Cognitive Rehabilitation Kathleen B. Kortte, PhD, ABPP-CN/RP Program Director The Outpatient NeuroRehabilitation Program Assistant Professor Division of Rehabilitation Psychology and Neuropsychology Department of Physical Medicine and Rehabilitation School of Medicine
I have no conflicts of interest to disclose.
Objectives Identify cognitive rehabilitation models Brief review literature of empiricallyvalidated cognitive rehab interventions
Goal of Rehabilitation To foster and guide natural recovery processes To decrease the development of maladaptive patterns To implement physical, pharmacological, cognitive, and behavioral interventions that will increase the rate and level of functional recovery.
Goal of Cognitive Rehabilitation Functional change must be the goal of treatment. Interventions should have as their ultimate goal an increase in skill or knowledge, a belief, a change in behavior, and /or the use of a compensatory strategy that will increase or improve some aspect of independent function. Sohlberg & Mateer, 2001
ESP framework for Cognitive Rehabilitation Education Skill Development Practice/Generalization
Cognitive Rehabilitation Models Compensation model (aim: to use alternative methods for performing the same task to improve life functioning) Restorative model (aim: to improve cognitive functioning Remediation model (aim: to cure or correct the underlying neuropathology)
What works in cognitive rehabilitation? Three systematic reviews of the literature by the Brain Injury Interdisciplinary Special Interest Group (BI-SIG) of the American Congress of Rehabilitation Medicine (ACRM): 2000, 2005, 2011 Cicerone, K et al (2011). Evidenced-Based Cognitive Rehabilitation: Update Review of Literature From 2003 to 2008. Cicerone, K., et al (2005). Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 1998 Through 2002 Cicerone, K et al. (2000). Evidence-based cognitive rehabilitation: recommendations for clinical practice.
Mechanism of Change in Functioning Compensation Using new skill thus tapping into different areas of the brain to accomplish same task Using external cues, aids, equipment so not relying as much on impaired domain of cognitive functioning
What works for attention? Attention training works essential elements are direct attention training and metacognitive training to promote development of compensatory strategies. Medications to enhance attention have their therapeutic effect post-tbi on speed of processing rather than attention processes per se. As such a combination of attention training and medications may be the most efficacious. Controlled Trial Whyte et al. (2004) Effects of Methylphenidate on Attention Deficits After Traumatic Brain Injury: A Multidimensional, Randomized
What works for visual-spatial deficits? Visual scanning training produces the greatest clinically significant impact on neglect. Egocentric Allocentric hemisphere stroke. Kortte & Hillis (2011). Recent trends in rehabilitation interventions for visual neglect and anosognosia for hemiplegia following right
What works for memory impairments? Compensatory memory strategy training Self-management techniques that help an individual rely upon external aids/assistive technology. Application of strategy use and selfmanagement techniques to functional activities applicable to the individual s daily life
What works for executive functioning impairments? Problem-solving training is effective for compensating for reasoning and problemsolving deficits. Rath et al (2003). Group treatment of problem-solving deficits in outpatient with traumatic brain injury: a randomized outcome study.
Restoration Interventions a skill-based approach to improve cognitive functioning
Memory Restorative memory interventions: methods that aim to restore or improve memory ability across a variety of tasks and contexts. memory practice drills mnemonic strategy training prospective memory training
Memory Restorative Methods - Do they work? Practice Drills - ( memory exercises ) - no empirical evidence of improvement in memory functioning Mnemonic Strategy Training - (ex. visual imagery) work best in artificial lab situations or in learning rote information and often have very little benefit in real-life situations.
Memory Restorative Methods- Do they work? Prospective Memory Training - (use of external aids/ compensatory methods that are taught using spaced retrieval methods) evidence supports that it is effective for skill acquisition and does generalize to similar skills
What works for apraxia? Gestural training in order to assist in learning the sequence of movements. Strategy use
What works for language and communication disorders? Cognitive-linguistic therapeutic interventions Cueing techniques for anomia Semantic analysis Learning basic communication skills
Awareness Training Metacognitive Training - (prediction exercises with feedback and review; teach reason/use of strategies) - evidence suggests that awareness training is effective. Toglia & Kirk (2000). Understanding awareness deficits following brain injury. Fleming & Ownsworth (2006). A review of awareness interventions in brain injury rehabilitation.
So compensation works, some restorative methods work, but what about remediation? Can we actually improve brain functioning through interventions?
Attention Process Training Direct attention training (computer-based) works, but only as an adjunct to compensatory (metacognitive) methods
Aphasia Treatment Cognitive-linguistic therapies are recommended during acute and post-acute rehabilitation for language deficits Computer-based interventions as an adjunct to clinician-guided treatment may be considers in the remediation of cognitive-linguistic deficits. Sole reliance on repeated exposure and practice on computer-based tasks is not recommended.
Proposed Interventions that have little to no empirical support for brain injury EEG biofeedback (pairing of auditory or visual cues to assist an individual in increasing or reducing EEG activity in certain frequency bands) Flexyx Neurotherapy (combines conventional EEG biofeedback and photic stimulation) Interactive Metronome (computer-based program that provides real-time guide sounds to indicate users temporal accuracy as they perform a series of prescribed movements. The tonally and spatially changing guide-sounds enable users to deliberately correct their rhythmicity and timing errors as they are occurring.) Craniosacral Therapy (Manually applying subtle movements to the cranium, sacrum intracranial membranes, and spinal meninges to bring the CNS into harmony.)
What works overall: Skill development aimed at restoration and compensation for the impaired cognitive function. Improvement can be achieved in several ways: Teaching strategies (skill development and equipment use) to enable people to achieve their goals in other ways Helping people to use their residual skills more effectively Adjusting the environment
Overarching recommendation for cognitive impairments from ACRM: Comprehensive-holistic programs of cognitive rehabilitation aimed at improving community reintegration, social participation, and productivity after brain injury are supported as clinically effective. Piece-meal services to address cognitive impairments have little empirical support for leading to functional change. Cicerone, K et al (2011). Evidenced-Based Cognitive Rehabilitation: Update Review of Literature From 2003 to 2008. Cicerone K et al., (2008). A Randomized Controlled Trial of Holistic Neuropsychologic Rehabilitation After Traumatic Brain
Provision of services Cognitive Rehabilitation is a class of interventions aimed at improving daily life functioning by reducing the impact of cognitive impairments Variety of rehabilitation professionals provide cognitive rehabilitation services (ex. Rehabilitation Neuropsychologists, Speech-Language Pathologists, Occupational Therapists) Practice Standard: services should be offered within a comprehensive, post-acute, communityreentry neurorehabilitation program