Arch Phys Med Rehabil. 2005 Aug;86(8):1681-92
Comment in: Arch Phys Med Rehabil. 2006 Mar;87(3):446.

Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002.

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.
JFK-Johnson Rehabilitation Institute, Edison, NJ 08820, USA.

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 non treatment 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.

PMID: 16084827 [PubMed – indexed for MEDLINE]

J Nerv Ment Dis. 2005 Sep;193(9):602-8 

Predictors of remediation success on a trained memory task.

Fiszdon JM, Cardenas AS, Bryson GJ, Bell MD.
Department of Psychology, VA Connecticut Healthcare System, West Haven, Connecticut 06516, USA.

Cognitive remediation has led to improvements for some but not all individuals with schizophrenia. The goal of the current investigation was to determine which variables predicted response to cognitive remediation training. In a sample of 58 patients with DSM-IV schizophrenia or schizoaffective disorder, normalization of performance on a trained memory task was selected as the criterion for successful remediation. The contribution of demographic, symptom, treatment process, and cognitive variables in predicting successful remediation was examined using a series of logistic regressions. A final regression evaluated the combined contribution of these variables. From among patients who were impaired before training, 43% reached normal levels of performance. Measures of attention, immediate verbal memory, hostility, and latency between last training and assessment were retained in the final step of the regression, resulting in 83% classification accuracy. Findings suggest that in addition to cognitive factors, motivational and training variables also significantly affect remediation outcomes.

PMID: 16131943

Brain Inj. 2002 Mar;16(3):185-95  

Remediation of “working attention” in mild traumatic brain injury.

Cicerone KD.
JFK-Johnson Rehabilitation Institute, 2048 Oak Tree Road, Edison, NJ 08820, USA.

Several studies have reported beneficial effects of treatments for attentional deficits following traumatic brain injury. Improvements in speed of processing appear to be less robust than improvements on non-speeded tasks, while several studies suggest greater benefits of training more complex forms of attention. The present study presents preliminary results concerning the effectiveness of an intervention for attentional deficits after mild traumatic brain injury. The treatment was based upon the conceptualization of deficits and interventions as a function of the central executive component of working memory, or “working attention” . A prospective, case-comparison design was employed comparing four treatment participants with an untreated comparison sample. Treatment tasks were derived from experimental procedures which have been demonstrated to elicit working memory demands, consisting of “n-back”, random generation, and dual-task procedures. The intervention emphasized the conscious and deliberate use of strategies to effectively allocate attentional resources and manage the rate of information during task performance. Treatment participants were more likely to exhibit clinically significant improvement on measures of attention and reduction of self-reported attentional difficulties in their daily functioning. Further analysis suggested that the principal effect of the intervention was on working memory, i.e. the ability to temporarily maintain and manipulate information during task performance, with no direct effect on processing speed. The results are consistent with a strategy training model of remediation, in which the benefits of treatment are due to participants’ improved ability to compensate for residual deficits and adopt strategies for the more effective allocation of their remaining attentional resources.

PMID: 11874612 [PubMed – indexed for MEDLINE]

Acta Psychiatr Scand. 2003 Aug;108(2):101-9  

Cognitive remediation of working memory deficits: durability of training effects in severely impaired and less severely impaired schizophrenia.

CBell M, Bryson G, Wexler BE.
Department of Psychiatry, Yale University School of Medicine, West Haven, CT, USA. Bell.Morris_D+@West-Haven.VA.Gov

OBJECTIVE: To determine whether augmenting work therapy (WT) with neurocognitive enhancement therapy (NET) yields greater improvement in working memory performance than WT alone and whether there is an interaction with severity of impairment. METHOD: A total of 102 participants with schizophrenia or schizoaffective disorder were categorized as severely or less severely cognitively impaired and randomly assigned to receive NET + WT or WT alone. NET consisted of cognitive training exercises in attention, memory, executive function, and social information processing, and WT was a 6-month work program. RESULTS: Comparison on Digits Backwards from intake to follow-up revealed significantly greater improvement for participants receiving NET + WT, but there was no interaction with severity group. Follow-up 6 months after training showed that training effects endured. CONCLUSION: NET + WT improved working memory for most participants regardless of impairment severity. Intensity and duration of training may have contributed to duration of effects. Findings support continued exploration of cognitive remediation.

PMID: 12823166

Arch Gen Psychiatry. 2001 Aug;58(8):763-8  

Neurocognitive enhancement therapy with work therapy: effects on neuropsychological test performance.

Bell M, Bryson G, Greig T, Corcoran C, Wexler BE.
VA Connecticut Healthcare System, West Haven, CT, USA.

