4.8 Cognitive Rehabilitation

Case Study 4 (continued)

In rehabilitation the patient was having difficulty making decisions, solving problems and processing information presented to him visually.  He has significant memory problems, in particular short-term memory.  He was an RLA-V.  The question arises as to whether he would benefit from cognitive rehabilitation.

4.8.1   Cognitive Rehabilitation Therapy

What is the evidence for cognitive rehabilitation therapy post ABI?

  1. There is conflicting evidence that a cognitive rehabilitation program focusing on memory strategies and selective attention will have a significant benefit relative to controls.
  2. There is Level 4 evidence that general cognitive rehabilitation therapy post acquired brain injury is effective for improving cognition. Although there are variable strategies and protocols for cognitive rehabilitation, all comprehensive interventions appear to provide benefit.
  3. There is Level 4 evidence that working memory training is effective in recovering the central executive system of working memory.
  4. There is Level 4 evidence that an outpatient day program is effective for assisting brain injury survivors in returning to competitive employment.

Several studies dealing with rehabilitative treatments of cognitive deficits have been identified. Listed below are their findings:

  1. In one RCT, overall significant improvements were noted in both groups at the post intervention phase; however no overall difference between groups was found when the experimental group was taught to use compensation strategies including verbalization, chunking and pacing32.
  2. When comparing two cognitive rehabilitation therapies (conventional and innovative) significant changes comparing baseline to post intervention outcomes were seen foreach group, however, the improvements were different for the interventions. No between-group comparisons were made 33.
  3. In a study where an intensive cognitive rehabilitation program was compared to a standard rehabilitation program results indicate those in the intensive cognitive rehab program showed significant improvement on post intervention composite neuropsychological scores who were on average more than two years post injury at the start of the intervention 34.
  4. Neistadt35 looked at two groups: a remedial group who received individual training with parquetry block assembly, and an adaptive group who received functional skills training over a six-week period. The remedial group improved significantly more than the adaptive group on the Parquetry Block test; however, there were no significant differences on the WAIS-R Block Design subtest after treatment.
  5. In another RCT an active treatment based group focusing on attention, spatial integration, memory and problem solving was compared to a control group that focused on computer and video games, coping skills, health, discussion forum, independent living and art. Although both groups improved, those in the treatment group experienced relative gains on memory testing and selective attention, suggesting that focusing on these specific elements has the potential to improve them 36.
  6. Sohlberg et al.37 found that those who were assigned to the attention process training group (APT), showed improved performance on cognitive function and executive attention tasks compared to than those in the brain education therapy group.
  7. Serino et al. 38 in a study looking to improve the central executive system of working memory, subjects were given various tasks to perform with varying degrees of intensity. Results indicate that those in the working memory training (WMT), compared to those in the general stimulus training (GST) program, showed significant improvements in working memory, divided attention, executive functions, and long term memory.
  8. Salazar et al. 39 compared an in-patient cognitive rehabilitation program to a limited home rehabilitation program with weekly telephone contact from a psychiatric nurse and concluded there were no differences between groups with regards to return to work or fitness for duty at one-year.
  9. In one study examining the benefits of individual cognitive therapy, results showed improvement in cognition for tests of intelligence, memory, processing speed and problem solving40.
  10. Following a two year structured cognitive retraining program consisting of 5 sequential instructional modules, significant cognitive improvement was found 41.
  11. A cognitive rehabilitation therapy program focusing on alertness, attention, concentration, perception, memory and problem solving, found only memory improved significantly post intervention 42.
  12.  In a study conducted my Miotto et al. 43 patients were assigned to 1 of 3 intervention groups.  Each group regardless of the treatment they received, showed improvement on executive function.
  13. In a study looking at cognitive retraining in the domains of attention, personal counseling, individual cognitive remediation and interpersonal communication exercises, all treatment mixes were equally effective with regards to level of vocational attainment 44.
  14. Turkstra 45 found patients with a TBI, compared to those without an injury, did not perform as well on various cognitive/communication tests among these were the .Video Social Inference Test (VSIT) and the Competing Language Processing Test (CLPT)
  15. Ownsworth et al. 46  found exposure to systematic feedback allowed for a reduction in the number of errors made while engaging in cooking tasks and volunteer work.
  16. Boman et al. 47 found patients, after completing 1 hour of an individual cognitive training 3 times a week for 3 weeks, showed significant improvement on the attention processing training test in sustained attention, selective attention and alternating attention. Improvement was also noted on the Rivermead Behavioural Memory Test (RBMT) scores.
  17. Participation in a comprehensive out patient day program, resulted in more than ¾ of the participants being competitively employed; however, at the end of a three year period, approximately half remained employed 48.
  18. Neuropsychological functioning improved in patients participating in an out-patient neuropsychological rehabilitation program. Improvement was noted on awareness and acceptance of injury and residual deficits, intensive cognitive retraining, compensatory skills development and neuropsychological performance 49.

