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MOUNT SINAI JOURNAL OF MEDICINE 76:173 –181, 2009 173
Cognitive Rehabilitation Following
Traumatic Brain Injury:
Assessment to Treatment
Theodore Tsaousides, PhD, and Wayne A. Gordon, PhD
Department of Rehabilitation Medicine, Mount Sinai School of Medicine, New York, NY
ABSTRACT
Cognitive rehabilitation refers to a set of inter-
ventions that aim to improve a person’s ability
to perform cognitive tasks by retraining previously
learned skills and teaching compensatory strate-
gies. Cognitive rehabilitation begins with a thor-
ough neuropsychological assessment to identify cog-
nitive strengths and weaknesses and the degree
of change in cognitive ability following a brain
injury. The conclusions of the assessment are used
to formulate appropriate treatment plans. Common
interventions for improvements in attention, mem-
ory, and executive function, as well as the nature
of comprehensive programs, which combine treat-
ment modalities, are reviewed. Cognitive rehabil-
itation is effective for mild-to-severe injuries and
beneficial at any time post-injury. Sufficient evi-
dence exists supporting the efficacy and effective-
ness of cognitive rehabilitation, which has become
the treatment of choice for cognitive impairments
and leads to improvements in cognitive and psy-
chosocial functioning. Mt Sinai J Med 76:173–181,
2009. 2009 Mount Sinai School of Medicine
Key Words: attention, cognitive deficits, cognitive
rehabilitation, comprehensive day treatment, execu-
tive function, memory, traumatic brain injury.
Traumatic brain injury (TBI) often results in physical,
cognitive, and emotional impairments that interfere
Address Correspondence to:
Theodore Tsaousides
Department of
Rehabilitation Medicine
Mount Sinai School of Medicine
New York, NY
Email: theodore.tsaousides@
mssm.edu
with independent living and disrupt psychosocial
and vocational functioning.1The consequences of
TBI are debilitating and persistent, especially when
they remain untreated. The aim of rehabilitation fol-
lowing TBI is to improve physical, cognitive, and
psychosocial functioning, to foster independence,
and to facilitate community integration.2Cognitive
rehabilitation is often the treatment of choice for these
diverse impairments. Although cognitive rehabilita-
tion targets cognitive and psychosocial functioning
more directly, improvements in cognitive functioning
could lead to improvements in physical functioning
indirectly. For example, improvements in memory
may facilitate medication compliance, improvements
in attention and comprehension may improve under-
standing of instructions given by medical personnel,
and improvements in executive function may facil-
itate initiating medical appointments or improve
decision-making with respect to treatment options.
The American Congress of Rehabilitation
Medicine has defined cognitive rehabilitation as ‘‘a
systematic, functionally oriented service of therapeu-
tic activities that is based on assessment and under-
standing of the patient’s brain-behavioral deficits’’
(Cicerone et al.,3p 1597). Thus, as in all med-
ical or psychological interventions, diagnosis and
treatment are tied together. The goal of cognitive
rehabilitation is to improve the person’s ability to
perform cognitive tasks, cope with affective distress,
and increase self-confidence, self-efficacy, and self-
awareness. This is achieved by retraining previously
learned skills and residual abilities, teaching the per-
son compensatory strategies, making environmental
modifications to the person’s domestic and vocational
setting, and facilitating adjustment to the cognitive
disability by increasing awareness and acceptance.
These approaches are often combined to optimize
the effects of treatment.3
Published online in Wiley InterScience (www.interscience.wiley.com).
DOI:10.1002/msj.20099
2009 Mount Sinai School of Medicine
174 T. TSAOUSIDES AND W. A. GORDON:COGNITIVE REHABILITATION FOLLOWING TRAUMATIC BRAIN INJURY
METHODOLOGY
The purpose of this article is 2-fold: to examine
the available literature that supports cognitive reha-
bilitation as an efficacious and effective treatment
following TBI and to provide an overview of com-
monly used cognitive rehabilitation interventions.
