NeuroRehabilitation 34 (2014) 87–100 87

DOI:10.3233/NRE-131015
IOS Press

A description of cognitive rehabilitation at

Sunnaas Rehabilitation Hospital – Balancing
comprehensive holistic rehabilitation and
retraining of specific functional domains
Frank Beckera,b,∗ , Melanie Kirmessa,c , Sveinung Tornåsa,d and Marianne Løvstada,d
a SunnaasRehabilitation Hospital, Nesoddtangen, Norway
b Institute
of Clinical Medicine, University of Oslo, Oslo, Norway
c Department of Special Needs Education, University of Oslo, Oslo, Norway
d Department of Psychology, University of Oslo, Oslo, Norway

Abstract.
BACKGROUND: Measures of cognitive rehabilitation should include comprehensive holistic rehabilitation as well as interven-
tions targeting specific cognitive functions; it is however not clear how this knowledge should be put into practice.
OBJECTIVE: To describe services provided at the cognitive rehabilitation unit at Sunnaas Rehabilitation Hospital (SRH), a
regional rehabilitation centre in Norway.
METHODS: Cognitive rehabilitation programs offered at SRH are described. For all patients served in 2011 and 2012, epidemi-
ological and hospitalization related data were retrieved. Results from a patient satisfaction survey are presented.
RESULTS: The services include individual holistic cognitive rehabilitation as well as group programs. 307 individual patients
were served in 355 hospitalizations; 68.1% were male; age ranged from 18 to 78 years. The largest patient groups were stroke
(46.6%) and traumatic brain injury (33.0%). Mean length of stay was 36.9 days. Median time post injury was 0.8 years (range 16
days – 14 years). More than 90% of the patients were satisfied with the services they received to a large or very large extent.
CONCLUSIONS: Providing cognitive rehabilitation that encompasses both a holistic approach and targets specific cognitive
functions is challenging. More research is warranted to illuminate further how cognitive rehabilitation services should be designed
and conducted in practice.

Keywords: Cognitive rehabilitation, stroke, traumatic brain injury

1. Introduction everyday life is increasingly acknowledged. Accord-

Over the last decades, cognitive rehabilitation fol-
lowing acquired brain injury (ABI) has gained raised
attention as the impact of cognitive impairment on
∗ Address for correspondence: Frank Becker, Institute of Clinical
Medicine, University of Oslo, P.b. 1171 Blindern, 0316 Oslo, Norway.
Tel.: +47 95144638; Fax: +47 66912576; E-mail: frank.becker@
medisin.uio.no.
ing to Barbara Wilson (1996), cognitive rehabilitation
can be defined as “a process whereby people with brain
injury work together with professional staff and oth-
ers to remediate or alleviate cognitive deficits arising
from a neurological insult”. This view appreciates that
rehabilitation is not done to or given to people, rather
the aims and goals of rehabilitation need to be negoti-
ated with the patients and their families. Comprehensive