Analysis of findings from this current review as well as those from Cicerone et al. 50and Gordon 51all suggest that future studies need to control for patient characteristics (e.g., level of impairment needs to be clearly defined, not just severity of injury), spontaneous recovery and practice effects on outcome measures used. Studies should not just rely on psychometric tests but should consider functional outcome measures and long-term effects of treatment interventions should be monitored through follow-up. 

For a more detailed discussion on each of these studies please see ERABI/Cognition Interventions Post ABI.

Describe Recommendations for cognitive rehabilitation post ABI.

  1.  Moderate to severe ABI patient should have a cognitive function assessment.
  2. Therapeutic interventions should include activities that are meaningful to the patient and can be applied to the patient’s home environment.
  3. Strategy training across all cognitive domains is recommended during postacute rehabilitation for persons with TBI.

According to ABIKUS Recommendations 27

Cognitive Rehabilitation

All patients after moderate to severe ABI should be referred for neuropsychology, occupational therapy and speech language assessment to evaluate cognitive functioning. (ABIKUS C) (G32-p.21)

The treatment team should be multidisciplinary and is based on the individual’s developing needs as determined by initial and ongoing assessment and goals. (ABIKUS C) (G33-p.21)

In order to facilitate/achieve generalization of skill/strategies to daily activities, rehabilitation should :

 Focus on engaging in activities that are perceived as meaningfulInclude therapy interventions in the affected person’s own environment and/or application to the person’s own life

(ABIKUS B) (G34-p.21)

Strategy training across all cognitive domains is recommended during postacute rehabilitation for persons with TBI (ABIKUS A, adapted from Cicerone et al. 2005) (G35-p.21)

Cognitive rehabilitation should include the use of periodic, random auditory alerting tones to improve sustained attention in subacute ABI/TBI. (ABIKUS A, adapted from Cicerone et al. 2005) (G36-p.22)

4.8.2   Remediation of Attention Deficits

Case Study 4 (continued)

While on rehabilitation it is particularly noted that the patient is having difficulty with attention which is having a negative impact on his rehabilitation as the patient is easily distracted and has trouble focusing on various tasks.

What is the evidence for remediation of attention deficits following a brain injury?

1.    Strategy training is recommended for improvement of attention deficits following TBI.

Evaluating the efficacy of remediation or rehabilitation of attention deficits following a brain injury is complicated by a number of factors:

  1. There is no consensus regarding a definition of attention.  Is it a general construct or does it reflect more specific sub-components or systems of functioning (e.g., sustained, divided, focused, selective, vigilance, speed of information processing, etc).
  2. Different researchers and clinicians will report using the same or similar tests to measure different aspects of attention.
  3. A study may use the same outcome measures repeatedly, thereby confounding practice and treatment effects(e.g., PASAT performance improves significantly with repeated exposure to the test).
  4. Studies may not consider and account for the rate of spontaneous recovery following brain injury(i.e. would participants naturally show recovery of function in the absence of treatment?).
  5. Comparing the efficacy of various remediation efforts is also complicated by cross-study variability in treatment duration(e.g. from 30 minutes once a day for 5 days to 5 hours, every day for 6 weeks).
  6. Severity of injury and time since injury may also fluctuatefrom study to study.

For a more detailed discussion please see ERABI/Cognition Interventions Post ABI

Case Study 4 (continued)

The patient does not respond to cognitive rehabilitation and still has severe attentional deficits.  It is suggested that pharmacological measures may be helpful.

4.8.3   Donepezil

What is the evidence for the use of a cholinesterase inhibitor in treatment of cognitive disorders following TBI?

  1. There is Level 1 evidence, based on a single RCT, that Donepezil improves attention and short-term memory.
  • The cholinesterase inhibitor, Donepezil, has been found to significantly increasescores on tasks of sustained attention and short-term memory when compared to placebo and that these improved results were sustained after the wash-out period 52.

4.8.4   Methylphenidate

What is the evidence for the use of methylphenidate in the treatment of cognitive disorders post TBI?

