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.

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.