Cognitive rehabilitation therapy

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Cognitive rehabilitation therapy
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Effects of cognitive rehabilitation therapy, assessed using fMRI.
Specialty neurology/psychiatry

Cognitive rehabilitation refers to a wide range of evidence-based interventions [1] [2] [3] [4] designed to improve cognitive functioning in brain-injured or otherwise cognitively impaired individuals to restore normal functioning, or to compensate for cognitive deficits. [5] It entails an individualized program of specific skills training and practice plus metacognitive strategies. Metacognitive strategies include helping the patient increase self-awareness regarding problem-solving skills by learning how to monitor the effectiveness of these skills and self-correct when necessary.

Contents

Cognitive rehabilitation therapy (offered by a trained therapist) is a subset of Cognitive Rehabilitation (community-based rehabilitation, often in traumatic brain injury; provided by rehabilitation professionals) and has been shown to be effective for individuals who had a stroke in the left or right hemisphere. [6] or brain trauma. [7] A computer-assisted type of cognitive rehabilitation therapy called cognitive remediation therapy has been used to treat schizophrenia, ADHD, and major depressive disorder. [8] [9] [10] [11] [12]

Cognitive rehabilitation builds upon brain injury strategies involving memory, [13] executive functions, activities planning and "follow through" (e.g., memory, task sequencing, lists). [14]

It may also be recommended for traumatic brain injury, the primary population for which it was developed in the university medical and rehabilitation communities, [15] [16] [17] [18] such as that sustained by U.S. Representative Gabby Giffords, according to Dr. Gregory J. O'Shanick of the Brain Injury Association of America. [19] Her new doctor has confirmed that it will be part of her rehabilitation. [20] Cognitive rehabilitation may be part of a comprehensive community services program and integrated into residential services, such as supported living, supported employment, family support, professional education, home health (as personal assistance), [21] [22] recreation, or education programs in the community.

Cognitive rehabilitation for spatial neglect following stroke

The current body of evidence is uncertain on the efficacy of cognitive rehabilitation for reducing the disabling effects of neglect and increasing independence remains unproven. [23] However, there is limited evidence that cognitive rehabilitation may have an immediate beneficial effect on tests of neglect. [23] Overall, no rehabilitation approach can be supported by evidence for spatial neglect.

Assessments

According to the standard text by Sohlberg and Mateer: [24]

Individuals and families respond differently to different interventions, in different ways, at different times after injury. Premorbid functioning, personality, social support, and environmental demands are but a few of the factors that can profoundly influence outcome. In this variable response to treatment, cognitive rehabilitation is no different from treatment for cancer, diabetes, heart disease, Parkinson's disease, spinal cord injury, psychiatric disorders, or any other injury or disease process for which variable response to different treatments is the norm.

Nevertheless, many different statistical analyses of the benefits of this therapy have been carried out. One study made in 2002 analyzed 47 treatment comparisons and reported "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." [6]

An internal study conducted by the Tricare Management Agency in 2009 is cited by the US Department of Defense as its reason for refusing to pay for this therapy for veterans who have had traumatic brain injury. According to Tricare, "There is insufficient, evidence-based research available to conclude that cognitive rehabilitation therapy is beneficial in treating traumatic brain injury." [25] The ECRI Institute, whose report serves as the basis for this decision by the Department of Defense, has summed up their own findings this way: [5]

In our report, we carried out several meta-analyses using data from 18 randomized controlled trials. Based on data from these studies, we were able to conclude the following:

The strength of the evidence supporting our conclusions was low due to the small number of studies that addressed the outcomes of interest. Further, the evidence was too weak to draw any definitive conclusions about the effectiveness of cognitive rehabilitation therapy for treating deficits related to the following cognitive areas: attention, memory, visuospacial skills, and executive function. The following factors contributed to the weakness of the evidence: differences in the outcomes assessed in the studies, differences in the types of cognitive rehabilitation therapy methods/strategies employed across studies, differences in the control conditions, and/or insufficient number of studies addressing an outcome.