1053-8135/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved
88 F. Becker et al. / Cognitive rehabilitation at Sunnaas Rehabilitation Hospital
holistic rehabilitation models as described by e.g. Bar-
bara Wilson (2002), Ben-Yishay and Prigatano (1990)
and Sohlberg and Mateer (2001) have strongly inspired
cognitive rehabilitation programs around the world,
including the program described in this paper. These
programs acknowledge that brain injuries will result
in cognitive, emotional, behavioral, psychosocial as
well as vocational challenges, and that a comprehen-
sive understanding of the complexity of living with
brain injury should form the basis of brain injury reha-
bilitation. Descriptions of several holistic cognitive
rehabilitation programs have been published revealing
similarities, but also – in part substantial – differences:
Most of the programs serve patients with traumatic
brain injury (TBI; e.g. Cicerone et al., 2008; Prigatano
et al., 1984; Vanderploeg et al., 2008), while others also
include persons with other etiologies as cerebrovascular
accidents (CVA; e.g. Klonoff et al., 2007; Schönberger
et al., 2001; Svendsen & Teasdale, 2006). The level of
cognitive and general functioning at admission differs
rather widely between programs, from patients who are
independent in activities of daily living (e.g. Sarajuuri
et al., 2005; Svendsen & Teasdale, 2006) to patients
who are confused when enrolled into the program (e.g.
Niemeier et al., 2005; Vanderploeg et al., 2008). Also
the time point after injury when the program is applied
varies. While participants in some programs have lived
on average five years or more with their brain injury
(e.g. Cicerone et al., 2008; Sherer, 1997), or even 17
years (Svendsen & Teasdale, 2006), other programs
include patients only weeks or few months post injury
(e.g. Braverman et al., 1999; Niemeier et al., 2005).
Most of the programs are outpatient services, while only
a few are inpatient services (e.g. Braverman et al., 1999;
Sarajuuri et al., 2005; Vanderploeg et al., 2008). Nev-
ertheless, also most of the outpatient programs provide
treatment four to six hours per day, four or five days
a week (e.g. Goranson et al., 2003; Prigatano et al.,
1984; Rattok et al., 1992). Treatment periods are often
between two to six months (e.g. Cicerone et al., 2008;
Prigatano et al., 1984; Schönberger et al., 2001).
The past decade has brought along significantly
increased optimism regarding the potential for plasticity
in the human brain, and thus also new hope and evidence
regarding the potential for training of specific cognitive
functions affected by brain injury (Nordvik et al., 2012;
Rabipour & Raz, 2012; Tomassini et al., 2012). Along
with this development, there has been increasing focus
on the need to deliver evidence based health practices,
including rehabilitation. The work of The Brain Injury
Interdisciplinary Special Interest Group (BI-ISIG) of
the American Congress of Rehabilitation Medicine
(ACRM) in providing up-to date reviews of the state
of the art in cognitive rehabilitation research (Cicerone
et al., 2000, 2005, 2011) has been tremendously inspir-
ing and trend-setting. One of the conclusions given
is that comprehensive, holistic rehabilitation programs
can improve community integration, functional inde-
pendence, and productivity, even many years post
injury, and thus that comprehensive rehabilitation pro-
grams should be considered practice standard following
moderate and severe TBI (Cicerone et al., 2011). It was
also noted that psychosocial interventions may facili-
tate the effectiveness of treatments directed at specific
cognitive impairments (Cicerone et al., 2005). A chal-
lenge with comprehensive programs is however that
they can be underspecified with regard to their approach
to distinct cognitive functions. They thereby run the
risk of not providing the specificity and/or intensity
of training that has been increasingly acknowledged as
necessary in domain-specific rehabilitation (Bhogal et
al., 2003; Kleim & Jones, 2008). Up to date cognitive
rehabilitation programs should include evidence-based
interventions on distinct cognitive domains that can be
regarded as effective, e.g. attention training or visual
scanning training (Cappa et al., 2011; Cicerone et al.,
2011). Also, research suggests that intensive, repetitive
and purposeful specific language therapy for persons
with aphasia can lead to improvement in language
skills, also when it is carried out over shorter time peri-
ods and in the chronic stage (Berthier & Pulvermüller,
2011).
Recently, Dams-O’Connor and Gordon (2013) have
proposed a synergistic approach to neurorehabilitation:
They describe cognitive processes as hierarchically
organized with functions as attention or arousal at
the basis and problem-solving and self-monitoring at
the top of a functional pyramid (Dams-O’Connor &
Gordon, 2013). The importance of both restorative
or “bottom-up” interventions and compensatory or
“top-down” approaches is stressed. Additionally, the
patient’s awareness of his or her impairments and emo-
tional factors influencing on cognitive capacity play a
crucial role. The authors suggest that bottom-up and
top-down training should not be regarded as mutually
exclusive, but rather integrated in all training activi-
ties (Dams-O’Connor & Gordon, 2013). This stands in
contradiction to other approaches that advocate starting
rehabilitation with efforts to improve basic functions
as attention, before moving on to higher order cogni-
tive functions (Laatsch et al., 2000). There is however
little controversy about the notion that comprehensive
 F. Becker et al. / Cognitive rehabilitation at Sunnaas Rehabilitation Hospital
cognitive rehabilitation should include impairment ori-
ented training as well as strategy learning, and different
opinions might arise from differences in the cognitive
level of patients served.
Another debate concerns whether holistic cogni-
tive rehabilitation always needs to address different
cognitive domains simultaneously, or whether specific
functions as e.g. memory or language should be put into
focus for certain time periods. A theoretical argument
for such an approach is constituted by the proposal that
– when different domains are treated simultaneously
– their “plasticities” might interfere with each other
in a negative manner (Kleim & Jones, 2008). Further-
more, high training intensity for specific functions can
be more readily obtained in this way.
At our facility, the principal aim is to provide rehabil-
itation services on the basis of evidence-based practice,
i.e. the integration of individual clinical expertise,
including patients’ preferences, with the best avail-
able external clinical evidence from systematic research
(Sackett et al., 1996). A major effort is currently put for-
ward in trying to establish an evidence based practice
where intensive, specific training of distinct cognitive
functions are provided within a general framework of
a comprehensive holistic rehabilitation program. Over
the past 5 years or so, there has thus been increas-
ing focus on establishing research projects and clinical
interventions targeting the cognitive functions most
often affected by injury, such as memory, executive
functions, working memory, and language. With regard
to the clinical services, this includes the introduction of
new, domain targeted services, and an increased focus
on the intensity of bottom-up interventions.
Although substantial improvements have been made
(cf. Wilson et al., 2009), cognitive rehabilitation ser-
vices are still under development and more detailed
descriptions of cognitive rehabilitation interventions
are lacking (van Heugten et al., 2012). Thus, the
purpose of this study is to describe the cognitive
rehabilitation program offered at KReSS (Kognitiv
Rehabiliteringsenhet Sunnaas Sykehus); the cognitive
rehabilitation unit at Sunnaas Rehabilitation Hospi-
tal (SRH) in Norway. To share and discuss different
cognitive rehabilitation programs including their theo-
retical approaches, organizational backgrounds, target
groups and rehabilitation activities can contribute to
an exchange of experiences and can stimulate further
development.
In addition to a qualitative presentation of the back-
ground for and content of the activities at KReSS, a
retrospective descriptive study was performed to further
89
illuminate some characteristics of the patients served.
Data from 2011 and 2012 are presented, including
epidemiological, disease related and service related
parameters in addition to results from a patient satisfac-
tion survey. We hypothesized that patients with different
types of brain injury were served, and that the patient
groups would differ with regard to age, sex, and post
injury time, but that there were no greater differences
in length of stay depending on the etiology of the brain
injury. Regarding patient satisfaction, we suspected that
patients respond that they have been informed about
the consequences of brain injury to a high or very high
degree, and that they are involved in their rehabilitation
process as these two areas are highly focused in our
individual cognitive rehabilitation program.
2. Methods
A qualitative description of services at KReSS is
given, based on the authors’ own experiences and con-
tributions to the programs, as well as existing program
manuals, procedures etc.
Furthermore, a retrospective descriptive study of
inpatient activities at KReSS in the years 2011 and 2012
was performed. In the following, the methodology for
this quantitative description is presented.
2.1. Participants
All patients discharged from KReSS between
1.1.2011 and 31.12.2012, were included. Thus, admis-
sion to KReSS was the sole inclusion criterion and no
exclusion criteria were applied (see below for admis-
sion criteria).
2.2. Procedure
Reports which included the following data were
retrieved from the hospital’s medical charts system:
social security number, dates of admission and dis-
charge, cause of admission, origin from which the
patient was admitted, type of discharge destination, and
county of residence.
In addition, data from the hospital-wide continuous
assessment of patient satisfaction were included. At the
end of their stay, all patients at SRH are offered to
respond to an anonymous web inquiry, either at the hos-
pital before discharge or from home within two weeks
after. Data from the patient satisfaction assessment are
aggregated every four months and included in quality
90 F. Becker et al. / Cognitive rehabilitation at Sunnaas Rehabilitation Hospital
reports. We summarized data from the six respective
reports from 2011 and 2012.
2.3. Measures
Sex and age at admission were derived from the
social security number. Length of stay was calculated
by subtracting date of admission from date of dis-
charge. Patients, who were admitted before 1.1.2011
or discharged after 31.12.2012, were excluded from
the length of stay analysis. Furthermore, stays are
sometimes interrupted due to planned or unplanned
admission to other hospitals, family reasons etc. Stays
interrupted for less than 14 days or for summer holidays
were merged, and the total length of stay is reported.
The “cause of admission” field in the medical chart
system includes information about diagnosis and type
of program; in case of doubt, the individual charts
were reviewed to ensure correct diagnosis and type of
program. Date of brain injury was looked up in each
patient’s medical chart, and time since injury (time from
injury to date of admission) was calculated. Descriptive
statistical analysis was performed using SPSS 18.0.
The patient satisfaction inquiry contains 17 questions
ranging from sex and age to satisfaction with food etc.
For this study, we selected the four questions which
we found most relevant with regard to the content of
the cognitive rehabilitation program; they concern 1)
the patients’ evaluation of provision of information
about the patient’s condition, 2) patient participation
in rehabilitation process, 3) preparation of the patient