The review of the evidence for cognitive rehabili-
tation is based on 3 systematic reviews that were
conducted by a subcommittee of the Brain Injury
Interdisciplinary Special Interest Group of the Ameri-
can Congress of Rehabilitation Medicine and 1 review
that was commissioned by the National Institute
on Disability and Rehabilitation Research. The goal
of these reviews was to examine the state of the
evidence for cognitive rehabilitation interventions fol-
lowing TBI and stroke, and they have resulted in
3 seminal publications to date.3–5 The methodology
used in these publications, including the search terms
used to identify publications, the number of articles
identified and retained, and the level of evidence
classification, is described in a subsequent section.
To accomplish the second goal, to provide
an overview of common cognitive rehabilitation
interventions, among the studies included in the
published reviews,3–5 those that focused on TBI
were located and reviewed. The description of the
cognitive rehabilitation interventions that follows is
thus based on class I and class II studies with TBI
samples.
ROLE OF ASSESSMENT PRIOR TO
COGNITIVE REHABILITATION
Neuropsychological assessment is the initial part of
cognitive rehabilitation and serves several purposes.
It identifies areas of cognitive function in need of
treatment as the data that result from the assessment
are used to make inferences about the nature
and extent of the person’s cognitive dysfunction.
Awareness of the person’s cognitive strengths and
weakness provides a means of targeting the cognitive
domains that will require remediation and capitalizing
on the person’s residual cognitive abilities to
facilitate treatment. In addition, neuropsychological
assessment provides a means for evaluating the
effectiveness of treatment.6
Neuropsychological assessment examines sev-
eral domains of cognitive function. The individual
measures included in a neuropsychological battery
are determined on a case-by-case basis according
to the patient’s self-report of his day-to-day cog-
nitive failures and clinical observation. The most
common domains of cognitive functioning that are
assessed post-TBI include intellectual function, mem-
ory function, psychomotor speed, processing speed,
attention, language, and executive function.
General Intellectual Functioning
Neuropsychological assessment involves an evalu-
ation of the individual’s general intellectual func-
tioning. Tests of intellectual function examine the
performance of diverse mental functions, including
attention, processing speed, visual-spatial perception
and construction, concept formation and abstrac-
tion, judgment, verbal comprehension, and fund of
knowledge. Assessing general intellectual function-
ing post-TBI provides the clinician with a means
of determining the affected individual’s cognitive
reserve (preserved premorbid abilities and residual
cognitive strengths), areas of cognitive function that
need further assessment, and cognitive deficits that
may interfere with the treatment, the extent of change
in cognitive function with respect to estimates of
premorbid function, and functional ability in real-
life settings. The Wechsler scales [Wechsler Adult
Intelligence Scale III (WAIS-III), Wechsler Abbrevi-
ated Scale of Intelligence, and Wechsler Intelligence
Scale for Children IV] are commonly used to assess
intellectual ability following TBI.
Memory and Learning
Memory is one of the more vital cognitive functions.
Memory deficits lead to dependency, isolation, and
interruption of a sense of personal continuity.6Mem-
ory impairments affect the individual’s ability to learn
and retain new information. Memory impairments
post-TBI often interfere with cognitive rehabilitation
as they affect attendance and compliance. Assessment
of memory facilitates the identification of impairments
in particular memory systems (eg, explicit/implicit
and verbal/visual) and in the specific memory pro-
cess that has been affected (eg, encoding, storage, or
retrieval). A variety of measures are used to assess
verbal memory (eg, California Verbal Learning Test,
Hopkins Verbal Learning Test, and Rey Auditory Ver-
bal Learning Test) and visual memory (Benton Visual
Retention Test and Rey-Osterrieth Complex Figure
Test). In addition, there are comprehensive memory
batteries, such as the Wechsler Memory Scale, that
comprehensively examine aspects of auditory and
visual declarative and working memory.7
Psychomotor Function
Manual dexterity is used to examine changes in
the differential superiority of the dominant hand
DOI:10.1002/MSJ
MOUNT SINAI JOURNAL OF MEDICINE 175
versus the nondominant hand as a means of
providing a quick assessment of the diffuseness of
the brain injury. Measures such as finger tapping and
grip strength provide additional useful information.7
A handful of measures of motor function that
are commonly included in a neuropsychological
assessment following TBI include the Finger Tapping
Test, Grooved Pegboard, and Purdue Pegboard.