Citing this 2009 assessment, US Department of Defense, one of the federal agencies not responsible for health care decisions in the US, has declared that cognitive rehabilitation therapy is scientifically unproved and should refer their concerns to the US Department of Health and Human Services, US Budget and Management, and/or the Government Accountability Office (GAO). As a result, it refuses to cover the cost of cognitive rehabilitation for brain-injured veterans. [25] [26] Cost-benefit and cost-effectiveness studies, together with an analysis of personnel and veterans' services for new our emerging groups in head and brain injuries, are recommended.[ citation needed ]

See also

Related Research Articles

<span class="mw-page-title-main">Aphasia</span> Inability to comprehend or formulate language

In aphasia, a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions. The major causes are stroke and head trauma; prevalence is hard to determine but aphasia due to stroke is estimated to be 0.1–0.4% in the Global North. Aphasia can also be the result of brain tumors, epilepsy, autoimmune neurological diseases, brain infections, or neurodegenerative diseases.

The Fregoli delusion is a rare disorder in which a person holds a delusional belief that different people are in fact a single person who changes appearance or is in disguise. The syndrome may be related to a brain lesion and is often of a paranoid nature, with the delusional person believing themselves persecuted by the person they believe is in disguise.

A vegetative state (VS) or post-coma unresponsiveness (PCU), is a disorder of consciousness in which patients with severe brain damage are in a state of partial arousal rather than true awareness. After four weeks in a vegetative state, the patient is classified as being in a persistent vegetative state (PVS). This diagnosis is classified as a permanent vegetative state some months after a non-traumatic brain injury or one year after a traumatic injury. The term unresponsive wakefulness syndrome may be alternatively used, as "vegetative state" has some negative connotations among the public.

<span class="mw-page-title-main">Brain damage</span> Destruction or degeneration of brain cells

Neurotrauma, brain damage or brain injury (BI) is the destruction or degeneration of brain cells. Brain injuries occur due to a wide range of internal and external factors. In general, brain damage refers to significant, undiscriminating trauma-induced damage.

Rehabilitation of sensory and cognitive function typically involves methods for retraining neural pathways or training new neural pathways to regain or improve neurocognitive functioning that have been diminished by disease or trauma. The main objective outcome for rehabilitation is to assist in regaining physical abilities and improving performance. Three common neuropsychological problems treatable with rehabilitation are attention deficit/hyperactivity disorder (ADHD), concussion, and spinal cord injury. Rehabilitation research and practices are a fertile area for clinical neuropsychologists, rehabilitation psychologists, and others.

Anosognosia is a condition in which a person with a disability is cognitively unaware of having it due to an underlying physical condition. Anosognosia results from physiological damage to brain structures, typically to the parietal lobe or a diffuse lesion on the fronto-temporal-parietal area in the right hemisphere, and is thus a neuropsychiatric disorder. A deficit of self-awareness, it was first named by the neurologist Joseph Babinski in 1914. Phenomenologically, anosognosia has similarities to denial, which is a psychological defense mechanism; attempts have been made at a unified explanation. Anosognosia is sometimes accompanied by asomatognosia, a form of neglect in which patients deny ownership of body parts such as their limbs. The term is from Ancient Greek ἀ- a-, 'without', νόσος nosos, 'disease' and γνῶσις gnōsis, 'knowledge'. It is also considered a disorder that makes the treatment of the patient more difficult, since it may affect negatively the therapeutic relationship.

The primary goals of stroke management are to reduce brain injury and promote maximum patient recovery. Rapid detection and appropriate emergency medical care are essential for optimizing health outcomes. When available, patients are admitted to an acute stroke unit for treatment. These units specialize in providing medical and surgical care aimed at stabilizing the patient's medical status. Standardized assessments are also performed to aid in the development of an appropriate care plan. Current research suggests that stroke units may be effective in reducing in-hospital fatality rates and the length of hospital stays.

<span class="mw-page-title-main">Traumatic brain injury</span> Injury of the brain from an external source

A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. TBI can be classified based on severity ranging from mild traumatic brain injury (mTBI/concussion) to severe traumatic brain injury. TBI can also be characterized based on mechanism or other features. Head injury is a broader category that may involve damage to other structures such as the scalp and skull. TBI can result in physical, cognitive, social, emotional and behavioral symptoms, and outcomes can range from complete recovery to permanent disability or death.

Closed-head injury is a type of traumatic brain injury in which the skull and dura mater remain intact. Closed-head injuries are the leading cause of death in children under 4 years old and the most common cause of physical disability and cognitive impairment in young people. Overall, closed-head injuries and other forms of mild traumatic brain injury account for about 75% of the estimated 1.7 million brain injuries that occur annually in the United States. Brain injuries such as closed-head injuries may result in lifelong physical, cognitive, or psychological impairment and, thus, are of utmost concern with regards to public health.