for time after discharge, and 4) overall satisfaction. For
these questions, one has to choose between five possi-
ble answers: “Not at all”, “To small extent”, “To some
extent”, “To a large extent”, or “To a very large extent”.
3. Results: Qualitative description of KReSS
activities
3.1. Background and setting
3.1.1. Norwegian health system
Providing hospital services is a public responsibil-
ity in Norway. With few exceptions, basic health care
is publicly funded for all persons legally residing in
the country. Four regional health trusts are commis-
sioned with hospital treatment, with the South Eastern
Regional Health Trust serving about 2.5 million people,
i.e. half of the Norwegian population. Sunnaas Reha-
bilitation Hospital is one of 8 health trusts in the South
Eastern health region, serving as the regional rehabil-
itation hospital with also some national services and
responsibilities, e.g. for patients with locked in syn-
drome.
3.1.2. Sunnaas Rehabilitation Hospital
Founded in the 1950s as a home for the disabled, in
the following decades, SRH became the leading neu-
rorehabilitation facility in Norway. Seven hundred and
fifty employees serve approximately 2.800 in-patient
stays and 3.500 out-patient consultations per year. Clin-
ical services are organized in three departments with a
total of 157 beds: 1) acquired brain injury, 2) spinal cord
injury, and 3) assessment and follow-up services. The
hospital is somewhat remotely located on a peninsula
in the Oslo fjord, with a 45 minute drive or 10 min-
utes helicopter fare to reach acute hospital facilities at
Oslo University Hospital. All rehabilitations programs
are accredited by the Commission on the Accreditation
of Rehabilitation Facilities (CARF, www.carf.org).
3.1.3. KReSS – background and history
KReSS has its roots in the rehabilitation ser-
vices provided for people with ABI since the latter
half of the 1970s. As cognitive impairments were
given increased attention in brain injury rehabilita-
tion, a need for targeted assessment and treatment
services emerged. An interdisciplinary team model
was established at SRH in the mid eighties that
involved a division of the TBI rehabilitation unit
into separate rehabilitation teams for three func-
tionally defined patient groups based on degree of
physical and cognitive impairment (Finset et al.,
1992, 1995). One group served patients with predom-
inantly cognitive symptoms of a mild to moderate
degree, where an intensive and adapted rehabilitation
program was developed, inspired by work from Israel,
Denmark, and the USA (Ben-Yishay & Prigatano,
1990; Christensen & Teasdale, 1995; Prigatano et al.,
1984).
Financed by governmental grants, KReSS was estab-
lished as a project in the 1990 s with three major goals:
1) Establish cognitive rehabilitation services in the
chronic phase (at least 1.5 years post injury).
2) Disseminate knowledge and information about
cognitive rehabilitation and brain injury to health
professionals, other agencies and the general pop-
ulation.
3) Exploring new technology (e.g. telemedicine) as
a method for delivering cognitive rehabilitation.
 F. Becker et al. / Cognitive rehabilitation at Sunnaas Rehabilitation Hospital
The precursor of the still existing chronic phase group
program was developed for patients with mild to mod-
erate cognitive impairments following ABI. More than
100 patients attended the programs, which were eval-
uated clinically (Skogan & Tornås, 2001; Sæther &
Tornås, 2001; Sæther et al., 2003). Unfortunately, scien-
tific evaluations of treatment effects were not performed.
In 2005, the program was merged with existing
inpatient cognitive rehabilitation activities in a distinct
unit within the Department of Brain Injuries. Thus,
Norway’s first permanent unit for cognitive rehabilita-
tion for ABI was established – offering individual and
group-based rehabilitation services. There has been a
steep increase in post-acute individual treatment over
the past years, which has been accompanied by a
larger focus on assessment, understanding of sequelae,
psycho-educational approaches, focus on facilitating
positive family interactions and psychosocial support
in the early phase following injury, as well as planning
of community interventions and vocational rehabilita-
tion together with local health workers. The treatment
approach at KReSS thus has a broad theoretical basis
(cf. Wilson, 2008).
3.1.4. Infrastructure, staff, equipment
To date, KReSS is one of nine rehabilitation units at
SRH and comprises 18 beds. The physical environment
of KReSS is less “hospital-like” than other parts of the
hospital. For example, staff does not wear hospital uni-
forms, and the ward includes areas for socializing, like
a gaming, pool- and TV-room, and a patient library.
Staff density at the ward has varied somewhat; per
date, approximately 1 specialist in physical medicine
and rehabilitation medicine, 2.5 neuropsychologists,
3.6 occupational therapists, 2 physiotherapists, 1 speech
and language therapist, 6.5 nurses, 1 nursing assistant,
0.5 cognitive testing assistant, 1 social worker, as well as
a team coordinator and a team manager run the 18 beds
available. Beyond this, KReSS makes use of personnel
at the Department of Brain Injury and the hospital at
large as needed.
3.1.5. Target population, admission criteria
KReSS serves adult patients with mild to moderate
cognitive impairments due to ABI. Typical diagnoses
are CVA, TBI, anoxic brain injury, brain tumors and
infectious brain diseases. Patients without verified ABI
are not admitted to avoid inducing a “brain injured
identity” in patients where factors not related to ABI
play a major role in symptom development. The follow-
ing indicators are regarded as sufficient to verify ABI:
91
positive neuroradiological findings, acute indicators of
severe pathology (e.g. prolonged unconsciousness), or a
neuropsychological profile indicating organically based
cognitive impairment. It is however well-known that
premorbid and secondary psychological problems are
common in the patient group in question, resulting in
a frequent need to address issues related to differential
diagnosis (Davis et al., 2012; Gould et al., 2011).
Further inclusion criteria require the need for inter-
disciplinary rehabilitation with focus on cognitive
dysfunction. The patient needs to be able to partici-
pate in an active rehabilitation program including both
individual and group treatment sessions. As efficient
communication is essential for successful participation
in KReSS’ services, adequate understanding of Norwe-
gian (or in some cases English) is required. People with
moderate to severe aphasia or moderate to severe motor
deficits are served by the hospital’s stroke or TBI units,
with the exception of the intensive language training
program. Most patients are able to entertain indepen-
dent living, and return to an active social life is a main
goal for most. Inpatients preferably spend the weekends
at home in order to facilitate generalization of treatment
efforts to daily living also during the admission period.
We consider it beneficial for patients not to be directly
transferred from acute hospitals to KReSS, but to first
experience their new life situation in their usual environ-
ment and during activities of everyday living. Actually,
patients are often not referred during their acute hospital
stay, but in later phases. It is not unusual that cogni-
tive impairment remains undiagnosed for a longer time
period, and that patients are referred to KReSS several
years after ABI.
3.1.6. Admission process, cooperation with
referring hospitals
Patients are referred from hospitals, family doctors
and private practitioners. Quite a few patients are treated
at our department’s CVA or TBI rehabilitation unit
before later being admitted to KReSS as a continua-
tion of their post acute rehabilitation. All referrals to
the Department of Brain Injury are considered accord-
ing to the Norwegian Patients’ bill of rights by the head
physician (first author F.B.) with regard to the individ-
ual patient’s needs for specialized rehabilitation. SRH
has concluded agreements of cooperation with 3 neigh-
boring hospital trusts. Guidelines for the referral of
patients from these are established and evaluated every
6 months. However, patients from other health trusts
within the region, and patients from the rest of Norway
can also be admitted.
92 F. Becker et al. / Cognitive rehabilitation at Sunnaas Rehabilitation Hospital
3.2. Inpatient services
3.2.1. Individual cognitive rehabilitation program
Inpatient individual cognitive rehabilitation within a
holistic approach is the dominant service provided at
KReSS. The typical length of stay is 20 to 50 days. The
individual rehabilitation program is based upon a broad
and multidisciplinary assessment within all domains of
the International classification of functioning (WHO,
2011), and includes neuropsychological assessment if
not already performed before admission. The first week
of the stay will typically focus on assessment and estab-
lishment of rehabilitation goals and a goal plan is set
actively involving the patient.
Every patient is designated a contact person from
the rehabilitation team. The contact person ensures the
involvement of the patient in all relevant decisions and
the information flow between the patient and the team.
This person will also be the main contact for relatives,
employers etc. Every patient meets his or her rehabili-
tation team once every three weeks to discuss progress
and consider further actions. The importance of signifi-
cant others in the life of persons with ABI is recognized
by providing information and trying to involve rela-
tives, friends etc. in the patients’ rehabilitation process.
The patient’s significant others will thus typically par-
ticipate in at least one of the treatment meetings during
rehabilitation. Other services exist, such as seminars for
patients and significant others, typically organized in
collaboration with user organizations. “Family weeks”
where the patient, his/her partner and their children
were admitted for a one-week stay in the hospital have
also been conducted.
All patients attend the “cognitive group”, where 12
subjects related to cognitive impairment are discussed
for 30 minutes four days per week. Information on the
subjects is presented by staff, but patient involvement
during discussions is essential and patients are often
given tasks related to the subjects. All patients are asked
to prepare a presentation about their own brain injury
and its consequences to 2 or 3 fellow patients.
Each morning, all patients gather for 15 minutes. Five
minutes are used for practical information (e.g. changes
in schedules), while the remaining 10 minutes are the
responsibility of one designated patient. The patient
chooses the subject, supported by staff if necessary. The
content might be a short quiz or a presentation of any
subject, e.g. regarding the patient’s work or preferred
leisure activities.
A number of group activities are offered. A 45 min-
utes “walking/hiking group” with three different levels
according to physical ability and capacity is offered
daily. Relaxation and mindfulness groups are conducted
on a daily basis. Several physical and other activities
are offered weekly, e.g. spinning, water polo, computer
games, handcraft, archery, a gardening group or yoga.
After working hours, i.e. after 4 p.m., social activities
such as quiz and parlor games, hiking trips, musical
activities and so forth are offered. Once a week, selected
patients and staff meet to discuss experiences related
to living with ABI. Patients who recently acquired
their brain injury can discuss with more “experienced”
patients. Education about cognitive skills and deficits
is furthermore provided at KReSS in weekly sessions
called “thematic coffee hour”. In a round-table forum,
one member of the rehabilitation team presents a cog-
nitive rehabilitation subject in a two-hour session. All
admitted patients are expected to participate; former
