Theories of Cognitive Rehabilitation

Cognitive rehabilitation interventions are typically based on one of several theories. These theories describe and conceptualize the cognitive processes that are addressed in treatment.

Cognitive Processing

• Cognitive processing models examine the target process or function based on a normally functioning population instead of using clinical samples.

Factor-analytic

• Factor-analytic models examine cognitive processing via analyses of performance on psychometric tests that assess attention, memory, and executive functions.

Neuroanatomical

• Neuroanatomical models examine attention, memory, and executive functions by identifying each of their neuroanatomical substrates.

Clinical

• Clinical models use clinical observations from the disordered population to examine cognitive function.

Functional

• Functional models describe how cognitive processes might be used for everyday tasks.

Factors Affecting Recovery of Cognitive Function¹

Age at Injury

• Infants and Children
  • Early injury can significantly affect the acquisition and development of motor, language, cognitive, and social skills.
    • This may not be obvious until the age at which these skills are supposed to develop.
  • Children who sustain injury after a skill is acquired may show significant recovery of abilities, as these cortical networks have already been established.
• Young Adults
  • Younger age groups show better recoveries than older age groups, even when these age groups are closely spaced.
• Older Adults
  • Research suggests that older adults are more vulnerable to the effects of brain injury, especially when sustained in the frontal region.
  • However, older adults often have a more stable lifestyles and better coping skills than younger adults which help facilitate rehabilitation.

Premorbid Intelligence and Educational Levels

• Higher premorbid intelligence and educational levels are associated with increased function recovery after TBI.
• This may be due to the increased connectivity of neural networks facilitated by learning.

Gender

• To date, there is limited research on gender differences in cognitive rehabilitation.
• The research that exists has shown:
  • Women recover better than men after injury to the left-hemisphere of the brain.
  • Some female hormones, especially progesterone may have a protective effect on neurological injury and a positive effect on recovery mechanisms.

Cultural Background

• Research suggests that multicultural patients are more likely to end treatment sooner due to misunderstanding, frustration and language barriers, and/or differences between patient and provider in treatment priorities.

Premorbid or Current Drug and Alcohol Abuse

• See Substance Use/Abuse and Recovery from TBI

Time Since Injury

• The recovery rate is fastest in the few months after injury and decreases over time following injury.
• There is some evidence that some cognitive skills can be improved even years after injury.

Injury Extent and Severity

• Individuals with mild brain injury typically recover faster than those with moderate to severe injuries.
• Recovery usually occurs more rapidly when the injury is focal rather than diffuse.
  • An exception to this is when the injury occurs in a critical brain area for which the function cannot be compensated.

Recovery of Different Functions at Different Rates

• Recovery of highly learned, simple tasks occurs at a faster rate than new or complicated tasks.
• Functions of the frontal lobe involved in attention, organizing, and problem solving are often among the last to recover.

Psychological Factors

• Depression and anxiety are common results of TBI and can lead to decreased motivation, cognitive efficiency, and social integration.
• Lack of awareness of deficit or general resistance to rehabilitation can pose significant barriers to treatment.

Model of Cognitive Rehabilitation²

Two conceptual frameworks have been described for cognitive rehabilitation, traditional and contextualized. The traditional approach dominated the research and interventions in the 1970s and early 1980s and is characterized by the goal to eliminate or reduce underlying cognitive impairments. The more recent context-sensitive framework or “contextualized” approach aims to achieve functional objectives for those with cognitive disabilities.

Contextualized Paradigm

Focus and Goals

• The primary goal is to help cognitively impaired individuals to achieve their real-world objectives and participate in their chosen activities.
• This can be achieved via three types of interventions:
  • Body structure/function-oriented interventions improve real-world functioning through retraining exercises.
  • Activity/participation intervention helps the individual to compensate for cognitive impairment and to improve performance of functional tasks
  • Context-oriented intervention changes the environment of the individual to reduce the impact of cognitive disability and encourages supportive behavior of the people in the individual’s life

Assessment

• Standardized tests are used to measure cognitive strengths and weaknesses (See Psychological/Neuropsychological Services section).
• Tests are supplemented by situational observation to confirm or disconfirm test findings.
• Measures are obtained to mark functional improvement, such as maintained employment and independent living, or success in school.
• Knowledge and support skills of the people involved in the individual’s everyday life are evaluated.

Treatment

• Treatment is characterized by a flexible combination of general cognitive exercises, task-specific training, compensatory behavior, strategic thinking training in a functional context, and environmental modifications.

Setting, Content, Providers

• Rehabilitation may be given in a clinical setting but will focus on improving performance in meaningful routines and activities that the individual has identified.
• Rehabilitation may also be given in personally meaningful setting (e.g., in home).
• Health care professionals offering rehabilitation may also recruit the support of people in the individual’s everyday life to help.

Evidence-Based Recommendations for Cognitive Rehabilitation^1,2

Research supports the use of cognitive rehabilitation strategies for difficulties in multiple domains of cognitive functioning.

Attention Deficits

• There is evidence to support strategy training for attention deficits during the post-acute period after TBI.
• Data are not clear regarding benefits during the acute period of recovery from TBI.
• Research supports benefits on regulation of attention during complicated tasks rather than basic attention tasks like reaction time or vigilance.

Visuospatial Deficits

• There is evidence to support visual scanning training for visual neglect.

Apraxia

• There is evidence supporting the effectiveness of training in compensation strategies.

Language and Communication Deficits

• Research supports the use of language therapies during acute and post-acute rehabilitation for left hemispheric stroke patients.
• Group communication treatments show significant improvements in language functioning.
• Interventions for specific language impairments, like reading comprehension or language formulation, are effective for persons with TBI.

Memory Deficits

• For persons with mild memory impairment, evidence supports strategy training, which includes:
  • Visual imagery to facilitate verbal recall
  • Memory notebooks or diaries
• For persons with moderate to severe memory impairment, evidence supports the use of compensatory strategies to improve functional activities, including:
  • Use of portable pagers as a memory aid for specific important behaviors that the person has identified (e.g., taking medications).

Executive Functioning, Problem-Solving, and Awareness

• There is evidence to support formal problem solving strategy training, such as goal management training and the application of it to everyday activities.
• There is some evidence to suggest benefits in training of self-regulation strategies (through self-awareness and self-instruction) for difficulties including anger management problems.

Comprehensive-Holistic Cognitive Rehabilitation

• Studies support programs in comprehensive-holistic cognitive rehabilitation for persons with moderate to severe TBI.
  • These address a combination of cognitive, emotional, motivational, and interpersonal impairments in the post-acute phase of recovery from TBI.