<span class="mw-page-title-main">Minimally conscious state</span> Disorder of Consciousness where overt signs of awareness are preserved

A minimally conscious state or MCS is a disorder of consciousness distinct from persistent vegetative state and locked-in syndrome. Unlike persistent vegetative state, patients with MCS have partial preservation of conscious awareness. MCS is a relatively new category of disorders of consciousness. The natural history and longer term outcome of MCS have not yet been thoroughly studied. The prevalence of MCS was estimated to be 9 times of PVS cases, or between 112,000 and 280,000 in the US by year 2000.

<span class="mw-page-title-main">Acquired brain injury</span> Brain damage caused by events after birth

Acquired brain injury (ABI) is brain damage caused by events after birth, rather than as part of a genetic or congenital disorder such as fetal alcohol syndrome, perinatal illness or perinatal hypoxia. ABI can result in cognitive, physical, emotional, or behavioural impairments that lead to permanent or temporary changes in functioning. These impairments result from either traumatic brain injury or nontraumatic injury derived from either an internal or external source. ABI does not include damage to the brain resulting from neurodegenerative disorders.

Post-concussion syndrome (PCS), also known as persisting symptoms after concussion, is a set of symptoms that may continue for weeks, months, years after a concussion. PCS is medically classified as a mild traumatic brain injury (TBI). About 35% of people with concussion experience persistent or prolonged symptoms 3 to 6 months after injury. Prolonged concussion is defined as having concussion symptoms for over four weeks following the first accident in youth and for weeks or months in adults.

Neurorehabilitation is a complex medical process which aims to aid recovery from a nervous system injury, and to minimize and/or compensate for any functional alterations resulting from it.

Post-traumatic amnesia (PTA) is a state of confusion that occurs immediately following a traumatic brain injury (TBI) in which the injured person is disoriented and unable to remember events that occur after the injury. The person may be unable to state their name, where they are, and what time it is. When continuous memory returns, PTA is considered to have resolved. While PTA lasts, new events cannot be stored in the memory. About a third of patients with mild head injury are reported to have "islands of memory", in which the patient can recall only some events. During PTA, the patient's consciousness is "clouded". Because PTA involves confusion in addition to the memory loss typical of amnesia, the term "post-traumatic confusional state" has been proposed as an alternative.

Remote therapy, sometimes called telemental health applications or Internet-based psychotherapy, is a form of psychotherapy or related psychological practice in which a trained psychotherapist meets with a client or patient via telephone, cellular phone, the internet or other electronic media in place of or in addition to conventional face-to-face psychotherapy.

Cognitive remediation is designed to improve neurocognitive abilities such as attention, working memory, cognitive flexibility and planning, and executive functioning which leads to improved psychosocial functioning.

Disorders of consciousness are medical conditions that inhibit consciousness. Some define disorders of consciousness as any change from complete self-awareness to inhibited or absent self-awareness and arousal. This category generally includes minimally conscious state and persistent vegetative state, but sometimes also includes the less severe locked-in syndrome and more severe but rare chronic coma. Differential diagnosis of these disorders is an active area of biomedical research. Finally, brain death results in an irreversible disruption of consciousness. While other conditions may cause a moderate deterioration or transient interruption of consciousness, they are not included in this category.

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Sleep disorder is a common repercussion of traumatic brain injury (TBI). It occurs in 30%-70% of patients with TBI. TBI can be distinguished into two categories, primary and secondary damage. Primary damage includes injuries of white matter, focal contusion, cerebral edema and hematomas, mostly occurring at the moment of the trauma. Secondary damage involves the damage of neurotransmitter release, inflammatory responses, mitochondrial dysfunctions and gene activation, occurring minutes to days following the trauma. Patients with sleeping disorders following TBI specifically develop insomnia, sleep apnea, narcolepsy, periodic limb movement disorder and hypersomnia. Furthermore, circadian sleep-wake disorders can occur after TBI.

Rehabilitation psychology is a specialty area of psychology aimed at maximizing the independence, functional status, health, and social participation of individuals with disabilities and chronic health conditions. Assessment and treatment may include the following areas: psychosocial, cognitive, behavioral, and functional status, self-esteem, coping skills, and quality of life. As the conditions experienced by patients vary widely, rehabilitation psychologists offer individualized treatment approaches. The discipline takes a holistic approach, considering individuals within their broader social context and assessing environmental and demographic factors that may facilitate or impede functioning. This approach, integrating both personal and environmental factors, is consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF).

