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.

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.

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.

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.

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.

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.

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.

Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002.

OBJECTIVE: To update the previous evidence-based recommendations of the Brain Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 1998 through 2002. DATA SOURCES: PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, and reasoning combined with each of the terms rehabilitation, remediation, and training. Reference lists from identified articles were reviewed and a bibliography listing 312 articles was compiled. STUDY SELECTION: One hundred eighteen articles were initially selected for inclusion. Thirty-one studies were excluded after detailed review. Excluded articles included 14 studies without data, 6 duplicate publications or follow-up studies, 5 nontreatment studies, 4 reviews, and 2 case studies involving diagnoses other than TBI or stroke. DATA EXTRACTION: Articles were assigned to 1 of 7 categories reflecting the primary area of intervention: attention; visual perception; apraxia; language and communication; 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 87 studies evaluated, 17 were rated as class I, 8 as class II, and 62 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 cognitive-linguistic therapies for people with language deficits after left hemisphere stroke. New evidence supports training for apraxia after left hemisphere stroke. The evidence supports visuospatial rehabilitation for deficits associated with visual neglect after right hemisphere stroke. There is substantial evidence to support cognitive rehabilitation for people with TBI, including strategy training for mild memory impairment, strategy training for postacute attention deficits, and interventions for functional communication deficits. The overall analysis of 47 treatment comparisons, based on class I studies included in the current and previous review, reveals a differential benefit in favor of cognitive rehabilitation in 37 of 47 (78.7%) comparisons, with no comparison demonstrating a benefit in favor of the alternative treatment condition. Future research should move beyond the simple question of whether cognitive rehabilitation is effective, and examine the therapy factors and patient characteristics that optimize the clinical outcomes of cognitive rehabilitation.

Remediation of "working attention" in mild traumatic brain injury.

Several studies have reported beneficial effects of treatments for attentional deficits following traumatic brain injury. Improvements in speed of processing appear to be less robust than improvements on non-speeded tasks, while several studies suggest greater benefits of training more complex forms of attention. The present study presents preliminary results concerning the effectiveness of an intervention for attentional deficits after mild traumatic brain injury. The treatment was based upon the conceptualization of deficits and interventions as a function of the central executive component of working memory, or "working attention" . A prospective, case-comparison design was employed comparing four treatment participants with an untreated comparison sample. Treatment tasks were derived from experimental procedures which have been demonstrated to elicit working memory demands, consisting of "n-back", random generation, and dual-task procedures. The intervention emphasized the conscious and deliberate use of strategies to effectively allocate attentional resources and manage the rate of information during task performance. Treatment participants were more likely to exhibit clinically significant improvement on measures of attention and reduction of self-reported attentional difficulties in their daily functioning. Further analysis suggested that the principal effect of the intervention was on working memory, i.e. the ability to temporarily maintain and manipulate information during task performance, with no direct effect on processing speed. The results are consistent with a strategy training model of remediation, in which the benefits of treatment are due to participants' improved ability to compensate for residual deficits and adopt strategies for the more effective allocation of their remaining attentional resources.

Participation as an outcome of traumatic brain injury rehabilitation.

OBJECTIVES: Participation in meaningful life situations is an important aspect of functioning after traumatic brain injury (TBI). However, to date, few studies have included measures of social participation or community integration as outcome measures after TBI rehabilitation. This paper is a selective review of the literature that examines the effects of TBI rehabilitation on measures of participation or community integration. It also addresses the related questions of clinically significant improvements in community integration, variability in patterns of community functioning, and the relationship of participation and quality of life after TBI. DESIGN: Literature review. CONCLUSIONS: A small number of studies suggest that postacute TBI rehabilitation can produce improvements in participation and community integration. However, a considerable amount of variability in rehabilitation outcomes may be apparent. Analysis of clinically significant changes in individual's functioning suggests that rehabilitation may exert its benefits not only by facilitating improvements, but also by preventing declines in community functioning. Subjective well-being and quality of life have generally been ignored as TBI rehabilitation outcomes. There is considerable evidence that participation and subjective well-being represent distinct and dissociable outcomes after TBI, which may reflect the importance of patients' preferences and values in evaluating the effectiveness of rehabilitation.

