Several studies have been conducted on cognitive rehabilitation post ABI. Five large, robust systematic reviews were conducted by the INCOG group on the following domains of cognition: post-traumatic amnesia (PTA), attention, executive functioning, communication, and learning and memory (Jennie Ponsford et al., 2014; J. Ponsford & Sinclair, 2014; R. Tate et al., 2014; L. Togher et al., 2014; Velikonja et al., 2014). When assessing cognitive impairment, initially, it is important to consider other factors besides the injury such as a patient’s cultural background, premorbid intelligence, substance abuse, or mental illness, as these have been found to impact one’s cognitive abilities (MacMillan, Hart, Martelli, & Zasler, 2002; Prigatano & Leathern, 1993; L. A. Taylor, Kreutzer, Demm, & Meade, 2003).
Deficits in attention are a common complaint amongst patients. Attentional disorders can impede patients’ activities of daily living, ability to drive and their vocational status. Rehabilitation strategies for attention include tasks that emulate everyday activities. In an RCT, Fasotti, Kovacs, Eling, and Brouwer (2000) employed a training program that emulated many real life tasks versus a verbal instruction program for improving attention. The authors noted greater concentration and speed of processing in participants exposed to the real life task program in their everyday tasks.
Dual task training is another effective way to train attention; this rehabilitation strategy encourages participants to actively engage in two attentional processes that are sometimes not even related to one another. In a recent RCT-crossover, patients were divided into an experimental program with dual task training for two specific cognitive tasks or a control group for six weeks before crossing over. At the six-week assessment, the experimental group showed significant improvement in reaction times and omissions compared to the control group (Couillet et al., 2010). Another RCT found similar improvements in dual-task training for cognitive-motor tasks (Evans, Greenfield, Wilson, & Bateman, 2009). Stablum, Umiltà, Mogentale, Carlan, and Guerrini (2000) demonstrated that patients who had a closed head injury, or had experienced an aneurysm after dual task training, could have reaction times similar to matched controls for attentional tasks.
After an acquired brain injury (ABI) some individuals have altered emotional and affective states. One RCT demonstrated that cognitive behavioural therapy (CBT) was effective in improving anxiety, depression, and divided attention (Tiersky et al., 2005) after a TBI; additionally, a prospective controlled trial demonstrated the efficacy of CBT for sleep/wake disorders (Wiseman-Hakes et al., 2013). Two review articles advocate for CBT in improving emotional and affective disorders after a TBI (Mateer, Sira, & O'Connell, 2005; R. Ruff, 2005).
Pharmacological agents have been suggested for use in cognitive rehabilitation post ABI. Methylphenidate has been found to increase reaction time, speed of processing and sustain attention (Kim, Ko, Na, Park, & Kim, 2006; Pavlovskaya, Hochstein, Keren, Mordvinov, & Groswasser, 2007; Plenger et al., 1996; Whyte et al., 2004; Willmott & Ponsford, 2009). An older study however found methylphenidate did not significantly improve attention, information processing speed, or learning compared to placebo. Additionally, one study found that attention and awareness from disorders of consciousness can be improved using amantadine (Mura et al., 2014). Finally, two RCTs demonstrated that amantadine produced significantly greater improvements than placebo medications in restoring consciousness (Giacino et al., 2012; Meythaler, Guin-Renfroe, Johnson, & Brunner, 2001). Three chart reviews also found to produce greater improvements in promoting consciousness over non-medication use (Hughes, Colantonio, Santaguida, & Paton, 2005; Saniova, Drobny, Kneslova, & Minarik, 2004) and compared to other medications (Whyte et al., 2004).
The use of computer-based attentional tasks can provide patients with repeated exposure to training tasks without the use of a therapist; however, these tasks are often hard to apply outside of this context because they cannot be generalized to other everyday tasks. Two meta-analyses found that cognitive rehabilitation interventions focusing on repetitive computer-based attentional tasks were only as effective control interventions (Park & Ingles, 2001; Rohling, Faust, Beverly, & Demakis, 2009). Similarly, numerous RCTs demonstrate that computer-based attentional tasks are less effective when compared to tasks that mimic everyday attentional abilities (Dirette & Hinojosa, 1999; Gray, Robertson, Pentland, & Anderson, 1992; J. Malec, Jones, Rao, & Stubbs, 1984; Niemann, Ruff, & Baser, 1990; Novack, Caldwell, Duke, Bergquist, & Gage, 1996; Sohlberg & Mateer, 1987).
The use of auditory stimulation has also been studied among individuals post ABI. Two RCTs have evaluated the use of auditory alerting tones to increase attention, although the findings are conflicting. Manly, Hawkins, Evans, Woldt, and Robertson (2002) report that tones significantly improved attentional abilities compared to no presence of tones, while Sweeney, Kersel, Morris, Manly, and Evans (2010) reported that tones had no effect on performance.
Memory impairments encompass a large portion of cognitive problems following a TBI. Internal compensatory strategies including mnemonics and self-cueing are an effective way to improve memory. Several RCTs have examined the use of imagery based mnemonics in patients with moderate and severe TBI and found them to be effective. Similarly, several studies have evaluated prospective memory interventions using self-awareness, imagery and active control and these have been found to be effective (Fleming, Shum, Strong, & Lightbody, 2005; Grilli & McFarland, 2011; Potvin, Rouleau, Senechal, & Giguere, 2011; Raskin & Sohlberg, 1996; Raskin & Sohlberg, 2009; Shum, Fleming, Gill, Gullo, & Strong, 2011). Two studies found that cueing strategies were effective (Manasse, Hux, & Snell, 2005; Schefft et al., 2008) and one study found that categorizing items based on their everyday function prompted successful memory retrieval (O'Neil-Pirozzi et al., 2010).
