519

REVIEW ARTICLE (META-ANALYSIS)

Evidence-Based Cognitive Rehabilitation: Updated Review of
the Literature From 2003 Through 2008
Keith D. Cicerone, PhD, Donna M. Langenbahn, PhD, Cynthia Braden, MA, CCC-SLP, James F. Malec, PhD,
Kathleen Kalmar, PhD, Michael Fraas, PhD, Thomas Felicetti, PhD, Linda Laatsch, PhD,
J. Preston Harley, PhD, Thomas Bergquist, PhD, Joanne Azulay, PhD, Joshua Cantor, PhD,
Teresa Ashman, PhD
ABSTRACT. Cicerone KD, Langenbahn DM, Braden C,
Malec JF, Kalmar K, Fraas M, Felicetti T, Laatsch L, Harley
JP, Bergquist T, Azulay J, Cantor J, Ashman T. Evidencebased cognitive rehabilitation: updated review of the literature
from 2003 through 2008. Arch Phys Med Rehabil 2011;92:
519-30.
Objective: To update our clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI)
and stroke, based on a systematic review of the literature from
2003 through 2008.
Data Sources: PubMed and Infotrieve literature searches
were conducted using the terms attention, awareness, cognitive, communication, executive, language, memory, perception,
problem solving, and/or reasoning combined with each of the
following terms: rehabilitation, remediation, and training for
articles published between 2003 and 2008. The task force
initially identified citations for 198 published articles.
Study Selection: One hundred forty-one articles were selected for inclusion after our initial screening. Twenty-nine
studies were excluded after further detailed review. Excluded
articles included 4 descriptive studies without data, 6 nontreatment studies, 7 experimental manipulations, 6 reviews, 1 single
case study not related to TBI or stroke, 2 articles where the
intervention was provided to caretakers, 1 article redacted by
the journal, and 2 reanalyses of prior publications. We fully
reviewed and evaluated 112 studies.
Data Extraction: Articles were assigned to 1 of 6 categories
reflecting the primary area of intervention: attention; vision and
visuospatial functioning; language and communication skills;
memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using
specific criteria.

From the Department of Physical Medicine and Rehabilitation, JFK-Johnson
Rehabilitation Institute, Edison, NJ (Cicerone, Kalmar, Azulay); Department of
Rehabilitation Medicine, Rusk Institute of Rehabilitation Medicine, New York, NY
(Langenbahn); Administration Research Department, Craig Hospital, Englewood, CO
(Braden); Department of Physical Medicine and Rehabilitation, Indiana University
School of Medicine and Rehabilitation Hospital of Indiana, Indianapolis, IN (Malec);
Department of Communication Arts and Sciences, Elmhurst College, Elmhurst, IL
(Fraas); Beechwood Rehabilitation Services, Langhorne, PA (Felicetti); Department
of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago,
IL (Laatsch); Marianjoy RehabLink, Wheaton, IL (Harley); Department of Psychiatry
and Psychology, Mayo Clinic College of Medicine, Rochester, MN (Bergquist);
Department of Rehabilitation Medicine, Mount Sinai School of Medicine, New York,
NY (Cantor, Ashman).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.
Reprint requests to Keith D. Cicerone, PhD, JFK-Johnson Rehabilitation Institute,
2048 Oak Tree Rd, Edison, NJ 08820, e-mail: kcicerone@solarishs.org.
0003-9993/11/9204-00776$36.00/0
doi:10.1016/j.apmr.2010.11.015

Data Synthesis: Of the 112 studies, 14 were rated as class I,
5 as class Ia, 11 as class II, and 82 as class III. Evidence within
each area of intervention was synthesized and recommendations for Practice Standards, Practice Guidelines, and Practice
Options were made.
Conclusions: There is substantial evidence to support interventions for attention, memory, social communication skills,
executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI. Evidence supports visuospatial rehabilitation after right hemisphere stroke, and interventions for aphasia and apraxia after left hemisphere stroke.
Together with our prior reviews, we have evaluated a total of
370 interventions, including 65 class I or Ia studies. There is
now sufficient information to support evidence-based protocols
and implement empirically-supported treatments for cognitive
disability after TBI and stroke.
Key Words: Brain injuries; Practice guidelines as topic;
Rehabilitation; Stroke.
© 2011 by the American Congress of Rehabilitation
Medicine
HE COGNITIVE REHABILITATION Task Force of the
T
American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest Group has previously
conducted 2 systematic reviews of cognitive rehabilitation after
TBI or stroke, which served as the basis for specific practice
recommendations. The first of these articles represents the
initial application of an evidence-based, systematic review to
the literature concerning the effectiveness of cognitive rehabilitation.1 The second article provided an update to the cognitive
rehabilitation literature through 2002 publications.2 Since then,
a number of systematic reviews have been conducted.
Rees et al3 conducted a systematic review of 64 studies addressing cognitive rehabilitation for attention, learning or memory,
executive functioning, and general cognitive rehabilitation approaches including pharmacologic interventions. Most of their
conclusions were based on moderate or limited evidence. They
found strong evidence supporting the use of external memory
aides to compensate for functional memory problems, without
necessarily improving underlying memory abilities. They also

