Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014.

OBJECTIVES: To conduct an updated, systematic review of the clinical literature, classify studies based on the strength of research design, and derive consensual, evidence-based clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) or stroke. DATA SOURCES: Online PubMed and print journal searches identified citations for 250 articles published from 2009 through 2014. STUDY SELECTION: Selected for inclusion were 186 articles after initial screening. Fifty articles were initially excluded (24 focusing on patients without neurologic diagnoses, pediatric patients, or other patients with neurologic diagnoses, 10 noncognitive interventions, 13 descriptive protocols or studies, 3 nontreatment studies). Fifteen articles were excluded after complete review (1 other neurologic diagnosis, 2 nontreatment studies, 1 qualitative study, 4 descriptive articles, 7 secondary analyses). 121 studies were fully reviewed. DATA EXTRACTION: Articles were reviewed by the Cognitive Rehabilitation Task Force (CRTF) members according to specific criteria for study design and quality, and classified as providing class I, class II, or class III evidence. Articles were assigned to 1 of 6 possible categories (based on interventions for attention, vision and neglect, language and communication skills, memory, executive function, or comprehensive-integrated interventions). DATA SYNTHESIS: Of 121 studies, 41 were rated as class I, 3 as class Ia, 14 as class II, and 63 as class III. Recommendations were derived by CRTF consensus from the relative strengths of the evidence, based on the decision rules applied in prior reviews. CONCLUSIONS: CRTF has now evaluated 491 articles (109 class I or Ia, 68 class II, and 314 class III) and makes 29 recommendations for evidence-based practice of cognitive rehabilitation (9 Practice Standards, 9 Practice Guidelines, 11 Practice Options). Evidence supports Practice Standards for (1) attention deficits after TBI or stroke; (2) visual scanning for neglect after right-hemisphere stroke; (3) compensatory strategies for mild memory deficits; (4) language deficits after left-hemisphere stroke; (5) social-communication deficits after TBI; (6) metacognitive strategy training for deficits in executive functioning; and (7) comprehensive-holistic neuropsychological rehabilitation to reduce cognitive and functional disability after TBI or stroke.

Computerized Cognitive Rehabilitation of Attention and Executive Function in Acquired Brain Injury: A Systematic Review.

OBJECTIVE: Comprehensive review of the use of computerized treatment as a rehabilitation tool for attention and executive function in adults (aged 18 years or older) who suffered an acquired brain injury. DESIGN: Systematic review of empirical research. MAIN MEASURES: Two reviewers independently assessed articles using the methodological quality criteria of Cicerone et al. Data extracted included sample size, diagnosis, intervention information, treatment schedule, assessment methods, and outcome measures. RESULTS: A literature review (PubMed, EMBASE, Ovid, Cochrane, PsychINFO, CINAHL) generated a total of 4931 publications. Twenty-eight studies using computerized cognitive interventions targeting attention and executive functions were included in this review. In 23 studies, significant improvements in attention and executive function subsequent to training were reported; in the remaining 5, promising trends were observed. CONCLUSIONS: Preliminary evidence suggests improvements in cognitive function following computerized rehabilitation for acquired brain injury populations including traumatic brain injury and stroke. Further studies are needed to address methodological issues (eg, small sample size, inadequate control groups) and to inform development of guidelines and standardized protocols.

Participation after multidisciplinary rehabilitation for moderate to severe traumatic brain injury in adults.

The article by Brasure et al represents a systematic review of the literature on effectiveness of multidisciplinary rehabilitation for traumatic brain injury using rigorous methodology and focusing on participation as an outcome. The review assumes that rehabilitation "seeks to restore an individual's functioning and participation to preinjury levels" and that participation is a preferentially valued outcome. Each of these assumptions can be challenged on clinical and/or methodologic grounds. For example, holistic neuropsychologic rehabilitation seeks to promote changes in a patient's social identity as much as their social participation. Participation may not be directly related to changes in patients' activity limitations or well-being, and will not be the appropriate outcome for all studies of treatment effectiveness. The emphasis on methodologic rigor needs to be balanced by the search for relevance and reliance on the best available evidence to guide clinical practice.

