Cognitive Rehabilitation Therapy

T Novakovic-Agopians and GM Abrams, University of California San Francisco, San Francisco, CA, USA; and San Francisco
Veterans Affairs Medical Center, San Francisco, CA, USA
r 2014 Elsevier Inc. All rights reserved.
This article is a revision of the previous edition article by Gary Abrams, volume 1, pp 740–743, r 2003, Elsevier Inc.

Introduction support interventions for attention, memory, executive func-

tion, social communication skills, and comprehensive–holis-
Cognitive rehabilitation therapy has been defined by the tic rehabilitation after TBI. There is also evidence to support
American Congress of Rehabilitation Medicine as systematic visuospatial rehabilitation after right hemisphere stroke, as
and functionally oriented therapeutic cognitive activities well as interventions for aphasia and apraxia after left hemi-
directed to achieve functional changes by (1) reestablishing sphere stroke.
or strengthening previously learned patterns of behavior or (2)
establishing new patterns of cognitive activity or compen-
satory mechanisms for impaired neurological systems. Similar
Attention
to the other types of rehabilitation therapy, cognitive re-
habilitation includes both restorative and compensatory ap-
A recent review of rehabilitation studies concluded that there
proaches. Restorative therapy is based on the principle that
is insufficient evidence to distinguish the effects of specific
repetitive ‘exercise’ of neural circuitry mediating cognitive
attention training during the acute recovery phase of TBI from
function will lead to learning of new skills, which will reverse
either spontaneous recovery or more general cognitive inter-
the impairment caused by injury. Restorative treatment as-
ventions. However, remediation of attention has been
sumes that surviving or nondiseased neural tissue is capable of
recommended as a practice standard during postacute re-
reorganization (neuroplasticity) to replace lost function. In
habilitation after TBI. It has further been recommended that
contrast, compensatory therapy relies on circumvention of
remediation of attention deficits should include both direct
the mechanisms that were previously necessary for a specific
attention training and metacognitive training to promote
ability. By substituting functional pathways, or using adaptive
development of compensatory strategies and foster general-
techniques or equipment, alternative methods are learned
ization to real-world tasks. An example of direct attention
to achieve a desired goal. In reality, separating restorative
training is attention process training (APS), designed to im-
from compensatory training is difficult because the cognitive
prove attention skills through a set of standardized auditory
processing practiced during compensatory therapy may be
and visual procedures made challenging by systematically in-
stimulating neural pathways mediating new learning.
creasing level of distractions. This intervention organizes at-
tention and concentration tasks into subcomponents of
sustained attention, selective attention, alternating attention,
and divided attention. Training procedures place gradually
General Cognitive Rehabilitation
increasing demands on attentional capacity by using visual
and auditory distractors, and combining single tasks into dual-
Historically, the practice of cognitive rehabilitation has been
task procedures where the patient must alternate attention or
most closely associated with the treatment of traumatic brain
divide attention across simultaneously presented procedures.
injury (TBI). Cognitive rehabilitation may address multiple
Approaches utilizing computer-based attention training
deficits concurrently, as is typical for most general rehabili-
have had difficulties with transfer, and generalization of gains
tation programs, or it can be directed at a unique cognitive
and transfer beyond practiced tasks. The current recom-
domain, such as attention or memory.
mendation is that computer-based interventions may be
The rehabilitation of cognitive deficits following brain in-
considered as an adjunct to clinician-guided treatment for the
jury has shown significant growth over the past three decades.
remediation of attention deficits after TBI or stroke, but that
Although cognitive rehabilitation for TBI has been shown to
sole reliance on repeated exposure and practice on computer-
improve many aspects of global functioning, its efficacy and
based tasks without intervention by a therapist is not
effectiveness have often been difficult to validate. Many studies
recommended.
in this area have been difficult to compare and interpret due to
a small number of subjects with heterogeneous neurological
deficits, different levels of acuity and severity of impairments,
nonstandardized interventions, and variable outcomes for Memory
defining successful treatment.
Nevertheless, in reviewing 370 published studies on cog- Memory acquisition, consolidation, and retrieval are complex
nitive rehabilitation in 1246 participants with TBI and stroke, and there are various types of memory. In general, declarative
Cicerone et al. concluded that cognitive rehabilitation is or explicit memory refers to the learning and recall of facts
clearly the best available form of treatment for people who or events. This is distinguished from procedural or implicit
exhibit neurocognitive impairment and functional limitations. memory, which is not conscious and may facilitate the
They further noted that there is substantial evidence to learning of skills or habits. Poor memory can often be an

