EditedRecsBestPracinCognRehabi PDF

The Society for Cognitive Rehabilitation, Inc.
Malia K, Law P, Sidebottom L, Bewick K, Danziger S,

Schold-Davis E, Martin-Scull R, Murphy K & Vaidya A
Practical Innovation in Cognitive Rehabilitation Therapy
The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk

The SCR Recommendations for Best Practice
in Cognitive Rehabilitation Therapy
ACKNOWLEDGMENTS
We are grateful to the following people for their independent review and
comments on this document:
Dave Arciniegas
Yehuda Ben-Yishay
Rita Cola-Carroll
Rosamond Gianutsos
Charlotte Lough
Heidi Rubin
Barbara Wilson
1
CONTENTS
Executive Summary 3
The Purpose of this Document 4
Section One: The Framework
1. Historical Perspectives 5
2. Defining CRT 8
3. Individuals Involved in CRT 9
Section Two: Assessment & Treatment
4. Assessment 12
5. Restoration and Compensation 16
6. The Importance of Integration with other aspects of the Multidisciplinary
Team 20
7. Psychosocial Factors 21
8. Functionally Oriented 23
9. Models 25
10. Education 29
11. Process Training 32
12. Strategies 35
13. Functional Activities Training 37
14. Awareness 38
15. Reporting 41
Section Three: The Evidence Base for the CRT Program
16. Introduction 43
17. The Evidence Base 44
18. CRT treatment can help with Emotional and Psychosocial Issues 46
19. CRT treatment can have a significant effect on Brain Structures 47
20. Determining if CRT works is a Complex Issue 47
21. CRT has Face Validity 49
Useful References 50
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Executive Summary
The long-term effects of cognitive difficulties following brain injury are an
established fact. The Society for Cognitive Rehabilitation is committed to
developing and ensuring best practice within the field of Cognitive
Rehabilitation.
This document was produced at a time when various organizations are

producing Guidelines and Standards for neurological rehabilitation. It aims to
present the basis for best practice in one aspect of this, namely Cognitive
Rehabilitation, so that planners, managers, practitioners, people with brain
injury, and their families can determine what is required.
The major part of the document is comprised of 81 Recommendations, under

a variety of headings, which have been designed to comprehensively cover
clinical practice in a range of acquired brain injury settings. These
recommendations are supported with evidence in the form of expert opinion.
In addition, a section has been included to enable the reader to gain a quick
overview of best practice. This is presented in the form of an Evidence Base.
While not complete, this evidence base is a good starting point for anyone
who needs to explore this in more detail. All references are included in full.
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The Purpose of this Document

The cognitive effects of brain injury, and the implications of this for future
quality of life, have been well documented in the literature (Turner-Stokes,
2003). It is now an established fact that cognitive problems are one of the
most disabling long-term consequences of brain injury.
The National Academy of Neuropsychology (NAN) in the United States has

produced a brief Position Statement on CRT (2002). In the United Kingdom,
the Royal College of Physicians and the British Society for Rehabilitation
Medicine have produced Guidelines for both post acute brain injury
rehabilitation and stroke rehabilitation, which stress the importance of
understanding and dealing with cognitive problems (Turner-Stokes, 2003;
Royal College of Physicians, 2004).
Cognitive Rehabilitation Therapy (CRT) is central to brain injury rehabilitation

success. However, there is still debate about which treatments work best,
under which conditions, and for which patients. As a result, there have been a
number of meta-reviews, some of which are ongoing, of the vast and ever
expanding published literature in this field (Chestnut, 1999; NIHCD, 1999;
Cicerone et al., 2000; Cappa et al., 2003; Frattali et al., 2003). These reviews
aim to summarize the scientific evidence that is available.
There is also a need to take into account expert opinion. The Society for
Cognitive Rehabilitation (SCR) consists of a Board and an Advisory Board,
composed of a large number of experts in the field of cognitive rehabilitation.
It is therefore appropriate and timely that the Society for Cognitive

Rehabilitation (SCR) produces this document: Recommendations for Best
Practice. This document should be considered a work in progress, which
will be updated as new evidence is published. It is based on clinical
experience supported by published evidence.
The purpose of this document is to:
Provide a comprehensive list of recommendations for best practice based

on published evidence and expert opinion.
To act as a more detailed resource than has been produced as a result of

the meta-reviews, position statements, and guidelines documents.
To help improve clinical practice across a wide variety of settings that

provide CRT.
Please contact us with your feedback and suggestions:
[email protected]
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SECTION ONE: THE FRAMEWORK

1. Historical Perspectives
Recommendation 1.1:
Brain injury rehabilitation programs must include cognitive

assessments and treatments (CRT).
Recommendation 1.2:
CRT should be included at every stage of rehabilitation, from coma

to community, as appropriate to the needs of the individual with
brain injury.
Recommendation 1.3:
All staff working within brain injury rehabilitation must be trained to

understand cognition and its impact upon their own professional
inputs.
CRT has developed as a result of growing knowledge about the long-term

effects of brain injury. CRT was used by the British and German military in
their attempts to rehabilitate troops during the two World Wars (Pentland et
al., 1989; Poser et al., 1996).
Since the Second World War, CRT has become an integral part of brain injury
rehabilitation:
The history of CRT is both old and new. World Wars I and II led to
considerable development of methods of rehabilitation of all kinds. However
in the 1970s and 1980s the field of CRT experienced the greatest change.
This revolution was stimulated first because rehabilitation researchers and
therapists became interested in cognitive psychology, which had gone
through a period of rapid growth in the 1960s. Also, certain distinguished
figures such as Alexander Luria advanced a number of important ideas about
neurocognition and the treatment of cognitive impairments.
Parente, R. & Herrmann, D. (1996). Retraining cognition. Aspen, Maryland, p. 1.
Although TBI may result in physical impairment, the more problematic

consequences involve the individuals cognition, emotional functioning and
behaviour. The consensus recommends that rehabilitation of persons with
TBI should included cognitive and behavioural assessment and intervention.
National Institutes of Health Consensus Development Conference Statement

Rehabilitation of Persons with TBI. Convened in 1998. Put to press in 1999.
5
Cognitive impairments in memory, reasoning, attention, judgement and self

awareness are prominent roadblocks on the path to functional independence
and a productive lifestyle for the person with a brain injury . . . it became
dramatically evident to professionals, patients and their families that cognitive
impairments, which interact with personality disturbance, were among the
most critical determinants of ultimate rehabilitation outcome. Therefore
cognitive rehabilitation became an integral component of brain injury
rehabilitation.
National Academy of Neuropsychology position statement on Cognitive Rehabilitation.

May 2002. wwwnanonline.org.
Until the past decade, CRT was not addressed in textbooks or made the
object of professional conferences. In recent years, various hospitals around
the country established CRT as part of their treatment offerings. There is now
a professional organisation, the Society for Cognitive Rehabilitation that has
established certification requirements for CRT professionals.
It can no longer be said that cognitive rehabilitation is a new field.
Sohlberg, M.M. & Mateer, C.A. (2001). Cognitive Rehabilitation:

An integrative neuropsychological approach. The Guilford Press, p. ix.
Cognitive retraining has been an accepted therapeutic intervention in the

areas of psycholinguistics and special education for learning disability in
children and adults for several decades.
Berrol, S. (1990). Issues in cognitive rehabilitation. Arch Neurol 47, 219-220.
The British Society for Rehabilitation Medicine (BSRM) emphasises the

importance of cognitive deficits following TBI: Acquiring new knowledge and
skills is particularly difficult when there are cognitive deficits. All those who are
involved with the patient who has a brain injury must understand cognitive
impairments and how they alter what the patient is able to comprehend
comply with and achieve.
Rehabilitation after traumatic brain injury. (1998). BSRM. Working Party Report.
Cognitive Rehabilitation is central to any treatment program designed for the

traumatically brain injured individual.
Cognitive Rehabilitation. (1994). Rattock, J. & Ross, B.P.

Ch. 21 in Neuropsychiatry of TBI. (Eds.) Silver J.M., Yudofsky S.C., & Hales, R.E., American Psychiatric Press Inc.,
Washington, DC.
95% of rehabilitation facilities serving the needs of persons with brain injury
provide some form of cognitive rehabilitation, including combinations of
individual, group and community based therapies.
Cicerone, K.D. et al. (2000). Evidence based cognitive rehabilitation: Recommendations for clinical practice.
Arch Phys Med Rehabil 81, 1596-1615.
The Helios Program reports on good practice at various stages post injury; as
patients show signs of regaining consciousness they should be transferred to
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a rehabilitation hospital setting, where a structured program of activities not

only promotes the redevelopment of cognitive skills, but also prevents
behavioural deterioration. This work is recommended to continue into the
post acute stage: cognitive, emotional and social assessment and
intervention, and into the prevocational stage: At the psycho-social/pre
vocational stage the emphasis is on building social autonomy by cognitive,
emotional and social training.
Guidelines for good practice. The Helios Programme. (1996). Working Group on Brain Injury
Rehabilitation in the Functional Rehabilitation Sector of the European Union Helios II programme.
The BSRM states: Cognitive, emotional and behavioural problems are

extremely common following acquired brain injury . . . where cognitive
impairment is causing management difficulties or limiting response to
rehabilitation, specialist advice should be sought and if appropriate, the
patient referred to a formal rehabilitation program focused on ameliorating the
consequences of their cognitive deficits directly or indirectly.
Guidelines for Rehabilitation following acquired brain injury in adults of working age. (2003). 7th Draft.
Produced by the BSRM Working Group. Section 7.5.2.
The program must be based on the results of physical, cognitive, executive,

communication, psychosocial and functional assessments in accordance with
the stated purpose.
South Thames Brain Injury Rehabilitation Association,

Minimum Recommended Standards for Post Acute Brain Injury Rehabilitation. (2000). Standard 4.2.
The program must be based on the results of physical, cognitive,

communication, psychosocial, functional and environmental assessments.
Turner-Stokes L. (2002). Clinical Governance in Rehabilitation Medicine.

