive-holistic approach to cognitive rehabilitation. These
included a prospective Class Ia trial of cognitive rehabilitation,167 4 Class II studies using nonrandomized or historical
controls,168-171 and 10 Class III studies.166,172-180
The Class Ia controlled trial compared the efficacy of cognitive and psychosocial day treatment programs on neuropsychologic performance.167 A subsequent publication181 reported
measures of psychosocial functioning for a subgroup of these
subjects and these findings are included in our discussion of the
present treatment efficacy study. To distinguish the contributions of structured neuropsychologic remediation and social
support, the authors of these papers “quasi-randomly” assigned
subjects with moderate to severe TBI to treatment conditions to
match for demographic and neurobehavioral factors. Besides
the group psychotherapy provided to all subjects, those in the
neuropsychologic treatment condition received specific treatments directed at improving attention, memory, visuospatial
ability, and problem solving. Subjects in the alternative (psychosocial) treatment condition received an equivalent treatment
directed at coping skills, interpersonal functioning, independent living skills, computer and video games, and personal
development. The entire treatment protocol was conducted in 8
weeks, totaling 160 hours of treatment for each subject. Both
groups improved significantly on measures of neuropsychologic functioning and depression, which could not be accounted for by spontaneous recovery (based on a stable pretreatment baseline). The subjects who received structured
neuropsychologic remediation showed marginally greater gains
of attention, memory, and verbal reasoning. The authors concluded that structured treatment was beneficial, but the results
did not indicate a specific advantage for the neuropsychologic
treatment. They noted that the neuropsychologic and psychosocial interventions shared some essential components, such as
participation in structured activities, establishment of a thera
peutic alliance, increased self-awareness, and expectations for
improvement.
The relative contributions of individualized cognitive remedial interventions and small-group based exercises in interpersonal communication within the context of a holistic neuropsychologic rehabilitation program were explicitly evaluated in a
controlled (Class II) study by Rattok et al.171 All subjects
received a 20-week treatment program that included basic
attention training, personal counseling, and community activities. Appropriate candidates received vocational counseling
and work trials after the initial 20-week treatment. During the
20-week treatment program, 1 group of subjects received a
mixture of additional cognitive remediation and interpersonal
interventions. The cognitive remediation consisted of individualized cognitive training modules addressing motor, constructional, visuospatial, or logical reasoning skills. This group also
received the group interpersonal training intended to improve
their awareness of deficits and acceptance of limitations, selfacceptance, and social relatedness. The second group of subjects received the basic attentional training and individualized
cognitive remedial interventions, but did not receive interpersonal communication training. The third group received the
initial, basic attentional training followed by the interpersonal
remediation, whereas the individualized cognitive interventions were withheld. Treatment effectiveness was evaluated on
an extensive battery of neuropsychologic measures, including
measures intended to assess both near transfer and far transfer
of the training procedures. Subjects improved on all the near
transfer measures and about half the far transfer measures.
Only the 2 groups receiving the individualized cognitive remediation improved on near transfer measures of motor dexterity,
constructional ability, and verbal reasoning, which may have
reflected practice effects as these measures were similar to the
tasks used in treatment. No group differences existed on far
transfer measures attributable to the type of treatment received.
This study also evaluated the incidence of “clinically significant change” (defined as an increase of at least 1 standard
deviation from pre- to posttreatment scores) on neuropsychologic measures. Clinically significant improvements in visual
processing, constructional skills, and verbal reasoning were
more common in the subjects receiving individualized cognitive interventions. These findings agree generally with the
Class I study, again suggesting slightly greater improvements
on specific neuropsychologic outcome measures with cognitive
interventions, with the greatest overall benefits resulting from
combined neuropsychologic and psychosocial treatments.