List of Abbreviations
ANCDS
APT
CIAT
IADLs
RCT
TBI
VRT

Academy of Neurologic Communication
Disorders and Sciences
attention process training
constraint induced aphasia therapy
instrumental activities of daily living
randomized controlled trial
traumatic brain injury
visual restoration therapy

Arch Phys Med Rehabil Vol 92, April 2011

The ANCDS also reviewed 21 studies addressing the effectiveness of external aids for memory compensation. The review was based on 5 key questions regarding participants. vision and visuospatial functioning. 2 articles where the intervention was provided to a caretaker. 6 reviews.7 There were several high-quality studies that supported the effectiveness of interventions for attention. (5) articles that did not include participants primarily with a diagnosis of TBI or stroke. the ANCDS6 conducted a systematic review and metaanalysis of 15 studies addressing interventions for executive functions after TBI. Treatment effects were moderated by the targeted cognitive domain. remediation. communication. Direct attention training was defined as the repeated stimulation of attention via graded exercises to improve the underlying neurocognitive system and attention functioning. Finally. executive function.3-6 only 2 articles were not included in our prior reviews. these were not classified as new studies but were evaluated and the findings are discussed. When assessing comparative effectiveness. and development of recommendations. and training for articles published between 2003 and 2008. The task force initially identified citations for 198 published articles. strategy use) for postacute or mildly impaired clients with intact vigilance. language and communication skills. 1 single case study of a patient not diagnosed with TBI or stroke. Twenty nine studies were excluded following further detailed review (4 descriptive studies without data. The review led to the recommendation of a practice standard for the use of metacognitive strategy training with young to middle-age adults with TBI in chronic stages of disability for difficulties with problem solving. We systematically reviewed and analyzed studies that allowed us to evaluate the effectiveness of interventions for cognitive limitations. online literature searches using PubMed and Infotrieve were conducted using the terms attention. The ANCDS has conducted 3 systematic reviews of cognitive rehabilitation. awareness. including improvements on participation outcomes. RCTs were considered class I evidence. the metaanalysis did not distinguish between studies comparing active with sham treatment conditions. and those comparing 2 alternative. problem solving. or Level III evidence. cognitive. Two reviews were based directly on the task force’s earlier systematic reviews. The authors concluded that treatment to establish the use of external aids for memory compensation might be considered a Practice Guideline as a means of improving day-to-day functioning for people with brain injury. using the key questions noted above. self-monitoring. executive. One of these evaluated the methodologic quality of 53 comparative effectiveness studies (32 RCTs and 21 observational studies) involving exclusively or primarily participants with TBI. The authors recommended use of direct attention training in conjunction with metacognitive training (feedback. METHODS The development of evidence-based recommendations followed our prior methodology for identification of the relevant literature. (6) studies of pediatric subjects. Given the inherent difficulty in blinding rehabilitation interventions. and classified as providing Level I. The meta-analyis revealed sufficient evidence for the effectiveness of attention training after TBI. 7 experimental manipulations. but ineffective for those with severe memory impairment. We fully reviewed and evaluated 112 studies. and reasoning combined with each of the terms rehabilitation. after controlling for improvements in nontreatment control groups. perception. One hundred forty-one articles were selected for inclusion following this screening process. we did not . 6 nontreatment studies. methodologic concerns. language treatment for aphasia. These studies supported metacognitive strategy training to improve problem solving for personally relevant activities.2 Well-designed. We integrated these findings in our current practice recommendations. and clinically applicable trends across studies. The meta-analysis also excluded noncontrolled and single-case studies that might elucidate innovative and potentially effective treatments. while other studies evaluated various electronic devices. Differing conclusions between this meta-analysis and the systematic reviews may reflect differences in methodology. (8) nonpeer reviewed articles and book chapters. and 1 article that was redacted by the journal). Ten of the studies (including 5 RCTs) utilized metacognitive strategy instructions (eg. studies using a prospective design with quasi-randomized assignment to treatment conditions were designated as class Ia studies. communication skills. Cicerone found strong evidence that internal strategies are effective in improving recall performance for people with mild impairment. (9) articles describing pharmacologic interventions. These methods are described in more detail in our initial publication.520 UPDATE ON COGNITIVE REHABILITATION 2003–2008. prospective. (2) theoretical articles or descriptions of treatment approaches. or comprehensive-integrated interventions) that specifically address the rehabilitation of cognitive disability. and organization. Among the systematic reviews discussed above. and visuospatial treatment for neglect syndromes after stroke. (4) articles without adequate specification of interventions. including nonclinical experimental manipulation. etiology. and comprehensive-holistic rehabilitation after TBI. planning. The abstracts or complete articles were reviewed in order to eliminate articles according to the following exclusion criteria: (1) nonintervention articles. for self-monitoring and control of cognitive processes). For example. nature of interventions. Rohling et al8 conducted a meta-analytic reexamination of the task force’s prior systematic reviews. We therefore identified the need to review the literature since 2002 and update our previous practice recommendations accordingly. (3) review articles. They found a small significant overall treatment effect that was directly attributable to cognitive rehabilitation. memory.1 For the current review. These conclusions are consistent with our earlier recommendations. and age. memory. April 2011 reviews. the level of evidence was determined based on criteria used in our prior reviews.5 The most common type of external aid was a written memory notebook or daily planner (9 studies). and (10) non-English language articles. They also noted moderate evidence that methylphenidate improved overall cognitive functioning and strong evidence that methylphenidate improves processing speed after TBI. (7) single case reports without empirical data. based on significant effect sizes for activity and participation outcomes compared with control treatments. active cognitive interventions. critical to the conclusions of our and other systematic Arch Phys Med Rehabil Vol 92. Level II. outcomes. This analysis also noted the value of non-RCTs in providing evidence for the effectiveness of cognitive rehabilitation for people with TBI. review and classification of studies.1. Sohlberg et al4 reviewed 9 studies and developed evidence-based practice guidelines for direct attention training after TBI. time since injury. the meta-analysis did not partial out the effect of impairment severity on memory interventions. executive functioning. language. For these 112 studies. The current study is an updated review of the literature published from 2003 through 2008 addressing cognitive rehabilitation for people with TBI or stroke. Articles were assigned to 1 of 6 possible categories (based on interventions for attention. Two studies were reanalyses of a prior publication. Articles were reviewed by 2 task force members who were experienced in the process of conducting a systematic review of cognitive rehabilitation studies.

