Summary of Evidence Base for Cognitive Rehabilitation as of June 2009

Kit Malia

This document has been put together from the published Position Papers, Meta-reviews, Meta-Analyses, Recommendations and Standards. If you are aware of any other evidence which is not included here, please let me know so that the information can be added to this document.

1) Introduction

a) Definition.

Cognitive Rehabilitation (CR) is defined as a:

‘Systematic, theory-based programme of integrated, didactic, experiential, procedural and psychosocial training activities, conducted to restore cognitively compromised adaptation, including decrements in interpersonal and vocational participation, self-awareness and self-determination. A focus on the psychosocial/emotional aspects of recovery is central, as defective insight and the consequent dearth of adjustive motivation are major rehabilitation obstacles in TBI.’

Schutz & Trainor (2007) Brain Injury, 21(6):545-557

This describes very neatly the approach to CR recommended by Brain Tree Training.

b) The Problem with Over Simplification.

Despite wide agreement on this type of definition for CR, most of the accepted evidence base in CR, as in other therapies, is acquired from published papers which, almost exclusively, either take a particular CR technique and study its effects in isolation, or ignore the other ongoing treatments that are being provided. Whilst such an approach is understandable in the context of a research paradigm, which sets out with the aim of determining how much impact a particular CR technique has on the patient, this approach has limited utility within real environments, because this is not how any therapists actually give CR. (See Schutz & Trainor [2007] for more discussion on this and other issues). It is therefore essential to understand the model of CR that is used and how CR is actually embedded within a treatment programme.

c) Model.

The model we recommend for CR provision is described as ‘Modified Holistic’ by Schutz & Trainor (2007) Brain Injury, 21(6):545-557:

‘Model Two combines intensive cognitive treatment with psychotherapy or counselling, but staged in a conventional clinic environment …. [It] approach[es] vocational, social, behavioural and practical disabilities as expressions of underlying cognitive impairments. Most [programmes]assume that the cognitive deficits require intensive intervention. Hence the treatment plans tend to be relatively complex, staging therapies for the defective cognitive processes in several content areas, including simulations, and/or in vivo training of job, social, daily living and community skills required for post-discharge adaptation’

d) CR & the Treatment Programme :

ii. Most of the team (CR, OT , SLT & Psychology) should be involved in providing CR, with specific emphases in certain areas of expertise

iii. CR should not be decontextualised from other aspects of the rehabilitation programme. CR should work as an integral part of the rehabilitation programme (Malia. 2002)

iv. The CR programme should be a sophisticated, rational, comprehensive, time-bonded, graded, systematic and structured approach which is solidly based on learning theory and neuropsychological principles (Bewick et al, 1995; Malia & Bewick, 1995; Raymond et al, 1996; Malia & Bewick, 1996; Raymond et al, 1996; Malia et al, 1996; Malia et al, 1997; Hartlage, 1998; ASHA, 1998; Malia et al, 1998; Bennett et al, 1998; Raymond et al, 1999; Danziger, 2000; Malia, 2002; Malia & Brannagan, 2005)

v. CR should be geared towards improving functional outcomes (Malia, 2002)

vi. The CR programme recommended is considered to be a model of best practice by many centres around the globe

vii. CR should deliberately and systematically engage the patient, as the key member of the treatment team, in taking responsibility for their cognitive improvements and provide them with the tools and feedback to make the necessary adjustments to do this (Malia, 1997; Malia, 2002)

viii. The CR programme should make use of 4 approaches to ensure a comprehensive integration between didactic, experiential, procedural and psychosocial aspects:

• Education – with the aim of developing awareness/adjustment
• Process Training – with the aim of overcoming specific underlying cognitive impairments
• Strategy Training – with the aim of teaching compensation for specific skill losses
• Functional Activities Training - with the aim of ensuring generalisation of learning and use of the above 3 approaches in real life situations

ix. The CR programme should recognise the strong interactive associations between emotional and cognitive issues and the programme should be consequently designed such that the overriding aim is to help the patient develop AWARENESS (insight) and to help them in their process of ADJUSTMENT to a new sense of self. These are the keys to successful rehabilitation. The modified awareness model (Malia 1997) is recommended to be used as the basis of the work on awareness and adjustment.

e) Process Training.