Diagnostic utility of attention measures in postconcussion syndrome.

Neuropsychological evaluation may be of particular relevance in the detection of subtle cognitive impairments after mild traumatic brain injury (MTBI), including the subgroup of MTBI patients with a persistent postconcussion syndrome (PCS). Attention measures may be the most sensitive indicators of dysfunction associated with MTBI; however, previous studies have typically relied on the analysis of overall group differences, which may not reflect the diagnostic accuracy of attention measures when applied to individuals with MTBI. In the present study, subjects with persistent symptoms at least 3 months following a mild traumatic brain injury were compared with a sample of community living, normal control subjects in order to evaluate the sensitivity, specificity, and diagnostic accuracy of attention measures. Patients with PCS, screened with conservative inclusion and exclusion criteria, and a matched normal control group were administered six clinical tests of attention: Digit Span, Trail Making Test, Part A and Part B, Stroop Color-Word Test, Continuous Performance Test of Attention (CPTA), Paced Auditory Serial Addition Test (PASAT), and Ruff 2 & 7 Selective Attention Test. Consistent with prior research, these measures exhibited a wide range of sensitivity and specificity to possible cognitive impairment among patients. Attention measures may be the most sensitive indicators of dysfunction associated with PCS. Measures with high specificity (e.g., Stroop Color, and 2 & 7 Processing Speed) were shown to have strong positive predictive value, while measures with high sensitivity (e.g., CPTA) demonstrated strong negative predictive value for diagnosing PCS. Examination of the Odds Ratios indicated that measures assessing processing speed had a reliable, positive association with PCS, while measures without a processing speed component did not. Implications for making informed clinical decisions are discussed.

Community integration and satisfaction with functioning after intensive cognitive rehabilitation for traumatic brain injury.

OBJECTIVE: To evaluate the effectiveness of an intensive cognitive rehabilitation program (ICRP) compared with standard neurorehabilitation (SRP) for persons with traumatic brain injury (TBI). DESIGN: Nonrandomized controlled intervention trial. SETTING: Community-based, postacute outpatient brain injury rehabilitation program. PARTICIPANTS: Fifty-six persons with TBI. INTERVENTIONS: Participants in ICRP (n=27) received an intensive, highly structured program of integrated cognitive and psychosocial interventions based on principles of holistic neuropsychologic rehabilitation. Participants in SRP (n=29) received comprehensive neurorehabilitation consisting primarily of physical therapy, occupational therapy, speech therapy, and neuropsychologic treatment. Duration of treatment was approximately 4 months for both interventions. MAIN OUTCOME MEASURES: Community Integration Questionnaire (CIQ); and Quality of Community Integration Questionnaire assessing satisfaction with community functioning and satisfaction with cognitive functioning. Neuropsychologic functioning was evaluated for the ICRP participants. RESULTS: Both groups showed significant improvement on the CIQ, with the ICRP group exhibiting a significant treatment effect compared with the SRP group. Analysis of clinically significant improvement indicated that ICRP participants were over twice as likely to show clinical benefit on the CIQ (odds ratio=2.41; 95% confidence interval, 0.8-7.2). ICRP participants showed significant improvement in overall neuropsychologic functioning; participants with clinically significant improvement on the CIQ also showed greater improvement of neuropsychologic functioning. Satisfaction with community functioning was not related to community integration after treatment. Satisfaction with cognitive functioning made a significant contribution to posttreatment community integration; this finding may reflect the mediating effects of perceived self-efficacy on functional outcome. CONCLUSIONS: Intensive, holistic, cognitive rehabilitation is an effective form of rehabilitation, particularly for persons with TBI who have previously been unable to resume community functioning. Perceived self-efficacy may have significant impact on functional outcomes after TBI rehabilitation. Measures of social participation and subjective well-being appear to represent distinct and separable rehabilitation outcomes after TBI.