or Practice Options was based on the decision rules applied in our initial review (table 1). The cognitive remediation consisted of direct attention training along with training in use of a memory notebook and problem-solving strategies. consistent with our prior reviews. Unlike the earlier study. Although improvements in attention-executive functioning have been related to self-reported improvements in attention and memory. completing 90 trials (taking about 40min) daily. The level of evidence required to determine Practice Standards. well-designed class I study with an adequate sample. it is representative of clinical practice. retrospective. 5 as class Ia.521 UPDATE ON COGNITIVE REHABILITATION 2003–2008. or well-designed class II studies with adequate samples. providing evidence of possible effectiveness to support a recommendation that the treatment be specifically considered for people with acquired neurocognitive impairments and disability. Insufficient evidence exists to distinguish the effects of specific attention training during acute recovery and rehabilitation from spontaneous recovery or from more general cognitive interventions. In 2 cases. April 2011 .13 improvement Table 2: Remediation of Attention Level of Recommendation Intervention Remediation of attention is recommended during postacute rehabilitation after TBI. Two studies evaluated direct attention training after stroke or TBI. This study supports the findings from a previous RCT. al- though there was no effect on community integration. providing evidence of probable effectiveness to support a recommendation that the treatment be specifically considered for people with acquired neurocognitive impairments and disability.10 and 6 class III studies11-16 addressing remediation of attention. A class I study10 utilized an automated. Disagreements between the 2 primary reviewers (as occurred for 3 articles) were first addressed by discussion between reviewers to correct minor sources of disagreement. with support from class II or class III evidence. improvements in reading comprehension were seen after APT. 11 as class II. Weekly telephone feedback was provided. and then by obtaining a third review. 14 were rated as class I. Practice Standard Practice Option Arch Phys Med Rehabil Vol 92. Remediation of Attention We reviewed 2 class I studies9. Remediation of attention deficits after TBI should include direct attention training and metacognitive training to promote development of compensatory strategies and foster generalization to real world tasks. computerized training program to treat adults who had sustained a stroke 1 to 3 years earlier. Three class III studies11-13 used single-subject methods to investigate the effects of direct attention training for individuals with mild aphasia after stroke. Class II studies consisted of prospective. Sole reliance on repeated exposure and practice on computer-based tasks without some involvement and intervention by a therapist is not recommended. When compared with an untreated control group. A class I study9 investigated the effectiveness of cognitive remediation and cognitivebehavioral psychotherapy for participants with persisting complaints after mild or moderate TBI. 5 days a week for 5 weeks. Cognitive-behavioral therapy was used to increase coping behaviors and reduce stress. Clinical series without concurrent controls. or single-subject designs with adequate quantification and analysis were considered class III evidence.17 demonstrating the beneficial effects of APT on complex attention. No improvements in neuropsychologic performance were seen after general stimulation. Computer-based interventions may be considered as an adjunct to clinician-guided treatment for the remediation of attention deficits after TBI or stroke. this occurred for 4 articles. participants who completed the computerized intervention demonstrated improvements on untrained working memory and attention tests. this study combined APT with compensatory strategy training and psychotherapeutic treatment. The treatment protocol required home use of computer software. Participants demonstrated improved performance on a measure of complex attention and reduced emotional distress compared with a wait-list control group. that directly addresses the effectiveness of the treatment in question. following the working memory training there were significant improvements on executive aspects of attention and self-reported everyday functioning. Studies that were designed as comparative effectiveness studies but did not include a direct statistical comparison of treatment conditions were considered class III. consider this as criterion for class I or Ia studies. nonrandomized cohort studies. While it is therefore not a pure test of APT. and 82 as class III. Practice Guidelines. Cicerone Table 1: Definition of Levels of Recommendations Practice Standards Practice Guidelines Practice Options Based on at least 1. All recommendations were reviewed for consensus by the entire task force through face-to-face discussion. A class III study15 compared general stimulation with repeated administration of working memory tasks to remediate central executive deficits after TBI. or multiple-baseline studies that permitted a direct comparison of treatment conditions. with no other therapist involvement. Based on 1 or more class I studies with methodologic limitations. The overall evidence within each predefined area of intervention was synthesized and recommendations were derived from the relative strengths of the evidence. that directly address the effectiveness of the treatment in question. Of the 112 studies. Based on class II or class III studies that directly address the effectiveness of the treatment in question. as well as a decrease in self-rated cognitive symptoms. providing substantive evidence of effectiveness to support a recommendation that the treatment be specifically considered for people with acquired neurocognitive impairments and disability.11. there is limited evidence of improvement in everyday functional activities after attention training.12 In 1 case. nonrandomized case-control studies. based on the assumption that training would increase working memory capacity. which would then generalize to other cognitive systems.