inpatients, significant others, guest students and other
interested people are welcome.
The treatment team strives to actively use the
patients’ personal knowledge, experiences and skills
in the rehabilitation process, rendering the treatment
efforts subjectively relevant. For example, patients
might be assigned to work out a budget, plan a journey,
or prepare an event. During the weekends, patients are
given assignments like preparation of a meal, or writing
of an essay, and these are evaluated on Mondays. Addi-
tionally, all patients will have treatment days where
they are required to plan and prepare a day of activities
which will typically be outside the hospital environ-
ment. Sometimes, a set of activities might be assigned
to two patients who perform them in fellowship; other
patients might need attendance from the staff.
Assessment of driving abilities will be conducted if
necessary, and for the majority of patients also assess-
ment of working ability and subsequent vocational
rehabilitation. For all patients living in up to about 3
hours of travelling distance from the hospital, a staff
member will join the patient in a visit of his working
place, typically meeting the employer and colleagues.
For patients where return to work is unlikely or who
already participate in a governmental return to work
program, this meeting might be held with the local office
of the Norwegian Labor and Welfare Administration.
Often, a simulated work day is conducted, based on the
patient’s actual vocational situation.
On one of the last days of the stay, a discharge meet-
ing will be held with usually 2 to 4 staff members.
The stay is summarized and plans for further rehabili-
tation are discussed. Significant others and sometimes
employers or local rehabilitation staff might participate.
 F. Becker et al. / Cognitive rehabilitation at Sunnaas Rehabilitation Hospital
Information on local user organizations is given. A
multidisciplinary report as well as a medical discharge
summary is prepared.
To update on recent developments, the staff meets
briefly (15 minutes) on a daily basis. All patients are
briefly discussed in a weekly one hour staff meeting,
and another one hour weekly meeting is dedicated to
preparation of the patient schedules for the week to
come. While the “thematic coffee hour” is arranged
by one of the team members every Friday, the remain-
ing staff will use this time for updating on literature
etc.
3.2.2. Group programs
3.2.2.1. Intensive language training. SRH offers a
clinical program for intensive language treatment (Sun-
CIST) for persons with sub-acute (>3 months post
stroke) aphasia which aims at improving expressive
language deficits after stroke and incorporates the prin-
ciples of constraint induced language therapy (CILT;
Kirmess et al., 2012). CILT involves card game activi-
ties using high- and low-frequency picture stimuli with
communicative relevance at different levels of com-
plexity, applied in a small group of three participants
by a trained SLP (Kirmess & Maher, 2010). In addi-
tion to CILT two to three hours a day, the program has
an interdisciplinary group approach that also focuses
on psychosocial and physical aspects, as well as on the
use of language skills in naturalistic communication
situations. The program is carried out as a 3-week, inpa-
tient intervention for groups of six patients. Overall,
SunCIST offers an average of 45 hours with structured
language activities, as well as 30 hours of other group
activities within a 15 working day schedule.
3.2.2.2. Memory group. Recently, a group program
focusing on the rehabilitation of mild to moderate
memory deficits has been introduced. The program is
conducted over four weeks with six to eight patients
at a time. Strategy training as well as education on
memory and memory related subjects is combined
with computer-based training of working memory using
Cogmed (Westerberg et al., 2007). Daily sessions are
scheduled for individual work with a memory aid which
is chosen beforehand. A major goal is to stimulate the
participants to continuously apply new knowledge and
skills in practical activities. As an example, the group
is instructed to prepare lunch where individual duties
are assigned and the participants shall use acquired
strategies when purchasing items and preparing food.
Furthermore, physical and social activities are included.
93
One day during the four week program is reserved for
a “network day” where significant others are informed
about memory deficits and rehabilitation.
3.2.2.3. Chronic phase group treatment. The chronic
phase program is a 6-week, inpatient program for per-
sons with chronic (>1.5 years post onset) cognitive
deficits. The program is conducted as group treatment
with six to eight patients and is grounded in a psycho-
educative approach, which combines the participants‘
individual experience with professional knowledge and
clinical experience from the multidisciplinary team.
The program’s principal aim is to enhance mastering
of daily life activities. The program consists of the fol-
lowing weekly themes covering cognitive subjects in
lectures and group discussions: brain and brain injury,
executive functioning, memory and attention, commu-
nication, social life in relation to significant others and
family, and social life in relation to more peripheral
friends and work/education. The program also includes
physical and leisure activities. As a home-work task
over the weekends, the participants are asked to pre-
pare a self-presentation related to their own personal
experience and needs. In order to apply their knowledge
and experience to normal life activities including social
interaction, the group also has to plan and carry out
a cultural group activity during their stay. Significant
others are invited to join the group at two day-courses.
Two four-day follow-ups are offered approximately six
and twelve months after the first stay.
3.3. Outpatient services, telerehabilitation
Due to the remote location of SRH as well as the
fact that patients from all over Norway are served, the
amount of outpatient services has been limited, but is
however now increasing as it is more and more recog-
nized that patients benefit from specialist services over
longer time periods than during hospitalization only.
Outpatient consultations typically involve assessment
of the patients’ need and motivation for cognitive reha-
bilitation, but sometimes also follow-up. All patients
externally referred to the chronic phase group pro-
gram or to the intensive language training program
are screened beforehand through an outpatient consul-
tation. Furthermore, all patients discharged from the
individual cognitive rehabilitation program are offered
a 3-month follow up phone call.
Telemedicine is part of ordinary clinical activities
at SRH; a telemedicine team has been established
94 F. Becker et al. / Cognitive rehabilitation at Sunnaas Rehabilitation Hospital
responsible for logistics and practical issues (Bach et
al., 2010; Normann et al., 2011). An agreement with the
Norwegian Labor and Welfare Administration makes
it possible to use the administration’s videoconfer-
ence infrastructure where equipment can be found in
almost every Norwegian community. Thus for patients
who live at a distance from the hospital, meetings
with relatives, employers or local health personnel are
often held by videoconference. In addition, SRH has
newly opened an outpatient clinic in the centre of
Oslo.
3.4. Education and information activities
Since its start as a pilot project in 1993, supplying the
public with information about cognitive consequences
of ABI has been an integrated part of KReSS. Being
the major institution for cognitive rehabilitation in Nor-
way, KReSS has a responsibility to increase awareness
of cognitive impairment and to inform about cognitive
rehabilitation. A number of popular science brochures
have been published, including titles as “What is ABI?”,
“My dad had a brain injury”, “Children with ABI”, or
“TBI and sexuality”. There is regular contact between
KReSS and user organizations, and information about
these organizations is provided to all patients. KReSS
has contributed to brochures and websites prepared
together with user associations. Numerous lectures on
cognitive consequences of ABI have been delivered in
e.g. local communities, hospitals, and other health insti-
tutions. KReSS-staff contributes in education of health
personnel at universities and university colleges. An e-
learning program explaining cognitive impairment and
providing information on how to cope with it and how
everyday life can be adapted in order to improve func-
tioning, has been elaborated (Kognitiv tilrettelegging,
2011). KReSS organizes annual conferences on cogni-
tive rehabilitation, where rehabilitation workers in local
communities are the target participants. These meetings
typically feature front-line international contributors in
the field of cognitive rehabilitation. Also, KReSS staff
and patients contribute regularly to media publications
on cognitive impairment.
All Norwegian hospitals are required to have a
“center for learning and coping” which provides rel-
evant information from user organizations as well as
organizes courses based on user demands and user
experience. The center also employs “user consultants”
which are employees who themselves have experience
from living with reduced function and from rehabilita-
tion. KReSS collaborates actively with this centre.
3.5. Research
3.5.1. Tradition/history/cooperation
Research efforts at SRH started in the 1970s with
neuropsychological studies (Finset et al., 1988; Rein-
vang, 1985; Sundet et al., 1988). While the total
research activity was sparse the first decades, in 2003,
the hospital’s board decided on a substantial increase
in research spending. A Department of Research was
established and the research budget increased from 0.7
in 2003 to 3.9 % in 2012, with a goal of attaining 7% of
budget spending on research within 2014. As a result,
the number of publications and PhDs has increased sub-
stantially, with now 15 to 20 ongoing PhD-projects.
In 2012, 5 PhDs were completed and 33 international
peer-reviewed papers were published.
One goal associated with increasing research activity
was to extend clinical research cooperation nation-
ally and internationally. Researchers and clinicians
associated with KReSS have established cooperative
relationships with a wide range of rehabilitation cen-
ters and research groups in Europe, USA and Australia.
Another aspect of the strategic development of research
at SRH has been a strengthening of the relationship
to the University of Oslo. Researchers who are also
involved in KReSS have part time affiliations with the
Faculty of Medicine, Department of Psychology, and
Department of Special Needs Education at the Uni-
versity of Oslo. This cooperation leads to an increased
number of students being trained at KReSS, provides
opportunity for smaller research projects as part of
bachelor and masters degrees, and allows for develop-
ment of new research projects in close collaboration
with strong research groups at the University of Oslo.
The combination of theoretical research interests with
clinical demands and concerns has led to a number of
interesting and successful studies (e.g. Becker & Rein-
vang, 2007; Kirmess, 2011; Løvstad, 2012; Nordvik
et al., 2012).
3.5.2. Ongoing research
The steep increase in research at the hospital at large
has also resulted in more research associated with the
KReSS patient population. One ongoing PhD project
investigates structural brain alterations associated with
effects of computer-based training of working mem-
ory (e.g. Engvig et al., 2010). Another PhD conducts
a Randomized Controlled Trial on group-based Goal
Management Training (GMT) in patients experiencing
executive deficit following ABI (Levine et al., 2011;
Stubberud et al., 2013). The SunCIST program for
 F. Becker et al. / Cognitive rehabilitation at Sunnaas Rehabilitation Hospital 95

