Evidence-based cognitive rehabilitation: Recommendations for clinical practice

Objective: To establish evidence-based recommendations for the clinical pra ctice of cognitive rehabilitation,, derived from a methodical review of the scientific literature concerning the effectiveness of cognitive rehabilita tion for persons with traumatic brain injury (TBI) or stroke. Data Sources: A MEDLINE literature search using combinations of these key w ords as search terms: attention, awareness, cognition, communication, execu tive, language, memory, perception, problem solving, reasoning, rehabilitat ion, remediation, and training. Reference lists from identified articles al so were reviewed; a total bibliography of 655 published articles was compil ed. 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; subj ects other than persons with TBI or stroke; pediatric subjects; pharmacolog ic interventions; and non-English language papers. After screening, 232 art icles were eligible for inclusion. After detailed review, 61 of these were excluded as single case reports without data, subjects other than TBI and s troke, and nontreatment studies.. This screening yielded 171 articles to be evaluated. Data Extraction: Articles were assigned to 1 of 7 categories according to t heir primary area of intervention: attention, visual perception and constru ctional abilities, language and communication, memory, problem solving and executive functioning, multi-modal interventions, and comprehensive-holisti c cognitive rehabilitation. All articles were independently reviewed by at least 2 committee members and abstracted according to specified criteria. T he 171 studies that passed initial review were classified according to the strength of their methods. Class I studies were defined as prospective rand omized controlled trials. Class II studies were defined as prospective coho rt studies, retrospective case-control studies, or clinical series with wel l-designed controls. Class III studies were defined as clinical series with out concurrent controls, or studies with appropriate single-subject methodo logy. 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 predefi ned area of intervention was then synthesized and recommendations were deri ved based on consideration of the relative strengths of the evidence. The r esulting 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 reco mmendations can be made for remediation of language and perception after le ft and right hemisphere stroke, respectively, and for the remediation of at tention, memory, functional communication, and executive functioning after I TBI. These recommendations may help to establish parameters of effective treatment, which should be of assistance to practicing clinicians.