Processing Speed
In addition to motor speed, the speed at which
information is processed is assessed post-TBI.
Following TBI, the rate of mental activity may
be slowed, and this reduction in speed manifests
itself as a delayed reaction time and/or increased
task completion time. Several commonly used
tests that measure processing speed are embedded
in comprehensive batteries, such as the WAIS-III
(Digit-Symbol Coding and Symbol Search subtests)
and the Woodcock-Johnson Test of Cognitive
Abilities (Decision Speed and Visual Match subtests).
Additionally, such measures as the Stroop Color Word
Test and the Trail Making Test are used to examine
processing speed.
Attention
Attention is a complex mental activity that refers
to how an individual receives and begins to
process internal and external stimuli.6Impairments
in attention following TBI may range from difficulty
remaining focused and ignoring distractions to
failure to complete tasks involving multiple steps
and learning new information. Several aspects
of attention are assessed after TBI, including
orientation, concentration, vigilance, distractibility,
working memory, and multitasking. Commonly used
measures of visual attention include the Conner’s
Continuous Performance Test and the Symbol Digit
Modalities Test. Measures of auditory attention
include the Paced Auditory Serial Attention Test
(PASAT) and subtests of the WAIS-III (Digit Span and
Letter-Number Sequencing), which assess auditory
attention.
Language
Verbal communication following TBI may be
impeded by deficits in receptive and expressive
language. Individuals with TBI may have difficulty
understanding conversation and instructions (oral
or written), responding to requests for information,
expressing their needs, and maintaining conversation.
Language measures include comprehensive batteries
(eg, the Multilingual Aphasia Examination and the
Boston Diagnostic Aphasia Examination) or individ-
ual tests of specific language functions, such as the
Boston Naming Test to assess visual naming abil-
ity, the Peabody Picture Vocabulary Test to assess
receptive vocabulary, and the Controlled Oral Word
Association Test to assess verbal fluency.
Executive Function
Executive function refers to the mental capacity to
‘‘engage successfully in independent, purposive, self-
serving behavior’’ (Lezak et al.,6p 31). Executive
function impairments post-TBI affect the individual’s
ability to initiate, plan, set goals, monitor perfor-
mance, anticipate consequences, and respond flexi-
bly and adaptively.7Frequently, executive dysfunc-
tion is the most disabling of all cognitive impairments
as difficulties in this domain are pervasive because
they can affect all aspects of the person’s ability to
function effectively in his personal or professional
life. There are several measures of executive func-
tion, including multitest batteries (eg, the Behavioral
Assessment of the Dysexecutive Syndrome and the
Delis-Kaplan Executive Function System) as well as
single-test measures (eg, the Category Test, the Stroop
Test, and the Wisconsin Card Sorting Test).
EVIDENCE FOR EFFECTIVENESS OF
COGNITIVE REHABILITATION
The toolkit of cognitive rehabilitation interventions
has grown rapidly in the last 3 decades. Several
interventions for individuals with TBI have been
developed to improve visual-perceptual skills, lan-
guage, attention, memory, and executive functioning.
As cognitive rehabilitation interventions began to
emerge and proliferate, the need for evidence sup-
porting their efficacy and effectiveness grew as well.