The authors suggested that there was no benefit from targeting visual attention skills. Recommendations.29 also investigated the effects of VRT on reducing the extent of visual field deficits. 1 class II study. after right hemisphere stroke as part of acute rehabilitation.29 Table 4: Remediation of Language and Communication Deficits Intervention Cognitive-linguistic therapies are recommended during acute and postacute rehabilitation for language deficits secondary to left hemisphere stroke. One class I study18 evaluated the effectiveness of visual attention training on the driving performance for 97 patients with stroke. Specific gestural or strategy training is recommended for apraxia during acute rehabilitation for left hemisphere stroke. Remediation of Vision and Visuospatial Functioning We reviewed 3 class I18. Direct attention training through repeated practice using computer-based interventions may be considered as an adjunct to treatment when there is therapist involvement (Practice Option) (see table 2). Cognitive interventions for specific language impairments such as reading comprehension and language formulation are recommended after left hemisphere stroke or TBI. but patients with right hemisphere stroke might benefit from specific skill training (eg. using a driving simulator).28.28. are recommended for social communication skills after TBI. This recent evidence is consistent with our recommendation of strategy training for attention deficits during postacute rehabilitation for people with TBI (Practice Standard) (table 2) and with ANCDS evidence-based practice guidelines for direct attention training. Five class III studies22. Systematic training of visuospatial deficits and visual organization skills may be considered for persons with visual perceptual deficits. including pragmatic conversational skills. Group based interventions may be considered for remediation of language deficits after left hemisphere stroke and for social-communication deficits after TBI. Cicerone Table 3: Remediation of Visuospatial and Praxic Deficits Level of Recommendation Intervention Visuospatial rehabilitation that includes visual scanning training is recommended for left visual neglect after right hemisphere stroke. Visuospatial cuing extended the topographic pattern of recovery and improved vision within the cued area. Inclusion of limb activation or electronic technologies for visual scanning training may be included in the treatment of neglect after right hemisphere stroke.23. Computer-based interventions intended to produce extension of damaged visual fields may be considered for people with TBI or stroke. Specific interventions for functional communication deficits. extending a prior class III study by these investigators using the useful field of view.26. Arch Phys Med Rehabil Vol 92. Results replicated the beneficial effects of scanning training. The use of isolated microcomputer exercises to treat left neglect after stroke does not appear effective and is not recommended. without visual neglect. but the addition of optokinetic stimulation did not further enhance visual scanning or attention.522 UPDATE ON COGNITIVE REHABILITATION 2003–2008.26. One class I study with 22 stroke patients20 investigated whether it is possible to strengthen the rehabilitation of visual hemineglect by combining a standard scanning intervention34. Remediation of attention deficits after TBI should include direct attention training and metacognitive training to promote development of compensatory strategies and foster generalization to real world tasks. A class I study19 investigated whether the use of a visuospatial cue to focus attention improved performance in areas of partially-defective residual vision during VRT. Treatment intensity should be considered a key factor in the rehabilitation of language skills after left hemisphere stroke. There were no significant differences between groups on measures of attention.19 or class Ia20 studies. with some evidence that these changes are associated with subjective improvements in visual function and reading speed. Computer-based interventions as an adjunct to clinician-guided treatment may be considered in the remediation of cognitive-linguistic deficits after left hemisphere stroke or TBI.21 and 11 class III studies22-32 addressing the remediation of visuoperceptual deficits after TBI or stroke.35 with optokinetic stimulation. visuoperception. or resumption of driving. April 2011 Level of Recommendation Practice Standard Practice Standard Practice Guideline Practice Guideline Practice Option Practice Option . Consistent with the task force’s prior recommendations.33 Training with useful field of view to address Practice Standard Practice Guideline Practice Option Practice Option Practice Option Practice Standard attention and processing speed was compared with traditional computerized visuoperceptual training. This finding suggests that increased attention to the areas of partially-defective vision helps to compensate for the visual defect. sole reliance on repeated use of computerbased tasks without some involvement and intervention by a therapist is not recommended. was limited to trained attention tasks with nominal change in auditory comprehension. Sole reliance on repeated exposure and practice on computer-based tasks without some involvement and intervention by a therapist is not recommended.