A pilot study examining the effect of mindfulness-based stress reduction on symptoms of chronic mild traumatic brain injury/postconcussive syndrome.

OBJECTIVE: To evaluate the effectiveness of the mindfulness-based stress reduction (MBSR) program tailored to individuals with mild traumatic brain injury (mTBI). DESIGN: A convenience sample recruited from clinical referrals over a 2-year period completed outcome measures pre- and posttreatment intervention. SETTING: Post-acute brain injury rehabilitation center within a suburban medical facility. PARTICIPANTS: Twenty-two individuals with mTBI and a time postinjury more than 7 months. Eleven participants were men and 11 were women, ranging in age from 18 to 62 years. INTERVENTION: A 10-week group (with weekly 2-hour sessions) modeled after the MBSR program of Kabat-Zinn, but with modifications designed to facilitate implementation in a population of individuals with brain injury. (The treatment involved enhancement of attentional skills, in addition to increased awareness of internal and external experiences associated with the perspective change of acceptance and nonjudgmental attitude regarding those experiences). MAIN OUTCOME MEASURES: Perceived Quality of Life Scale, Perceived Self-Efficacy Scale, and the Neurobehavioral Symptom Inventory. Secondary measures included neuropsychological tests, a self-report problem-solving inventory, and a self-report measure of mindfulness. RESULTS: Clinically meaningful improvements were noted on measures of quality of life (Cohen d = 0.43) and perceived self-efficacy (Cohen d = 0.50) with smaller but still significant effects on measures of central executive aspects of working memory and regulation of attention. CONCLUSION: The MBSR program can be adapted for participants with mTBI. Improved performance on measures associated with improved quality of life and self-efficacy may be related to treatment directed at improving awareness and acceptance, thereby minimizing the catastrophic assessment of symptoms associated with mTBI and chronic disability. Additional research on the comparative effectiveness of the MBSR program for people with mTBI is warranted.

Facts, theories, values: shaping the course of neurorehabilitation. The 60th John Stanley Coulter memorial lecture.

We have seen an increase in efforts to establish evidence-based parameters for the practice of rehabilitation. This effort has been placed in a broader context involving the role of theory in advancing rehabilitation science, particularly in relation to specifying the active ingredients and mechanisms of action of interventions. One approach to cognitive rehabilitation is through direct training of cognitive functions such as working memory, which purportedly relies on mechanisms of neuroplasticity. However, this approach is also shown to be dependent on qualities of active attention and learning, feedback, effort, and motivation. Changes in functional and structural connectivity after cognitive rehabilitation suggest that the dynamic adjustment of task-related and resting activity in areas connected to the site of injury is the most likely mechanism underlying recovery of function. Behavioral interventions that address this process have emphasized the role of metacognitive and emotional regulation, as well as an appreciation of the role of subjective experience and beliefs, as central to the rehabilitation process. Our understanding of these processes occurs in the context of scientific values that influence judgments about how much evidence is sufficient to support the evaluation and acceptance of scientific results, including judgments about the effectiveness of rehabilitation. Evidence and theory are necessary to understanding rehabilitation, but we also need to acknowledge the values that directly and indirectly guide our research and practice.

Insomnia, fatigue, and sleepiness in the first 2 years after traumatic brain injury: an NIDRR TBI model system module study.