This is the most misunderstood Of the 4 approaches used for CR, so it warrants a section just to itself.

i. It is essential to understand that process training is not repetitive drill type exercise or general stimulation. Thus any evidence which says that drill training or general stimulation does not work should not be applied to process training. The recommended CR approach does not use repetitive drill type exercise or general stimulation approaches.

ii. Stimulation approaches and repetitive drill approaches assume that the mind is a muscle and that through exercising it will eventually improve cognition, which will in turn generalise to real life functions. This approach has some utility to it since the individual will usually improve on the tasks given, but there does not seem to be a corresponding improvement in everyday life skills – i.e. poor generalisation. There is little published evidence to support these approaches in the brain injury literature.

iii. Process training is a sophisticated process based on learning and neuropsychological principles. It involves the following steps, which are incorporated in the provisional model of CR published by Wilson (2002):

• An initial assessment to identify which skills are deficient
• Analysis to form an hypothesis about the underlying causes of functional problems
• Designing of exercises to target the causes/deficit skills
• Setting of goals
• Implementation of the exercises in a structured, consistent manner, including ongoing monitoring of progress and feedback to the patient
• Reassessment and reanalysis

iv. The recommended Process Training materials to use are called ‘Brainwave-R’ (Malia et al, 1997). These materials were written by two CR specialists along with 2 Neuropsychologists, following neuropsychological principles and the evidence base of published materials. A strong meta-cognitive component is included in all the exercises. Independent review of these materials demonstrates that they fit well within the definition of CR which opened this section:

‘The authors demonstrate in clear and compelling fashion that neuropsychology has moved well beyond diagnosis to take its place at the cutting edge of treatment of brain disorders….

this pragmatic, highly applicable programme reflects the obvious experience and expertise of individuals knowledgeable and sophisticated in the area of brain-behaviour relationships and the rehabilitation of impairments common to individuals with brain injury….

this eminently practical book can certainly enhance the treatment repertoire, scope and comprehensiveness of facility-based neurological rehabilitation programmes, by providing therapists with a wide and useful array of well conceived and carefully designed procedures…

this work is recommended for most individuals who do, or would like to do, cognitive rehabilitation.’

Hartlage (1998)

2. Position Papers

Position papers serve to clarify the accepted view of particular organisations. Several position papers have been produced with regard to CR, including the following:

1) The National Institutes of Health, USA

‘Evidence supports the use of certain cognitive and behavioural rehabilitation strategies for individuals with brain injury in particular circumstances. These interventions share certain characteristics in that they are structured, systematic, goal-directed, and individualised and they involve learning, practice, social contact, and a relevant context.’

National Institutes of Health. Report of the Consensus Development Conference on the Rehabilitation of Persons with TBI. Bethesda, MD. (Sept 1999)

2) The National Academy of Neuropsychology, USA

‘It became dramatically evident to professionals, patients and their families that cognitive impairments, which interact with personality disturbance, were among the most critical determinants of ultimate rehabilitation outcome. Therefore, CR became an integral component of brain injury rehabilitation…..the National Academy of Neuropsychology supports such empirically and rationally based cognitive rehabilitation techniques that have been designed to improve the quality of life and functional outcomes for individuals with acquired brain injuries. There remains a need for more evidence-based work to further define and tailor cost-effective CR interventions, and also for an expansion of the graduate academic curriculum by offering training courses in neuropsychological rehabilitation to adequately prepare clinical neuropsychologists to assess for rehabilitation and to treat individuals with brain injuries. Most importantly, the last several decades have created a clinical and empirical foundation to provide patients with effective CR interventions to promote neurobehavioural recovery and to improve opportunities for returning to productive lives.’