A subcommittee of the Brain Injury Interdisciplinary
Special Interest Group of the American Congress
of Rehabilitation Medicine conducted 2 systematic
reviews of the existing literature on cognitive reha-
bilitation interventions for TBI and stroke in order
to assess the status of the evidence and to pro-
vide recommendations for clinical practice.3,4 An
extensive search using several keywords, includ-
ing attention, awareness, cognition, communication,
executive, language, memory, perception, problem
solving, reasoning, rehabilitation, remediation, and
training, was conducted. The studies that were
identified were subsequently classified by the cogni-
tive skill that was targeted for treatment: attention,
DOI:10.1002/MSJ
176 T. TSAOUSIDES AND W. A. GORDON:COGNITIVE REHABILITATION FOLLOWING TRAUMATIC BRAIN INJURY
visual perception, apraxia, language and communica-
tion, memory, executive functioning, problem solving
and awareness, and comprehensive-holistic cognitive
rehabilitation. The first review included 171 interven-
tion studies published between 1971 and 1997.3Of
these, 29 were rated as class I (prospective, ran-
domized or quasi-randomized controlled studies), 35
were rated as class II (prospective, nonrandomized
cohort or retrospective, nonrandomized case-control
or clinical series with controls), and 107 were rated
as class III (clinical series without controls or single-
case designs). The second review included 87 studies
published between 1998 and 2002; 17 were rated as
class I, 8 were rated as class II, and 62 were rated as
class III.4The same special interest group is currently
reviewing cognitive rehabilitation studies published
between 2003 and 2007.
The conclusions drawn from the 2 reviews sup-
ported the effectiveness of cognitive rehabilitation
interventions. The authors reported that the cognitive
rehabilitation interventions that they reviewed were
more effective than traditional types of treatment.3,4
Cicerone et al.3,4 used these reviews to develop
evidence-based practice standards, guidelines, and
options for practitioners working with individuals
with TBI in the domains of attention, memory, and
executive function. Practice standards were based on
solid evidence from class I or class II studies and
affirmed the efficacy of cognitive rehabilitation inter-
ventions in the form of strategy training to improve
attention and memory and interventions to improve
functional communication and conversational skills.
Practice guidelines were based on class II evidence
and included recommendations for attention train-
ing (varying modalities, levels of complexity, and
response demands), methods to improve reading
comprehension and language formation, training in
problem-solving strategies, and participation in com-
prehensive neuropsychological rehabilitation. Finally,
practice options were based on class II and class III
evidence and included the use of memory notebooks
or other external aids to address memory impairments
and the use of methods of self-instruction, self-
questioning, and self-monitoring to improve exec-
utive function. In addition, Cicerone et al.4argued
that the next step for cognitive rehabilitation research
is to investigate the relationship between treatment
outcome and patient characteristics.
COGNITIVE REHABILITATION
INTERVENTIONS AFTER TRAUMATIC
BRAIN INJURY
Cognitive rehabilitation interventions are applicable
at all stages of postinjury recovery (acute, subacute,
and postacute) and in different settings (eg, inpatient,
outpatient, and domestic environments). In addition,
they can be administered in different modalities (eg,
individual, family, and group) and by profession-
als in different disciplines (eg, neuropsychologists,
occupational therapists, and speech-language pathol-
ogists) with proper training and supervision. The
following sections include an overview of selective
evidence-based cognitive rehabilitation interventions
that address impairments in attention, memory, and
executive functions following TBI.
Cognitive Rehabilitation for Attention
Interventions for attention deficits range from
simple tasks such as using flashcards to improve
basic attention skills8to more complex tasks to
improve complex attention and working memory
using a variety of visual and verbal tasks.9–11
Sohlberg and Mateer12 developed a training program
to improve visual and auditory attention. The
Attention Process Training (APT) program (APT-
I and APT-II) is a theory-based intervention that
hierarchically organizes attention into 5 components:
focused attention, sustained attention, selective
attention, alternating attention, and divided attention.
The training program consists of various tasks
organized by increasing difficulty. Competence is
achieved through repetition at a certain skill level
and progression to a higher skill level when
the easier task is mastered. In addition, the
developers have incorporated generalization tasks
within the intervention to increase generalizability.
Treatment is provided through a combination
of individual and group treatments by trained
clinicians. There is ample evidence supporting the
effectiveness of APT.13 – 15 The ease of implementing
the treatment notwithstanding, clinical skill is a
necessary component of any intervention. The role
of the clinician is indispensable, and the APT is a
good tool only insofar as it is applied by therapists
with a good understanding of the training program
as well as the deficits of the person being treated.