OBJECTIVE: To determine the prevalence of insomnia and posttraumatic brain injury (TBI) fatigue (PTBIF) in individuals with moderate to severe TBI, to explore the relationship between PTBIF and insomnia and their association with outcomes. DESIGN: Cross-sectional study. SETTING: Five National Institute of Disability and Rehabilitation Research TBI Model Systems. PARTICIPANTS: Three hundred thirty-four individuals with TBI who completed 1-year (n = 213) or 2-year (n = 121) follow-up interviews between 2008 and 2012. MAIN OUTCOME RESULTS: Insomnia occurred in 11% to 24% and PTBIF in 33% to 44% of the individuals. Insomnia and fatigue were both related to sleep disturbance, sleep hygiene, satisfaction with life, anxiety, and depression. PTBIF was associated with greater disability and sleepiness. Insomnia without fatigue was rare (2%-3%) but PTBIF without insomnia occurred in 21% to 23% of the individuals. Comorbidity occurred in 9% to 22% of the individuals. CONCLUSIONS: Although PTBIF and insomnia are closely related and both associated with poorer quality of life, they are affected independently by a variety of factors, especially psychopathology and sleep quality. A majority of individuals with PTBIF do not have insomnia; and PTBIF appears to be related to disability severity and daytime sleepiness, where insomnia is not. Demographic and injury variables are not strong predictors of insomnia or PTBIF.

Development of the participation assessment with recombined tools-objective for use after traumatic brain injury.

OBJECTIVE: To develop a new measure, the Participation Assessment With Recombined Tools-Objective (PART-O), based on items from 3 participation instruments. DESIGN: Instrument development based on survey research. SETTING: Community. PARTICIPANTS: Adults (N=400) with traumatic brain injury (TBI) 1 to 15 years postinjury, recruited from 8 TBI Model Systems (TBIMS). INTERVENTIONS: None. MAIN OUTCOME MEASURE: Community Integration Questionnaire version 2; Participation Objective, Participation Subjective; Craig Handicap Assessment and Reporting Technique; PART-O. RESULTS: Using Rasch rating scale analysis to evaluate the psychometric properties of participation items drawn from 3 instruments, a set of 24 items was developed that covered a broad range of participation content and formed a measure with person separation of 2.47, person reliability of .86, item spread of 4.25 logits, item separation of 11.36, and item reliability of .99. Items were well targeted on the sample with only 1 item misfitting. The PART-O showed expected relationships with measures of impairment, activity limitations, and subjective well-being. CONCLUSIONS: The 24-item PART-O is an acceptable measure of objective participation for persons with moderate and severe TBI. It has been adopted as the measure of participation in the TBIMS.

Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008.

OBJECTIVE: To update our clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 2003 through 2008. DATA SOURCES: PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognitive, communication, executive, language, memory, perception, problem solving, and/or reasoning combined with each of the following terms: rehabilitation, remediation, and training for articles published between 2003 and 2008. The task force initially identified citations for 198 published articles. STUDY SELECTION: One hundred forty-one articles were selected for inclusion after our initial screening. Twenty-nine studies were excluded after further detailed review. Excluded articles included 4 descriptive studies without data, 6 nontreatment studies, 7 experimental manipulations, 6 reviews, 1 single case study not related to TBI or stroke, 2 articles where the intervention was provided to caretakers, 1 article redacted by the journal, and 2 reanalyses of prior publications. We fully reviewed and evaluated 112 studies. DATA EXTRACTION: Articles were assigned to 1 of 6 categories reflecting the primary area of intervention: attention; vision and visuospatial functioning; language and communication skills; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria. DATA SYNTHESIS: Of the 112 studies, 14 were rated as class I, 5 as class Ia, 11 as class II, and 82 as class III. Evidence within each area of intervention was synthesized and recommendations for Practice Standards, Practice Guidelines, and Practice Options were made. CONCLUSIONS: There is substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI. Evidence supports visuospatial rehabilitation after right hemisphere stroke, and interventions for aphasia and apraxia after left hemisphere stroke. Together with our prior reviews, we have evaluated a total of 370 interventions, including 65 class I or Ia studies. There is now sufficient information to support evidence-based protocols and implement empirically-supported treatments for cognitive disability after TBI and stroke.

Methodological quality of research on cognitive rehabilitation after traumatic brain injury.