824 Encyclopedia of the Neurological Sciences, Volume 1 doi:10.1016/B978-0-12-385157-4.00481-4

 Cognitive Rehabilitation Therapy 825

artifact of poor attention, and some memory deficits respond attention regulation and goal management strategies to indi-
quite well to remediation of attentional problems. vidually defined real-life goals during the second part of
Memory training has a controversial past. Therapies based training. GOALS participants with chronic brain injury
on repetitive drills have shown little evidence of efficacy. showed improvements in a number of targeted domains
However, other approaches to memory training have shown including: neurocognitive measures of attention and executive
efficacy. These approaches include mnemonic techniques and function; performance on a complex ‘real-life’ functional task;
other strategies that enhance registration and encoding of and self-reported use of trained strategies in daily life, in-
information, and development of memory search methods. cluding the ability to ‘stop, relax, and refocus’ during stressful
Memory strategy training appears to be most effective for times. Functional magnetic resonance imaging results indi-
persons with mild TBI and/or mild memory impairment, with cated significantly enhanced modulation of neural processing
decreasing effectiveness as injury severity and memory im- in the extrastriate cortex posttraining, and neural changes in
pairment increase. the prefrontal cortex.
External aids have been used to address both memory and
executive function impairments. The majority of more recent
memory training studies have focused on the use of memory
Spatial Perception
notebook and electronic equivalents, essentially serving as
‘memory prosthetics.’ Several studies have compared different
Hemispatial neglect and the related disorders of visuospatial
memory notebook formats and training procedures to identify
recognition accompany extensive disruption of neural circuitry
the most effective. A recent study combined strategy training
and are classically associated with right hemisphere injury.
with memory notebook training, using the eight-session group
There are multiple approaches to treatment of hemineglect,
program, and found improvement in the use of both memory
including environmental adaptation, vestibular stimulation,
prosthetics and memory strategies, with improvements ex-
phasic alerting, and visual scanning modules. A recent review
tending into patients’ everyday memory functioning.
of published studies has recommended visuospatial rehabili-
tation that includes visual scanning training for left visual
neglect after right hemisphere stroke. A carefully designed
Executive Functions
study of adaptive prisms to reverse spatial neglect has shown
that sustained visuospatial perception can be restored under
The term executive functions refers to those cognitive abilities
experimental conditions. Furthermore, functional imaging
required for formulating goals, planning how to achieve them,
studies have demonstrated reorganization of the brain in
and carrying out the plans effectively. These functions are crit-
individuals who clinically recover from spatial neglect. These
ically important in social and vocational situations, and are
encouraging observations need to be extended to other cog-
a specific target of cognitive remediation. Increasing clinical
nitive domains and emphasize that cognitive deficits are likely
experience supports the proposition that training-based thera-
to be influenced by experiential therapy. There is a continued
pies targeting problem solving, involving the use of metacogni-
need for studies assessing effects of training to improve com-
tive strategies, may improve functioning in individuals with
plex visuospatial abilities required for functional activities
chronic brain injury. Programs that allow individuals to practice
(e.g., driving).
planning, analyzing, and applying personally and functionally
relevant tasks and goals, to monitor task performance, and
to evaluate outcomes have been associated with improved
functional skills. Conclusion
Several interventions have been developed and successfully
implemented with such an approach. For example, goal The rehabilitation of cognitive deficits following brain injury
management training emphasizes the cessation of ongoing has shown significant growth over the past three decades,
activity and a metacognitive strategy for breaking down goals despite the complexity of the problems being treated and the
into manageable substeps. Learning of these strategies in a difficulty in designing valid scientific studies to guide therapy.
brief intervention improves goal management on tasks. Evans Many studies in this area have been difficult to compare and
has described another intervention that combines attention interpret due to the small numbers of subjects with hetero-
and problem solving in a group-based training protocol. Ini- geneous neurological deficits, different levels of acuity and
tial group sessions address attentional difficulties, and later severity of impairments, nonstandardized interventions, and
sessions introduce and practice the use of a problem-solving variable outcomes for defining successful treatment.
strategies. During group sessions, participants are encouraged Nevertheless, cognitive rehabilitation training has been
to adopt a systematic approach to solving problems and to repeatedly shown to improve processes such as attention,
manage and monitor goal achievement through a periodic memory, and executive functions after brain injury. Compen-
mental check. In a recent study, participants with chronic satory interventions, such as prosthetic memory devices and
frontal lesions showed improvement on a functional measure electronic alerting systems, also help improve functional skills.
and on caregiver ratings of executive functioning after the Moreover, cognitive rehabilitation therapy techniques have
implementation of the training relative to control conditions. been successfully applied to the problems of social integration
Goal-oriented attentional self-regulation (GOALS) is another and vocational training. Experience suggests that the most
group intervention that targets attention regulation skills effective therapy occurs when cognitive training is conducted
during the first phase of training, and application of trained in real-life situations and has high interest to the individual.
826 Cognitive Rehabilitation Therapy

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Cicerone KD, Langenbahn D, Braden C, Malec JF, et al. (2011) Evidence-based Journal of Head Trauma Rehabilitation 22: 303–313.
cognitive rehabilitation: Updated review of the literature from 2003 through
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Consensus conference (1999) Rehabilitation of persons with traumatic brain injury.
NIH development panel on rehabilitation of persons with traumatic brain injury.
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