Other interventions for attention have included
using the PASAT or variations of the PASAT such
as the n-back procedure. PASAT-type tasks require
listening to a sequence of stimuli and responding
according to a rule. For example, in the original
DOI:10.1002/MSJ
MOUNT SINAI JOURNAL OF MEDICINE 177
PASAT, respondents are required to listen to a
sequence of numbers and utter aloud the sum of
each number when it is added to the number
that immediately preceded it. Evidence suggests that
use of these interventions leads to improvements
in measures of working memory and self-report of
attention difficulties.9,11
Cognitive Rehabilitation for Memory
Interventions for improving memory are an essen-
tial component of cognitive rehabilitation. Several
interventions focus on improving different aspects of
memory, such as face-name associations, memory
for past events, prospective memory, and learn-
ing new information. Memory interventions have
included restorative approaches, such as word-list
learning, paragraph listening, visual imagery, and
use of mnemonic strategies,16,17 as well as com-
pensatory approaches, such as the use of memory
notebooks and other methods of recording and track-
ing information and the use of assistive technology
tools, including personal computers, portable elec-
tronic devices, voice recorders, and pagers, which
have been found to be instrumental in enhancing
prospective memory (ie, the ability to remember to
carry out a certain action at a specified time in the
future or in response to a specific future event).18 – 21
One of the most effective interventions for the
rehabilitation of memory impairments post-TBI is the
memory notebook. The use of a memory notebook
has been supported empirically.22,23 Sohlberg and
Mateer16 presented a systematic method for using a
memory notebook to facilitate learning. A memory
notebook usually includes sections for orientation
(autobiographical and/of injury-related information),
a memory log, a calendar, to-do lists, transportation
(eg, maps, public transportation schedules, and taxi
phone numbers), a feelings log (a section to record
emotions occurring in certain situations), names
(names and other identifying information about other
individuals), and any other section that may be
personally relevant. There are 3 phases to learning
how to use a memory book: acquisition, application,
and adaptation. During the acquisition phase, the
individual with TBI becomes familiar with the
different sections and the purpose of the notebook.
During the application phase, the individual learns
to use the memory notebook in simulated settings.
Finally, during the adaptation phase, the person
learns to extend the use of the memory notebook
to naturalistic environments, such as household
or vocational settings. There are several factors
that interfere with the successful use of memory
notebooks and other external memory aids. They
include client characteristics (eg, a lack of awareness
of the need for the memory notebook and an
unwillingness to draw attention to oneself), features
of the memory notebook per se (eg, too simple or too
complicated), environmental factors (eg, a low level
of demand, especially if the patient is home-bound),
and clinician variables (eg, training approach and
identification of client-relevant sections).24
Cognitive Rehabilitation for
Executive Functioning
Interventions to improve executive functioning fol-
lowing TBI have targeted problem solving,25 – 28
planning and organization,29,30 goal-directed be-
havior,31,32 and self-monitoring and self-regu-
lation.25,33,34 In a meta-analysis of intervention studies
for executive functioning post-TBI, Kennedy et al.35
reported favorable findings in terms of improve-
ments in problem solving, planning, organization,
and multitasking. Improvements extended to per-
sonally relevant functional activities, and treatment
effects were maintained and generalized. The authors
concluded that interventions using metacognitive
strategies appeared to be the most efficacious and
effective. Metacognitive strategy instruction was the
type of intervention used across several studies that
were reviewed, including randomized clinical tri-
als and single-case studies. Metacognitive strategy
instruction includes using and internalizing step-
by-step procedures intended to enhance problem
solving, planning, organization, and multitasking by
increasing the capacity for self-regulation.35 Metacog-
nitive strategies aim at improving self-regulation by
increasing self-awareness, which promotes the for-
mation of personally relevant goals, self-monitoring,
which enables individuals to assess their performance
and reduce or prevent errors, and self-control, which
facilitates initiation and behavioral change.35 Inter-
ventions for executive functioning are administered
individually, in groups, or with a combination of
individual and group treatments.
