Cognitive Rehabilitation for Traumatic Brain Injury & Stroke

ed according to specific criteria. For each of the remaining 87 studies, the level of evidence was determined using the same criteria as in our prior review. Update on Evidence-based Cognitive Rehabilitation 3 Of the 87 studies evaluated, 17 were rated as Class I, 8 as Class II, and 62 as Class III. Evidence within each predefined area of intervention was synthesized and recommendations were derived from consideration of the relative strengths of the evidence. The resulting practice parameters reflected three types of recommendations: Practice Standards, Practice Guidelines, and Practice Options. Based on the initial and updated reviews, the Task Force concludes that there is substantial evidence from Class I studies to support the clinical recommendations for cognitive-linguistic therapies for people with language deficits after left hemisphere stroke, and visuospatial rehabilitation for deficits associated with visual neglect after right hemisphere stroke. There is additional evidence to support the use of gestural or strategy training for apraxia after left hemisphere stroke. There is substantial evidence to support the clinical recommendations for strategy training for people with mild memory impairment after TBI, strategy training for attention deficits due to TBI during the post acute period of rehabilitation, and interventions for functional communication deficits after TBI, including pragmatic conversational skills. The overall analysis of 47 treatment comparisons, based on Class I studies included in the current and previous review, reveals that a differential benefit in favor of cognitive rehabilitation was evident 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 or not cognitive rehabilitation is effective, and look more precisely at the therapy factors and patient characteristics that optimize the clinical outcomes of cognitive rehabilitation. Update on Evidence-based Cognitive Rehabilitation 4 Cognitive Rehabilitation for Traumatic Brain Injury and Stroke: Updated Review of the Literature from 1998 through 2002 with Recommendations for Clinical Practice The Brain Injury – Interdisciplinary Special Interest Group (BI-ISIG) of the American Congress of Rehabilitation Medicine has previously conducted an evidence-based review of the literature regarding cognitive rehabilitation for persons with traumatic brain injury (TBI) or stroke, leading to specific recommendations for clinical practice. In that paper, the committee defined cognition as the “process of knowing” through the selection and acquisition of information, the understanding of that information, and the application of knowledge in the appropriate situation. Cognitive rehabilitation was defined as a systematic, functionally oriented service of therapeutic activities intended to improve cognitive functioning through (1) reestablishing previously learned patterns of behavior; (2) establishing new patterns of cognitive activity through compensatory cognitive mechanisms for impaired neurological systems; (3) establishing new patterns of activity through external compensatory mechanisms or environmental support; and/or (4) enabling persons to adapt to their cognitive disability in order to improve their overall level of functioning and quality of life. Regardless of the specific approach to intervention, we recognized that cognitive rehabilitation should be directed at changes that improve persons’ functioning in areas of relevance to their everyday lives. Based on the review and classification of studies published through 1997, the committee made several specific recommendations regarding the effectiveness of cognitive rehabilitation for individuals with traumatic brain injury (TBI) or stroke. We recognize that clinical guideline development is an ongoing process that should include an updated review of the literature within five years of the initial recommendations. This report represents the updated evidence-based review and recommendations based on the additional literature published during the five year Update on Evidence-based Cognitive Rehabilitation 5 period from 1998 through 2002. METHOD The development of evidence-based recommendations for this review followed our prior methodology involving identification of the relevant literature, review, analysis and classification of the existing research, and development of recommendations based upon the strength of available evidence. Online literature searches using Pubmed and Infotrieve were conducted using combinations of attention, awareness, cognitive, communication, executive, language, memory, perception, problem solving, reasoning, rehabilitation, remediation, and training as search terms. Relevant articles were identified by members of the committee, all of whom are experienced in brain injury rehabilitation and have contributed to published literature in the area of brain injury rehabilitation. Reference lists from identified articles were searched to complete the initial list of references. We identified several papers published prior to 1998 that had not been identified for our prior review. We elected to include randomized controlled trials published prior to 1998 that had not been included in the prior review, but not other studies. Two such papers were identified and included in this review. This resulted in the identification of 312 published articles. The abstracts or complete papers were reviewed in order to eliminate papers according to the following exclusion criteria: (1) papers not addressing intervention, (2) theoretical articles or descriptions of treatment approaches, (3) review papers, (4) papers without adequate specification of interventions, (5) papers that did not include participants primarily with a diagnosis of TBI or stroke, (6) studies of pediatric subjects, (7) single case reports without empirical data, (8) non-peer reviewed articles and book chapters, (9) papers describing pharmacologic interventions, and (10) non-English language papers. One hundred and eighteen articles were selected for inclusion following this screening Update on Evidence-based Cognitive Rehabilitation 6 process. Based upon the initial review, articles were assigned to one of six categories reflecting the primary area of intervention: attention; visual perception and constructional abilities; language and communication; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. We did not classify studies as multi-modal interventions for this review. All of these articles were reviewed by at least two committee members and abstracted according to specific criteria: subject characteristics, treatment characteristics, methods of monitoring and analyzing change, statistical analyses performed, evidence of treatment effectiveness, and nature of the comparison condition. Thirty-one additional studies were excluded following detailed review. The excluded articles included 14 studies without data, 6 papers representing duplicate publications or followup studies, 5 papers that were non-treatment studies or experimental manipulations, 4 reviews, and 2 single case studies of individuals with diagnoses other than TBI or stroke. For each of the remaining 87 studies, the level of evidence was determined based upon criteria used in our prior review. Well-designed, prospective, randomized controlled trials were considered Class I evidence; studies using a prospective design with "quasi-randomized" assignment to treatment conditions were designated as Class Ia studies. Given the inherent difficulty in blinding rehabilitation interventions, we did not consider this as criterion for Class I or Ia studies. Class II studies consisted of prospective, non-randomized cohort studies; retrospective, non-randomized case-control studies; or multiple-baseline studies that permitted a direct comparison of treatment conditions. Clinical series without concurrent controls, or singlesubject designs with adequate quantification and analysis were considered Class III evidence. All classifications were based upon the agreement of at least two reviewers. Disagreement between Update on Evidence-based Cognitive Rehabilitation 7 any two reviewers was resolved through a third review and, if necessary, joint discussion of the three reviewers and the committee chairperson. Classification of all studies was also reviewed by the entire committee to ensure consensus prior to the final classification. Of the 87 studies evaluated, 17 were rated as Class I, 8 as Class II, and 62 as Class III. Following the classification of studies, the overall evidence within each predefined area of intervention was synthesized and recommendations were derived from consideration of the relative strengths of the evidence. The level of evidence required to determine Practice Standards, Practice Guidelines or Practice Options was slightly modified from our initial definitions to reflect the actual decision rules applied in our initial review (Table 1). All recommendations were reviewed by the entire committee to ensure consensus. Update on Evidence-based Cognitive Rehabilitation 8 Table 1. Definition of Levels of Recommendations