The state of the art in 2002. Clinical Rehabilitation 16 (suppl. 1): 1-58. Appendix 1:
Standards for specialist in-patient and community rehabilitation services, p. 41, Standard 5.1.
Cognitive rehabilitation must be available because, sometimes, more direct

attempts to remediate functional skills (for example hygiene, cooking) are
unsuccessful due to underlying cognitive dysfunction.
Vogenthaler, D. (1987). An overview of head injury:

Its consequences and rehabilitation. Brain Injury 1(1): 113-127.
The Brain Injury Special Interest Group of the American Congress of

Rehabilitation Medicine (ACRM BI-ISIG) was set up in 1994 to examine the
role of psychology in CRT. The group identified the positive role and value of
CRT.
Bergquist, T.F. & Malec, J.F. (1997). Psychology: Current practice and training issues in
treatment of cognitive dysfunction. Neurorehabilitation 8, 49-56.
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2. Defining CRT
Recommendation 2.1:
It is essential to have a clear definition of CRT in order to direct the

assessment and treatment activities.
In order to define CRT, it is essential to have a clear idea of what the term
Cognition refers to:
What we call cognition is a complex collection of mental skills that includes

attention, perception, comprehension, learning, remembering, problem
solving, reasoning and so forth. These mental attributes allow us to
understand our world and to function within it. After a brain injury, a person
typically loses one or more of these skills. Cognitive rehabilitation is the art
and science of restoring these mental processes after injury to the brain.
Parente, R. & Herrmann, D. (1996). Retraining cognition. Aspen, Maryland, p.1.
This general definition gives an overview of what CRT is, but the definition in
most common usage was published by the American Congress of
Rehabilitation Medicine, Brain Injury Special Interest Group (ACRM BI-SIG) in
1997:
CRT is a systematic, functionally oriented service of therapeutic cognitive

activities and an understanding of the persons behavioural deficits. Services
are directed to achieve functional changes by:
Reinforcing, strengthening or establishing previously learned patterns

of behaviour, or
Establishing new patterns of cognitive activity or mechanisms to

compensate for impaired neurological systems.
Bergquist, T.F. & Malec, J.F. (1997). Psychology: Current practice and training
issues in treatment of cognitive dysfunction. Neurorehabilitation 8, 49-56.
This definition has been adopted by the Commission on Accreditation of

Rehabilitation Facilities (CARF) and by the National Academy of
Neuropsychology (NAN) in their position statement on Cognitive Rehabilitation
(May 2002).
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3. Individuals involved in CRT
Recommendation 3.1:
CRT provision crosses disciplinary boundaries. Attempts should be

made to utilize the skills brought to this field by a variety of
individuals who have received their training in related subjects.
Practitioners of CRT should be licensed/qualified in a relevant
discipline.
Recommendation 3.2:
Relevant and extensive postgraduate training in CRT should be

completed by all individuals who provide the CRT service.
The following references support the view that CRT is a cross-disciplinary

provision and is not, nor should be, the sole domain of any single discipline:
These services (cognitive rehabilitation) are provided by college educated

individuals who, for the most part, have completed a social science curriculum
(i.e., psychology, sociology, special education).
Raymond, M.J. (1994). Neuropsychological consultation in rehabilitation.

New Jersey Rehab, March issue, pp. 18-27.
Because its roots are interdisciplinary, practitioners of CRT come from

several areas.
With a view toward efficacy, cognitive deficits should be treated within a

comprehensive neurorehabilitation program that incorporates a wide variety
of treatment modalities. Physiatry and physical therapy, individual
counselling, family interventions, vocational issues, and community re-entry
all need to be addressed. Unless all of these are integrated into the treatment
program, successful outcome of the rehabilitation process is jeopardised.
Rattok, J. & Ross, B.P. (1992). A Practical Approach to Cognitive

Rehabilitation. NeuroRehabilitation, 2(3): 31-37.
Since the cognitive deficits of patients with TBI can undermine skill learning in
all disciplines, it is incumbent upon staff to develop as many opportunities as
possible in which cognitive difficulties are the focus of treatment, and to
incorporate remedial strategies in all therapeutic encounters to maximise
learning and outcome.
Waxman, R. & Gordon, W.A. (1992). Group-Administered Cognitive Remediation for

Patients with Traumatic Brain Injury. NeuroRehabilitation, 2(3): 46-54.
9
Wilson (2002) illustrates clearly the recognition that there is a need to

incorporate information from a wide variety of sources if there is any hope of
achieving a meaningful model of CRT. Crossing disciplinary boundaries is one
way in which this goal can be furthered.
The Brain Injury Interdisciplinary Special Interest Group of the American

Congress of Rehabilitation Medicine specifies the training necessary for
qualified practitioners in cognitive rehabilitation, including:
Documented course work, relevant experience, and formalised training in the

understanding of neurological, behavioural, and cognitive functioning and
specialised training in the rehabilitation of cognitive disorders.
Head Injury ISIG of ACRM. (1992). Guidelines for Cognitive Rehabilitation.
NeuroRehabilitation 2(3): 62-67.
The Society for Cognitive Rehabilitation is a non-discipline specific body,

which seeks to bring together everyone who is providing, or who is interested
in, CRT. The SCR recognizes that different professions have different skills
that can be brought to the field for the benefit of the clients/patients.
Recommendation 3.3:
The person with brain injury should be seen as an integral member

of the team.
Recommendation 3.4:
The person with brain injury must be involved in the cognitive

treatment endeavor in the following aspects:
a) The rationale for the training must be endorsed by the individual
b) The methods and materials to be used for cognitive training must be
understood and accepted by the individual
c) The need for persistent motivation to engage must be accepted by the
individual.
These authors document that clients who were active participants in their goal
setting and monitoring of progress showed superior goal attainment and
maintenance.
Webb, P.M. & Glueckhauf, R.L. (1994). The effects of direct involvement in goal setting on rehabilitation outcome for
persons with traumatic brain injuries. Rehabilitation Psychology 39, 179-188.
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Recommendation 3.5:
The family/support system of the person with brain injury plays an

important role in intervention and should be actively involved
throughout treatment.
Clinical evidence and research data suggest a relationship between the

familys ability to adapt and cope with the trauma and the patients success in
rehabilitation. That is, there is a dynamic relationship between the patient and
family such that the injury has a dramatic impact on the family system, and
the familys response to the injury has an impact on treatment outcome. Thus,
there is a critical need to develop effective family treatment interventions.
Maitz, E.A. & Sachs, P.R. (1995). Treating families of individuals with traumatic brain injury from
a family systems perspective. J Head Trauma Rehabil 10(2): 1-11.
Rehabilitation success . . . depends upon a true collaboration with the client

and family members or other significant support persons in the clients life . . .
Collaboration (1) facilitates the identification of therapeutic goals that matter
to those individuals affected by brain injury; (2) shapes the intervention
process so that it will work for real individuals in real-world contexts; (3)
acknowledges that family members other than the person with the injury also
need support; and (4) can enhance the rehabilitation research process to
develop and evaluate effective interventions.
Sohlberg, M.M. & Mateer, C.A. (2001). Cognitive Rehabilitation. Guilford, NY, pp. 401-404.
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SECTION TWO: ASSESSMENT & TREATMENT
4. Assessment
Recommendation 4.1:
A standard battery of assessments should be administered in each

setting that provides CRT.
Recommendation 4.2:
The assessment battery should provide sufficient information to

form hypotheses about the underlying cognitive impairments and
deficits that interfere with the persons cognitive functioning.
Recommendation 4.3:
The results of the assessment battery should enable the therapist

to make decisions about which treatments are necessary, rather
than merely describing the problems.
For instance, it is not considered to be appropriate to a rehabilitation setting if

a memory test, for example, just tells the examiner that the patient has a
verbal memory deficit of so many points or standard deviations; rather the
memory test should enable the examiner to decide which aspect of the
memory process is failing and, therefore, where to target the therapy.
Recommendation 4.4:
In rehabilitation settings, standardized psychometric assessments,

questionnaires, structured interviews, and behavioral observations
across a range of functional settings should all be used without
giving stronger emphasis to any one approach.
Recommendation 4.5:
It is essential to cross-reference the results of tests with each other

