Review Article
Evidence-based cognitive rehabilitation: Recommendations for clinical practice☆,☆☆,★,★★,♢

https://doi.org/10.1053/apmr.2000.19240Get rights and content

Abstract

Cicerone KD, Dahlberg C, Kalmar K, Langenbahn DM, Malec JF, Bergquist TF, Felicetti T, Giacino JT, Harley JP, Harrington DE, Herzog J, Kneipp S, Laatsch L, Morse PA. Evidence-based cognitive rehabilitation: recommendations for clinical practice. Arch Phys Med Rehabil 2000;81:1596-615. Objective: To establish evidence-based recommendations for the clinical practice of cognitive rehabilitation, derived from a methodical review of the scientific literature concerning the effectiveness of cognitive rehabilitation for persons with traumatic brain injury (TBI) or stroke. Data Sources: A MEDLINE literature search using combinations of these key words as search terms: attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, reasoning, rehabilitation, remediation, and training. Reference lists from identified articles also were reviewed; a total bibliography of 655 published articles was compiled. Study Selection: Studies were initially reviewed according to the following exclusion criteria: nonintervention studies; theoretical, descriptive, or review papers; papers without adequate specification of interventions; subjects other than persons with TBI or stroke; pediatric subjects; pharmacologic interventions; and non-English language papers. After screening, 232 articles were eligible for inclusion. After detailed review, 61 of these were excluded as single case reports without data, subjects other than TBI and stroke, and nontreatment studies. This screening yielded 171 articles to be evaluated. Data Extraction: Articles were assigned to 1 of 7 categories according to their primary area of intervention: attention, visual perception and constructional abilities, language and communication, memory, problem solving and executive functioning, multi-modal interventions, and comprehensive-holistic cognitive rehabilitation. All articles were independently reviewed by at least 2 committee members and abstracted according to specified criteria. The 171 studies that passed initial review were classified according to the strength of their methods. Class I studies were defined as prospective, randomized controlled trials. Class II studies were defined as prospective cohort studies, retrospective case-control studies, or clinical series with well-designed controls. Class III studies were defined as clinical series without concurrent controls, or studies with appropriate single-subject methodology. Data Synthesis: Of the 171 studies evaluated, 29 were rated as Class I, 35 as Class II, and 107 as Class III. The overall evidence within each predefined area of intervention was then synthesized and recommendations were derived based on consideration of the relative strengths of the evidence. The resulting practice parameters were organized into 3 types of recommendations: Practice Standards, Practice Guidelines, and Practice Options. Conclusions: Overall, support exists for the effectiveness of several forms of cognitive rehabilitation for persons with stroke and TBI. Specific recommendations can be made for remediation of language and perception after left and right hemisphere stroke, respectively, and for the remediation of attention, memory, functional communication, and executive functioning after TBI. These recommendations may help to establish parameters of effective treatment, which should be of assistance to practicing clinicians. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Section snippets

Method

To develop its evidence-based recommendations, the committee identified and refined the questions to be addressed, identified the relevant literature, reviewed, analyzed, and classified the existing research, and wrote recommendations based on the strength of available evidence. A MEDLINE literature search was conducted using the following combinations of search words: attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, reasoning,

Remediation of attention deficits

Attempts to remediate impairments of attention have generally relied on drill and practice, with exercises designed to address specific aspects of attention (eg, processing speed, focused attention, divided attention). Most of the reported interventions in this area have used stimulus-response paradigms, which required subjects to identify and select among relevant auditory or visual stimuli, and often used speeded stimulus presentations. The implicit, if not explicit, rationale for most of

Conclusion

From a comprehensive review of the empirical literature on cognitive rehabilitation, 29 Class I studies were identified. Of these, 20 provide clear evidence supporting the effectiveness of cognitive rehabilitation for subjects with acquired TBI or stroke. Several studies showed an advantage of cognitive rehabilitation over conventional forms of rehabilitation. In most of the controlled studies with negative or equivocal results, the intervention in question was compared with an alternative form

Acknowledgements

This work was conducted through the Brain Injury–Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. We gratefully acknowledge Cindy Cotter, Dawn Wentar Henry, MA-CCC, Miriam Kragness, PhD, Anne Lindsay, PhD, Carolyn Lemsky, PhD, and Clare Morey for their assistance with the review of articles, and Lena Feld, MS, for her assistance with the literature search.

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    No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.

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    Reprint requests to Keith D. Cicerone, JFK-Johnson Rehabilitation Institute, 2048 Oak Tree Rd, Edison, NJ 08820, e-mail: [email protected].

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    Copyright © 2000 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.