with semantic treatment related to improved semantic processing and phonologic treatment related to improvement of phonologic processing. providing strong support for this intervention as a Practice Standard (see table 3). Cicerone Table 5: Remediation of Memory Deficits Level of Recommendation Intervention Memory strategy training is recommended for mild memory impairments from TBI. In the current review. with limited transfer to novel tasks or reduction in overall functional memory problems.19 We previously noted1 that the observed reductions in visual field defects were insufficient to explain the associated reduction in functional impairments after VRT. Inclusion of limb activation or electronic technologies for visual scanning training was recommended as a Practice Option.42-44 and 32 class III studies45-76 in the area of cognitivelinguistic rehabilitation.20 The task force previously recommended that visual restoration training to reduce the extent of damaged visual fields should be considered a Practice Option. visual imagery) and external memory compensations (eg. There was no effect of therapy intensity on a standardized assessment of aphasia. there was a significant difference between the 2 standard treatment groups. We continue to recommend that interventions intended to reduce the extent of damaged visual fields should be considered a Practice Option (see table 3).18 Remediation of Language and Communication Skills We reviewed 6 class I36-40 or Ia41 studies. The task force previously identified 9 class I studies demonstrating the efficacy of visual scanning training for visual neglect after right hemisphere stroke. but a current class I study does not support the addition of optokinetic stimulation as a component of visual scanning treatment. which may have reflected the amount of treatment actually received (averaging 1. notebooks). errorless learning techniques may be effective for learning specific skills or knowledge. April 2011 . most of the studies involved persons with stroke. In the current review. For people with severe memory impairments after TBI. Training in formal problem-solving strategies and their application to everyday situations and functional activities is recommended during postacute rehabilitation after TBI. As in past reviews.6 vs 0. Two class II42. The current class I study is consistent with this interpretation. this recommendation is supported by class III evidence. One study42 suggests that the effectiveness of contextually-based language treatment may not depend on therapy intensity. Of interest. an additional group of patients were clinically assigned to standard therapy. Treatment-specific effects were related to type of impairment. The authors posited that there may be a critical threshold of treatment intensity required to improve acute recovery after stroke.6h/wk). one class I study suggests limited benefit from targeting visual attention deficits skills and the need for specific. The second study43 compared constraintinduced aphasia therapy with constraint-induced aphasia therapy combined with additional training in everyday communication.523 UPDATE ON COGNITIVE REHABILITATION 2003–2008. and emphasized the need for future research to address the optimal timing for starting intensive therapy after acute stroke. Practice Standard Practice Guideline Practice Option Arch Phys Med Rehabil Vol 92. and only 80% received the prescribed treatment. functional skill training to improve driving ability after stroke. including impairments of emotional self-regulation. and that functional improvement was associated with increased compensation rather than change in the underlying visual field deficit. The task force previously identified the need for class I studies to improve complex visuospatial abilities required for functional activities (eg.38-41 Language remediation after stroke. Both groups improved on a measure of verbal communication. 3 class II studies. Recommendations. Use of external compensations with direct application to functional activities is recommended for people with severe memory deficits after TBI or stroke. although few of the patients in the intensive therapy condition could tolerate the prescribed therapy. The authors Table 6: Remediation of Executive Function Deficits Level of Recommendation Intervention Metacognitive strategy training (self-monitoring and self-regulation) is recommended for deficits in executive functioning after TBI.43 studies addressed the intensity of aphasia treatment after stroke. There was greater improvement in communication effectiveness among participants who received additional communication exercises. neglect. A class I study suggests that a combination of top-down (cuing attention) and bottom-up (VRT) interventions. first stroke. Group-based interventions may be considered for remediation of memory deficits after TBI. and as a component of interventions for deficits in attention. Participants were randomly allocated to receive either intensive therapy (5h/wk) or standard therapy (2h/wk). although 4 of the class I studies Practice Standard Practice Guideline Practice Option Practice Option investigated interventions for communication deficits resulting from TBI. including the use of internalized strategies (eg. may enhance conscious visual perception. with no difference between groups. linking visual and attentional neuronal networks. Group-based interventions may be considered for remediation of executive and problem solving deficits after TBI. and memory. One class I study36 examined whether the amount of speech and language therapy influenced recovery from aphasia after a single. driving). One class I study37 investigated the effects of semantic versus phonologic treatment on verbal communication in 55 patients with aphasia after left hemisphere stroke.