References

  1. ↑ Cicerone, Keith D.; Dahlberg, Cynthia; Kalmar, Kathleen; Langenbahn, Donna M.; Malec, James F.; Bergquist, Thomas F.; Felicetti, Thomas; Giacino, Joseph T.; Harley, J.Preston (December 2000). "Evidence-based cognitive rehabilitation: Recommendations for clinical practice". Archives of Physical Medicine and Rehabilitation. 81 (12): 1596–1615. doi:10.1053/apmr.2000.19240. ISSN   0003-9993. PMID   11128897.
  2. ↑ Cicerone, Keith D.; Dahlberg, Cynthia; Malec, James F.; Langenbahn, Donna M.; Felicetti, Thomas; Kneipp, Sally; Ellmo, Wendy; Kalmar, Kathleen; Giacino, Joseph T. (August 2005). "Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 1998 Through 2002". Archives of Physical Medicine and Rehabilitation. 86 (8): 1681–1692. doi:10.1016/j.apmr.2005.03.024. ISSN   0003-9993. PMID   16084827.
  3. ↑ Cicerone, Keith D.; Langenbahn, Donna M.; Braden, Cynthia; Malec, James F.; Kalmar, Kathleen; Fraas, Michael; Felicetti, Thomas; Laatsch, Linda; Harley, J. Preston (April 2011). "Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 2003 Through 2008". Archives of Physical Medicine and Rehabilitation. 92 (4): 519–530. doi:10.1016/j.apmr.2010.11.015. ISSN   0003-9993. PMID   21440699.
  4. ↑ Cicerone, Keith D.; Goldin, Yelena; Ganci, Keith; Rosenbaum, Amy; Wethe, Jennifer V.; Langenbahn, Donna M.; Malec, James F.; Bergquist, Thomas F.; Kingsley, Kristine (March 2019). "Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014". Archives of Physical Medicine and Rehabilitation. 100 (8): 1515–1533. doi:10.1016/j.apmr.2019.02.011. hdl: 1805/18829 . ISSN   0003-9993. PMID   30926291. S2CID   88480565.
  5. 1 2 "Cognitive Rehabilitation Therapy for Traumatic Brain Injury: What We Know and Don't Know about Its Efficacy" (PDF). ECRI Institute. 2011-01-21. Archived from the original (PDF) on 2014-04-19. Retrieved 2014-04-17. Approaches to cognitive rehabilitation therapy are generally separated into two broad categories: restorative and compensatory.
  6. 1 2 Keith D. Cicerone; Cynthia Dahlberg; James F. Malec; Donna M. Langenbahn; Thomas Felicetti; Sally Kneipp; Wendy Ellmo; Kathleen Kalmar; Joseph T. Giacino; J. Preston Harley; Linda Laatsch; Philip A. Morse; Jeanne Catanese (August 2002). "Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 1998 Through 2002". Archives of Physical Medicine and Rehabilitation. xxx: Elsevier. 86 (8): 1681–1692. doi:10.1016/j.apmr.2005.03.024. PMID   16084827 . Retrieved 2011-01-22. 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.
  7. ↑ Soderback I.; Ekholm J. (1992). "January–March). Medical and social factors affecting behavior patterns in patients with acquired brain damage: a study of patients living at home three years after incident". Disability and Rehabilitation. 14 (1): 30–35. doi:10.3109/09638289209166424. PMID   1586757.
  8. ↑ Elgamal S, McKinnon MC, Ramakrishnan K, Joffe RT, MacQueen G (Sep 2007). "Successful computer-assisted cognitive remediation therapy in patients with unipolar depression: a proof of principle study". Psychol. Med. 37 (9): 1229–38. doi:10.1017/S0033291707001110. PMID   17610766. S2CID   19958026.
  9. ↑ Wykes T (May 2007). "Cognitive remediation therapy in schizophrenia: randomised controlled trial". Br J Psychiatry. 190: 421–7. doi: 10.1192/bjp.bp.106.026575 . PMID   17470957.
  10. ↑ Wykes T (Aug 2007). "Cognitive remediation therapy (CRT) for young early onset patients with schizophrenia: an exploratory randomized controlled trial". Schizophr. Res. 94 (1–3): 221–30. doi:10.1016/j.schres.2007.03.030. PMID   17524620. S2CID   46117743.