and with tests done in different departments (wherever this is
possible) and with testing done on different days or at different
times of day.
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With some experience, typical patterns of deficits and strengths can be readily
identified from such a battery in the majority of patients. Where such patterns
are not clear, then expert advice must be sought, usually from a
neuropsychologist or neuropsychiatrist.
Recommendation 4.6:
Wherever possible assessment results should be shared with the

brain-injured person. They should be explained in terms that the
individual can understand and explicitly related back to the
functional problems that have been identified.
Recommendation 4.7:
A cognitive treatment plan should be drawn up with the brain-

injured person, as a direct result of the assessments. Agreement
should be reached on this between the therapist and brain-injured
person.
Recommendation 4.8:
Reassessment should be undertaken at regular intervals in order

to monitor and report on progress.
Account must be taken of test-retest biases, but it is acknowledged that there

is a lack of repeatable batteries. The guiding philosophy on retesting should
be to demonstrate to the client/patient that he or she is making progress.
Sometimes this will mean utilizing tests that may have a retest bias. However,
this underscores the importance of using questionnaires, structured
interviews, and behavioral observations alongside formal tests.
Neuropsychological, or formal, assessments are necessary, but not sufficient

for establishing levels of functioning in everyday life:
The clinical neuropsychological examination is a useful but limited tool. Full

appreciation for its diagnostic, predictive and rehabilitation-guiding strengths
and weaknesses is as much related to the clinical training of the examiner as
to technical expertise and administration of the various tests. . . .
Test scores do provide some indication of overall intellectual performance

and a general idea of relative dysfunction on the neuropsychological
measures used. However, there are many forms of intelligence or
competency that are not well tapped by even a very thorough
neuropsychological examination. These include social intelligence or the
ability to get along well with other people, work capacity, susceptibility to
fatigue, desire to do well, responsibility, etc. These are all capacities that
13
people possess which can be expected to exacerbate or minimise the impact

of certain cognitive deficits. . . .
The exact relationship of these scores to ultimate level of psychosocial

adjustment and to specific intervention activities is still far from well
understoodIf we are going to make recommendations about the
reintegration of an individual into the community following brain damage,
based on test results, we need to have a better understanding of how our
current test procedures relate to such aspects of functioning as job
performance and independence in activities of daily living.
Prigatano, G.P., Pepping, M. & Klonoff, P. (1986). Cognitive, personality and psychosocial
factors in the neuropsychological assessment of brain injured patients. Ch. 7 in Clinical
Neuropsychology of intervention. (Eds.) B.P. Uzzell & Y. Gross. Martinus Nijhoff Publishing,
Boston.
Ongoing assessment is valuable and desirable. Consistent use of procedures

that generate meaningful scores allows quantitative tracking of results. The
person with brain injury can be taught to tabulate his or her own scores on
charts provided for the individual. Especially desirable is the entry of scores
on a structured spreadsheet that produces a graphic display of results.
People with brain injury who learn to do this may acquire vocationally
valuable skills.
Rosamond Gianutsos. (2005). Personal communication.
Recommendation 4.9:
Wherever possible, assessment results and the treatment plan

should be explained, discussed, and agreed with the caregiver or
significant other.
Recommendation 4.10:
The assessment results should be used by the therapy team to

help them make a prognosis for what they can achieve with the
person with brain injury. This should be stated clearly in writing,
with justifications, to the brain-injured person and his or her
caregiver or relative. These form the 'Outcome goals.'
Treatment goals should be specified as a result of the assessment.

These should include outcome goals, long-term goals, and short-
term goals. These should be agreed with the person with brain
injury.
14
All goals should be written as SMART goals and clearly

documented.
The acronym SMART ensures that goals are:
S - Specific, M - Measurable, A - Attainable, R - Realistic/Resourced, and T -

Timely and Time bonded.
This provides structure for the brain-injured person and allows both the person
and you to monitor progress to see improvements. You should have a clear
objective for each session or activity, i.e., exactly what the person should be
able to do by the end of the session. An objective is something that can be
stated clearly and precisely, which you can observe the person doing. State
clearly what is to be achieved, under what specific conditions, by when, and
the level of correct response required. Be realistic in setting these aims and
objectives. Do not develop objectives at so high a level that you and the
person become frustrated. Review your objectives and if they are too high,
modify them.
Each of the components represented by the SMART acronym should be

present; otherwise, the goal will not happen.
McMillan T & Sparks C. (1999). Goal Planning and neurorehabilitation. Neuropsychological Rehabilitation 9, 345-361.
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5. Restoration and Compensation
Recommendation 5.1:
CRT treatments should encompass attempts at restoration of lost

function at the same time as teaching compensatory strategies to
minimize the cognitive impairments.
Recommendation 5.2:
The person with brain injury should never be told that his or her old
cognitive functions can be fully restored; they should be advised
that the aim is to maximize or optimize these skills, while learning
new ways of doing things to minimize the problems
(compensation).
The argument over whether to overcome the neurological problem or to

compensate for it has been ongoing for a couple of decades. This should not
be seen as an either/or situation. It is more appropriate to match the
approach to the needs of each client/patient.
It can be seen from the ACRM definition that CRT is concerned with both
compensating for cognitive difficulties and with restoring lost cognitive
functions. In fact this is a theme that is echoed in the works of many published
authors, for example:
Although cognition has been studied for a long time, procedures for assisting
in the restoration of cognitive functions are only now being developed.
Minimally, we ought to be able to help people identify their losses.
Additionally, people can be helped in coming to terms with the problem and
working out methods to cope with it. Finally, attempts can be made to restore
lost function. Often people ask if training is directed at compensation or at
restoration of function. The most prudent answer is both.
Gianutsos, R. (1980) What is cognitive rehabilitation?

Journal of Rehabilitation, Jul/Aug/Sep, pp. 36-40.
General cognitive therapeutic strategies consist of teaching compensatory

skills and brain retraining. Through practice and repetition, impaired cognitive
functions can be strengthened. This may occur by reinforcing foundation skills
such as attention/concentration, reaction time, visual processing, and the
ability to organise new information. These basic building blocks . . . can be
integrated into more complex functional behaviours (dressing, cooking,
balancing a chequebook and operating an automobile). Pencil and paper
tasks, computer software programs, and video feedback are used for
developing these skills.
Raymond M.J. (1994) Neuropsychological Consultation in rehabilitation.

New Jersey Rehab, March issue, pp. 18-27.
16
CRT is a process whereby people with brain injury work together with health
service professionals and others to remediate or alleviate cognitive deficits
arising from a neurological injury.
Wilson, B. (2002). Towards a comprehensive model of cognitive rehabilitation.

Neuropsychological Rehabilitation 12(2): 97-110.
Evidence for experience dependent plasticity of the brain, including cell

regeneration, means that rehabilitation can aim at reinstituting impaired
cognitive function, as well as at training compensatory strategies for the
function.
Robertson, I.H. (1999). Setting goals for cognitive rehabilitation. Curr Opin Neurol 12(6): 703-8.
Sometimes we try to restore lost functioning, or we may wish to encourage

anatomical reorganisation, help people use their residual skills more
efficiently, find an alternative means to the final goal (functional adaptation),
use environmental modifications to bypass problems or use a combination of
these methods.
There is an increasing body of evidence and opinion demonstrating that

restoration approaches are valid:
Interventions to improve neural network and cognitive function may involve

particular types of experience and stimulation (e.g., complex environments)
with experience-dependent changes demonstrable in the biology of neural
connections, small blood vessels and even the organisation of brain layers.
National Institutes of Health Consensus Development Conference

Statement Rehabilitation of Persons with TBI. Convened in 1998. Put to press in 1999.
Theoretically direct retraining of impaired cognitive functions appears to be

possible. If accomplished such training would be of substantial help to
patients.
From the NIH report. Prigatano, G.P. (1998). Cognitive Rehabilitation:
An impairment oriented approach embedded in a holistic perspective.
My first point is that restoration is an appropriate goal for the beginning of

therapy because it just might work. To the extent that it does work, it will
obviate the need for alternative treatments and reduce the total need for
rehabilitative services. To those who are concerned about the ethics of
holding out false hope, I would propose that we should question the
proprieties of ruling out hope. . . . the point is, who really has the knowledge
to justify the elimination of hope?
Gianutsos, R. (1991). Cognitive rehabilitation: Neuropsychological speciality comes of age.

Brain Injury 5(4): 353-368.
Cognitive exercise helps change the brain itself. It seems almost self evident
that this should be the case . . . systematic cognitive activation may promote
dendritic sprouting in the victims of stroke or head injury; this in turn facilitates
17
the recovery of function . . . it is logical that the more broad based a cognitive
workout regimen the more general the effects.
Goldberg, E. (2001) The Executive Brain, OUP, p. 204.
Retraining tasks do more than just restore lost functions; they also can be
instrumental in helping patients to develop compensatory strategies and vice
versa. This illustrates that restoration and compensation approaches are not
mutually exclusive:
This study looked at two groups of patients, 15 in each group. Group 1

received four 45-minute session over 4 weeks in computer tasks on a visual
remediation-training task without instruction in compensatory training. Group
2 had four 45-minute sessions over 4 weeks, consisting of instruction in the
use of three internal compensation strategies (verbalisation, chunking and
pacing). 80% of both groups used compensatory strategies. Therefore many
people following brain injury will develop these themselves whilst doing the
appropriate training tasks. It is therefore appropriate and beneficial to use
retraining tasks.
Dirette, D.K., Hinojosa, J. & Carnevale, G.J. (1999).

