Review article
Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 1998 Through 2002

https://doi.org/10.1016/j.apmr.2005.03.024Get rights and content

Abstract

Cicerone KD, Dahlberg C, Malec JF, Langenbahn DM, Felicetti T, Kneipp S, Ellmo W, Kalmar K, Giacino JT, Harley JP, Laatsch L, Morse PA, Catanese J. Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002.

Objective

To update the previous evidence-based recommendations of the Brain Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 1998 through 2002.

Data Sources

PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, and reasoning combined with each of the terms rehabilitation, remediation, and training. Reference lists from identified articles were reviewed and a bibliography listing 312 articles was compiled.

Study Selection

One hundred eighteen articles were initially selected for inclusion. Thirty-one studies were excluded after detailed review. Excluded articles included 14 studies without data, 6 duplicate publications or follow-up studies, 5 nontreatment studies, 4 reviews, and 2 case studies involving diagnoses other than TBI or stroke.

Data Extraction

Articles were assigned to 1 of 7 categories reflecting the primary area of intervention: attention; visual perception; apraxia; language and communication; 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 87 studies evaluated, 17 were rated as class I, 8 as class II, and 62 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 cognitive-linguistic therapies for people with language deficits after left hemisphere stroke. New evidence supports training for apraxia after left hemisphere stroke. The evidence supports visuospatial rehabilitation for deficits associated with visual neglect after right hemisphere stroke. There is substantial evidence to support cognitive rehabilitation for people with TBI, including strategy training for mild memory impairment, strategy training for postacute attention deficits, and interventions for functional communication deficits. The overall analysis of 47 treatment comparisons, based on class I studies included in the current and previous review, reveals a differential benefit in favor of cognitive rehabilitation in 37 of 47 (78.7%) comparisons, with no comparison demonstrating a benefit in favor of the alternative treatment condition. Future research should move beyond the simple question of whether cognitive rehabilitation is effective, and examine the therapy factors and patient characteristics that optimize the clinical outcomes of cognitive rehabilitation.

Section snippets

Methods

We followed prior methodology for identifying relevant literature, reviewing, and classifying, and developing recommendations. These methods are described in more detail in our initial publication.1 For the current review, we searched PubMed and Infotrieve for articles published between 1998 and 2002, using the terms attention, awareness, cognitive, communication, executive, language, memory, perception, problem solving, and reasoning combined with each of the terms rehabilitation, remediation,

Discussion

This updated review of the literature regarding cognitive rehabilitation included 17 class I studies of 291 patients with TBI and 247 patients with stroke, with 16 of the 17 studies providing evidence for the effectiveness of cognitive rehabilitation. Five class I studies provide evidence for the effectiveness of remediation for visual inattention17, 18, 19 or apraxia30, 31 in patients with stroke, and 4 studies support the effectiveness of interventions for communication deficits after stroke.

Conclusions

We have now systematically reviewed 46 class I studies, 43 class II studies, and 169 class III studies of cognitive rehabilitation for people with TBI or stroke. Our overall analysis of 47 treatment comparisons from class I studies, representing 1801 patients, indicates that cognitive rehabilitation is of significant benefit when compared with alternative treatments. The resulting recommendations should help guide clinical treatment and facilitate additional research.

Acknowledgments

The Cognitive Rehabilitation Task Force of the BI-ISIG of ACRM conducted this work. We would like to acknowledge Joanne Azulay, PhD, Thomas Bergquist, PhD, Douglas Katz, MD, and Virginia Mills, RPT, for their contributions to the review and classification of the literature.

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