  1. There is conflicting evidence regarding the effectiveness of the administration of methylphenidate following brain injury for the improvement of cognitive functioning.
  • Methylphenidate is a stimulant whose exact mechanism is unknown 53, although believed to act on the presynaptic nerve and acts to restrain the reabsorption of serotonin and norephinephrine 54
  • Methylphenidate has been extensively used as a treatment for attention deficit disorder, as well as narcolepsy 55

Results of Four Randomized Controlled Trials:

  1. Speed of processing, attentiveness during individual work tasks and caregiver ratings of attention were all significantly improvedwith methylphenidate treatment.  No treatment related improvement was seen in divided or sustained attention or in susceptibility to distraction 56.
  2. Methylphenidate significantly improved attention 57.
  3. In a double blind placebo controlled trial evaluating the effects of the stimulant medication methylphenidate following closed head injury. In this study methylphenidate did not demonstrate significant differences compared to placebo on measures of attention, information processing speed, or learning 58.
  4. The effects of a single-dose treatment of methylphenidate were examined and, although a trend was found in favour of improved working and visuospatial memory for the treatment group, these results did not reach significance 54.

What dose of methylphenidate is recommended in the treatment of cognitive disorders post TBI?

1.    The recommended dose of methylphenidate is 0.25-0.30 mg/kg bid.

According to ABIKUS Recommendations 27:

Medication for Attention and Arousal

Methylphenidate (0.25-0.30 mg/kg bid) is recommended in adults to enhance attentional function in the adult population.  Methylphenidate (0.25-0.30 mg/kg bid) is also recommended to enhance the speed of cognitive processing, although only one study provides evidence to support a change in speed in a naturalistic task. (ABIKUS A, adapted from GPT, I, p.1482) (G44-p.23).


4.8.5   Treatment of Learning and Memory Deficits

Memory impairment is one of the most common symptoms following brain injury and it is estimated that time and cost of care would be reduced if effective medical treatments were found to improve memory 59.

Case Study 4 (continued)

The patient continues to have memory deficits, in particular difficulties with short-term memory, which is interfering with progression of his rehabilitation.

Describe the two major approaches to learning and memory deficits post ABI.

  1. Restoration: remediation of memory deficits.
  2. Compensation: circumventing the difficulty which arises because of the memory deficit.

 What are different examples of these two approaches?

Restoration: remediation of memory deficits.

  • External compensatory aids including computers, pagers and notebooks;
  • Individualized remediation program;
  • Family/social support;
  • Environmental adaptations;
  • Didactic lessons and homework

Compensation:  circumventing the difficulty which arises because of the memory deficit.

  • Rehearsal;
  • Organizational strategies;
  • Visual imagery;
  • Verbal labeling:
  • Use of mnemonics;
  • Implicit memory tasks
  • The literature indicates that there are two main approaches to improving memory performance following an ABI: restoration or compensation. 
  • Compensation includes “training strategies or techniques that aim to circumvent any difficulty that arises as a result of the memory impairment.” 
  • Compensatory techniquesinclude internal aids, which are “mnemonic strategies that restructure information that is to be learned.” 

Interventions have focused on:

  • Remediation of memory deficitsin individuals with TBI, including external compensatory aids (computers, pagers, and notebooks), individualized remediation programs, family/social support and environmental adaptations, didactic lessons and homework;
  • Compensatory strategiesincluding rehearsal, organizational strategies, visual imagery, verbal labeling, and use of mnemonics, as well as implicit memory tasks.
  • Strategies used to improve memory deficits without the use of electronic, external aids were judged to be “possibly effective.”  Specific learning strategies (e.g. errorless learning) were found to be “probably effective” 60.

For a more detailed review examining the effectiveness of various interventions to improve memory impairment following stroke and TBI, please see ERABI/Cognition Interventions Post ABI.

4.8.6   External Aids for Remediation of Memory Deficits

Case Study 4 (continued)

The most commonly studied remediation approach is the use of external memory aids.  The therapist recommends the use of a number of external memory aids.

What evidence is there for external memory aids?

  1. There is conflicting evidence as to whether external memory aides are an effective strategy for memory-impaired individuals.

External aids assist memory by use of external methods of recording and accessing information.