Comparison of remedial and compensatory interventions for adults with acquired brain injuries.
J Head Trauma Rehabil 14(6): 595-601.
Restorative training focuses on improving a specific cognitive function,

whereas compensatory training focuses on adapting to the presence of a
cognitive deficit. Compensatory approaches may have restorative effects at
certain times. Some cognitive rehabilitation programs rely on a single strategy
(such as computer assisted cognitive training), while others use an integrated
or interdisciplinary approach. A single program can target either an isolated
cognitive function or multiple functions concurrently. . . . Compensatory
devices, such as memory books and electronic paging systems, are used
both to improve particular cognitive functions and to compensate for specific
deficits. Training to use these devices requires structured, sequenced and
repetitive practice.

Rehabilitation of Persons with TBI. Convened in 1998. Put to press in 1999.
Recommendation 5.3:
Whichever mix of restoration and compensation approaches are

used, the therapy needs to be systematic, structured, and
repetitive according to the needs of each particular client/patient.
The training must be progressive and adapted to each training subject. The
training schedule must be repetitious and intense.

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The treatment consists of hierarchically organised treatment tasks and

provides exercises, which require repetitive use of the impaired cognitive
system in a created, progressively more demanding sequence. . . .
Luria theorised that recovery of function can occur through new learned
connections established through cognitive retraining exercises specifically
targeted at the source of problems for the basic processes that have been
disrupted. . . . In the process specific approach to cognitive rehabilitation,
practice or drills are simply a means of attacking deficient cognitive capacity;
the exercises do not have any inherent value in and of themselves. . . .
The process specific approach is different from general stimulation in that a

constellation of related tasks, all of which target the same component of a
particular cognitive process, are systematically and repetitively administered. .
..
Repetition is perhaps the hallmark of the process specific approach to

cognitive rehabilitation. This orientation is based, in part, on the Lurian
concept, which states a direct retraining of cognitive processes can result in a
reorganisation of higher level, thought processes. In order to do this,
however, multiple trials providing stimulation and activation of the target
process are required to achieve neurologic reorganisation. The notion is that
the repeated taxing of the same neurological system facilitates and guides the
reorganisation of function. Thus the process specific approach requires
implementation of repetitive exercises within the planned program that places
demands on the patient to perform an impaired skill.
As soon as the patient has mastered a particular exercise or group of

exercises, higher-level treatment tasks targeting the same cognitive
component need to be available so that the continued stimulation and
activation of the objective cognitive processes can occur. The final principle of
process specific therapy is a reminder that the ultimate measure of success in
therapy lies with improvement in living and work status rather than change on
test scores.
Sohlberg, M.A. & Mateer, C.A. Introduction to cognitive rehabilitation and practice.
Paper on the net (www.pacelearningrx.com/cognitiverehab.html).
19
6. The Importance of Integration with other aspects of the

Multi-disciplinary team
Recommendation 6.1:
CRT cannot be seen as a stand alone therapy, but must form

part of the multi-disciplinary approach.
Cognitive Rehabilitation is central to any treatment program designed for the

traumatically brain injured individual. Although specific cognitive exercises
have their own unique place as training tools, when used in isolation, they are
of doubtful value in aiding a traumatically brain injured person to attain true
functionality. However, when utilised as part of a comprehensive
interdisciplinary program of rehabilitation for TBI, they can be crucial and
efficacious components of treatment.
Cognitive Rehabilitation. (1994). Rattock, J. & Ross, B.P. Ch. 21 in Neuropsychiatry of TBI.
(Eds.) Silver, J.M., Yudofsky S.C. & Hales, R.E., American Psychiatric Press Inc., Washington,
DC.
There are five principles that guide the implementation of the therapies to be
discussed below (medical care, physical therapy, speech therapy,
occupational therapy, cognitive rehabilitation, psychological counselling,
behaviour management, art, and music therapy, therapeutic recreation). They
are:
Implement these various practices as early after the injury as is

feasible. Research has shown that doing so enhances eventual
outcome.
Provide the services in an holistic manner.
Provide services in an interdisciplinary manner.
Various therapies must focus on both the micro deficits and macro
deficits simultaneously. While it is important to remediate specific
cognitive problems within a laboratory/treatment setting, it is equally
important to focus on the clients functional domain (i.e., daily living
activities). Therefore, attempts to remediate a cognitive problem
should occur on both fronts simultaneously.
The design and implementation of the various therapeutic regimens
should emanate from a comprehensive, systematic, interdisciplinary
evaluation process.
Vogenthaler, D. (1987). An overview of head injury: Its consequences and rehabilitation.

Brain Injury 1(1): 113-127.
20
7. Psychosocial Factors
Recommendation 7.1:
CRT should incorporate work on the patients awareness and

psychosocial skills (e.g., coping, anxiety, mood, self-esteem, self-
concept, motivation, locus of control, adjustment).
The neuropsychological rehabilitation of traumatically head-injured people

can best be achieved by a holistic and integrated program. Such a program
must co-ordinate cognitive remedial interventions with efforts to improve
functional skills and interpersonal functions, providing specialised methods of
clinical management designed to ameliorate problems stemming from poor
compliance, lack of adequate malleability, lack of sufficient awareness and
lack of acceptance of ones existential situation.
Ben-Yishay, Y. & Gold, J. (1990). Therapeutic milieu approach to neuropsychological

rehabilitation. Ch. 11 in Neurobehavioural sequelae of traumatic brain hope. (Ed.)
Wood R.L., Taylor and Francis, London.
Cognitive and affective impairments are related to the achievement of

rehabilitation goals during the early stages after TBI and stroke.
Prigatano GP & Wong JL. (1999). Cognitive and affective improvement in brain
dysfunctional patients who achieve inpatient rehabilitation goals. Arch Phys Med
Rehabil 80: 77-84.
When emotional and motivational disturbances become the focus of

rehabilitation as well as cognitive impairments, improved psychosocial
outcomes have been reported. He then describes three aspects of this:
patients overall energy to sustain mental effort on cognitive tasks,
insight/self-awareness, speed of information processing. He states that all
three of these are very important to remediate following TBI. . . .
When the direct retraining of an underlying cognitive impairment is attempted,

it should be recalled that both cognitive and affective functions are intimately
interconnected. Consequently they must be addressed simultaneously to
maximise their usefulness for the patient. . . .
Training must help patients to adjust to whatever permanent disabilities they

have sustained and provide them with appropriate methods for doing so from
both cognitive and psychotherapeutic perspectives.

Description is provided of the holistic model of treatment that addresses

cognitive, social, emotional and functional aspects of brain injury together:
Clinically the holistic model makes sense and despite its apparent expense,
in the long term it is probably cost effective.

21
The term cognitive rehabilitation covers any intervention strategy or technique

that enables patients and their families to come to terms with, manage or to
reduce acquired cognitive deficits.
Rehabilitation after TBI. (1998).

British Society Rehabilitation Medicine (BSRM) Working Party Report.
Sohlberg and Mateer (2001) suggest that the term cognitive rehabilitation is
too narrow and it is better to talk about rehabilitation of individuals with
cognitive impairments. Wilson agrees that this seems a sensible suggestion
as it implies that people with cognitive impairment may have additional
problems that should also be addressed in rehabilitation programmes.
22
8. Functionally Oriented
Recommendation 8.1:
CRT treatment goals are tailored to enhance the individuals ability

to function as independently as possible in the least restrictive
setting. The end result of CRT must be to improve quality of life
and real life skills.
Treatment aims shall be directed towards enhancing the overall outcome. All
CRT endeavors shall be tailored to enhance the functional abilities of the
client to promote the clients ability to live as independently as possible in the
least restrictive environment. Treatment goals are directed towards
maximizing independence in skills needed for daily life and the ability to enjoy
life.
Ideally, all rehabilitative efforts aim towards returning the individual with TBI to
the community. For some, this means return to work and family
responsibilities. For others, this means living in the community with needed
services and supports.
All CRT treatment is directed towards maximizing the level of independence

through helping the individual maximize their remaining cognitive skills, along
with the use of cognitive compensatory strategies and practical application of
daily living skills using these strategies.
Wilson stresses the need for CRT to focus on functional competence as the
end point.
CRT is: The systematic use of instruction and structured experience to

manipulate the functioning of cognitive systems such as to improve the quality
or quantity of cognitive processing in a particular domain. Cognitive
rehabilitation is, therefore, a specialised component of more general
rehabilitation, the aim of which is the maximisation of the functional
independence and adjustment of the brain-damaged individual.
Robertson, I. (1999). Setting goals for cognitive rehabilitation.