  11. ↑ O'Connell RG, Bellgrove MA, Dockree PM, Robertson IH (Dec 2006). "Cognitive remediation in ADHD: effects of periodic non-contingent alerts on sustained attention to response". Neuropsychol Rehabil. 16 (6): 653–65. doi:10.1080/09602010500200250. PMID   17127571. S2CID   38725935.
  12. ↑ Stevenson CS, et al. (Oct 2002). "A cognitive remediation programme for adults with Attention Deficit Hyperactivity Disorder". Aust N Z J Psychiatry. 36 (5): 610–6. doi:10.1046/j.1440-1614.2002.01052.x. PMID   12225443. S2CID   24904215.
  13. ↑ Zencius A.; Wesolowski M.; Burke W.H. (1990). "January–March). A comparison of four memory strategies with traumatically brain-injured clients". Brain Injury. 4 (1): 33–38. doi:10.3109/02699059009026146. PMID   2297598.
  14. ↑ Burke W.H.; Zencius A.H.; Weslowski M.D.; Doubleday F. (1991). "Improving executive function disorders in brain-injured clients". Brain Injury. 5 (3): 241–252. doi:10.3109/02699059109008095. PMID   1933075.
  15. ↑ Ben-Yishay, Diller L (1993). "Cognitive remediation in traumatic brain injury: Update and issues". Archives of Physical Medicine and Rehabilitation. 74 (2): 204–213. PMID   8431107.
  16. ↑ Crowley J.; Miles J. (1991). "Cognitive remediation in pediatric head injury: A case study". Journal of Pediatric Psychology. 16 (5): 611–627. doi:10.1093/jpepsy/16.5.611. PMID   1744809.
  17. ↑ Gordon W.; Hibbard M.; Kreutzer J. (1989). "Cognitive remediation: Issues in research and practice". Journal of Head Trauma Rehabilitation. 4 (3): 76–84. doi:10.1097/00001199-198909000-00011.
  18. ↑ Kreutzer, J. & Wehman, P. (1991). Cognitive Rehabilitation for Persons with Traumatic Brain Injury: A Functional Approach. Baltimore, MD: Paul H. Brookes.
  19. ↑ Thomas M. Burton (2011-01-10). "Brain at Risk Despite Quick Aid". The Wall Street Journal . Retrieved 2011-01-21. "The rapid treatment she received needs to be matched by a seamless course of rehabilitation such as cognitive rehabilitation," Dr. O'Shanick said.
  20. ↑ "'Intensive Rehabilitation' Is Next for Giffords, New Doctor Says". ABC News Radio . 2011-01-21. Archived from the original on 2011-01-31. Retrieved 2011-01-29. The key is get into intensive rehabilitation...Bringing in lots of different people from different specialties to work as a coordinated team, speech, cognitive, physical rehabilitation.
  21. ↑ Watson, S. (1991). PAS and head injury. In: J. Weissman, J. Kennedy, & S.Litvak, Personal Perspectives on Personal Assistance Services. (pp. 72-75). Oakland, CA: Rehabilitation Research and Training Center on Public Policy and Independent Living, World Institute on Disability.
  22. ↑ Ulciny, G. & Jones, M. (1985). Enhancing the attendant management skills of persons with disabilities. American Rehabilitation, 18-20.
  23. 1 2 Bowen, Audrey; Hazelton, Christine; Pollock, Alex; Lincoln, Nadina B (2013-07-01). "Cognitive rehabilitation for spatial neglect following stroke". The Cochrane Database of Systematic Reviews. 2013 (7): CD003586. doi:10.1002/14651858.CD003586.pub3. ISSN   1469-493X. PMC   6464849 . PMID   23813503.
  24. ↑ McKay Moore Sohlberg; Catherine A Mateer (2001). Cognitive rehabilitation: an integrative neuropsychological approach. Guilford Press. p. 4. ISBN   978-1-57230-613-4.
  25. 1 2 Andrew Tilghman (2011-01-01). "Military insurer denies coverage of new brain injury treatment". USA Today . Retrieved 2011-01-21. In an internal 2009 study, the Tricare Management Agency found that cognitive rehabilitation therapy is scientifically unproved and does not warrant coverage as a stand-alone treatment for brain injuries.
  26. ↑ Letter to The Honorable Robert Gates from Senator Claire McCaskill (January 19, 2011)
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