Comprehensive-Holistic Day Treatment
Programs
Comprehensive-holistic day treatment programs
(CHPs) offer a combination of therapeutic services
and are a popular treatment option for individ-
uals with TBI. A typical CHP includes individual
and group cognitive rehabilitation, psychotherapy,
psycho-education, and family therapy. Interventions
are focused on specific cognitive domains, and group
interventions are used to focus on executive dys-
function and to promote generalization of learning.
DOI:10.1002/MSJ
178 T. TSAOUSIDES AND W. A. GORDON:COGNITIVE REHABILITATION FOLLOWING TRAUMATIC BRAIN INJURY
Within such programs, treatment goals are articu-
lated clearly, and progress is monitored regularly.
The goals of treatment include improving cogni-
tive function, increasing awareness, and addressing
interpersonal, social, and emotional concerns. Treat-
ment is usually administered by a transdisciplinary
team, it incorporates community activities and voca-
tional trials, and involvement of significant others
is highly encouraged.36 The evidence supports the
effectiveness of CHPs, which in addition to result-
ing in improvements in cognitive functioning appear
to facilitate skill transfer and generalization and to
increase self-awareness, behavioral and affective reg-
ulation, psychosocial functioning, and community
integration.3,4 Comprehensive-holistic approaches to
treatment have thus become the standard of care in
rehabilitation following TBI.37
Two randomized clinical trials are currently in
progress at the Mount Sinai School of Medicine to
examine the efficacy of a CHP consisting of individual
and group interventions for executive dysfunction.25
The intervention is based on a metacognitive
strategy intended to improve problem-solving and
self-regulation abilities. The intervention entails the
following:
•Individual training to improve diverse aspects
of attention (selective, sustained, alternating, and
divided).
•Group and individual instruction in a step-by-
step problem-solving procedure that facilitates
identification of problems, awareness of various
aspects of problems, generation of alternatives,
initiation of action, and self-monitoring.
•Group and individual training in strategies to
improve emotional regulation. Individualized goal
setting, repetition, and feedback are used exten-
sively in order to enhance maintenance of the
self-instructional abilities and to achieve general-
ization of the use of the metacognitive strategies to
a variety of real-life settings.
Individuals receive the experimental CHP treatment,
a standard-of-care CHP treatment, or no treatment
(wait-list control group). The efficacy of the exper-
imental intervention will be based on differences
in performance on standardized neuropsychologi-
cal tests and psychosocial measures. It is expected
that individuals with TBI receiving the experimen-
tal intervention will exhibit superior performance
on neuropsychological measures and improved psy-
chosocial outcome in comparison with the wait-
list control group or the standard-of-care treatment
group.
Use of Technology in
Cognitive Rehabilitation
The use of technology in neuropsychological rehabil-
itation ranges from using computers as passive tools
to project visual and verbal stimuli during cognitive
training to using technological aids actively and in
naturalistic settings as compensatory tools or cogni-
tive orthotics.38 Computer use in cognitive rehabilita-
tion extends to memory training,39 – 41 attention,39,42
problem solving,39 and job simulation.43 Technologi-
cal aids are frequently used in cognitive rehabilitation
to improve performance on cognitive tasks. For
example, a recent randomized control trial showed
that use of a pager has been found to enhance
prospective memory, which refers to the ability to
remember to perform an activity in the future.19
In an extensive review of existing technological
aids, LoPresti et al.38 classified aids into technolo-
gies for memory and executive function impairments
and technologies for information processing impair-
ments. Devices for memory and executive function
compensation include digital watches, alarms, voice
organizers, mobile phone-computer interactive sys-
tems, and handheld devices, such as personal digital
assistants. Devices for information processing impair-
ments include a keyboard for typing instead of writ-
ing, software that alters the features of text (eg, size
and color) on a computer screen to facilitate reading,
and speech output/speech recognition software.
Although the use of technology in TBI rehabili-
tation permits the administration of tasks that would
be otherwise difficult to administer (eg, tracking reac-
tion time in milliseconds or using a pager to cue
oneself), these aids are intended not to replace a
therapist but to augment the therapeutic experience.