Fig. 1. Age distribution. Age distribution of patients served at KReSS in 2011 and 2012. Number of patients per age interval (years).

intensive aphasia rehabilitation is part of an ongoing Table 1

post doctoral project (Kirmess et al., 2012). Participations in treatment programs
In our experience, clinical research trials greatly Type of program n percent
enhance the quality of the clinical programs as well, Individual rehabilitation 206 58.0
both as a direct result of the knowledge derived through Individual assessment and follow-up 41 11.5
Chronic phase group 41 11.5
the studies, but also due to the increased focus on the Intensive language training 30 8.5
use of scientifically sound clinical tools and outcome Chronic phase group follow-up 24 6.8
measures. Furthermore, the requirement of a scien- Memory group 13 3.7
Total 355 100.0
tific basis for the choice of interventions fosters a staff
culture where evidence-based up-to-date knowledge is
expected, encouraged and appreciated. In total, the 307 patients were subjected to 355
hospitalizations. More than two thirds of the hos-
4. Results: Inpatient activities in 2011 and 2012 pital stays were due to individual rehabilitation or
assessment/follow-up (n = 247, 69.5%), the remain-
In total, 307 unique patients were treated at KReSS ing hospitalizations were participations in one of the
in 2011 and 2012. Almost 70% of the patients were group programs (Table 1). Forty-eight patients (13.5%)
male (n = 209, 68.1%). The age range (18–78 years, had more than one hospitalization during the two-year
mean 47.6 years, SD 13.6) shows that KReSS offers period.
treatment to the whole adult age range, although with Table 2 provides information about patients admit-
a certain predominance of patients between 35 and 65 ted to the individual cognitive rehabilitation program.
(Fig. 1). CVA patients are the largest group (46.6%; all stroke
Almost all patients (n = 305, 99.3%) were admitted including subarachnoid hemorrhage) followed by the
from their home and only 2 (0.7%) from other health TBI group (33.0%). 7.3% are brain tumor patients and
institutions. KReSS patients are almost exclusively 5.8% have anoxic brain injury, while the remaining
returned to their homes when discharged (n = 296, causes (infectious diseases, subdural hemorrhage and
96.4%), which would be expected given the require- other etiology) have a frequency of less than 5% each.
ments for admission. Due to medical complications As expected, age varies between etiologies, with
or planned controls, the remaining few patients were TBI patients being younger than stroke patients. Time
admitted to an acute hospital. Persons from all over since onset varies in all etiologies, in total from 16
Norway were treated at KReSS, although with a clear days to more than 14 years (median 0.8 years). While
predominance of patients living in the South-Eastern a large number of patients are admitted to KReSS
region (89.3%), which is the main area of responsibility within the first 6 months after injury, another substantial
for SRH. group begins their individual cognitive rehabilitation at
96 F. Becker et al. / Cognitive rehabilitation at Sunnaas Rehabilitation Hospital

Table 2
Patient etiology, sex, age, time since injury, and length of stay in individual rehabilitation program
Diagnosis n (% of total) % female Age (mean, SD) Years post onset Length of
(median, min/max) stay (mean, SD)
Stroke 86 (41.7) 29.1 52.2 (11.4) 0.5 (0.0–11.1) 39 (15)
Traumatic brain injury 68 (33.0) 20.6 38.5 (14.8) 0.9 (0.1–14.1) 34 (18)
Brain tumor 15 (7.3) 53.3 43.7 (15.4) 1.7 (0.2–5.4) 38 (12)
Anoxic brain injury 12 (5.8) 25.0 48.7 (14.6) 0.6 (0.2–7.8) 36 (17)
Subarachnoid hemorrhage 10 (4.9) 60.0 52.0 (9.8) 1.2 (0.2–3.5) 33 (10)
Infectious brain disease 9 (4.4) 22.2 39.8 (10.3) 1.0 (0.1–11.0) 43 (13)
Subdural hemorrhage 3 (1.5) 0.0 51.0 (11.5) 0.2 (0.1–1.2) 25 (11)
Other 3 (1.5) 33.3 49.8 (5.4) 5.5 (0.2–7.8) 52 (18)
Total 206 (100.0) 28.6 46.2 (14.2) 0.8 (0.0–14.1) 36.9 (16.0)
Age in years, length of stay in days. SD: standard deviation.

Fig. 2. Time post injury. Time since injury for patients who participated in the holistic individual rehabilitation program. Number of patients per
time interval (months).