Three Class II studies have been conducted that allow comparison between subjects receiving comprehensive-holistic
cognitive rehabilitation and untreated control subjects; 2 studies used nonrandomized cohorts168,169 and another used historical case controls.170 Prigatano et al169 evaluated the effects of
neuropsychologic rehabilitation on productivity for 18 subjects
with TBI compared with 17 subjects with TBI who underwent
traditional rehabilitation but were unable to participate in the
neuropsychologic treatment program. After adjusting for the
contributions of demographic factors and initial level of performance, evidence existed that treated subjects performed
significantly better than control subjects on measures of memory and nonverbal intellectual functioning, and had improved
personality functioning relative to control subjects. Half the
subjects receiving the neuropsychologic rehabilitation program
were engaged in productive activity after treatment, compared
with approximately one third of control subjects. In a subsequent study,170 87% of subjects receiving neuropsychologic
rehabilitation, which included a therapeutic work trial, were
participating in voluntary or gainful employment 2 or more
years postinjury, compared with 55% of the historical control
subjects. Fryer and Haffey168 reported significant reductions in
disability status for a group of 18 treated subjects compared
with 9 nontreated control subjects. Half the subjects receiving
treatment were engaged in their preinjury role-related activities
at 1 year postdischarge.
Although most studies of cognitive rehabilitation have relied
on neuropsychologic measurement to evaluate the effectiveness of treatment, evidence exists that persons with acquired
neurocognitive impairments can improve in their life functioning absent major changes in their specific cognitive faculties.169,172-174 Return to productivity after participation in comprehensive cognitive rehabilitation programs has ranged from
40% to 78%.166,170-172,175-177 It is difficult to compare these
results across treatment studies or with nontreatment-related
outcome studies, because of injury variables, subject characteristics, length of follow-up, and lack of a standard outcome
measures. A previous review of postacute brain injury rehabilitation182 included several studies of comprehensive-holistic
rehabilitation. They reported that 71% of 856 subjects were
employed after completing postacute brain injury rehabilitation, whereas 53% of 796 subjects who received no, unspecified, or only inpatient rehabilitation were employed.
Two controlled (Class II) studies have reported psychosocial
outcomes. Prigatano169 reported that emotional distress and
psychopathology were significantly lower in treated subjects.
Rattok171 also evaluated differential effects of treatments on
measures of functional competence (eg, adaptation to community, regulation of affect, involvement with others) and intra/
interpersonal functioning (self esteem, self appraisal, empathy,
social cooperation). All 3 types of treatment produced functional and interpersonal improvements with approximately the
same number of subjects showing clinically significant improvement on measures of functional competence, although
more subjects receiving the interpersonal training tended to
improve on measures of affect regulation, self-appraisal, and
self-esteem. The results of an uncontrolled study indicated
significant reductions in self-perceived distress, a finding that
remained stable for at least 1 year after they completed the
rehabilitation program,179 and these improvements were accompanied by improvements in psychosocial functioning in
terms of personal relationships and leisure activities.175,176
Although external factors, such as lack of social support and
financial disincentives, may influence treatment outcomes, subject selection variables should be considered in evaluating the
effectiveness of comprehensive-holistic neuropsychologic rehabilitation programs. Neuropsychologic test scores, both before and after treatment, appear to bear a modest relationship to
functional outcomes.172,183 Subjects’ awareness and acceptance
of limitations, compliance with treatment objectives, and active
participation in treatment are all related to treatment effectiveness.170,177 The presence of multiple disabilities—physical, behavioral, and emotional—will affect patients’ ability to benefit
from cognitive rehabilitation.166
Recommendations. There were 3 controlled (Class II)
studies168-170 with a total of 138 subjects in which comprehensive holistic neuropsychologic rehabilitation was compared
with untreated control subjects. These studies suggest significantly greater reductions in disability after treatment and provide evidence for the effectiveness of comprehensive-holistic
neuropsychologic rehabilitation, which the committee recommends as a Practice Guideline. One Class Ia study167 comparing cognitive rehabilitation with a structured, psychosocial
intervention reported only marginal improvements on neuropsychologic measures related to cognitive rehabilitation. This
study did not include measures of functional outcome, and the
length of treatment was shorter than a typical, postacute, comprehensive-holistic rehabilitation program. The results of another controlled (Class II) study171 comparing cognitive and
interpersonal interventions suggest that clinically significant
improvements in neuropsychologic functioning are associated
with individualized cognitive remediation, and improvements
in psychosocial functioning (eg, affective regulation, self-appraisal) are associated with small group interpersonal training.