External Aids to Assist with Memory Deficits Post ABI

  1. Memory Aids(appointment diary, notebook and to do list): Overall, those participants who had previously used a memory aid made significantly more diary entries compared to those who had not previously used a memory aid. The majority of subjects used all three aids 61;62.
  2. Cell Phonesthat were set up to send reminder messages that were specific to the individuals (ie - medical appointments etc): In this study, the outcome measure was the percentage of success achieved on 4-5 items to be remembered independently over a 12-week period. Results indicate that 92-100% of subjects showed improvement in remembering the 4-5 items presented to them 63.
  3. NeuroPage(a portable paging system): Results indicated that all subjects significantly benefited from using the NeuroPage system and that following 12 weeks of use, performance remained at improved levels compared to baseline 64.
  4. Paging systemdesigned to improve independence in people with memory problems as well as to reduce deficits in executive function: In this study, results demonstrated that the pager system significantly increased patients’ ability to carry out daily tasks, and successful task achievement was more efficient after the pager intervention was introduced 65.
  5. Hand Held Recordersto remind moderate-to-severely impaired patients of their therapy goals.  Goals were correctly recalled when using the hand held recorder compared to when goals were reviewed. It should be noted that the study examined only if the goals could be elicited during recall (either free recall or cued) and did not examine whether the subjects actually followed through with their goals 66
  6. Complex Computerized Tracking System to remind and direct 5 patients on an acute rehabilitation unit to their next therapy appointment while still in an acute setting: Results indicated that the subjects arrived earlier to their appointments and required fewer prompts67
  7. The Diary-SIT(Self-Instructional Training) approach trains compensation using higher cognitive skills of self-regulation and self-awareness vs the Diary-Only group.  The Diary-SIT approach trains compensation using higher cognitive skills of self-regulation and self-awareness. Diary-Only approach taught subjects how to use the diary: Those in the Diary-SIT group made consistently more diary entries, reported a reduction in everyday memory problems and made more positive ratings on treatment efficacy compared to the Diary-Only group 68
  8. Memory Note Books(treatment group) vs an interpersonal support group (control group): On cognitive measures of memory functioning, there was no difference between groups and on observed everyday memory failures (questionnaire), performance improved (i.e., less failures) following treatment, although performance was not maintained at 6-month follow-up 69.
  9. Notebook training to enhance recall of components of homework assignments:Notebook training enhanced recall of components of homework assignments as compared to baseline performance 70
  10. Calendar to enhance orientation following an acquired brain injury: Results indicated that the presence of a calendar did not enhance performance on a temporal orientation test (date and time). It is difficult to judge the outcome of this study as no scores were reported for either the control or treatment group, and it is not clear whether post-traumatic amnesia, and/or severity of injury had an impact on performance 71.
  11. Visual memory program consisted of pairing pictures of staff with an imagery statement, while the real-world treatment consisted of name restating: The visual memory program was the only program where subjects consistently used both target names. When questioned directly 4 of the 5 subjects could consistently identify one or both of the target names. Because subjects did not use the names was not indicative of whether or not they knew them 72.
  12. Voice Organizer (a compensatory external aid): All five participants benefited from the use of the Voice Organizer as measured by the Message-Passing Test 73.

For a more detailed discussion on each of these studies and their findings, please see ERABI/Cognition Interventions Post ABI.

4.8.7   Internal Aids as a Compensatory Strategy for Memory Deficits

Case Study 4 (continued)

The therapist has been teaching the patient a number of internal memory aid strategies to assist with short-term memory recall.

What is the evidence for internal memory aids?

  1. There is Level 2 evidence (from several studies) that internal strategies appear to be an effective aid in improving recall performance. 
  2. There is Level 3 evidence from several case-control studies that internal strategies appear to assist in improving recall performance.

Several studies examining the effect of strategy use on memory following brain injury were reviewed.

Internal Strategies to Assist with Memory Retention Post ABI

Visual Imagery Techniques

  • A visual-imagery technique(Ridiculously Imaged Story technique) was evaluated by using two difference versions (computerized vs pictorial version): Results indicated that although the computerized version resulted in a slightly better performance, the difference was non significant 74.
  • Ridiculously Imaged Story technique:Subjects performed better at tasks that they were already trained for and this helped them improved their abilities to generalize to other tasks 75.
  • Name learning task (learning a new name face association to improve recall of names): Learning procedures were more effective on 1 task (where subjects were required to learn the name-occupation and town) compared to the other tasks (famous-faces or name learning) 76.