The development of cognitive rehabilitation strategies, and the presence of therapists who can facilitate these strategies, is crucial to cognitive skills training. Computer-based training can be an effective way to develop strategies; however, their restorative capacity is limited. While pre-post studies have shown that computerized cognitive skills training is effective (Fernandez et al., 2012; Johansson & Tornmalm, 2012), an RCT comparing computer-based training to traditional therapy reported no significant difference between the two methods of delivery (Dou, Man, Ou, Zheng, & Tam, 2006).
One useful application of technology-based interventions includes personal device assistants which prompt individuals to remember an action. Several RCTs have examined the use of pagers or mobile devices for setting reminders or to prompt an action, and have found them to be more effective than traditional techniques such as the use of a notebook or a calendar (Dowds et al., 2011; Fish, Manly, Emslie, Evans, & Wilson, 2008; Powell et al., 2012; Wilson, Emslie, Quirk, & Evans, 2001). Traditional notebooks and diaries are still effective as memory aids (Cicerone et al., 2000; Ownsworth, Fleming, Shum, Kuipers, & Strong, 2008; Schmitter-Edgecombe, Fahy, Whelan, & Long, 1995; Zencius, Wesolowski, & Burke, 1990; Zencius, Wesolowski, Krankowski, & Burke, 1991). The use of apps such as Google calendar (McDonald et al., 2011) or instant messaging services (Bergquist, Gehl, Lepore, Holzworth, & Beaulieu, 2008) are also useful environmental aids for memory.
In general, objectives and targets of rehabilitation should be identified and align with both the patients’ and therapists’ goals (Powell et al., 2012). An RCT found that teaching strategies that minimize errors through either a therapist or a computer were more effective than conventional training (Dou et al., 2006). Systematic instruction which broke tasks down into smaller target components was better than trial and error learning (Ehlhardt, Sohlberg, Glang, & Albin, 2005; Powell et al., 2012).
Other strategies to improve memory include specialized memory groups (Jennett & Lincoln, 1991; Thickpenny-Davis & Barker-Collo, 2007). Groups provide an effective way to discuss and brainstorm memory strategies. Several pre-post studies have found that groups are useful memory-aids and social support avenues (Evans et al., 2009; O'Neil-Pirozzi et al., 2010).
Pharmacological agents have also been used post ABI for treatment of memory and attention. It is important to note that individuals are often receiving seizure prophylactic medications such as phenytoin. Several studies have found that administration of anticonvulsants s such as phenytoin may actually inhibit functional recovery (Bhatnagar, Iaccarino, & Zafonte, 2016; Bhullar et al., 2014; Bogner et al., 2015; Szaflarski, Nazzal, & Dreer, 2014). There are two pharmaceutical options to treat memory impairments after a brain injury: rivastigmine and donepezil. In two RCTs rivastigmine was administered to patients who had sustained a moderate to severe TBI (Silver et al., 2006; Silver et al., 2009). Study results, from both studies, indicate that rivastigmine did improve cognitive function and memory impairment, although results were not significantly different from control treatments. For pharmacological treatment of attention disorders donepezil may be effective. One RCT found that donepezil significantly increased scores on tasks of sustained attention and short-term memory when compared to placebo and that these improved results were sustained after the wash-out period (Zhang, Plotkin, Wang, Sandel, & Lee, 2004).
Executive function disorders are another common problem after a TBI. One way to remediate these problems is through the use of metacognitive strategies. Several RCTs have evaluated and found the following metacognitive strategies to be effective: time pressure management to slow information processing (Fasotti et al., 2000), problem solving strategies using metacomponents or focus groups (Fong & Howie, 2009; Rath, Simon, Langenbahn, Sherr, & Diller, 2003), goal management training (Levine et al., 2011) and goal setting (McPherson, Kayes, & Weatherall, 2009; P. M. Webb & Glueckauf, 1994). Finally, a multi-center RCT evaluated a combination of the former strategies using a multifaceted approach which was effective (Spikman et al., 2010).
Strategies that can increase reasoning skills include self-cueing to reinforce autobiographical memories (Delazer Thomas Bodner Thomas Benke, 1998; Hewitt, Evans, & Dritschel, 2006), categorization techniques (Constantinidou, Thomas, & Robinson, 2008), tele-rehabilitation to communicate problem solving techniques (Man, Soong, Tam, & Hui-Chan, 2006; Soong, Tam, Man, & Hui-Chan, 2005) and the use of interactive pictorials (Man et al., 2006).
To increase a patient’s awareness of their cognitive deficits, feedback can be provided verbally to a person with a brain injury by a therapist describing the positive and negative aspects of the person’s task performance, visually by watching video-recordings of the one’s task performance, and in a group setting through peer feedback. Goverover, Johnston, Toglia, and Deluca (2007) found that self-awareness training through therapist feedback greatly increased activities of daily living performance. Group therapy serves as an effective way to provide feedback and social support between participants; it has been found to increase behavioural competency and psychological well-being (Ownsworth et al., 2008). Schmidt, Fleming, Ownsworth, and Lannin (2012) evaluated different ways of providing feedback training and found that feedback provided in a video with verbal instruction was most effective for increasing self-awareness. Finally, Rath et al. (2003) demonstrated that group therapy was an effective way for individuals with TBI to improve their problem solving skills. Group therapy allowed patients to identify their problems, observe their own and others’ reactions, and come up with plans and alternatives to deal with their problems. Group therapy is an appealing option because it helps patients improve goal attainment (Ownsworth et al., 2008).
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