Although this finding has not been confirmed by a controlled
study comparing treated and untreated subjects, the evidence in
this area suggests that the greatest overall improvements in
functioning may be achieved by persons who receive an integrated treatment of individualized cognitive and interpersonal
therapies, which the committee recommends as a Practice
Option. Evaluating program outcomes, the committee finds
evidence suggesting that subject selection factors, particularly
the capacity to recognize and adapt to residual cognitive limitations, may moderate the effectiveness of comprehensiveholistic neuropsychologic rehabilitation.
CONCLUSION
From a comprehensive review of the empirical literature on
cognitive rehabilitation, 29 Class I studies were identified. Of
these, 20 provide clear evidence supporting the effectiveness of
cognitive rehabilitation for subjects with acquired TBI or
stroke. Several studies showed an advantage of cognitive rehabilitation over conventional forms of rehabilitation. In most
of the controlled studies with negative or equivocal results, the
intervention in question was compared with an alternative form
of treatment (in some instances, an alternative form of cognitive remediation), and in all but a single study the subjects
improved significantly even though there was not evidence of
a differential treatment effect. Of the 64 controlled Class I and
Class II studies that were reviewed, only 2 studies failed to
show improved functioning among subjects receiving cognitive
rehabilitation. In no study was there evidence that cognitive
rehabilitation was less effective than an alternative treatment.
These latter findings provide indirect support for cognitive
rehabilitation, while raising questions about the role of nonspecific factors in determining treatment effects.
Of the 20 Class I studies providing clear evidence in support
of cognitive remediation, 8 offer evidence to support visuospatial remediation of impairments of visual scanning from right
hemisphere stroke, and 4 offer evidence to support language
remediation after left hemisphere stroke. Twelve Class I studies evaluated the effectiveness of cognitive remediation for
samples consisting primarily of persons with TBI. (Of the 12
Class I studies addressing TBI, 8 were also reviewed by the
NIH consensus panel. We included 2 studies not identified in
that review and 2 studies that were classified as comparative
studies. We excluded as experimental 1 study that was included
in the NIH review.) Eight of these studies clearly support
cognitive remediation’s effectiveness for impairments of attention, functional communication, memory, and problem solving
after TBI. In 2 studies, subjects receiving specific neuropsychologic interventions showed marginally greater improvements than subjects receiving treatments that were primarily
functional or psychosocial in nature, and 1 study revealed no
difference in improvement between a specific attention treatment protocol and more general cognitive rehabilitation during
the acute postinjury period. In another study, the beneficial
effects of compensatory memory training became apparent
when treatment outcomes were analyzed independently for
those subjects with milder degrees of impairment.
Specific recommendations based on the evidence of effectiveness of cognitive rehabilitation for persons with stroke and
TBI are in table 2. All the recommendations for Practice
Standards are based on evidence from randomized, controlled
trials. The other recommendations required, at minimum, evidence from at least 1 controlled, Class II study that directly
addressed the intervention in question.
Future Directions
Because persons with acquired brain injury are likely to
exhibit multiple forms of cognitive impairment, we must continually evaluate the effectiveness of integrated therapies that
address the complex interactions of cognitive, functional, and
social impairments with the goal of alleviating disability and
handicapping conditions. Similarly, the presence and interaction of physical, cognitive, and emotional factors appear related
to treatment effectiveness. Although attempts to control for
these factors by methods such as randomized allocation of
subjects to treatment conditions do have merit, greater practical
and clinical value may accrue from identifying subject variables and other prognostic factors that contribute to treatment
efficacy and to adjust interventions accordingly. This issue has
been addressed most directly through the provision of comprehensive-holistic programs of rehabilitation for persons with
brain injury and evidence suggests that the greatest overall
improvements in functioning may be achieved by subjects
receiving an integrated treatment of individualized cognitive
and interpersonal therapies.