Current Opinion in Neurology 12, 703-708.
CRT is the therapeutic process of increasing or improving an individuals

capacity to process and use incoming information so as to allow increased
functioning in everyday life.
Sohlberg, M.M. & Mateer, C.A. Introduction to cognitive rehabilitation and practice.
Paper on the net (www.pacelearningrx.com/cognitiverehab.html).
23
The final principle of process specific (cognitive rehabilitation) therapy is a

reminder that the ultimate measure of success in therapy lies with
improvement in living and work status rather than change on test scores.
Sohlberg, M.M. & Mateer, C.A. Introduction to cognitive rehabilitation and practice. Paper on the net
(www.pacelearningrx.com/cognitiverehab.html).
In short cognitive rehabilitation should focus on real life functional problems, it

should address associated problems such as mood or behavioural problems
in addition to the cognitive difficulties and it should involve the person with
brain injury, relatives and others in the planning and implementation of
cognitive rehabilitation. Within the discussion on what to focus of trauma
makes the point that the end point is functional improvements.

Neuropsych Brain Rehabilitation 12(2): 97-110.
Recommendation 8.2:
Each functional task needs to be analyzed in terms of its

constituent functions, and those functions that are impaired need
to be compensated for in order to make possible the normal
performance of that functional task.
Recommendation 8.3:
The therapist must make explicit to the brain-injured person how

these impairment-based goals link with functional competence.
Recommendation 8.4:
Opportunities to practice in real life settings should be provided as

part of this process in order to develop generalization and transfer
of learning.
24
9. Models
Recommendation 9.1:
CRT cannot be informed by a single model (such as cognitive

neuroscience), but needs to incorporate models from diverse areas
of human function.
Rehabilitation is one of many fields that needs a broad theoretical base

incorporating frameworks, theories and models from a number of different
areas. Gianutsos (1989) stated, Cognitive rehabilitation came of mixed
parentage including neuropsychology, occupational therapy, speech and
language therapy and special education. McMillan and Greenwood (1993)
stated, These authors understood that cognitive rehabilitation should not be
confined by one theoretical framework or model. A description is given of the
holistic model of treatment that addresses cognitive, social, emotional and
functional aspects of brain injury together: Clinically the holistic model makes
sense and despite its apparent expense, in the long term it is probably cost
effective. A diagramatic provisional model of CRT is proposed to encompass
the variety of aspects that need to be considered when undertaking CRT.

Barbara Wilsons (2002) provisional model of cognitive rehabilitation.
25
Recommendation 9.2:
Cognitive skills should be considered as a hierarchy.
Hierarchical Cognitive Model
Community Metacognition
integration (Awareness &
Regulation)
Language,
Executive Memory,
Visual Processing,
Information Processing,
Attention & Orientation
Arousal
Psychosocial Functions
Recommendation 9.3:
The following five cognitive skill areas should be comprehensively

assessed and, wherever necessary, treated.
26
Attention skills include the following aspects: Sustained, Selective, Alternating,

and Divided.
Visual Processing skills include the following aspects: Acuity, Oculomotor

Control, Fields, Visual Attention, Scanning, Pattern Recognition, Visual
Memory, and Visual Cognition or Perception.
Information Processing skills include the following aspects: Auditory and other
Sensory Processing skills, Organisational Skills, Speed, and Capacity of
Processing.
Memory Skills include the following aspects: Orientation, Episodic,

Prospective, Encoding, Storage, Consolidation, and Recall.
Executive Skills include the following aspects: Self-Awareness, Goal Setting,

Self-Initiation, Self-Inhibition, Planning and Organization, Self-Monitoring, Self-
Evaluation, Flexible Problem Solving, and Metacognition.
Recommendation 9.4:
Attention skills should be seen as the underlying foundation of all

other cognitive skills. Assessment and treatment should always
begin at this level if problems are evident.
Recommendation 9.5:
It is essential to work on executive skills and awareness at all

stages of cognitive development.
Recommendation 9.6:
It is important to determine whether the commonly reported

memory difficulties are dependent upon attention or information
processing failures, i.e. secondary manifestations of impulsivity,
attention deficits, and information processing failures or the result
of interactions among these three functions.
27
There are four approaches to successful cognitive rehabilitation (Malia &

Brannagan, 2000):
1. Education
2. Process Training
3. Strategy development and implementation
4. Functional Application
Recommendation 9.7:
The four approaches to CRT should be used concurrently with all

patients but the relative balance between them will alter according
to the presenting neurological condition (e.g., tumors may not
benefit from process training), stage post-injury, awareness level of
the patient, and time constraints of the staff.
28
10. Education
All individuals with brain injury should receive education

appropriate to their abilities and needs. In an inpatient center, this
is usually best done through a formal education group. In settings
or circumstances that preclude this, the therapist should ensure
that the individual receives appropriate education at sufficient
intensity and with adequate repetition to ensure learning. The
following recommendations do not necessarily apply if it is not
possible or appropriate to run an education group.
Wherever possible, all individuals with brain injury should attend an

education group at least once, so long as their language skills,
attention skills and awareness levels permit.
The decision to include in or exclude from an education group

should be made by mutual consent of the whole team at the
treatment planning or multidisciplinary team meeting, wherever this
is possible.
Education should take place in a formal education group and in

individual sessions. It should be seen as an ongoing process
rather than only occurring on one occasion
The education group should take place regularly. In institutions it is

often helpful to run this for one hour each day until the content has
been covered (see recommendation 10.8).
29
The education group should be conducted by therapists with

training/expertise in running therapeutic groups. It is recommended
that two therapists should be involved in the group.
There should be a minimum of 3 and a maximum of 7 patients in

any group.
Education should cover the following areas:

Neuroanatomy, understanding the own brain injury and what
rehabilitation is all about.
Cognitive problems following brain injury.
Emotional problems following brain injury, how to cope with the
changes one experiences and developing a new sense of self.
Generally, the brain-injured person should be fully apprised of his

or her cognitive problems, the fact that he or she has had a brain
injury and the likely prognosis for the individual cognitively, at the
earliest stage possible. If this is not done, there should be a clear
and compelling reason.
This will often be started during the assessment phase, but will certainly be
completed immediately after assessment. This aspect of education is
considered to be an ongoing process which aims to help the patient to
develop appropriate self-awareness, heighten self-esteem, develop
confidence, develop feelings of personal control, and develop a trusting,
working relationship with the therapist.
The importance of education cannot be overemphasized. Without good

awareness much of what is subsequently offered will have no lasting effects
on the brain-injured person's life once he or she leaves the rehabilitation
environment. Education should continue as long as is necessary; in some
cases, this may mean years.
30
A range of appropriate materials should be available for the brain-

injured person, including books, CD-ROMs, Internet access, and
relevant articles, along with the education group notes.
31
11. Process Training

The purpose of process training is essentially to stimulate poorly functioning
neurological pathways in the brain in order to maximize their efficiency and
effectiveness. This will sometimes mean using new undamaged pathways
(redundant representations) and, sometimes, old partially damaged pathways.
Process training therefore aims to overcome the damage.
Process training is not general stimulation or drill training, although this may
have some benefits they are not specific and may not generalize to real life.
Process training relies on two components:
Good comprehensive assessment

Analysis of the results according to a practical cognitive model
The analysis should always ask, Why is that problem occurring? until an
impaired component skill or cluster of skills is revealed. A task, or preferably a
series of tasks, is then designed to develop and improve the impaired skills. If
this approach is successful, then any real life skills that rely on that underlying
impaired skill should improve as it improves.
The analysis should essentially result in the generation of a hypothesis, which

is then tested with appropriate training materials. Formal reassessment helps
to determine the accuracy of the hypothesis.
Process training should be used with the majority of people with

brain injury to work on the hypothesized underlying impairments, at
the same time as working on functional goals.
Process-training approaches must rely on the results of a

comprehensive assessment that seeks to help the therapist
analyze the underlying causes of functional breakdowns.
Process-training exercises should be extensive. A wide range of

exercises should be available to target particular impairments. In
order to avoid mere training on a task, Individual process training
exercises should not usually be repeated an excessive number of
times. It is better to work towards generalization of the skill by
32
using multiple exercises, each targeting the impairment in slightly

different ways.
Process training exercises should be arranged systematically in a

structured program that will help lead the person with brain injury
towards accomplishment of a range of functional skills or
behaviors.
Regular reassessment should be completed to ensure that the

person with brain injury is moving towards his or her functional
goals. The results of this should determine the direction and
progress through the process training exercises.
Experience shows that the use of process training materials that have been
designed on the basis of neuropsychological theories, and arranged into a
structured program format, usually lead to good gains in the majority of
patients (Malia et al., 1993, 1995, 1995, 1995, 1996, 1998; Bewick et al., 1995;
Raymond et al., 1996, 1996, 1999; Bennett et al., 1998; Fuii et al., 2001).
The reasons for progress on these process-training exercises are complex,

but the relationship between the following factors is thought to play a major
role in the success:
1. The development of awareness through the exercises.