OBJECTIVE: To evaluate the methodological quality of research on cognitive rehabilitation after traumatic brain injury (TBI). DATA SOURCES: Secondary analysis of studies identified in prior systematic reviews of cognitive rehabilitation. STUDY SELECTION: Randomized controlled trials (RCTs) and observational studies involving exclusively or primarily participants with TBI. DATA EXTRACTION: Criteria for evaluating methodological quality were adapted from prior reviews of rehabilitation research. These criteria were modified to be relevant to cognitive rehabilitation research. Sixteen criteria for evaluating the quality of RCTs were applied: 8 relating to the internal validity of studies, 5 descriptive criteria, and 3 statistical criteria. Twelve of these criteria were used to evaluate non-RCT observational studies. DATA SYNTHESIS: Thirty-two RCTs and 21 observational studies were independently reviewed and rated by 2 of the authors. Initial agreement between raters for individual studies ranged from 57% to 100%. Interrater reliabilities based on the kappa statistic indicated moderate to substantial agreement. CONCLUSIONS: Several high-quality RCTs support the effectiveness of interventions for attention, communication skills, and executive functioning after TBI. Several high-quality observational studies support the effectiveness of comprehensive-holistic rehabilitation after TBI, including improvements in participation outcomes. The proposed criteria appear useful for evaluating the quality of research on cognitive rehabilitation and improving the design and reporting of future research in this area.

Care partner problem solving training (CP-PST) for care partners of adults with traumatic brain injury during inpatient rehabilitation: Study protocol for a multisite, randomized, single-blind clinical feasibility trial.

Traumatic brain injury (TBI) often leads to immediate and chronic functional impairments that affect care partners, or those providing physical and/or emotional support to individuals with TBI. The many challenges associated with being a care partner often lead to caregiver burden and can compromise the well-being and quality of life of care partners and individuals with TBI under their care. Equipping care partners with problem-solving skills could facilitate and sustain their transition into this supportive role. Problem-solving training (PST) has demonstrated efficacy for providing such skills to care partners of individuals with TBI after discharge from inpatient rehabilitation. We propose that PST delivered to care partners during inpatient rehabilitation of individuals with TBI will provide care partners with the skills to manage their caregiving roles across the transition from hospital to home. Herein, we describe the methodology of a current randomized controlled trial that examines the feasibility and efficacy of PST plus TBI education compared to TBI education alone to improve care partner burden, emotional distress, and adaptive coping when delivered during the inpatient rehabilitation stay of individuals with moderate-severe TBI.

A randomized controlled trial of holistic neuropsychologic rehabilitation after traumatic brain injury.

OBJECTIVE: To evaluate the effectiveness of comprehensive, holistic neuropsychologic (NP) rehabilitation compared with standard, multidisciplinary rehabilitation for people with traumatic brain injury (TBI). DESIGN: Randomized practical controlled trial. SETTING: Postacute brain injury rehabilitation center within a suburban rehabilitation hospital. PARTICIPANTS: Participants with TBI were recruited from clinical referrals and referrals from the community. Sixty-eight participants who met inclusion criteria were randomly allocated to treatment conditions. Most participants (88%) had sustained moderate or severe TBI, and greater than half (57%) were more than 1 year postinjury at the beginning of treatment. INTERVENTIONS: Treatment was conducted 15 hours per week for 16 weeks. Standard neurorehabilitation consisted primarily of individual, discipline specific therapies (n=34). Intensive cognitive rehabilitation emphasized the integration of cognitive, interpersonal, and functional interventions within a therapeutic environment (n=34). MAIN OUTCOME MEASURES: Primary outcomes were the Community Integration Questionnaire (CIQ) and Perceived Quality of Life scale (PQOL). Secondary outcomes included NP functioning, perceived self-efficacy, and community-based employment. RESULTS: NP functioning improved in both conditions. Intensive cognitive rehabilitation participants showed greater improvements on the CIQ (effect size [ES]=0.59) and PQOL (ES=0.30) as well as improved self-efficacy for the management of symptoms (ES=0.26) compared with standard neurorehabilitation treatment. These gains were maintained at the 6-month follow-up. Standard neurorehabilitation participants showed improved productivity at the 6-month follow-up associated with the need for continued rehabilitation. CONCLUSIONS: Improvements seen after intensive cognitive rehabilitation may be related to interventions directed at the self-regulation of cognitive and emotional processes and the integrated treatment of cognitive, interpersonal, and functional skills. The results show the effectiveness of comprehensive holistic NP rehabilitation for improving community functioning and quality of life after TBI compared with standard rehabilitation.