KReSS between 6 and 24 months post injury (Fig. 2).
While the median time post injury is shortest for stroke
and anoxic brain injured persons (0.5 and 0.6 years
respectively), patients with brain tumor have the longest
median time post onset (1.7 years).
Mean length of stay for individual rehabilitation
patients is 36.9 days, and no substantial differences
in length of stay were observed between the most fre-
quent etiologies. Figure 3 illustrates that the majority of
patients have a length of stay between 20 and 50 days.
The patient satisfaction survey was completed by
185 KReSS patients (52.1%). More than 3/4 of the
responders (76.6%) regarded their information needs
as satisfied to a large or very large degree (Table 3).
While the majority of the patients answered that they
were to some or to a large extent involved in decisions
about their own rehabilitation process, about a quarter
(26.4%) of the patients stated that they only were “to
some extent”, and 12.0% that they were little or not at
all involved. More than two thirds (68.8%) replied that
they to a large or very large degree were prepared for
time after discharge. Overall satisfaction was high: half
of the patients (50.5%) were satisfied to a very large
extent with their rehabilitation at KReSS, and 41.3% to
a large extent.
5. Discussion
This paper describes rehabilitation services pro-
vided at the Cognitive Rehabilitation Unit at Sunnaas
Rehabilitation Hospital, and characterizes the persons
served. It is the first description of comprehensive cog-
nitive rehabilitation in Norway. The study presents one
model of how cognitive rehabilitation services can be
organized in a rural country where the provider has
the liability to ensure specialized rehabilitation for the
population of a defined geographical area. The find-
ings furthermore illustrate a model for the combination
 F. Becker et al. / Cognitive rehabilitation at Sunnaas Rehabilitation Hospital 97

Fig. 3. Length of stay. Length of hospitalization in days for patients who participated in the holistic individual rehabilitation program, number of
patients per 10-day interval. Patients whose stay began in 2010 or ended in 2013, are excluded (remaining n = 193).

Table 3
Patients’ degree of satisfaction with services∗
Not at all To small extent To some extent To a large extent To a very large extent
Did the professionals provide you with sufficient 0.6 3.3 19.4 54.4 22.2
information about your condition?
Did you participate in decisions regarding your 4.0 8.0 26.4 43.7 17.8
rehabilitation process?
Did you experience that the professionals prepared you 2.8 4.5 23.9 46.6 22.2
for the time after discharge?
All in all, how satisfied are you with the services you 0.0 1.1 7.1 41.3 50.5
received at Sunnaas Rehabilitation Hospital?
∗ Percentage of responses for each category.