2. The structured programmed approach to the materials.
3. Daily concrete feedback and concrete goals.
4. The relatively short time frames to complete blocks of work.
5. The development of patient self-confidence.
6. The development of patients feelings of being in control.
7. The massed practice available via homework exercises.
8. Activation of neurological pathways through appropriately targeted
repetitive cognitive exercises.
9. The development and utilization of compensatory strategies to
improve performance.
10. Process training is a neutral activity and most patients do not feel
threatened by it; this enables them to accept constructive feedback
more readily.
11. The activities are easily quantifiable and scoreable.
12. Results can be easily graphed to demonstrate improvement and
this, in turn, leads to improved motivation and self-esteem.
33
Process-training exercises should incorporate a strong emphasis

on developing self-awareness of problems and their implications
for the future. This can be achieved via self-prediction and self-
rating scales, as well as daily feedback.
SMART goals should be written for each process training exercise.
Ideally, blocks of process-training exercises should be completed

intensively over relatively short time periods, interspersed with
reassessment, feedback with the person with brain injury, and
reevaluation of the next step.
Intensive work can be enhanced with the aid of process training

exercises being given for homework sessions, whenever this is
possible.
Each process training exercise should be scored as soon after

completion as possible. The score should be compared with
previous scores on the same exercise and related to self-predicted
and self-rated scores. In many cases, it is a good idea to present
this information in a graphical format. The score should also be
related to the criterion for success specified in the SMART goal.
Process training should be used in conjunction with strategy

training; the process training exercises can be used to show the
person with brain injury how well the implementation of a strategy
improves his or her performance. This, in turn, should be related to
the functional activities training.
34
12. Strategies
It is not always possible to utilize new neurological pathways in the brain to
overcome the problems, so strategies can then be taught to compensate for
the remaining difficulties. Strategies can be divided into two types: external
and internal. External strategies consist of those things that are external to the
person, such as alarms, notebooks, notes, and calendars. Internal strategies
are those mnemonics that cannot be observed by anyone else, such as
visualizations and word associations (Malia & Brannagan, 1997).
Internal strategies require greater cognitive capacity than external strategies

because the strategy has to be remembered at the very time when the person
is beginning to struggle with a task, i.e., when he or she is becoming
overloaded (Malia & Brannagan, 2004).
The independent use of strategies is entirely dependent upon the level of

awareness that the person with brain injury has. If the individual has no
awareness, then he or she will not perceive the need to implement a strategy,
even when he or she beings to fail on a task. This level of awareness problem
therefore necessitates the use of environmental modification and/or strategies
implemented by other people. If the brain-injured person has good awareness,
he or she can reasonably be expected to implement taught strategies
independently (Malia & Brannagan, 2004).
Strategy training should be used with the majority of people with

brain injury to minimize the problems they are experiencing.
The person with brain injury should be advised that he or she may
always need to use the taught strategies, which will involve
learning a new way of operating.
External strategies are easier to apply than internal strategies.

They should therefore be the strategies that are taught first.
35
Strategy training should be matched to the level of awareness

shown by the person with brain injury. As awareness increases,
different strategy training should be incorporated.
The value of strategies can be taught very quickly on the process

training exercises. Process training and strategy training should
therefore be incorporated simultaneously in the majority of
rehabilitation programs for individuals.
36
13. Functional Activities Training
All cognitive rehabilitation tasks should focus on improving real life

functioning.
Functional activities should be used in two distinct ways:

As a vehicle within which to treat the cognitive skill deficits
To train the person to complete the particular functional task
Goals should be written for each of these approaches.
Functional goals should be selected in close consultation with the

person with brain injury. They should be goals that are valuable
and important to the person with brain injury, rather than to the
therapist.
Functional activities should be broken down into their component

parts and these should be related to the process training and
strategy training components of the rehabilitation program in each
case.
37
14. Awareness
Awareness should be considered to be the key to successful

rehabilitation. A great deal of the rehabilitation work should aim at
developing appropriate awareness of cognitive skills and how
these are important in the direction the person with brain injury will
take in the future.
The development of appropriate awareness should be directly

worked on, rather than left to chance.
Patients lack of awareness regarding the existence or severity of deficits after
brain injury represents a particular area of significance and is often a central
concern for neuropsychological interventions. . . .
Clinically the findings suggest that for patients unable to engage in treatment
due to their unawareness of deficits, priority needs to address the patient's
awareness deficits and resistance in therapy. One of the most common and
costly errors of treatment may be the failure to confront the patient's
unawareness. . . .
Therapist actions that can facilitate collaboration need to be considered in

neuropsychological remediation; schema like Crosson and coworkers (1989)
distinction among types of awareness deficits represent a valuable start in
this direction.
Cicerone, K.D. & Tupper, D.E. (1991). Neuropsychological rehabilitation treatment of

errors in everyday functioning. Ch. 11 in (Eds.) Tupper, D.E. & Cicerone, K.D., The
neuropsychology of everyday life: Issues in development and rehabilitation. Academic
Publ., Kluwer, Boston.
All staff members should be trained to understand awareness, how

it links to cognitive skills and what can be done to enhance it. A
model should be used to guide this process.
38
Crossons modified model of

awareness (Malia, 1997)
Maximal Maximal
Full Acceptance
Cognitive
Executive
Metacognitive
Skills Growing Acceptance
Anticipatory
Awareness
Emergent Awareness
None Personal happiness
Self esteem etc.
Intellectual Awareness
Minimal Minimal
Intellectual awareness has been achieved when the person is able to

demonstrate that he or she knows what his or her problems are and what they
have in common, i.e., I keep forgetting things people say to me and this is
because I have had a brain injury. This can be documented through self-
rating charts and assessments.
Emergent awareness has been achieved when the person is able to

demonstrate that he or she knows a problem is happening as it is occurring
without prompting, i.e., on line awareness of a problem. This can only be
documented through observation of his or her behavior.
Anticipatory awareness has been achieved when the person is able to

predict or anticipate the situations in which his or her problems are likely to
occur. This only can be documented through observation of the persons
behavior. It is only at this stage that the person will be able to implement
compensatory strategies for cognitive deficits unaided. Thus, the development
of awareness levels needs to be taken into account when setting goals and
making prognoses about rehabilitation efforts.
Crosson, B. et al. (1989). Awareness and compensation in post acute head injury rehabilitation.
Journal of Head Trauma Rehabilitation 4, 46-54.
Education, process training, and strategy training approaches

should all be matched to the level of awareness.
39
Level of awareness of cognitive weaknesses and strengths should

be explicitly documented in the treatment plan. CRT therapists
should encourage other team members to do this as well for each
domain of function, e.g., physical, executive, emotional,
communication, and ADLs.
The importance of awareness, why it is often compromised

following brain injury, and what will be done to try to improve it,
should all be explained to the person with brain injury as part of his
or her educational program.
Even when the person with brain injury achieves anticipatory awareness in the
rehabilitation environment, he or she may still believe he or she will wake up
one day and everything will be fine. This is quite common. Thus, the second
part of the model deals with the level of acceptance of ones problems. This
forms part of the journey towards a new sense of self, which is at the core of
every rehabilitation program (Ben-Yishay & Daniels-Zide, 2000).
The importance of developing a new sense of self should be

emphasized to every person with brain injury.
40
15. Reporting
Assessment should result in the production of a document that

clearly lists each of the problems, including the level of severity,
and an analysis of the underlying causes of the difficulties. This
same document should include the predicted length of treatment,
the goals to be achieved by discharge and the short-term
objectives to achieve these. This document forms the basis of the
treatment plan.
Treatment plans should be provided for the person with the brain
injury, (unless he or she is unable to benefit from it due to severity
of cognitive impairment), any caregivers or family members, and all
relevant staff members.
The treatment plan should not be finalized until the person with
brain injury indicates that he or she has understood and agrees to
the content. This may involve some negotiation and/or education.
The treatment plan should be written in a manner that is easily

comprehended by the person with brain injury.
Progress notes should be maintained regularly in order to

document any major events which take place during therapy.
41
The treatment plan is the guide that should be followed in

designing the treatment. If new issues arise, or progress is better
or worse than predicted, then this needs to be annotated on a
revised treatment plan.
Progress on the treatment plan should be reviewed regularly with

all team members, including the person with brain injury. It is
recommended that this review take place every 2-3 weeks in an
institutional setting or after a pre-determined number of sessions in
other settings, e.g., after every 10 treatment sessions.
42
SECTION THREE: THE EVIDENCE BASE FOR CRT
16. Introduction
A common question asked of CRT is does it work? This is too simplistic a

question. CRT involves multiple facets, and the challenge is to determine
when and in what way each of these facets works best.
A huge amount of effort has been, and continues to be, expended on these
types of questions, which is only to the credit of this field, since the same
quantity and quality of research does not exist for the following aspects of
brain injury rehabilitation:
The value and role of medicine

The value and role of psychology
The value of occupational therapy
The value of physical therapy
The value of speech and language therapy (outside of
dysphasia following stroke)
Evidence-based practice is an essential component to gaining greater

understanding, but it is not the whole story. The people who undertake
evidence-based studies need to have a good understanding of the field,
particularly because brain injury rehabilitation is such a complex area (see
section 20). This has not always been the case:
If any methodology is applied without considering the complexities of the

phenomena under investigation and other relevant sources of information,
inaccurate or incomplete conclusions can easily be made in the name of
science. . . . let us not replace careful clinical observation and judgement with
statistics and research design and call it good practice.
Prigatano, G.P. (2000). Letters to the Editor. J of Head Trauma Rehabilitation 15(1): x.
My comments are offered as someone who worked with Carney et al. to

prepare the report, (and I) reviewed much of the research. . . . Many of us
would agree that practice should be based on empirical research. . . . the
shortcomings (of this review) were exacerbated by the reviewers lack of
familiarity with the material. I view the evidence-based report on cognitive
rehabilitation as substantially flawed.
Kreutzer, J.S. (2000). Letters to the Editor. J Head Trauma Rehabilitation 15(1): x.
The following references illustrate the evidence and expert opinion, as well as
point out some of the problems with establishing evidence based practice. It is
recommended that the meta-reviews be read in detail to obtain further
information.
43
17. Evidence Base

There is increasing evidence that intervention through retraining or provision
of compensatory memory aids can result in improved cognitive functioning.
Wilson (1998). Recovery of functions following non-progressive brain injury.