Recall of Information

  1. Subjects were asked toreview job ads,learn the information through (verbal rehearsal, written rehearsal, acronym formation or notebook logging) and recall the information presented in each at a later time: 3 of 4 strategies resulted in improved performance; written rehearsal did not. Notebook logging resulted in the best performance 77.
  2. Three groups of patients (treatment, pseudo-treatment and no treatment group). Internal and external strategies to enhance memory were taught to the treatment group:  Those in the strategy-use group showed improvement in memory recall; however a later study found the benefits to patients were no longer evident 78;79.
  3. Patients were taught verbal labeling for visual information or visual imagery for verbal information:Learning and recall were enhanced 80.
  4. Patients were divided into 1 of 3 groups (errorless learning, self-generated; errorless learning, experimenter generated and errorful learning): Regardless of severity level, subjects recalled more in the errorless learning condition than in the errorful learning condition 81.
  5. The effect of stimulus modality on verbal learning of patients with moderate-to-severe closed head injury was studied:Information presented visually (with and/or without auditory presentation of names) allowed for more information to be learned than when information is presented within the auditory modality alone 82

 For a more detailed discussion on each of these studies and their findings, please see ERABI/Cognition Interventions Post ABI.


Post-Traumatic Amnesia (PTA) and Retention of New Information

  • It is generally thought that while patients are experiencing post-traumatic amnesia (PTA), they are not able to learn and retain new information, and as a result, cognitive rehabilitation is usually postponed until PTA has resolved.
  • In one study, authors evaluated implicit memory (priming using a stem completion task) and the use of vanishing cues when learning semantic information in a small number of TBI patients who were still experiencing PTA. Findings revealed that learning and recall of information (once PTA has resolved) had occurred, albeit at reduced levels 83.  
  • Ewert et al. 84also demonstrated procedural learning and retention in a group of 16 severely closed head injured participants and matched controls.

4.8.8   Memory Programs

What is the evidence for memory-retraining programs post ABI?
  1. There is Level 2 evidence, based on a single RCT, that memory-retraining programs appear effective, particularly for functional recovery although performance on specific tests of memory may or may not change.
  2. Mildly impaired patients appear to benefit more than severely impaired patients

Five studies looking at memory-retraining programs post ABI were reviewed:

  1. Initially no differences were observed between groups (mild to severely impaired patients) on neuropsychological measures of memory.  When groups were subdivided based on neurocognitive severity, results indicated that the mildly impaired group benefited more than the severely impaired group from memory retraining85.
  2. Executive and compensatory memory retraining in traumatic brain injured patients was evaluated. A significant difference was found between the treatment group (n=6) and the control group’s (n=6) post-training measures with the experimental group improving considerably more than the control group. Results suggest that memory remediation is effective for brain-injured patients with memory impairments 86.
  3. The effects of a memory group that met weekly for 11 months (2 hours a week for approximately 48 weeks) were examined. Scores on neuropsychological measures of memory did not change over time. A main drawback of this study is the researchers’ failure to describe the nature and content of the memory program 87.
  4. Memory rehabilitation following severe TBI was examined. Results indicated little improvement in standard measures of memory functioning, although patients and family members report meaningful functional gains (self-report and observed behaviour in everyday functioning 88.
  5. The effect of training frequency on face-name recall was examined.  Mnemonics and visual imagery strategies were effective for approximately 50% of participants regardless of frequency of intervention sessions 89.

 For a more detailed discussion of each of these studies please see ERABI/Cognition Internvetion Post ABI

4.8.9   Pharmacological Intervention   Amantadine

What is the evidence for amantadine in treating memory deficits post ABI?

  1. There is Level 4 evidence that amantadine does not help to improve learning and memory deficits based on the conclusions of a single group intervention study.
  • Amantadine is a non-competitive N-methyl-D-aspartate receptor antagonist 90.
  • It is thought to work pre- and post-synaptically by increasing the amount of dopamine 53.
  • Results from one study demonstrated that the administration of amantadine over a 12-week treatment period does not improve measures of memory deficits or attention 91.   Donepezil

What is the evidence for the use of a cholinesterase inhibitor in treatment of attention disorders following TBI?

  1. There is Level 1 evidence, based on a single RCT, that donepezil improves attention and short-term memory.
  • The effectiveness of the cholinesterase inhibitor, Donepezil, for improving cognitive functioning following brain injury was assessed in one study. 
  •  Results from one RCT  demonstrated that donepezil significantly increased scores on tasks of sustained attention and short-term memory when compared to placebo and that these improved results were sustained after the wash-out period 52.

According to ABIKUS Recommendations 27

Medication for Management of Memory

Donepezil (5-10 mg/day) is recommended to enhance aspects of memory function for patients with moderate to severe TBI in subacute and chronic periods of recovery (ABIKUS B, adapted from GPT, 1, p. 1482) (G39-p.22)

Methylphenidate in a dose of 0.30 mg/kg bid may be considered as an option to enhance learning and memory in persons who are within a few months of brain injury onset when other strategies are ineffective (ABIKUS B, adapted from GPT, I, p.1483) (G40-p.22)