77 adults with chronic TBI were trained to use compensatory strategies for personally-relevant memory problems through errorless learning or didactic strategy instruction.80 and 11 class III studies. There was no difference between treatments in generalized strategy use or frequency of memory problems reported by participants or caregivers. Positive transfer was seen on a slightly revised procedure. replicated across all 4 subjects and maintained at 30-day follow-up. as well as improved quality of life at 6-month follow-up.87 Compensatory strategy training. Both active treatment conditions utilized an errorless learning method and consisted of 20 sessions of memory skills training. social behaviors. These studies support potential benefits of errorless learning for treatment for teaching new knowledge.86. Dahlberg et al38 conducted a class I study to investigate the efficacy of social communication skills training for 52 participants with TBI who were at least 1 year postinjury. Treatment consisted of process-oriented memory training (20h). There is a continued need to investigate the aspects of intensive language treatment (eg. and facilitate the effectiveness of specific interventions. Four class I or Ia studies38-41 support the task force’s recommendation of social communication skills interventions for interpersonal and pragmatic conversational problems for people with TBI (Practice Standard) (see table 4). One class Ia study.86 In a subsequent class I study. with limited generalization of strategy use. an equivalent amount of strategy training. The class Ia study78 compared computer-assisted and therapist-assisted memory training with a no-treatment control condition for participants with TBI. therapy intensity should continue to be considered as a factor in the rehabilitation of language skills after left hemisphere stroke (Practice Guideline) (table 4). such as taking medications at mealtime or keeping keys in a consistent location. When compared with both control conditions. Integrated treatment of individualized cognitive and interpersonal therapies is recommended to improve functioning within the context of a comprehensive neuropsychologic rehabilitation program. Results showed a strong relationship between the instructional program and learning the e-mail procedures. Cicerone Table 7: Comprehensive-Holistic Neuropsychologic Rehabilitation Level of Recommendation Intervention Comprehensive-holistic neuropsychologic rehabilitation is recommended during postacute rehabilitation to reduce cognitive and functional disability for persons with moderate or severe TBI. Two class I studies conducted a more detailed investigation of the intervention for social and emotional perception. Between-group analyses demonstrated a significant treatment effect on 7 of 10 scales on the Profile of Functional Impairment in Communication and on the Social Communication Skills Questionnaire. and the consolidation and generalization of those skills. Improvements were noted in recognition of emotional expressions but these improvements were not reflected on a more general measure of psychosocial functioning. and cognitive abilities required for successful social interactions. The class II study80 evaluated an instructional sequence for people with severe memory and executive function impairments resulting from chronic TBI. who were at least 12-months postinjury and residing in the community. A preliminary study suggested that errorless learning can be used to teach compensatory strategies for specific memory problems. and use of simple . or control treatment of low dose. However.40 Both interventions resulted in modest improvements in judging facial expressions and drawing social inferences. April 2011 Practice Standard Practice Option Practice Option reanalyses of an earlier RCT92 restricted to participants with TBI93 or stroke. The social skills training was devoted to pragmatic communication behaviors (listening. Several studies investigated group administered memory remediation. Another class Ia study41 investigated social communication skills training among 51 participants with acquired brain injury. including knowledge of compensatory strategies.80 and 4 class III studies82.79 1 class II study. management of daily tasks that utilize memory skills.78. Remediation of Memory We reviewed 3 new class I77 or Ia studies. Group-based interventions may be considered as part of comprehensive-holistic neuropsychologic rehabilitation after TBI. board games).39 A subsequent study compared errorless learning and self-instructional training strategies for treating emotion perception deficits. Errorless learning techniques appear to be effective for teaching specific information and procedures to patients with mild executive disturbance as well as memory impairment. Processoriented training included mass practice.78 a class II study. process-oriented memory training (7h).90 investigated the benefits of errorless learning in memory remediation. Both treatments produced improvement on neuropsychologic tests of memory functioning compared with no treatment. A class Ia study79 investigated type and intensity of memory training to treat mild memory impairment after recent onset stroke.87.94 Errorless learning. timing. the presence of severe executive dysfunction may limit effectiveness of this form of memory rehabilitation. Recommendations. Treatment of cognitive communication disorders after TBI. Participants either received social skills training. dosage) that contribute to therapy effectiveness. training to manage interference between acquisition and recall. along with psychotherapy for emotional adjustment. Participants were taught to use a simple e-mail interface through a combination of errorless learning and metacognitive strategy training. suggest that improvement in either linguistic route may contribute to improved verbal communication patterns. An additional class III study55 suggests that incorporation of cognitive-linguistic therapies in postacute rehabilitation is related to cognitive and functional progress for patients with language impairment after TBI. starting a conversation) and social perception of emotions and social inferences. with some advantage for self-instructional training. Although. but not to a novel task with different content. to people with severe memory deficits resulting from TBI. predominantly TBI. Participants trained with errorless learning reported greater use of strategies after training. Training incorporated pragmatic language skills. social communication skills training produced significant improvement in participants’ ability to adapt to the social context of conversations. or no treatment.524 UPDATE ON COGNITIVE REHABILITATION 2003–2008. cooking. an equivalent amount of group social activities (eg.81-91 We also reviewed 2 Arch Phys Med Rehabil Vol 92.

