Linda Laatsch

Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 2003 Through 2008

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. 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.

An evidence-based review of cognitive and behavioral rehabilitation treatment studies in children with acquired brain injury

ObjectiveThe aim of this study was to complete a systematic evidence-based review of published cognitive and behavioral treatment studies with pediatric subjects who have a history of an acquired brain injury (ABI). Data sourcesWe utilized PubMed and EMBASE to search peer-reviewed journals from 1980 to 2006. Data selectionTerms such as cognitive rehabilitation, speech therapy, language therapy, and behavior therapy were employed in the search and 28 studies met established criteria. Data extractionThe data extracted from each study included specific details about the cognitive or behavioral treatment, subjects, study design, outcome measurements, and treatment effectiveness. Data synthesisThe studies, involving 366 children and youth with ABI, were classified as 1 Class I study, 5 Class II studies, 6 Class III studies, and 16 Class IV studies. ConclusionsDespite a limited number of studies, 2 treatment recommendations and 1 option were developed from this systematic literature search.

Investigating the neurobiological basis of cognitive rehabilitation therapy with fMRI

The neurobiological changes occurring during cognitive rehabilitation therapy (CRT) have yet to be systematically studied. In the present study, functional magnetic resonance imaging (fMRI) was used to demonstrate brain plasticity in response to CRT (n = 5) following mild traumatic brain injury. Neuropsychological tests and two fMRI activation tasks, a visually guided saccades and a reading comprehension task, were employed pre- and post-CRT. CRT was used to systematically address the identified deficits in visual scanning and language processing. As hypothesized, changes in the pattern and extent of activation within expected neuroanatomical areas occurred post-CRT. Changes in fMRI activation are discussed for each subject and related to changes on neuropsychological measures. This study demonstrates how fMRI can illustrate the neurobiological mechanisms of recovery in individual subjects. The variability in subject responses to CRT supports the notion of tailoring rehabilitation strategies to each subject in order to optimize recovery following brain injury.

Incorporation of SPECT imaging in a longitudinal cognitive rehabilitation therapy programme

In this clinical study, five consecutive referrals to a cognitive rehabilitation therapy (CRT) programme were followed in a longitudinal protocol involving a resting SPECT and neuropsychological evaluation at pre-treatment, post-treatment, and post non-treatment intervals. All clients had acquired brain injury and initially demonstrated neuropsychological deficits and various degrees of hypoperfusion on SPECT. Statistical Parametric Mapping (SPM) was used to evaluate change in successive SPECT images. Following CRT, all clients were able to return to productive employment or schooling. Examination of the neuropsychological testing results revealed significant improvement in performance following CRT which were generally maintained during the non-treatment period. SPM analysis of the SPECT data revealed that, in a majority of cases, most of the significant increases in relative cerebral blood flow redistribution were seen during the treatment period, rather than the non-treatment period. The results suggest that, even in individuals who are more than 2 years post-brain damage, relative increases in rCBF can be demonstrated following individualized CRT and that most of these changes can be related to improvements on neuropsychological tests.

Impact of cognitive rehabilitation therapy on neuropsychological impairments as measured by brain perfusion SPECT: a longitudinal study

Three patients, with known brain injury and neuropsychological impairments, are followed through an individualized cognitive rehabilitation programme and post discharge from the treatment programme. Single Photon Emission Computed Tomography (SPECT) of the brain was employed to evaluate resting relative cerebral blood flow (rCBF) during the process of recovery from brain injury. All patients experienced significant improvements on measures of neuropsychological functioning and improvements in rCBF during this longitudinal study. The specific changes in rCBF appear to be related to the location of the patients brain injury and strategies particular to cognitive rehabilitation therapy. Continued improvements in rCBF, functional abilities, and cognitive skills were documented in these three cases up to 45 months post brain injury.

Changes in fMRI activation following rehabilitation of reading and visual processing deficits in subjects with traumatic brain injury

In this case series fMRI was used to examine activation patterns during presentation of a reading comprehension (RC) task in three adult subjects with a history of severe traumatic brain injury (TBI). These subjects received cognitive rehabilitation therapy (CRT) for visual processing and acquired reading deficits. fMRI and neuropsychological testing occurred pre- and post-rehabilitation. The studys objective was to evaluate the neurobiological changes using fMRI occurring with CRT and to compare these results to repeat fMRI in matched control subjects. While improvements in neuropsychological testing occurred post-CRT, diffuse and variable activation patterns in the subjects with TBI were still demonstrated when compared to the control subjects repeat imaging. Multiple networks exist to accomplish the complex task of sentence reading and rehabilitation of the cognitive components of reading, such as visual processing; in subjects with TBI, can alter the activation pattern demonstrated during reading comprehension in subjects many years post-injury. This is the first demonstration of changes in network activation patterns post-CRT in patients with severe, chronic TBI on an fMRI task shown to have imaging stability in a normal control sample.

The Halstead Category Test: A Fifty Year Perspective

The Category Test, a major part of the Halstead-Reitan Neuropsychological Battery, was first described in a 1943 article by Halstead and Settlage. This paper reviews the development of the test, the psychometric properties of the instrument, available administration and scoring methods, discusses various interpretative strategies, and the empirical support for the tests clinical validity. Recent developments are then reviewed, as well as what the authors see as the future potential for this instrument.

The relationship between age, gender and psychological distress in rehabilitation inpatients

Although commonly accepted as the dominant emotional reaction to functional loss, the reported occurrence of depression in rehabilitation patients varies widely. Rather than focusing solely on depressive symptoms, this study furthers our understanding of emotional distress following a functional loss by assessing a range of psychiatric symptoms. A series of rehabilitation patients admitted to an urban hospital inpatient unit is used as the sample (n = 48). Demographic, neuropsychological, and a functional independence measure were included as independent variables. The statistical analysis revealed that-although age was not correlated with years of education, functional status, or neuropsychological impairment-there was a significant inverse relationship between age and reported emotional distress. Utilizing MANCOVA to explore the impact of age and gender on specific groups of psychiatric symptoms revealed that both younger and male patients tended to express psychiatric symptoms more frequently. The importance of considering age and gender in evaluation of emotional distress in rehabilitation is supported in this comprehensive study of psychiatric symptoms.

Cluster-branching methodology for adaptive testing and the development of the Adaptive Category Test

Adaptive testing involves the adjustment of a set of test items, in accordance with an individuals characteristics, to minimize items that do not yield useful information. The best known methodology used to develop adaptive tests, item response theory (IRT), cannot be used with most psychological instruments. The authors propose using cluster analysis to develop a branching logic that would allow the adaptive administration of such instruments. The proposed methodology is described in detail and is used to develop an adaptive version of the Halstead Category Test (W. Halstead & P. Settlage, 1943) from archival data. Real-data simulations show the Adaptive Category Test to yield scores that are not significantly different from the scores actually obtained on the original version of the test