Executive attention deficits after traumatic brain injury reflect impaired recruitment of resources.

Deficits in attention are a common and devastating consequence of traumatic brain injury (TBI), leading to functional impairments, rehabilitation barriers, and long-term disability. While such deficits are well documented, little is known about their underlying pathophysiology hindering development of effective and targeted interventions. Here we evaluate the integrity of brain systems specific to attentional functions using quantitative assessments of electroencephalography recorded during performance of the Attention Network Test (ANT), a behavioral paradigm that separates alerting, orienting, and executive components of attention. We studied 13 patients, at least 6 months post-TBI with cognitive impairments, and 24 control subjects. Based on performance on the ANT, TBI subjects showed selective impairment in executive attention. In TBI subjects, principal component analysis combined with spectral analysis of the EEG after target appearance extracted a pattern of increased frontal midline theta power (2.5-7.5 Hz) and suppression of frontal beta power (12.5-22.5 Hz). Individual expression of this pattern correlated (r = - 0.67, p < 0.001) with executive attention impairment. The grading of this pattern of spatiotemporal dynamics with executive attention deficits reflects impaired recruitment of anterior forebrain resources following TBI; specifically, deafferentation and variable disfacilitation of medial frontal neuronal populations is proposed as the basis of our findings.

Comments on defining the targets, mechanisms, and active ingredients of rehabilitation.

Hart and Ehde (2015) provide a cogent framework for conceptualizing rehabilitation psychology interventions, within a broader classification of rehabilitation treatments. The tripartite structure of treatment seems simple and straightforward but, with further consideration, reveals a depth of complexity and richness.

Mental health system funding of cognitive enhancement interventions for schizophrenia: summary and update of the New York Office of Mental Health expert panel and stakeholder meeting.

TOPIC: A growing research literature indicates that cognitive enhancement (CE) interventions for people with schizophrenia can improve cognitive functioning and may benefit psychosocial functioning (e.g., competitive employment, quality of social relationships). Debate continues regarding the strength of evidence for CE and related policy implications, such as the appropriateness of funding CE services. PURPOSE: This paper summarizes and updates a meeting of experts and stakeholders convened in 2008 by the New York Office of Mental Health to review evidence on the impact of CE for people with schizophrenia and other serious mental illnesses, and addresses whether the evidence base for CE interventions is sufficient to warrant funding. SOURCES USED: Specific recommendations based on the extant literature are provided regarding the structure and components of CE programs that should be present in order to improve cognitive and psychosocial outcomes and therefore merit consideration of funding. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These recommendations may serve as a starting point in developing standards for CE programs. Establishing evidence-based practice standards for implementing CE interventions for people with serious mental illnesses may facilitate dissemination of programs that have the greatest potential for improving individuals' functional outcomes while minimizing incremental costs associated with providing CE services. Important open questions include how the performance of CE programs should be monitored and which individuals might be expected to benefit from CE as evidenced by improved functioning in their everyday lives.

Perceived self-efficacy and life satisfaction after traumatic brain injury.