56 and social skills40. with experiential exercises requiring participants to predict. planning a vacation). In the problem-solving intervention. such as pagers. whose performance either did not improve or decline. use of self-regulations strategies. We now recommend this as a Practice Option (see table 5). self-monitoring and self-regulation) have particular value and effectiveness over conventional rehabilitation in treating patients with impaired self-awareness after moderate or severe TBI. including training in metacognitive strategies.97. Recommendations. group format memory training program. The use of externally-directed assistive devices. The second class I study95 employed self-awareness and verbal self-regulation strategies during performance of IADLs tasks.97 compared an awareness-training protocol with conventional occupational therapies after moderate or severe TBI (n⫽33) or stroke (n⫽8). Strategy training was aimed at teaching strategies adapted to different situations with memory requirements. self-appraisal of clear thinking. Cicerone principles to optimize memory performance. April 2011 . assess the amount of assistance required to successfully perform the task. A number of studies indicate that interventions directed at improving metacognitive skills (ie. Unlike TBI participants. Remediation of Executive Functioning We reviewed 3 class I95.99 and 14 class III studies100-113 addressing the remediation of executive functioning. marital difficulties). The awareness intervention was associated with greater increase in self-awareness of deficits after treatment.UPDATE ON COGNITIVE REHABILITATION 2003–2008. and improved performance on neuropsychologic assessment of memory following a 4-week structured. The studies in this area are consistent with the task force’s recommendation of training in formal problem-solving strategies. select a strategy to circumvent difficulties.104. predict task performance. Results indicated that frequency and intensity of memory training were critical in improving memory performance. but not with better performance of IADLs or general functioning compared with 525 conventional rehabilitation. Two of the class I and Ia studies95. and self-evaluate their performance. A randomized cross-over design was used to examine the impact of pager use on successful achievement of target behaviors.98. Fish et al94 analyzed the effectiveness of the paging system for 36 participants with stroke. Improvements in awareness.95. job loss. A number of single-case studies support the benefits of metacognitive training and suggest that the most consistent benefits of this treatment are apparent on participants’ online monitoring. introduction of the paging system produced immediate benefits in compensating for memory and planning deficits. Participants who received the awareness intervention demonstrated significant improvements in self-regulation skills and cognitive aspects of IADLs performance when compared with participants receiving conventional therapy. who were an average of 4 years postinjury. and a carryover effect for the first group after removing the pager. including problem orientation (emotional regulation). but received conventional practice without the awareness intervention. were described as being “higher functioning” but with persistent impairments in social/vocational functioning (eg. appears to be beneficial for persons with moderate to severe memory impairments after TBI or stroke. including training in metacognitive strategies to increase awareness. and their application to everyday activities and functional situations during postacute rehabilitation for people with TBI (Practice Guideline) (table 6). Only the problem-solving treatment resulted in significant beneficial effects on measures of executive functioning.97 the awarenesstraining protocol incorporated feedback to increase participants’ awareness of their abilities.41 after TBI or stroke.80. Based on the current evidence.87 language deficits. Participants.114-116 memory. No differences between groups were evident on either general or task-specific measures of awareness or a measure of community integration after the 6 treatment sessions. self-monitor.108 One class I study96 evaluated the use of autobiographical memory cuing to improve performance on a planning task by people with TBI.110 There also is continued evidence that the incorporation of interventions. the task force now recommends the use of metacognitive strategy training for people with deficits in executive Arch Phys Med Rehabil Vol 92. anticipate difficulties. A class III study91 demonstrated increased knowledge of memory strategies and use of memory aids. The task force continues to recommend training in the use of external compensations (including assistive technology) with direct application to functional activities for persons with moderate or severe memory impairment after TBI or stroke as a Practice Guideline (see table 5). For patients with severe memory impairments after TBI. This analysis supports the initial findings that a paging system was effective in reducing everyday memory and planning problems experienced by persons with TBI. and error management. In 1 of these studies. awareness of errors. errorless learning techniques may be effective for learning specific skills or knowledge. and self-evaluate performance. Externally directed assistive devices. suggesting that this procedure might be an effective component of training on problem-solving techniques. 2 class II studies.96 or Ia97 studies. The presence of significant executive dysfunction appears to limit the effectiveness of these interventions for severe memory deficits. the behavior of stroke participants returned to baseline levels after removal of the pager. Further analyses suggested that maintenance of treatment benefits was associated with executive functioning.85. and overall function were evident for both groups. Participants in the experimental group received a single session of instruction on the use of specific examples from their memory of similar activities in order to solve a functional problem situation (eg. self-appraisal of emotional self-regulation. can facilitate the treatment of attention. Results demonstrated significantly increased task behavior in each group when using the pager. A notable study110 evaluated an innovative social problemsolving intervention after TBI. Wilson et al93 examined the results for 63 people with chronic TBI with memory and/or planning problems. compared with conventional neuropsychologic rehabilitation. The intervention was successful in increasing the recall of specific memories and effectiveness of functional planning. Participants were asked to define their performance goals. and objective observer-ratings of interpersonal problem solving behaviors in naturalistic simulations. reduced behaviors indicative of memory impairment. performance of IADLs. and systematic analysis of real-life problem situations. emotional self-regulation was taught as the basis for effective problem-orientation and a necessary precursor to support training in the clear thinking underlying problem-solving skills. with limited transfer to novel tasks or reduction in overall functional memory problems. Role play was used to promote internalization of self-questioning. The task force previously recommended the use of compensatory strategy training for subjects with mild memory impairment as a Practice Standard (table 5). There were 2 reanalyses of an RCT92 studying the benefits of a paging system for subjects with acquired brain injury. Recommendations. and the stroke participants had poorer executive functioning. Participants in the control condition performed the same IADLs tasks as the treatment group. As found with TBI participants.