Curr Opin Neurobiol 8(2): 281-7.
Since the mid 1980s the effectiveness of CRT has been repeatedly evaluated
and several reviews have documented its efficacy (Butler & Namerow, 1988;
Gianutsos, 1991; Glisky & Schacter, 1989; Godfrey & Knight, 1987; Gordon &
Hibbard, 1991; Gouvier, 1987; Hayden, 1986; Parente & Anderson-Parente,
1991; Prigatano & Fordyce 1987; Seron & Deloche, 1989; Sohlberg & Mateer,
1989; Wehman et al., 1989; Wood & Fussey, 1990). Each of these reviews
attests to the success of one or more methods of CRT.
Parente, R. & Herrmann, D. (1996). Retraining cognition. Aspen, Maryland, p.1.
A review of the literature for CRT in TBI published from January 1988 to
August 1998 was conducted by the National Institute for Health Consensus
Development Panel. This review included 11 randomised clinical trials. The
NIH statement provides state of the art information regarding effective
rehabilitation measures for persons who have suffered a TBI and presents the
conclusions and recommendations of the consensus panel regarding these
issues. Although studies are relatively limited, available evidence supports the
use of certain cognitive and behavioural strategies for individuals with TBI. . . .
Cognitive exercises, including computer-assisted strategies, have been used

to improve specific neuropsychological processes, predominantly attention,
and memory and executive skills. Both randomised controlled studies and
case reports have documented the success of these interventions using
intermediate outcome measures. Certain studies using global outcome
measures also support the use of computer assisted exercises in cognitive
rehabilitation. Compensatory devices, such as memory books and electronic
paging systems, are used both to improve particular cognitive functions and
to compensate for specific deficits.
National Institutes of Health Consensus Development Conference Statement Rehabilitation of

Persons with TBI. Convened in 1998. Put to press in 1999.
The American Congress of Rehabilitation Medicine (ACRM) conducted a

meta-analysis of CRT. Cicerone et al. took 171 articles on cognitive
rehabilitation from a referenced set of 655 published articles, assigned them
to different categories of cognitive function and to level of evidence (Class I, II
or III, see note below). 29 were class I, 35 were class II, and 107 were class
III. 20/29 of the Class I studies (69%) support clearly the effectiveness of
CRT. 62/64 class I and class II studies combined (97%) showed improved
functioning among people receiving CRT.
Cicerone, K.D. et al. (2000). Evidence based cognitive rehabilitation: recommendations for clinical practice.
Arch Phys Med Rehabil 81, 1596-1615.
44
Class I = prospective, randomised controlled and well designed studies

Class II = prospective, non-randomised studies, retrospective, non-
randomised case control studies, or clinical series with controls
Class III = studies with no controls, or single case studies
In 1999, a Task Force was set up under the auspices of the European
Federation of Neurological Societies with the aim to evaluate the existing
evidence for the clinical effectiveness of cognitive rehabilitation and to provide
recommendations for practice based on this evidence:
There is enough overall evidence to award a grade A recommendation

(based on Randomly Controlled Trial studies) to some forms of cognitive
rehabilitation in patients with neuropsychological deficits in the post acute
stage after focal brain lesion (stroke, TBI). These include neglect and apraxia
rehabilitation after stroke, attention training after TBI . . . and memory
rehabilitation with compensatory training in patients with mild amnesia.
Cappa S.F. et al. (2003). EFNS guidelines on cognitive rehabilitation: report

of an EFNS task force. European Journal of Neurology 10, 11-23.
The AHCPR panel formulated five questions addressing the effectiveness of

early rehabilitation in the acute care setting, intensity of rehabilitation,
cognitive rehabilitation, supported employment, and case management. For
the question on cognitive rehabilitation, 15 randomised controlled trials and
comparative studies that met specified inclusion criteria were placed into
evidence tables. They report that there is evidence from two small studies
(class I and class III) that a personally adapted electronic device, a notebook
and an alarm wristwatch, reduce everyday memory failures for people with
TBI. There is evidence from one study (class IIa) that compensatory cognitive
rehabilitation reduces anxiety and improves self-concept and relationships for
people with TBI. Evidence from two studies (class I and class IIb) supports
the use of computer aided cognitive rehabilitation to improve immediate recall
on neuropsychological testing, but the clinical importance of this finding has
not been validated.
Chestnut, R.M. et al. (1999). Rehabilitation for traumatic brain injury. Summary,
Evidence Report/Technology Assessment: Number 2. Agency for Health Care Policy
and Research (AHCPR), Rockville, MD.
Rattock et al. studied three types of treatment:
Cognitive remediation, small group interpersonal communication

training, therapeutic community activities and personal counselling
Similar to mix one, but omitted the cognitive remediation and
stressed the small group interpersonal communication training
Emphasised cognitive remediation and eliminated the small group
interpersonal activities.
Results showed that all three mixes produced near and far transfer of
remedial training in certain circumscribed areas of cognition, but that
systematic cognitive remedial training yielded additional specific carryover
cognitive effects. Carry over to everyday life was best done by mix one,
although all were effective.
45
Taken together the findings from this study appear to disprove the arguments
of those critics of cognitive remediation who question both its validity and
efficacy on the grounds that it can produce no more than practice effects
rather than a genuine improvement in cognitive functioning . . . the evidence
from this study points to the superiority of the balanced mix of treatments over
the other two variations.
Rattock, J.D. et al. (1992). Outcome of different treatment mixes in a

multidimensional neuropsychological rehabilitation programme.
Neuropsychology 6(4): 395-415.
Palmese and Raskin found that the Attention Process Training program
(Sohlberg & Mateer, 1986) improved attention and performance speed in
each of the three people studied with mild TBI.
Palmese, C.A. & Raskin, S.A. (2000). The rehabilitation of attention in individuals with mild TBI,
using the APTII programme. Brain Injury 14(6): 35-48.
There have been no Cochrane reviews of traumatic brain injury to datethey

have all focused exclusively on stroke. These reviews conclude that there is
insufficient evidence to support or refute the effectiveness of CRT following
stroke. However, these reviews only examine Class I evidencethere are not
enough of these studies and many authors advocate the use of well designed
Class II and Class III studies to be included, and in many cases state that
these are preferable for this patient group (Cope, 1998; Cappa et al., 2003):
The Cochrane Library, Issue 1 concludes that there is some indication that
training improves alertness and sustained attention, but no evidence to
support or refute the use of cognitive rehabilitation for attention deficits to
improve functional independence following stroke.
Lincoln NB, Majid MT & Weyman N (2003).

Cognitive rehabilitation for attention deficits following stroke (Cochrane review).
The Cochrane Library, Issue 1 concludes that there is insufficient evidence to

support or refute the effectiveness of cognitive rehabilitation for memory
problems after stroke.
MT Majid, Lincoln NB & Weyman N (2003).