National Academy of Neuropsychology, Cognitive Rehabilitation: Official Statement. (2002)

3) The Royal College of Physicians / British Society of Rehabilitation Medicine, UK

‘Cognitive, emotional and behavioural problems are extremely common following acquired brain injury and may be more problematic in the longer term than physical disability.
Guideline #120: Where cognitive impairment is causing management difficulties or limiting response to rehabilitation, specialist advice should be sought and, if appropriate, the patient referred to a formal cognitive rehabilitation programme
Guideline #121: Patients with persistent cognitive deficits following ABI should be offered cognitive rehabilitation’

RCP/BSRM (2003)

4) The Royal College of Physicians, UK

‘4.2.1: All patients should be screened for the presence of cognitive impairments a soon as is practicable. The nature of the impairment should be determined, and its impact on activity and participation should be explained to patients, carers and staff…..All members of the multidisciplinary team should take into consideration the patient’s cognitive status when planning and delivering treatment’

RCP (2004)

5) The Society for Cognitive Rehabilitation (SCR), USA

‘The long term effects of cognitive difficulties following brain injury are an established fact. The SCR is committed to developing and ensuring best practice within the field of CR. This document was produced at a time when various organisations are producing Guidelines and Standards for neurological rehabilitation. It aims to present the basis for best practice in one aspect of this, namely CR, so that planners, managers, practitioners, people with brain injury, and their families can determine what is required. The major part of the document is comprised of 81 Recommendations, under a variety of headings, which have been designed to comprehensively cover clinical practice in a range of acquired brain injury settings. These recommendations are supported with evidence in the form of expert opinion. In addition, a section has been included to enable the reader to gain a quick overview of best practice. This is presented in the form of an Evidence Base. While not complete, this evidence base is a good starting point for anyone who needs to explore this in more detail.‘

SCR, Malia et al (2004)

6) The Brain Injury Association of America

‘The benefits of CR have been discussed in more than 770 published research studies and are evident in positron emission tomography (PET) scans and other neuroimaging techniques in both human beings and animal models. More than ten scientific organisations and professional associations have adopted treatment guidelines or position statements in support of CR for individuals with brain injury.’

Katz et al (2006) Brain Injury Association of America

7) The British Psychological Society (BPS), UK

The BPS does not have a position statement on CR.

 

3. Guidelines/Standards & Recommendations Summary

a) It is important to note that none of these reviews claims to know what does or does not work. What they do is inform us about the evidence that exists to support the use (or non-use) of particular techniques with particular groups of patients. Lack of evidence does not automatically lead to a conclusion that a technique should not be used.

b) Levels of evidence used in the reports:

Class I: Prospective randomised, controlled and well designed studies
Class II: Prospective non-randomised studies; or retrospective non-randomised case-control studies; or clinical series with controls
Class III: Studies with no controls, or single case studies with appropriate methodology
Class IV: Expert committee reports, opinions and/or experience of respected authorities

c) 78 % of all Class I studies support clearly the effectiveness of CR (36 out of 46 studies) (Cicerone et al, 2000; 2005)

d) 97% of all Class II studies showed improved functioning among people receiving CR (62 out of 64 studies) (Cicerone et al, 2000)

e) Comprehensive holistic neuropsychologically oriented rehabilitation programmes, for adults with moderate or severe traumatic brain injury (TBI) or stroke, in the post acute rehabilitation stage, is supported by Class I and II evidence (Cicerone et al 2000; 20005 Gordon et al, 2006; Rees et al, 2007)

f) Process training for Attention deficits, for adults with TBI or stroke, in the post acute rehabilitation stage is supported primarily by Class I & Class II evidence, and some Class III evidence. (Cicerone et al, 2000; Cappa et al, 2003; RCP/BSRM, 2003; Lincoln et al, 2003; Majid et al, 2003; Sohlberg et al, 2003; National Clinical Guidelines for Stroke, 2004; Cicerone et al, 2005; Gordon et al, 2006; Rohling et al, 2009; Cappa, 2009; Sohlberg & Kennedy, 2009). It should be noted that Rees et al (2007) are the one dissenting voice in the literature on this issue.