of holistic cognitive rehabilitation with interventions
targeted at specific cognitive domains.
The main limitation of this study is the small amount
of measurable data both regarding patient characteris-
tics and quantitative parameters of the interventions.
Although qualitative descriptions of cognitive rehabil-
itation programs are warranted and contribute to the
exchange of ideas and possibly even the detection of
different procedures, quantitative data provide impor-
tant insights into the clients and the services and ease the
comparison of programs. The retrospective and descrip-
tive nature of the present study limits the validity of
the results. The response rate in the patient satisfaction
survey (52.1%) is somewhat low.
Another limitation is the lack of outcome data –
we describe some aspects of our cognitive rehabilita-
tion services, but have per date no data on how this
affects our patients. Thus, two aspects are essential
in further improving services at KReSS: there is a
need of becoming better informed about KReSS’ tar-
get groups, and the impact of KReSS’ services on the
patients’ functioning needs to be investigated. Ongo-
ing research projects regarding the language training
program, training of executive functions, as well as
working memory training are examples in this respect,
and scientific evaluations will be published in years to
come. Further scientific studies are warranted, espe-
cially concerning outcome related to the comprehensive
cognitive rehabilitation program as well as intervention
research in unselected patient groups on an “inten-
tion to treat” basis. Since early 2013, the Sunnaas
Rehabilitation Register is in operation, which gradu-
ally will provide detailed information on functioning
with regard to all ICF-domains as well as follow-up
data. In other fields of health psychology, there has been
an increasing interest in characterizing premorbid, psy-
chosocial and other factors contributing to resilience
(Bonanno, 2012; Quale & Schanke, 2010). The interest
has shifted from attempts to characterize risk factors for
poor outcome, to investigation of protective factors that
contribute to good adjustment following adverse life
events. Research on protective factors that contribute
98 F. Becker et al. / Cognitive rehabilitation at Sunnaas Rehabilitation Hospital
to resilient trajectories in the ABI population is sorely
needed (Sarre et al., 2013).
When comparing our individual holistic cognitive
rehabilitation program with existing descriptions, a
number of similarities can be found: the post injury time
ranges from few weeks to several years and patients dif-
fer with regard to their age, but means are comparable
with the majority of existing studies (e.g. Schönberger
et al., 2001), with the exception of TBI only programs,
where patients usually are younger (e.g. Goranson et al.,
2003). The length of stay at KReSS is rather short, but
comparable with other inpatient programs (e.g. Sara-
juuri et al., 2005). While a number of programs report
only participants with TBI, we also serve patients with
brain lesions of other etiologies, as some other pro-
grams also do (e.g. Svendsen & Teasdale, 2006). The
content of our program seems to be rather similar to
other well-known programs (Ben-Yishay & Prigatano,
1990; Wilson, 2002), which is not surprising, given that
these programs were the role models when our program
first was established.
One distinct feature of services at KReSS is the high
degree of inpatient services for patients who are able to
live independently, and thus are not necessarily in need
of hospitalization. Only the Finnish program seems to
be comparable in this regard (Sarajuuri et al., 2005). The
main reason for in-hospital admission is the rural Nor-
wegian geography in addition to the somewhat remote
location of the hospital. Also, the existing financing
system for specialist rehabilitation services in Norway
encourages inpatient services. A positive effect is that
patients spend more time together during their stay,
providing ample opportunity to exchange ideas and
experiences.
As outpatient services are underdeveloped and partly
difficult to deliver due to geography, services that follow
patients through their rehabilitation process over longer
time periods are difficult to establish. For the time being,
the described group based interventions are the main
services available in chronic stages; however, relying
purely on group based treatment is not advisable. The
establishment of more comprehensive services ranging
from the first post injury period into later stages and
a more flexible combination of in- and outpatient ser-
vices is a challenge in a further development of KReSS’
services.
Results from the patient satisfaction survey indicate
a high level of satisfaction with the cognitive reha-
bilitation services at KReSS. It is however notable
that a substantial proportion of the patients did answer
that they only to a small extent or even less partici-
pated in decisions regarding their rehabilitation process
(38.4%); this also regards preparation for discharge
(31.2%). This is particularly interesting as user partic-
ipation and involvement in the rehabilitation process
as well as community related work, are regarded as
highly important ingredients in the rehabilitation pro-
gram. Whether the patients actually were not involved
or this mainly is their retrospective perception, war-
rants further investigation, as does an exploration of the
cause of this shortcoming. However, one has to take into
account that the patient satisfaction survey includes all
KReSS patients and can not be analyzed for the differ-
ent programs separately; the language group program,
for example, focuses mainly on intensive training of
language functions. Still, the results might indicate that
the group programs could benefit from a larger degree
of individualization.
Cognitive rehabilitation services at KReSS both
comprise programs offering holistic cognitive rehabili-
tation and programs targeted at specific cognitive func-
tions. Comprehensive, holistic rehabilitation programs
as well as interventions for distinct cognitive impair-
ments e.g. regarding attention, memory, aphasia, and
executive function are supported by available evidence
(Cicerone et al., 2000, 2005, 2011). In our experience, it
is a clinical challenge to balance the two aims. Broad,
holistic interventions address the complexity of ABI-
symptomatology, but run the risk of lacking the speci-
ficity of highly targeted programs. Interventions target-
ing distinct functions, on the other hand, offer the focus
needed to achieve the necessary intensity, but might not
give enough room for the broad emotional, psychoso-
cial and vocational needs of the patients. At KReSS, we
aim to integrate interventions targeting specific func-
tions into holistic programs, but also to expand the
array of services by offering specified programs target-
ing impairments of distinct cognitive functions. Future
research should investigate the optimal manner of offer-
ing and combining these two approaches, including
the definition of possible subgroups with regard to
impairment patterns or etiology, the best timing of inter-
ventions and their optimal length and intensity.
In addition to the clinical services, the unit is highly
engaged in education and research activities. In a coun-
try with a small population as Norway, a major or
sole centre for a certain field needs to take responsibil-
ity for developing, spreading and ensuring up-to-date
expertise. To balance efforts in direct patient work
with education and research activities is a continuous
and challenging task even in a prosperous country as
Norway.
 F. Becker et al. / Cognitive rehabilitation at Sunnaas Rehabilitation Hospital
Declaration of interest
Research on the Sunnaas CILT program (SunCIST)
is financially supported by the Norwegian ExtraFoun-
dation for Health and Rehabilitation through EXTRA
funds.
References
Bach, B., Sørli, H., Driveklepp, A. M. (2010). Telemedicine in reha-
bilitation. NST-report 06-2010.
Becker, F., & Reinvang, I. (2007). Event-related potentials indicate bi-
hemispherical changes in speech sound processing during aphasia
rehabilitation. Journal of Rehabilitation Medicine, 39(8), 658-
661.
Ben-Yishay, Y., & Prigatano, G. P. (1990). Cognitive remediation. In:
Rosenthal, M., Bond, M. R., Griffith, E. R., Miller, J. D. (Eds).
(1990). Rehabilitation of the adult and child with traumatic brain
injury (2nd ed.). Philadelphia, PA, US: F A Davis, 393-409.
Berthier, M. L., & Pulvermüller, F. (2011). Neuroscience insights
improve neurorehabilitation of poststroke aphasia. Nature
Reviews Neurology, 7(2), 86-97.
Bhogal, S. K., Teasell, R., & Speechley, M. (2003). Intensity of
aphasia therapy, impact on recovery. Stroke, 34(4), 987-993.
Bonanno, G. A. (2012). Uses and abuses of the resilience construct:
Loss, trauma, and health-related adversities. Social Science &
Medicine, 74(5), 753-756.
Braverman, S. E., J. Spector, R., Warden, D. L., Wilson, B. C., Ellis, T.
E., Bamdad, M. J., & Salazar, A. M. (1999). A multidisciplinary
TBI inpatient rehabilitation programme for active duty service
members as part of a randomized clinical trial. Brain Injury, 13(6),
405-415.
Cappa, S. F., Benke, T., Clarke, S., Rossi, B., Stemmer, B., van
Heugten, C. M., Gilhus, N. E., Barnes, M. P., & Brainin, M.
(2011). Cognitive rehabilitation, European handbook of neuro-
logical management, 545-567.
Christensen, A. L., & Teasdale, T. W. (1995). A clinical and neuropsy-
chological led post-acute rehabilitation programme. Traumatic
brain injury rehabilitation: services, treatments and outcomes.
London: Chapman, Hall, 88-98.
Cicerone, K. D., Dahlberg, C., Kalmar, K., Langenbahn, D. M.,
Malec, J. F., Bergquist, T. F., et al. (2000). Evidence-based
cognitive rehabilitation: Recommendations for clinical practice.
Archives of physical medicine and rehabilitation, 81(12), 1596-
1615.
Cicerone, K. D., Dahlberg, C., Malec, J. F., Langenbahn, D. M.,
Felicetti, T., Kneipp, S., et al. (2005). Evidence-based cogni-