BACKGROUND: Cognitive deficits are a major determinant of social and occupational dysfunction in schizophrenia. In this study, we determined whether neurocognitive enhancement therapy (NET) in combination with work therapy (WT) would improve performance on neuropsychological tests related to but different from the training tasks. METHODS: Sixty-five patients with schizophrenia or schizoaffective disorder were randomly assigned to NET plus WT or WT alone. Neurocognitive enhancement therapy included computer-based training on attention, memory, and executive function tasks; an information processing group; and feedback on cognitive performance in the workplace. Work therapy included paid work activity in job placements at the medical center (eg, mail room, grounds, library) with accompanying supports. Neuropsychological testing was performed at intake and 5 months later. RESULTS: Prior to enrollment, both groups did poorly on neuropsychological testing. Patients receiving NET + WT showed greater improvements on pretest-posttest variables of executive function, working memory, and affect recognition. As many as 60% in the NET + WT group improved on some measures and were 4 to 5 times more likely to show large effect-size improvements. The number of patients with normal working memory performance increased significantly with NET + WT, from 45% to 77%, compared with a decrease from 56% to 45% for those receiving WT. CONCLUSIONS: Computer training for cognitive dysfunction in patients with schizophrenia can have benefits that generalize to independent outcome measures. Efficacy may result from a synergy between NET, which encourages mental activity, and WT, which allows a natural context for mental activity to be exercised, generalized, and reinforced.

PMID: 11483142

Ann N Y Acad Sci. 2005 Dec;1060:189-94

The power of listening: auditory-motor interactions in musical training.

Lahav A, Boulanger A, Schlaug G, Saltzman E.
The Music, Mind and Motion Lab, Boston University, 635 Commonwealth Ave., MA 02215, USA.

We trained musically naive subjects to play a short piano melody by ear in a fully monitored computerized environment and tested their potential to acquire a functional linkage between actions and sounds. Individual notes that were simply acoustic pretraining signals became “physically meaningful” posttraining. In addition, we found preliminary evidence that passive listening to a newly learned musical piece can enhance motor performance in the absence of physical practice.

PMID: 16597764

Brain Inj. 2006 Mar;20(3):219-25

Computerized errorless learning-based memory rehabilitation for Chinese patients with brain injury: a preliminary quasi-experimental clinical design study.

Dou ZL, Man DW, Ou HN, Zheng JL, Tam SF.
Department of Rehabilitation Medicine, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, PR China.

AIM: To evaluate the effectiveness of a computerized, errorless learning-based memory rehabilitation program for Chinese patients with traumatic brain injury (TBI). METHODS: This study adopted a pre- and post-test quasi-experimental design. A total of 37 patients with TBI were randomly assigned to a Computer-Assisted Memory Training Group (CAMG), a Therapist-administered Memory Training Group (TAMG) and a Control Group (CG). Except for the CG, the patients in both the CAMG and TAMG groups received, respectively, 1-month memory training programmes that were similar in content but differed in delivery mode. All patients were followed up 1 month after treatment. The outcome measures that were taken were the Neurobehavioural Cognitive Status Examination (NCSE or Cognistat), the Rivermead Behavioural Memory Test (RBMT) and The Hong Kong List Learning Test (HKLLT). Repeated measure analyses were performed to investigate differences among the three groups. RESULTS: The patients in the Computer-assisted Memory Rehabilitation (CAMG) and Therapist-administered Memory Rehabilitation group (TAMG) were found to perform better than the CG in the NCSE and RBMT, but no significant differences were found between the CAMG and TAMG. The CAMG showed significant improvement in their HKLLT assessment as compared with the TAMG and CG. No statistically significant differences were found between the CAMG and TAMG when comparing the post-training outcome measures with the follow-up results. CONCLUSION: There is no difference between CAMG and TAMG, but the efficacy has been demonstrated when comparing with CG. It is suggested that the combined use of an errorless learning and a computerized approach may be an effective way of enhancing the memories of patients with TBI. This new method may smooth the progress of the whole human memory process and produce a better carryover treatment effect.

PMID: 16537263

Brain Inj. 1994 Jan;8(1):3-14.

Efficacy study of THINKable in the attention and memory retraining of traumatically head-injured patients.

Ruff R, Mahaffey R, Engel J, Farrow C, Cox D, Karzmark P. University of California at San Francisco. The efficacy of computer-assisted attention and memory retraining was evaluated with 15 severely head-injured patients. Training with selected exercises tailored to the individual’s needs were provided from the THINKable program for up to 20 hours in both the attention and memory remediation modules. The experimental design evaluated outcome by juxtaposing multiple baseline procedures with a pre- and post-group comparison. Significant results were documented on the computerized tasks, psychometric measures and on patient and observer ratings of everyday behaviours of attention and memory. PMID: 8124315