g) Process and Strategy training for Visual Scanning deficits to reduce visual neglect, for adults with a right or left hemisphere stroke, is supported by Class I, II and III evidence (Cicerone et al, 2000: Cappa et al, 2003; RCP/BSRM, 2003; Cicerone et al,2005; Rohling et al, 2009; Cappa, 2009)

h) Process training for extending Visual fields, for adults following right hemisphere stroke, is supported by Class I and II evidence (Cicerone et al 2000; 2005)

i) Process training for Information Processing deficits in adults with TBI, is supported with Class I, II and III evidence (RCP/BSRM, 2003; Rees et al, 2007)

j) Strategy training for Memory deficits, for adults with mild traumatic brain injury (TBI) is supported with Class I, II and III evidence (Cicerone et al, 2000; Cappa et al, 2003; RCP/BSRM, 2003; Cicerone et al , 2005; Gordon et al, 2006; Rees et al, 2007; Sohlberg & Kennedy, 2009)

k) Process training for Memory deficits, using virtual reality environments is rated as possibly effective (Cappa. 2009)

l) Trial and error learning should be avoided in patients with memory impairment (Class II & III evidence) (RCP/BSRM, 2003)

m) Education, Strategy training and Functional Application of interventions of metacognitive and executive dysfunction, for adults during the post acute rehabilitation period, following stroke or TBI, is supported by Class I, II and III evidence (Cicerone et al, 2000; Sohlberg et al, 2003; RCP/BSRM, 2003; Cicerone et al, 2005; Gordon et al, 2006; Rees et al, 2007; Kennedy et al, 2008; Sohlberg & Kennedy, 2009)

n) The use of computer assisted CR training is probably not an effective adjunct, based on Level II evidence (Rees et al, 2007)

 

4. Guidelines/Standards & Recommendations Detail

a) Recommendations from Cappa et al, 2003:

There is enough overall evidence to award a Grade A Recommendation (based on Class I studies) to the following forms of CR for patients at the post acute stage after focal brain lesions: Attention training following TBI; Visual scanning training; Visuo-spatial motor training; Neglect and Apraxia training following stroke; Training compensatory memory strategies following mild TBI (Cappa et al, 2003)

b) Recommendations from Sohlberg et al, 2003:

9 Class I and II studies support direct attention training
26 Class I, II or III studies support intervention of metacognitive and executive dysfunction (Sohlberg et al, 2003)

c) Recommendations from Cicerone et al, 2000; 20005:

They split the recommendations into 3 levels:

• Practice Standards – reflects a high degree of certainty
• Practice Guidelines – reflects moderate clinical certainty
• Practice Options – reflects inconclusive or conflicting evidence or opinion

Attention.

Recommended attention training as a practice guideline for TBI and stroke patients at the post acute phase.
To be most successful attention training should use different stimulus modalities, incorporate graded levels of complexity and response demands, ensure the therapist monitors patient performance, provides feedback to them and teaches them compensatory strategies.(Based on 2 Level I and 2 Level II studies – total of 116 cases studied).

Attention training is not recommended during the acute phase due to lack of evidence.

Memory.

Recommended training in the use of compensatory memory strategies as a practice standard for patients with mild memory impairments.
Patients for whom this will be successful need to be fairly independent in adl’s, actively involved in identifying their own memory problems, and capable and motivated to continue in the use of the strategy. (Based on 4 Level I studies – total of 91 cases studied).

For patients with moderate to severe memory impairments it is recommended as a practice option that they are facilitated to acquire specific skills and domain specific knowledge.

There is no evidence for working towards restoring memory functions in patients with severe memory impairments

Visuospatial.

Visuospatial training consists of tasks in the following areas: visual scanning and visual perception, constructional and functional activities requiring spatial relationships.
Recommended as a practice standard for patients after a right hemisphere stroke to receive visual scanning training as part of a visuospatial programme in order to reduce their visual neglect. For this to be successful it is also necessary to provide training on increasingly complex visuospatial tasks in order to facilitate generalisation. Based on 6 Level I studies and 8 Level II studies – total of 534 cases studied).

It is recommended as a practice guideline for patients with left or right hemisphere strokes to have daily scanning training for 20 one hour sessions over a 4 week period.

It is recommended that computer based interventions are used to extend visual fields after right hemisphere stroke.

Executive functions and Problem solving.

Training in formal problem solving strategies and their application to real life settings is recommended as a treatment guideline. (Based on 1 Level I study, and 2 Level II studies – total of 43 cases studied).

Holistic CR approaches.