tive rehabilitation: Updated review of the literature from 1998
through 2002. Archives of physical medicine and rehabilitation,
86(8), 1681-1692.
Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J. F., Kalmar,
K., Fraas, M., et al. (2011). Evidence-based cognitive rehabilita-
tion: Updated review of the literature from 2003 through 2008.
Archives of physical medicine and rehabilitation, 92(4), 519-530.
Cicerone, K. D., Mott, T., Azulay, J., Sharlow-Galella, M. A., Ellmo,
W. J., Paradise, S., & Friel, J. C. (2008). A randomized controlled
trial of holistic neuropsychologic rehabilitation after traumatic
brain injury. Archives of Physical Medicine and Rehabilitation,
89(12), 2239-2249.
99
Dams-O’Connor, K., & Gordon, W. A. (2013). Integrating Interven-
tions after Traumatic Brain Injury: A Synergistic Approach to
Neurorehabilitation. Brain Impairment, 1-12.
Davis, L. C., Sherer, M., Sander, A. M., Bogner, J. A., Corrigan, J. D.,
Dijkers, M. P., Hanks, R. A., Bergquist, T. F., & Seel, R. T. (2012).
Preinjury predictors of life satisfaction at 1 year after traumatic
brain injury. Arch Phys Med Rehabil, 93(8), 1324-1330.
Engvig, A., Fjell, A. M., Westlye, L. T., Moberget, T., Sundseth,
Ø, Larsen, V. A., & Walhovd, K. B. (2010). Effects of memory
training on cortical thickness in the elderly. Neuroimage, 52(4),
1667-1676.
Finset, A. (1992). Subacute brain injury rehabilitation: A program
description and a study of staff evaluation. Scandinavian Journal
of Rehabilitation Medicine (Suppl. 26), 25-33.
Finset, A., Sundet, K., & Haakonsen, M. (1988). Neuropsychologi-
cal syndromes in right hemisphere stroke patients. Scandinavian
Journal of psychology, 29(1), 9-20.
Finset, A., Krogstad, J. M., Hansen, H., Berstad, J., Haarberg, D.,
Kristiansen, G., Saether, K., & Wang, M. D. (1995). Team
development and memory training in traumatic brain injury reha-
bilitation: Two birds with one stone. Brain Injury, 9(5), 495-
507.
Goranson, T. E., Graves, R. E., Allison, D., & Freniere, R. L. (2003).
Community integration following multidisciplinary rehabilitation
for traumatic brain injury. Brain Injury, 17(9), 759-774.
Gould, K. R., Ponsford, J. L., Johnston, L., & Schönberger, M. (2011).
The nature, frequency and course of psychiatric disorders in the
first year after traumatic brain injury: A prospective study. Psy-
chological medicine, 41(10), 2099-2109.
Kirmess, M. (2011). The applicability and outcome of constraint
induced language therapy (CILT) in early aphasia rehabilitation.
Dissertation for the Degree of PhD, University of Oslo, Oslo.
Kirmess, M., Becker, F., Hvistendahl, A. K., & Günther, L. (2012).
The SunCIST program – A clincial approach for intensive aphasia
rehabilitation. Procedia - Social and Behavioral Sciences, 61,
18-19.
Kirmess, M., & Maher, L. M. (2010). Constraint induced language
therapy in early aphasia rehabilitation. Aphasiology, 24(6), 725-
736.
Kleim, J. A., & Jones, T. A. (2008). Principles of Experience-
Dependent Neural Plasticity: Implications for Rehabilitation
After Brain Damage. Journal of Speech, Hearing, & Language
Research, 51(1), 225-239.
Klonoff, P. S., Talley, M. C., Dawson, L. K., Myles, S. M., Watt, L.
M., Gehrels, J. A., & Henderson, S. W. (2007). The relationship
of cognitive retraining to neurological patients’ work and school
status. Brain Injury, 21(11), 1097-1107.
Kognitiv tilrettelegging (2011). Retrieved October 24, 2013, from
http://www.sunnaas.no/fagfolk/utdanning/elaering/Kognitiv%20
tilrettelegging/Course/asset/main.html
Laatsch, L., & Stress, M. (2000). Neuropsychological change
following individualized cognitive rehabilitation therapy. Neu-
roRehabilitation, 15(3), 189-197.
Levine, B., Robertson, I. H., Clare, L., Carter, G., Hong, J., Wilson,
B. A., et al. (2000). Rehabilitation of executive functioning: An
experimental–clinical validation of goal management training.
Journal of the International Neuropsychological Society, 6(3),
299-312.
Løvstad, M. (2012). Executive functions after focal lesions to the
lateral, orbital and medial subdivisions of the prefrontal cortex:
Neuropsychological, behavioral and electrophysiological find-
100 F. Becker et al. / Cognitive rehabilitation at Sunnaas Rehabilitation Hospital
ings. Dissertation for the Degree of PhD, University of Oslo,
Oslo.
Niemeier, J. P., Kreutzer, J. S., & Taylor, L. A. (2005). Acute cog-
nitive and neurobehavioural intervention for individuals with
acquired brain injury: Preliminary outcome data. Neuropsycho-
logical rehabilitation, 15(2), 129-146.
Normann, T., Breivik, E., Skipenes, E., Christiansen, E. K., &
Knarvik, U. (2011). Bringing telemedicine into routine service
- prerequisites and actions. NST-report 02-2011.
Nordvik, J. E., Schanke, A. K., Walhovd, K., Fjell, A., Grydeland,
H., & Landrø, N. I. (2012). Exploring the relationship between
white matter microstructure and working memory functioning
following stroke: A single case study of computerized cognitive
training. Neurocase, 18(2), 139-151.
Prigatano, G. P., Fordyce, D. J., Zeiner, H. K., Roueche, J. R., Pep-
ping, M. A. R. Y., & Wood, B. C. (1984). Neuropsychological
rehabilitation after closed head injury in young adults. Journal of
Neurology, Neurosurgery & Psychiatry, 47(5), 505-513.
Quale, A. J., & Schanke, A.-K. (2010). Resilience in the face of
coping with a severe physical injury: A study of trajectories of
adjustment in a rehabilitation setting. Rehabilitation Psychology,
55, 12-22.
Rabipour, S., & Raz, A. (2012). Training the brain: Fact and fad
in cognitive and behavioral remediation. Brain and Cognition,
79(2), 159-179.
Rattok, J., Ross, B., Ben-Yishay, Y., Ezrachi, O., Silver, S., Lakin,
P., & Diller, L. (1992). Outcome of different treatment mixes in
a multidimensional neuropsychological rehabilitation program.
Neuropsychology, 6(4), 395.
Reinvang, I. (1985). Aphasia and Brain Organization. New York,
Plenum Press.
Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., &
Richardson, W. S. (1996). Evidence based medicine: What it is
and what it isn’t. BMJ: British Medical Journal, 312(7023), 71.
Sarajuuri, J. M., Kaipio, M. L., Koskinen, S. K., Niemelä, M. R.,
Servo, A. R., & Vilkki, J. S. (2005). Outcome of a comprehen-
sive neurorehabilitation program for patients with traumatic brain
injury. Archives of Physical Medicine and Rehabilitation, 86(12),
2296-2302.
Sarre, S., Redlich, C., Tinker, A., Sadler, E., Bhalla, A., & McKevitt,
C. (2013). A systematic review of qualitative studies on adjusting
after stroke: Lessons for the study of resilience. Disabil Rehabil,
25, Epub ahead of print.
Schönberger, M., Humle, F., Zeeman, P., & Teasdale, T. W. (2006).
Patient compliance in brain injury rehabilitation in relation to
awareness and cognitive and physical improvement. Neuropsy-
chological Rehabilitation, 16(5), 561-578.
Sherer, M., Meyers, C. A., & Bergloff, P. (1997). Efficacy of postacute
brain injury rehabilitation for patients with primary malignant
brain tumors. Cancer, 80(2), 250-257.
Skogan, A. H., & Tornås, S. (2001). “CRUSH, A Late Phase Reha-
bilitation programme - from the participants’ point of view”.
Presentation 4th World Congress on Brain Injury, Torino, Italy.
Sohlberg, M. M., & Mateer, C. A. (Eds.). (2001). Cognitive reha-
bilitation: An integrative neuropsychological approach. Guilford
Press.
Stubberud, J., Langenbahn, D., Levine, B., Stanghelle, J., & Schanke,
A. K. (2013). Goal Management Training of Executive Functions
in Patients with Spina Bifida: A Randomized Controlled Trial.
Journal of the International Neuropsychological Society, 19, 1-
14.
Svendsen, H. A., & Teasdale, T. W. (2006). The influence of neuropsy-
chological rehabilitation on symptomatology and quality of life
following brain injury: A controlled long-term follow-up. Brain
Injury, 20(12), 1295-1306.
Sæther, K., & Tornås, S. (2001). CRUSH - description of a model
for the very late phase rehabilitation. Presentation 4th World
Congress on Brain Injury, Torino, Italy.
Sæther, K., Tornås, S., & Hauger, S. L. (2003). Changes in satisfac-
tion with family life and sexuality after Acquired Brain Injury.
Presentation 5th World Congress on Brain Injury, Stockholm,
Sweden.
Sundet, K., Finset, A., & Reinvang, I. (1988). Neuropsychologi-
cal predictors in stroke rehabilitation. Journal of Clinical and
Experimental Neuropsychology, 10(4), 363-379.
Tomassini, V., Johansen-Berg, H., Jbabdi, S., Wise, R. G., Pozzilli,
C., Palace, J., & Matthews, P. M. (2012). Relating brain damage
to brain plasticity in patients with multiple sclerosis. Neuroreha-
bilitation and neural repair, 26(6), 581-593.
van Heugten, C., Gregório, G. W., & Wade, D. (2012). Evidence-
based cognitive rehabilitation after acquired brain injury: A
systematic review of content of treatment. Neuropsychological
Rehabilitation, 22(5), 653-673.
Vanderploeg, R. D., Schwab, K., Walker, W. C., Fraser, J. A., Sigford,
B. J., Date, E. S., et al. (2008). Rehabilitation of traumatic brain
injury in active duty military personnel and veterans: Defense
and Veterans Brain Injury Center randomized controlled trial of
two rehabilitation approaches. Archives of physical medicine and
rehabilitation, 89(12), 2227-2238.
Westerberg, H., Jacobaeus, H., Hirvikoski, T., Clevberger, P., &
Wilson, B. A., Östensson, M. L., Bartfai, A., & Klingberg, T.
(2007). Computerized working memory training after stroke-A
pilot study. Brain Injury, 21(1), 21-29.
Wilson, B. A. (1996). A practical framework for understanding com-
pensatory behaviour in people with organic memory impairment.
Memory, 4(5), 465-486.
Wilson, B. A. (2002). Towards a comprehensive model of cognitive
rehabilitation. Neuropsychological Rehabilitation, 12(2), 97-110.
Wilson, B. A. (2008). Neuropsychological rehabilitation. Annu Rev
Clin Psychol, 4, 141-162.
Wilson, B. A., Gracey, F., Evans, J. J., & Bateman, A. (2009).
Neuropsychological rehabilitation: Theory, models, therapy and
outcome. New York: Cambridge University Press.
World Health Organization (2001). International classification of
functioning disability and health (ICF).
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