OBJECTIVE: To investigate the contribution of activity-related satisfaction and perceived self-efficacy to global life satisfaction after traumatic brain injury (TBI). PARTICIPANTS: Convenience sample of 97 adults who were living in their community at least 6 months after sustaining a TBI. MEASURES: Community Integration Questionnaire, Quality of Community Integration Questionnaire, Self-Efficacy Questionnaire for TBI, Perceived Quality of Life Scale, Satisfaction with Life Scale. RESULTS: Among demographic and injury-related variables, gender and time since injury made significant contributions to the prediction of global life satisfaction. Productivity made a modest, significant contribution to life satisfaction. Satisfaction with productivity and with leisure/social activities both contributed to global life satisfaction. The greatest contribution to the prediction of global life satisfaction was made by the person's perceived self-efficacy, particularly perceived self-efficacy for the management of cognitive symptoms. Perceived cognitive self-efficacy also appeared to mediate the relation between community integration and global life satisfaction. CONCLUSION: Community integration, activity-related satisfaction, and global life satisfaction represent distinct constructs, and dissociable aspects of psychosocial outcome after TBI. Perceived self-efficacy for the management of cognitive symptoms may mediate the relation between the individual's expectations and achievements and thereby contribute to overall subjective well-being.

Cognitive rehabilitation interventions for executive function: moving from bench to bedside in patients with traumatic brain injury.

Executive function mediated by prefrontally driven distributed networks is frequently impaired by traumatic brain injury (TBI) as a result of diffuse axonal injury and focal lesions. In addition to executive cognitive functions such as planning and working memory, the effects of TBI impact social cognition and motivation processes. To encourage application of cognitive neuroscience methods to studying recovery from TBI, associated reorganization of function, and development of interventions, this article reviews the pathophysiology of TBI, critiques currently employed methods of assessing executive function, and evaluates promising interventions that reflect advances in cognitive neuroscience. Brain imaging to identify neural mechanisms mediating executive dysfunction and response to interventions following TBI is also discussed.

Vocational services for traumatic brain injury: treatment definition and diversity within model systems of care.

OBJECTIVE: To examine characteristics and diversity among vocational treatment services in model programs for traumatic brain injury (TBI) rehabilitation. SETTING: Vocational or postacute treatment components of 16 TBI Model System (TBIMS) centers. PARTICIPANTS: Vocational director/coordinator from each TBIMS surveyed in semistructured phone interview. MEASURE: Survey of vocational services for people with TBI, with about 100 closed and open-ended questions on vocational assessments; pre- and postjob placement treatments; program philosophies; funding; and integration of cognitive, behavioral, family, and medical rehabilitation interventions. RESULTS: Great diversity was found among the vocational services of the 16 TBIMS. Programs fell into 3 clusters emphasizing medical rehabilitation services, supported employment, or a combination of these with an emphasis on case management. Job coaching was identified as a key intervention, but there was great variability in intensity, availability, and funding of coaching services. CONCLUSION: Diversity in vocational services appears related to funding differences and "parallel evolution" rather than strong treatment philosophy or scientific evidence base. Multicenter research on effectiveness or establishment of best practices in vocational rehabilitation after TBI must deal with substantial existing variability in treatment models and specific interventions, and must examine the relationship of treatment variations to case-mix factors.

Evidence-based practice and the limits of rational rehabilitation.

Both the American Congress of Rehabilitation Medicine and the field of physical medicine and rehabilitation have entered an age of evidence-based rehabilitation. Despite some concerns over the difficulties in applying the methods of evidence-based practice to rehabilitation research, there is little question that we will continue to move in this direction. This will also require the translation of scientific evidence into clinical practice. Rather than representing opposing approaches to practice, the integration of the best available scientific evidence with clinical experience and judgment represent 2 of the pillars of evidence-based practice. However, we also need to recognize the subjective nature of clinical decision making as a fundamental aspect of human judgments. Finally, we need to acknowledge the subjective meanings of illness and disability to the patients we serve. Any efforts to build our practice based on the best available systematic evidence are unlikely to succeed unless we include patients values and beliefs and incorporate this perspective into our rehabilitation research. This aspect of evidence-based rehabilitation raises important questions about our fundamental roles and how we will choose to practice and define our field in the future.