Unlike medical interventions that attempt to reverse pathology, rehabilitation of persons with acquired brain injury is
primarily concerned with reducing levels of disability and
handicap. Most of the studies we reviewed assessed treatment
effectiveness by means of psychometric measures presumed to
reflect a change in the level of neurocognitive impairments.
Even when the measured improvements can be attributed to
treatment, the relationship between these changes and functional improvements may not be clear or may be limited by
lack of generalization to everyday situations. Also, in some
instances, the intervention goal was to train subjects to use
adaptive, compensatory strategies for residual cognitive impairments. In these cases, the actual treatment benefits may not
be apparent on measures that do not provide the opportunity to
use such compensations. Cognitive rehabilitation should always be directed toward improving everyday functioning, and
should include active attempts to promote generalization or
directly apply compensatory strategies to functional contexts as
a part of the intervention.
Relatively few studies have directly evaluated the generalization of treatment effects to everyday situations and behaviors, although several provide evidence to support the practical
utility of cognitive rehabilitation. For example, subjects receiving visuospatial remediation improve in functional activities
that require visual scanning; subjects treated for specific language and pragmatic communication deficits improved in academic classroom functioning and interpersonal interactions;
subjects trained to use compensatory memory strategies had
fewer everyday memory failures; and subjects treated for executive dysfunction improved their behavioral self-control and
problem solving in everyday situations.
Few researchers have evaluated the long-term maintenance
of improvements produced by cognitive rehabilitation. In several studies reporting follow-up information, it appeared that
the lasting benefits of treatment depended on the subjects’
continued use of compensatory strategies in functional situations. This finding suggests the need not only for long-term
follow-up of subjects, but also for continued support and intervention after the initial period of rehabilitation. In general, it
appears that the maintenance and generalization of benefits
from cognitive rehabilitation are greatest when treatment is
provided for appropriately long periods of time, when efforts
are made by the clinician and patient to identify and apply
interventions to personally relevant areas of functioning, and
when patients are able to assume responsibility for using compensatory strategies in their everyday functioning.
Cognitive rehabilitation typically relies on individually tailored interventions to provide the best available treatment
within a clinical setting. It is strongly recommended that outcome measures also be tailored to the specific, intended effects
of cognitive interventions to evaluate realistically the rehabilitation program’s effectiveness. Ideally, these measures should
reflect meaningful improvements and functional outcomes such
as the use of compensatory strategies to accomplish real-life
demands, performance on everyday activities in the person’s
home or community, changes in level of productivity, and
measures of subjective well-being. We also recommend that
future efforts to validate the effectiveness and utility of cognitive rehabilitation include outcome measures that reflect the
levels of disability and handicap, such as community integration184 and the quality of life of the persons served. In addition,
a need exists to develop novel, multivariate research designs
and clinical trials that accurately evaluate the outcomes of
cognitive rehabilitation.185
In sum, the evidence-based review of cognitive rehabilitation provides at least preliminary support for the effectiveness
of several forms of this intervention for persons with brain
injury resulting from stroke and TBI. Specific recommendations of this review may help to establish parameters of effective treatment, which should be of assistance to practicing
clinicians.
Acknowledgments: This work was conducted through the Brain
Injury–Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. We gratefully acknowledge Cindy
Cotter, Dawn Wentar Henry, MA-CCC, Miriam Kragness, PhD, Anne
Lindsay, PhD, Carolyn Lemsky, PhD, and Clare Morey for their
assistance with the review of articles, and Lena Feld, MS, for her
assistance with the literature search.
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