This approach is recommended as a treatment guideline. (Based on 3 Level II studies – total of 138 cases studied)

 

d) Recommendations from the RCP/BSRM (2003) National Clinical Guidelines:

Guideline #121:

‘Patients with persistent cognitive deficits following ABI should be offered cognitive rehabilitation which may include:

• Management in a structured and distraction free environment and targeted programmes for those with executive difficulties (ie problems with planning, organisation, problem solving, and divided attention) (Class I evidence)
• Attempts to improve attention and information processing skills (Class II & III evidence)
• Teaching compensatory techniques to overcome their everyday problems (Class IV evidence)
• The use of external memory aids to enhance independence in the presence of memory deficits (Level I evidence)

Guideline #122

‘Trial and error learning should be avoided in patients with memory impairment.’ (Class II & III evidence)

 

e) Recommendations from the National Clinical Guidelines for Stroke (2nd Edition) 2004:

Spatial awareness (neglect/inattention):

‘Patients with persisting, disabling impairment should receive therapy for their neglect/inattention using techniques such as cueing, scanning, limb activation, aids and environmental adaptations’ (Class II & III evidence)

Memory:

People with memory difficulties should
‘Be taught compensatory techniques to reduce their disabilities, such as using notebooks, diaries, audiotapes and electronic organisers. Auditory alarms may be particularly helpful in prompting actions, such as taking medication ‘ (Class II & III evidence)

‘Be taught approaches aimed at directly improving their memory, but the evidence to date is inadequate to support the use of ‘strategy training’ over ‘repetition’ (Class II & III evidence)
Attention. People who appear easily distracted or unable to concentrate

‘Should receive therapy (eg computerised practice) to improve alertness and the ability to sustain attention’ (Class II & III evidence)

Executive Function:

‘People with impaired executive functions should be taught compensatory techniques, such as using electronic organisers/pagers or written checklists to increase their ability to perform daily activities’ (Class II & III evidence)

 

f) Recommendation from the Academy of Neurologic Communication Disorders and Sciences (ANCDS) Kennedy et al (2008):

‘There is sufficient evidence to make the clinical recommendation that metacognitive strategy instruction should be used with young to middle aged adults with TBI, when improvement in everyday, functional problems is the goal’ (Class I evidence)

g) Recommendations from Cochrane Reviews (Lincoln et al 2003, Majid et al 2003):

‘There is some indication that training improves alertness and sustained attention but no evidence to support or refute the use of CR for attention deficits to improve functional independence following stroke.’

‘There is insufficient evidence to support or refute the effectiveness of CR for memory problems following stroke’

h) Recommendations from Rohling et al (2009):

‘It is better to start patients in treatment as early as possible rather than waiting for more complete neurological recovery’

‘Even older patients can and do benefit from CR, particularly if the brain injury is due to stroke’

‘Comprehensive non targeted interventions appear to be less effective and generalisation does not happen as well as many may have hoped. Thus clinicians should focus their efforts on direct cognitive skills training rather than broad generalised interventions with the expectation of subsequent generalisation to broader use in the real world.’

‘The meta analyses revealed sufficient evidence for the effectiveness of attention training after TBI and of language and visuospatial training for aphasia and neglect syndromes after stroke.’

i) Recommendations from Gordon et al (2006):

‘Clinical studies of comprehensive holistic neuropsychological rehabilitation have demonstrated improvements in community functioning after this type of intervention.’
‘Training in the use of compensatory strategies seems to be effective for the remediation of attention deficits and mild memory impairments after TBI.’ Note that this term ‘compensatory strategies’ includes process training as well as time pressure management training – more of an executive treatment approach.

j) Recommendations from Rees et al (2007):

Attention.

‘There is moderate evidence to suggest that specific structured training programmes are not effective for improving attention following moderate to severe brain injury.’
Information Processing. ‘Based on a single RCT, there is moderate evidence that dual task training on speed of processing is an effective intervention for patients with brain injury.’

Memory.

‘There is strong evidence surrounding the effectiveness of external aids as a compensatory strategy for memory impaired individuals for functional day to day memory problems. However, results do not necessarily indicate improved underlying memory abilities and the long term effect has not been adequately demonstrated.’

‘There is strong evidence that internal strategies appear to be an effective aid in improving recall performance following relatively mild impairment, however the sustained effect of treatment is not known. There is strong evidence that internal strategies are not effective for those with severe impairments.

‘Based on one RCT, there is limited evidence to suggest that memory retraining programmes are not effective for functional recovery. Memory retraining may be of benefit to those with mild impairment compared to severely impaired individuals at least in functional day to day memory.’

