What is cognitive rehabilitation?

 

'Cognitive rehabilitation is a “systematic, functionally-oriented service of therapeutic cognitive activities, based on an assessment and understanding of the person’s brain-behavior deficits,” as defined by the Brain Injury Interdisciplinary Special Interest Group (BI-ISIG) of the American Congress of Rehabilitation Medicine (Harley et al., 1992). Cognitive rehabilitation achieves functional change with interventions that:

a) reinforce, strengthen, or re-establish previously learned patterns of behavior, or b) establish new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems (Harley et al, 1992).'

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Why is cognitive rehabilitation important for patients with brain injury?

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"Cognitive rehabilitation focuses on improving executive functioning (problem solving, decision-making, planning), emotional regulation, attention, memory, and cognitive-communication skills. The emphasis is on self-management with a goal of resumption of meaningful activities that the person wants, needs, or is expected to perform in their life roles. Cognitive rehabilitation addresses compromised cognitive function and behavioral and affective regulation, whereas cognitive behavioral therapy focuses on treating psychological health disorders, including mood, sleep, and anxiety."

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How do I determine if I or my loved one is good candidate for cognitive rehabilitation?

"You or your loved one may be a good candidate for cognitive rehabilitation if they:

Exhibit, report, or are observed having a change in performance of complex activities of daily life (home, community, work, school or leisure)."

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"When you compare yourself to how you were before this injury, would you say you are now having any difficulty with…

Examples:

- Focusing and paying attention to things?

- Being distracted and unable to concentrate on things you are doing?

- Listening and understanding what others are saying?

- Not comprehending what others are saying – feeling like conversations are moving faster than you can follow?

- Speaking?

- Trouble finding the right words?

- Understanding what you are reading?

- Having to re-read things over and over again?

- Remembering things you need or want to do?

- Forgetting to take medications or attend appointments?

- Following conversations?

- Having trouble remembering what others are saying or forgetting what you meant to say

- Doing things as efficiently as you used to?

- Making mistakes and having to repeat what you do or not being able to do more than  one thing at a time?

- Making good decisions?

- Not knowing what to prioritize in your day?

- Planning well for things?

- Controlling your emotions?

- Getting angry and frustrated more easily or blurting out things that you normally would have kept to yourself?"

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How do I address comorbid conditions and are they a contraindication for cognitive rehabilitation?

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Conditions including some psychological health disorders, sleep disturbances, headaches, and chronic pain may be contraindications for cognitive rehabilitation. In some cases, we recommend addressing these conditions either prior to or concurrent with the initiation of cognitive rehabilitation. 

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Most common contraindications for cognitive rehabilitation include patients with an active substance abuse disorder or active psychotic disorder, or who present with decreased alertness and severely diminished attention, until adequately managed.

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How soon after a brain injury should I seek cognitive rehabilitation?

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"The VA/DoD Clinical Practice Guideline for Management of Concussion-mild Traumatic Brain Injury (2016) suggests that patients with a history of mild TBI who report cognitive symptoms that do not resolve within 30-90 days and have been refractory to treatment for associated symptoms (e.g., sleep disturbance, headache) be referred as appropriate for a structured cognitive assessment or neuropsychological assessment to determine functional limitations and guide treatment."

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"Note that patients can benefit from cognitive interventions even years after injury. Exercise sound clinical judgment and consider the patient’s motivation when referring these cases."

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What can my patient expect from cognitive rehabilitation and how will they benefit?

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"Before cognitive rehabilitation starts, patients can expect to:

- Receive an evaluation by one or more cognitive rehabilitation specialists.

- Identify patient-centered goals aimed at specific activity or participation outcomes with the help of therapist(s) and relevant key persons.

- Determine with the therapist(s) the frequency, modality (e.g., individual/group/combination), and length of therapy needed to meet the goals.

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During cognitive rehabilitation, patients can expect to learn more about:

- Their condition.

- Their specific cognitive deficits.

- Strategies they can use to target their specific cognitive difficulties for better self-management in the challenges of daily life."

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What are the benefits of cognitive rehabilitation?

 

"The benefits of cognitive rehabilitation include:

- Greater awareness and understanding of their specific cognitive deficits.

- Better management of their lives by applying skills and strategies they learned to improve cognitive functioning.

- Increased and more successful and efficient participation in meaningful life activities."

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Direct extraction:

DoD Clinical Recommendations | February 2019 Cognitive Rehabilitation for Service Members and Veterans Following Mild to Moderate Traumatic Brain Injury

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References:

Harley, J. P., C. Allen, T. L. Braciszewski, K. D. Cicerone, C. Dahlberg, S. Evans, M. Foto, W. A. Gordon, D. Harrington, W. Levin, J. F. Malec, S. Millis, J. Morris, C. Muir, J. Richert, E. Salazar, D. A. Schiavone, and J. S. Smigelski. (1992). Guidelines for cognitive rehabilitation. NeuroRehabilitation 2(3):62–67. Department of Veterans Affairs (VA) & Department of Defense (DoD). (2016) VA/DoD clinical practice guideline for the management of concussion-mild traumatic brain injury. Version 2. Retrieved from this link.

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