Standard neurorehabilitation consisted primarily of individual.38. and 251 class III studies) that provide evidence for the comparative effectiveness of cognitive rehabilitation. functional independence. The Practice Standards for metacognitive strategy training for executive deficits and comprehensive-holistic neuropsychologic rehabilitation after TBI represent upgraded recommendations from our prior reviews.117. Based on our current review.526 UPDATE ON COGNITIVE REHABILITATION 2003–2008.131 and executive functioning and problem solving. The cognitivedidactic group showed better immediate posttreatment cognitive function but the 2 groups did not differ on functional or employment outcomes at 1-year follow-up. the task force recommends that group interventions be considered for treating cognitive and communication deficits after TBI and left hemisphere stroke (Practice Option) (see tables 4 –7). there were 15 comparisons (which included 550 participants) of cognitive rehabilitation with no active treatment.119-122 and class III studies. self-efficacy.5 hours of occupational and physical therapy. In every one of these comparisons. and functional skills.91 social communication skills. There is substantial evidence to support the use of direct attention training and metacognitive training after TBI to promote the development of self-directed strategies during postacute rehabilitation and foster generalization to real-world tasks. A number of recommended Practice Standards reflect the lateralized nature of cognitive dysfunction that is characteristic of stroke. The holistic neuropsychologic intervention included individual and group therapies that emphasized metacognitive and emotional regulation for cognitive deficits. Examining this evidence base.5 hours daily of protocol-specific therapy along with 2 to 2. we evaluated 112 studies of cognitive rehabilitation after TBI or stroke. even for patients who are many years postinjury. receiving comprehensive-holistic rehabilitation were twice as likely to make clinically significant gains in community functioning than those receiving conventional rehabilitation. For impairments of higher cognitive functioning after TBI. There were 17 comparisons (with 696 participants) between cognitive rehabilitation and conventional forms of rehabilitation. with different interventions for mild versus severe impairment. Cognitive rehabilitation was shown to be of greater benefit than conventional rehabilitation in 94. discipline-specific therapies (physical therapy. Finally. There is also evidence for the effectiveness of group treatment for memory deficits.110 Based on this evidence. April 2011 DISCUSSION In this systematic review.41 aphasia. Additional research needs to elucidate the mechanisms of change underlying the efficacy of cognitive rehabilitation and the comparative effectiveness of different interventions.119-122 and 8 class III studies123-130 of comprehensive-holistic rehabilitation after TBI or stroke. Cicerone functioning (including impaired self-awareness) after TBI as a Practice Standard (see table 6). Comprehensiveholistic programs typically incorporate a combination in individual and group therapies. and speech therapy) along with 1 hour of individual cognitive rehabilitation. Vanderploeg et al117 conducted an RCT comparing cognitive-didactic and functional-experiential treatment approaches among 360 service members with moderate or severe TBI at 4 Veterans Administration acute inpatient rehabilitation programs. Self-directed strategy training is recommended for the remediation of mild memory deficits after TBI. Comprehensive-Integrated Neuropsychologic Rehabilitation There were 2 class I studies. Participants received 1.119.122 Recommendations. Neuropsychologic functioning improved in both conditions. Most notable. interventions should address the cognitive. and interpersonal difficulties of people with acquired brain injury. interventions that promote self-monitoring and self-regulation for deficits in executive functioning (including impaired selfawareness) and social communication skills interventions for interpersonal and pragmatic conversational problems are recommended after TBI.119 The study found that participants. emotional. Arch Phys Med Rehabil Vol 92. improvements in community functioning. Results from a class I study. The presence of executive functioning deficits may moderate the response to treatment.129 are consistent with prior findings suggesting that comprehensiveholistic neuropsychologic rehabilitation can improve community integration.118 several class II studies. and metacognitive strategy training may need to be incorporated in these interventions. remediation of memory should be tailored to the severity of memory impairment. there are some indications regarding consideration of patient characteristics in cognitive rehabilitation. we now have evaluated a total of 370 interventions (65 class I or Ia. but the holistic neuropsychologic rehabilitation produced greater improvements in community functioning and productivity. interpersonal behaviors. . Several class II studies of comprehensive-holistic rehabilitation demonstrated reductions in symptoms.118 4 class II studies. there is evidence from numerous studies indicating that cognitive rehabilitation is effective during the postacute period. The Practice Options for errorless learning for memory deficits after TBI and for group treatments for cognitive and communication deficits after TBI or left hemisphere stroke represent new recommendations since our prior reviews.121.118. we recommend 2 new Practice Standards and the strengthening or refinement of several Practice Standards previously advanced.5 to 2. 54 class II. occupational therapy.124 The task force recommends that postacute. Comprehensive-holistic neuropsychologic rehabilitation is recommended to improve postacute participation and quality of life after moderate or severe TBI.79. even many years after the initial injury. Additional research is needed to investigate the patient characteristics that influence treatment effectiveness. Cognitive-linguistic interventions for aphasia and gestural strategy training for apraxia are recommended after left hemisphere stroke. multidisciplinary rehabilitation for 68 participants with TBI. Cicerone et al118 conducted an RCT to evaluate the effectiveness of comprehensive-holistic neuropsychologic rehabilitation compared with standard. Although not the primary focus of our reviews. emotional difficulties.123-125. there is clear indication that cognitive rehabilitation is the best available form of treatment for people who exhibit neurocognitive impairment and functional limitations after TBI or stroke. and better quality of life compared with conventional treatment120 or no treatment. Most participants (88%) had sustained moderate or severe TBI and over half were more than 1-year postinjury. Visuospatial rehabilitation that includes visual scanning training for left visual neglect is recommended after right hemisphere stroke. Among the 65 class I and Ia studies. Together with our prior reviews. despite being more severely disabled and further postinjury. and life satisfaction.1% of these comparisons. An earlier (class II) study compared these interventions for clinical referrals. Within this context. cognitive rehabilitation was shown to be of benefit.109. and productivity. comprehensive-holistic neuropsychologic rehabilitation should be provided to reduce cognitive and functional disability after moderate or severe TBI (Practice Standard) (table 7).128.

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