Executive functions.

‘There is limited evidence that demonstrated the short term effectiveness of group based interventions for the treatment of executive dysfunction post brain injury…..Moderate evidence, based on a single RCT, demonstrated that goal management training was effective for improving paper and pencil daily activities and preparation skills.’

General CR approaches:

‘There is limited evidence that general CR therapy (when all approaches are taken as a whole) following brain injury is effective for improving cognition. Although there are variable strategies and protocols for CR, all comprehensive interventions appear to provide benefit.’

Computer assisted CR training:

‘There is limited evidence that computer assisted CR is not an effective adjunct to the rehabilitation programme following brain injury based on 3 non randomised studies.’

k) Recommendations from Cappa (2009):

‘Specific interventions for attention during the acute phase are not recommended, because the available evidence does not allow clinicians to distinguish the effects of specific attention training from spontaneous recovery. On the other hand, there is considerable evidence from good quality studies suggesting that attention training in the post acute phase after TBI is effective.’

‘The use of memory strategies without electronic aid are rated as possibly effective. Specific learning strategies such as errorless learning are probably effective. There is evidence for possible efficacy of non-electronic external memory aids, such as diary or notebook keeping. Electronic external memory devices such as computers, paging systems or portable voice organisers are probably effective aids for improving TBI or stroke patients’ everyday activities. Finally there is evidence that memory training in virtual environments is rated as possibly effective.’

‘The available evidence, coming from a number of high quality studies, is that rehabilitation is effective in reducing neglect symptoms. What is still in need of further investigation is whether the improvement has an impact at the functional level.’

l) Recommendations from Sohlberg & Kennedy (2009):

‘Practice guidelines were recommended for the use of attention training with adults who were able to sustain their attention during most activities and who were at stable points in their recovery. The research suggests that attention training should use exercises tailored to the individual client’s attention profile and should be administered at least weekly in combination with metacognitive training in order to achieve improvement on tests of attention impairment and client/caregiver reports of functional attention changes…..with considerations and conditions, attention training should be considered as a practice guideline if part of a comprehensive rehabilitation programme’

‘Memory aids should be considered a practice guideline for people with acquired memory impairments.’

‘Metacognitive strategy instruction should be an integral part of therapeutic instruction when training adults with TBI to solve functional problems.’

5. Conclusion

• There are a great number of papers produced in the field of CR – currently something in the region of 7 new papers each week are being published, to add to the large number already published. This means that the field of CR has more evidence base behind it than any other form of therapy in neurological rehabilitation.

• As with all areas of evidence based practice there are many methodological problems with the published papers which makes it hard to draw definitive conclusions.

• The meta-reviews tend to agree on their conclusions (see Sections 3 & 4 above), and recommendations have been made.

• The majority of studies have taken a treatment approach out of the context of the normal rehabilitation programme in order to study its effects. However, the beneficial effects can probably only be fully seen when the particular technique is provided within the therapeutic milieu (See Schutz & Trainor 2007, for a full discussion of this issue).

• The actual numbers of patients studied in these meta-reviews needs to be taken into account – e.g. what works (or does not work) for the 116 patients from the Attention sections of the ACRM studies will not necessarily work (or not work) for all the other people in the world who sustain brain injury – this is after all a very small number upon which to base decisions on withholding or providing a particular treatment approach.

• Lack of evidence is not the same thing as evidence to show that an activity should not be done.

• None of the studies produced in CR to date have taken account of the patient’s level of awareness when examining if particular techniques worked well or not. Given that awareness is the crucial variable in successful rehabilitation this is likely to be considered a massive oversight in the future. This single fact may explain why particular techniques may work for some individuals but not others – an observation that is lost in group studies.

• The emphasis on Level I and II evidence may not be appropriate in the field of brain injury rehabilitation – due to the heterogeneity of this group of people (a theme discussed in detail by many eminent authors – see Kennedy & Turkstra (2006), Sohlberg & Kennedy (2009), Playford (2009) and Cicerone (2009) for discussion on this theme.