Cognitive rehabilitation for memory deficits following stroke (Cochrane review).
18. CRT treatment can help with emotional and

psychosocial issues
The present data suggest that structured activities can ameliorate some of
the emotional adjustment difficulties, even if years have passed since the
injury.
Ruff, R.M. & Niemann, H. (1990). Cognitive rehabilitation versus day treatment in head injured adults:
Is there an impact on emotional and psychosocial adjustment? Brain Injury 4(4): 339-347.
Carney et al. looked at 600 potential references; 32 of these were used. Two
randomised controlled trials and one observational study provided evidence
46
that specific forms of CRT reduce memory failures and anxiety, and improve
self-concept and interpersonal relationships for persons with TBI.
Carney, N.A. et al. (1999). Effect of cognitive rehabilitation on outcomes for persons with TBI:
A systematic review. J Head Trauma Rehabil 14, 277-307.
19. CRT treatment can have a significant effect on brain

structures
Of the three cases used in this study, two began their CRT programme at 1
and 2 months post-injury and were both diagnosed as severely injured. All
cases demonstrated significant increases in regional cerebral blood flow in
the areas of brain damage and adjacent to them. These changes were
maintained at follow up done 12-45 months post-injury.
Laatsch, L. et al. (1997). Impact of cognitive rehabilitation therapy on

neuropsychological impairments as measured by brain perfusion SPECT.
Brain Injury 11(12): 851-863.
20. Determining if CRT works is a complex issue
Rattock and Ross describe their efforts to measure the efficacy of CRT
using a rational scientific approach, involving pre- and post-testing on a
range of measures including a neuropsychological battery, specific
domain measures, functional real life skills, and quality of life. This
allowed improvements to be measured both on the specifically treated
domain and in terms of generalization to other tasks.
They report that these brave attempts to use this scientific approach
have been equivocal due to the following: the neuropsychological
batteries currently in use are not sensitive enough to detect small
changes in specific cognitive domains; and CRT cannot be provided as
the sole intervention due to the emotional and physical difficulties also
presented by the patients.
They report that the proof of efficacy of outcome in CRT lies in the
overall improvement of everyday life activities, social life, and work
related situations.
Cognitive Rehabilitation. (1994). Rattock, J. & Ross, B.P. Ch. 21 in Neuropsychiatry of TBI.
(Eds.) Silver, J.M., Yudofsky, S.C. & Hales, R.E., American Psychiatric Press Inc, Washington,
DC.
The NIH consensus conference addressed several questions, including:

What are the common therapeutic interventions for the cognitive and
behavioural sequelae of TBI? What is their scientific basis and how effective
are they? The report states that, despite many descriptions of specific
strategies, programs or interventions, limited data on the effectiveness of
cognitive rehabilitation programs are available due to the following factors:
Heterogeneity of subjects, interventions and outcomes studied . . . the
studies have also been limited by small sample size, failure to control for
spontaneous recovery, and the unspecified effects of social contact. . . . It is
47
important to recognise that a great deal of the scientific evidence to support

the use of these approaches derives from relatively limited studies that should
be replicated in larger, more definitive clinical trials.
National Institutes of Health Consensus Development Conference Statement Rehabilitation of

Persons with TBI. Convened in 1998. Put to press in 1999.
These problems of proof of efficacy are not peculiar to CRT, but apply to all
rehabilitation studies. Studies of efficacy remain hampered by myriad
methodological problems and a lack of long term health outcome results:
One major shortcoming in the area of TBI rehabilitation is the inability to

compare studies. This arises because of insufficient description of study
cohorts, lack of any uniformity in choices of outcome measures, and
inadequate characterisation of rehabilitative interventions. Not only are most
studies not comparable with each other, but most individual investigations
would be extremely difficult to replicate with any probability of reproducing
similar results.
This in the context of rehabilitation studies from TBI generallynot just for
CRT.
From the NIH report. Chestnut, R.M. et al. (1998) Agency for health care policy and research.
Evidence based practice report.
Readers may be interested to know that in all the recent evidence based
medicine initiatives concerning neurotrauma and neurorehabilitation, the
outcome has been essentially the samefew of the treatments investigated
are adequately supported by scientific evidence. In a recent review of
neurosurgical strategies for management of acute severe head injury, only
three of fourteen commonly used procedures met evidence based medicine
criteria for effectiveness associated with a high degree of clinical certainty.
Giacino, J.T. (2000). Letters to the Editors. J Head Trauma Rehabilitation 15(1): ix.
This level of evidence (21%) in such an invasive and potentially damaging

area of medicine (neurosurgery) falls far short of the evidence base reported
for the efficacy of CRT (67-97%, Cicerone et al. 2000)!
There are problems with studying efficacy that include the following:
Partitioning out the effects of spontaneous recovery from the treatment

effect
The effects of concurrent treatments, i.e., language therapy and

physiotherapy, which may assist with emotional adjustment, which
then can interact with the cognitive gains
The standardised treatment usually required for experimental research

reduces the opportunity to tailor the treatment to the needs of the
individual.
From the NIH report. Ruff, R.M. (1998). Cognitive Rehabilitation: Research Approaches.
48
CRT is rarely offered in isolation
CRT cannot be easily studied in a blind or double blind experimental

design
It is difficult to maintain experimental control for the length of time one

would expect to be required for meaningful change of brain function
CRT is not just about restoration; rehabilitation includes compensation

and environmental re-designwhich are patently helpful, e.g., giving a
patient a talking watch (modified to prevent resetting), which keeps a
cortically blind stroke survivor from waking his wife all night to find out if it
is time to get up
Rosamond Gianutsos (2005). Personal Communication.
One approach, which is responsive to all of these issues, is the single-case

experimental design strategy. This approach is considered to be highly
applicable to the problems facing researchers in this field.
21. CRT has face validity
Clinical evidence is now categorised as class I, II, or III. The premium

evidence is from class I studies based on the randomised controlled trial.
These studies are challenging to design, are expensive, and have the
potential for creating ethical dilemmas. . . .
When class I evidence is not available, all remaining treatments are likely to
be labelled as experimental. The conference should remain aware that some
ABI rehab management has face validity. Development of consensus
statements, including standards and guidelines for ABI rehab, must therefore
rely on class II and class III, as well as class I, evidence. Conclusions must, in
the end, be based largely on these levels of evidence, including expert
opinion, because of the limitations and lack of objective class I data.
From the NIH report. Cope, N.D. (1998).
While many clinicians have been pessimistic, saying that treating these
cognitive and related personality disturbances is futile, it has been our
experience that intensive rehabilitative efforts can substantially help many
individuals.
Prigatano, G.P. & Fordyce, D.J. (1986). Cognitive dysfunction and psychosocial adjustment after
brain injury. Ch 1 in Neuropsychological rehabilitation after brain injury (Eds.) Prigatano, G.P. et
al., Johns Hopkins University Press, Baltimore, MD.
Useless therapies whither on the vine, or continue without building consensus

support. There is a consensus of support for CRTas demonstrated by near
universal inclusion in ABI rehabilitation programs.
Rosamond Gianutsos (2005). Personal Communication.
49
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The Society for Cognitive Rehabilitation, Inc.

Malia K, Law P, Sidebottom L, Bewick K, Danziger S,

Practical Innovation in Cognitive Rehabilitation Therapy

The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk

The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk

Section One: The Framework

Section Two: Assessment & Treatment

Section Three: The Evidence Base for the CRT Program

The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk

This document was produced at a time when various organizations are

The major part of the document is comprised of 81 Recommendations, under

The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk

The Purpose of this Document

The National Academy of Neuropsychology (NAN) in the United States has

Cognitive Rehabilitation Therapy (CRT) is central to brain injury rehabilitation

It is therefore appropriate and timely that the Society for Cognitive

The purpose of this document is to:

Provide a comprehensive list of recommendations for best practice based

To act as a more detailed resource than has been produced as a result of

To help improve clinical practice across a wide variety of settings that

Please contact us with your feedback and suggestions:

The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk

SECTION ONE: THE FRAMEWORK

Brain injury rehabilitation programs must include cognitive

CRT should be included at every stage of rehabilitation, from coma

All staff working within brain injury rehabilitation must be trained to

CRT has developed as a result of growing knowledge about the long-term

Parente, R. & Herrmann, D. (1996). Retraining cognition. Aspen, Maryland, p. 1.

Although TBI may result in physical impairment, the more problematic

National Institutes of Health Consensus Development Conference Statement

The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk

Cognitive impairments in memory, reasoning, attention, judgement and self

National Academy of Neuropsychology position statement on Cognitive Rehabilitation.

Parente, R. & Herrmann, D. (1996). Retraining cognition. Aspen, Maryland, p. 5.

It can no longer be said that cognitive rehabilitation is a new field.

Sohlberg, M.M. & Mateer, C.A. (2001). Cognitive Rehabilitation:

Cognitive retraining has been an accepted therapeutic intervention in the

Berrol, S. (1990). Issues in cognitive rehabilitation. Arch Neurol 47, 219-220.

The British Society for Rehabilitation Medicine (BSRM) emphasises the

Cognitive Rehabilitation is central to any treatment program designed for the

Cognitive Rehabilitation. (1994). Rattock, J. & Ross, B.P.

a rehabilitation hospital setting, where a structured program of activities not

The BSRM states: Cognitive, emotional and behavioural problems are

The program must be based on the results of physical, cognitive, executive,

South Thames Brain Injury Rehabilitation Association,

The program must be based on the results of physical, cognitive,

Turner-Stokes L. (2002). Clinical Governance in Rehabilitation Medicine.

Cognitive rehabilitation must be available because, sometimes, more direct

Vogenthaler, D. (1987). An overview of head injury:

The Brain Injury Special Interest Group of the American Congress of

The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk

It is essential to have a clear definition of CRT in order to direct the

What we call cognition is a complex collection of mental skills that includes

CRT is a systematic, functionally oriented service of therapeutic cognitive

Reinforcing, strengthening or establishing previously learned patterns

Establishing new patterns of cognitive activity or mechanisms to

This definition has been adopted by the Commission on Accreditation of

The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk

3. Individuals involved in CRT