‘As researchers and clinicians, we recognise that even the most carefully designed, well controlled study will never be sufficient to determine the best clinical practice for an individual client. This requires clinical judgement, which in some circles has taken on a pejorative connotation. Clinical judgement does not mean ‘anything goes if it seems reasonable.’ Rather, it is the skilled use of logical reasoning, knowledge, and experience to make decisions. The challenge for researchers and clinicians is to generate good judgements, avoid judgements that will not benefit the client, and learn to recognise the difference.’

Kennedy & Turkstra, (2006)

References

Working Practices/ Model of Cognitive Rehabilitation/Materials used

• Schutz & Trainor (2007) Evaluation of cognitive rehabilitation as a treatment paradigm. Brain Injury 21(6):545-557

• Malia (2002). Working practices for Cognitive Rehabilitation Therapy. DMRC Headley Court 1- 26

• Bewick, Raymond, Malia & Bennett (1995). Metacognition as the ultimate executive: Techniques and tasks to facilitate executive functions. NeuroRehabilitation, 5:367-375

• Malia & Bewick, (1995). Treatment of Visual Skills Disorders. SCR Newsletter, 3(1):11-16

• Raymond, Bennett, Malia & Bewick, (1996). Rehabilitation of visual processing deficits following brain injury. NeuroRehabilitation, 6:229-240

• Malia & Bewick, (1996). Strategies and techniques for executive function deficits. SCR Newsletter, 4(4):16-20

• Raymond, Malia, Bewick & Bennett, (1996). A comprehensive approach to memory rehabilitation following brain injury. The Journal of Cognitive Rehabilitation, 14(6):18-23

• Malia, Bewick, Raymond & Bennett, (1996). Memory – A comprehensive approach. SCR Newsletter, 4(3):13-16

• Malia, Bewick, Raymond & Bennett(1997). Users Guide from Brainwave-R: Cognitive strategies and techniques for brain injury rehabilitation. ProEd, Texas, USA

• Hartlage (1998) Brainwave-R: Cognitive strategies and techniques for brain injury rehabilitation. Book and Test review. Archives of Clinical Neuropsychology 13(5):189-191

• American Speech-Language Hearing Association (1998) Brainwave-R review. ASHA Leader 3(11)

• Malia, Raymond, Bewick & Bennett, (1998). Information processing deficits and brain injury: preliminary results. NeuroRehabilitation, 11:239-247

• Bennett, Raymond, Malia, Bewick & Linton, (1998). Rehabilitation of attention and concentration deficits following brain injury. The Journal of Cognitive Rehabilitation, March/April:8-13

• Raymond, Bewick, Bennett & Malia, (1999) A comprehensive functional approach to brain injury rehabilitation. Brain Injury Source 3(4):30-34

• Danziger (2000). A review of Brainwave-R. Brainwave 5(1):44-45

• Malia & Brannagan. How to do Cognitive rehabilitation therapy Parts 1 & 2. Brain Tree Training, UK

• Malia (1997) Insight after brain injury: What does it mean? The Journal of Cognitive Rehabilitation, 15(3):10-16

• Wilson (2002) Toward a comprehensive model of cognitive rehabilitation. Neuropsychological rehabilitation 12(2):97-110

 

Position Papers

• The National Institutes of Health. Report of the Consensus Development Conference on the rehabilitation of persons with TBI. (1999) Bethesda, MD

• National Academy of Neuropsychology (NAN) (USA) (2002) Cognitive rehabilitation: Official statement of the NAN 1-2

• Royal College of Physicians and British Society of Rehabilitation Medicine (2003) Rehabilitation following acquired brain injury: National Clinical Guidelines Ed: Turner-Stokes. London

• Royal College of Physicans (2004) National Clinical Guidelines for stroke: 2nd edition. London

• Malia et al (2004) Recommendations for best practice in cognitive rehabilitation therapy: acquired brain injury. The Society for Cognitive Rehabilitation, USA

• Katz et al (2006) Cognitive rehabilitation: the evidence, funding and case for advocacy in brain injury. Brain Injury Association of America

 

Guidelines/Standards/Recommendations

• Cicerone et al (2000) Evidence based cognitive rehabilitation: recommendations for clinical practice. Arch Phys Med Rehabil 81:1596-615

• Cicerone et al (2005) Cognitive rehabilitation for traumatic brain injury and stroke: Updated review of the literature from 1998 through 2002 with recommendations for clinical practice. Archives of Physical Medicine and Rehabilitation 86(8):1681-1692

• Gordon et al (2006) Traumatic brain injury rehabilitation: State of the science. Am J of Phys Med Rehabil 85(4):343-382

• Rees et al (2007) Cognitive interventions post acquired brain injury. Brain Injury 21(2):161-200

• Cappa et al (2003) EFNS guidelines on cognitive rehabilitation: report on an EFNS task force. European Journal of Neurology 12:665-680

• Lincoln et al (2003) Cognitive rehabilitation for attention deficits following stroke (Cochrane Review Abstract) Issue 1

• Majid et al (2003) Cognitive rehabilitation for memory deficits following stroke (Cohcrane Review Abstract) Issue 1

• Sohlberg et al (2003) Practice guidelines for direct attention training. Journal of Medical Speech-Language Pathology 11(3):xix-xxxix

• Rohling et al (2009) Effectivenenss of cognitive rehabilitation following acquired brain injury: A meta-analytic re-examination of Cicerone et al’s (200, 2005) systematic reviews. Neuropsychology 23(1):20-39

• Cappa (2009) A summary of evidence.: The European guidelines for cognitive rehabilitation . Brain Injury Professional, (The official publication of the North American Brain Injury Society), 6(2):8-9

• Sohlberg & Kennedy (2009) Evidence base practice: Reminders and updates for clinicians who treat cognitive communication disorders after brain injury Brain Injury Professional, (The official publication of the North American Brain Injury Society), 6(2):10-14

• Kennedy et al (2008) Intervention for executive functions after traumatic brain injury: A systematic review, meta-analysis and clinical recommendations. Neuropsychological Rehabilitation iFirst, 1-43

 

Additional Papers of special interest – referenced in this document

• Kennedy and Turkstra (2006) Group intervention studies in cognitive rehabilitation of individuals with traumatic brain injury: Challenges faced by researchers Neuropsychol Rev 16:151-9

• Playford (2009) Developing and understanding an evidence base in rehabilitation. Brain Injury Professional, (The official publication of the North American Brain Injury Society), 6(2):16-18

• Cicerone (2009) Interview. Brain Injury Professional, (The official publication of the North American Brain Injury Society), 6(2):30

 

Additional Papers of special interest – not referenced in this document

• Abreu & Toglia (1987) Cognitive rehabilitation: a model for occupational therapy. The American Journal of Occupational Therapy 41(7):439-448

• Harley et al (1992) Guidelines for cognitive rehabilitation. NeuroRehabilitation 2(3):62-67

• Fujii et al (2001) Efficacy of attention training performed in severe traumatic brain injury subjects. Paper presented at the 4th World Congress on brain injury, Turin, Italy May 5-9th

• Turkstra et al (2005) Practice guidelines for standardised assessment for persons with traumatic brain injury. Journal of Medical Speech Language Pathology 13(2):ix-xxxviii

• Turner-Stokes et al (2005) Multi-disciplinary rehabilitation for acquired brain injury in adults of working age (review) Cochrane database of systematic reviews. Issue 3

• Ylvisaker et al (2007) Behavioural interventions for children and adults with behaviour disorders after TBI: A systematic review of the evidence. Brain Injury 21(8):769-805

• Malia (2007) Brainwave-R audit completed in 2007 with 56 patients. www.braintreemanagement.co.uk/braintreetraining/bwr_audit.htm

• Vanderploeg et al (2008) Rehabilitation of traumatic brain injury in active duty military personnel and veterans: defense and veterans brain injury center randomised controlled trial of two rehabilitation approaches. Arch Phys Med Rehabil 89:2227-38

• Savage (2009) Editorial: Cognitive rehabilitation. Brain Injury Professional (The official publication of the North American Brain Injury Society), 6(2):4

• Malia (2009) Guest Editors Message. Brain Injury Professional, (The official publication of the North American Brain Injury Society), 6(2):6

• Academy of Neurologic Communication Disorders and Sciences. Practice Guidelines of the ANCDS. Evidence based practice guidelines for the management of communication disorders in neurologically impaired individuals. Project Introduction. www.ancds.org