Indeed, research has failed to show an advantage
of computer-assisted interventions over traditional
interventions,39,42 once again reminding us that the
clinician is an active ingredient in the treatment. The
role of the therapist in cognitive rehabilitation is ‘‘to
set and maintain the structure, determine treatment
needs and readiness, provide feedback and guidance,
teach and reinforce the use of tools, and process emo-
tional reactions,’’44 which to date no technological aid
can accomplish successfully.
ROLE OF TIME SINCE INJURY IN
COGNITIVE REHABILITATION
There is no empirical evidence supporting the idea
that there is a critical period during which cognitive
rehabilitation is more effective.45 Research on the
role of time since injury in treatment is divided,
DOI:10.1002/MSJ
MOUNT SINAI JOURNAL OF MEDICINE 179
Table 1. Key Concepts in Cognitive Rehabilitation Following Traumatic Brain Injury.
Cognitive rehabilitation is a treatment for cognitive impairments related to traumatic brain injury that is strongly
supported by well-designed research.
A neuropsychological assessment is required in order to assess cognitive function and develop an appropriate
treatment plan.
Cognitive rehabilitation consists of diverse interventions that must be tailored to the individual patient.
Cognitive rehabilitation can be effective regardless of the length of time since the injury and the injury severity level.
Cognitive rehabilitation leads to improvements in cognitive and psychosocial functioning.
with some studies showing no difference in terms
of the benefits of treatment in neuropsychological
measures and psychosocial and vocational outcomes
and other studies showing only a slight advantage
of early rehabilitation.44 Recent studies about brain
plasticity suggest that interventions delivered at later
stages post-injury may be more beneficial.46 The
lack of strong evidence about the optimal timing
of the intervention suggests that there is no critical
window for new learning. Learning can occur at any
point post-injury, and there are no time limits in
terms of the benefits that can accrue to the person
from cognitive rehabilitation. Making individuals with
TBI aware that treatment is beneficial at any time
post-injury is likely to instill hope and increase their
motivation and eventually lead to improvements in
cognitive, emotional, and psychosocial functioning.
ROLE OF INJURY SEVERITY IN
COGNITIVE REHABILITATION
Cognitive rehabilitation interventions are used in the
treatment of individuals with TBI whose severity of
injury ranges from mild to severe. Intervention studies
typically report the level of severity of the participants
using traditional measures of injury severity (eg, the
Glasgow Coma Scale or the duration of posttraumatic
amnesia). Little research, however, exists that directly
examines the role of injury severity in cognitive
rehabilitation.45 The literature generally suggests that
severity of injury per se may not be as instrumental
in designing and delivering a cognitive rehabilitation
intervention as is identifying particular cognitive
strengths and weaknesses and functional deficits
of the person.46 The target, intensity, and difficulty
level of the intervention are better determined by the
individual’s cognitive profile, functional ability, level
of self-awareness, and availability of environmental
supports than by severity of injury.
CONCLUSION
Cognitive rehabilitation interventions have prolifer-
ated in the last 30 years and have been implemented
widely in the treatment of the cognitive deficits
resulting from TBI (Table 1TBL 1). The toolkit
includes interventions that can be adapted to facili-
tate improvements in functioning at different levels of
severity, and that is not limited by the length of time
since injury. Evidence from class I and class II studies
has been amassed that supports the effectiveness of
these interventions not only in terms of improving
cognitive functioning but also in terms of improved
psychosocial functioning and vocational outcomes.
In order to render these interventions more suc-
cessful, ‘‘they must be embedded in an appropriate
context, be delivered systematically and creatively,
and be individualized to fit the unique cognitive and
psychotherapeutic needs of each individual’’ (Gor-
don and Hibbard,45 p 660). Further research is still
needed to identify the patient and treatment factors
that contribute to successful outcome, to explicate
the theoretical models underlying the interventions,
and to identify the extent of the clinical significance
of these interventions. Cognitive rehabilitation inter-
ventions are promising treatments that contribute to
the well-being and quality of life of individuals with
TBI.
ACKNOWLEDGMENT
The preparation of this article was supported
in part by grants from the US Department
of Education National Institute on Rehabilitation
Research (H133B040033 and H133A070033) and from
the Centers for Disease Control and Prevention
(1R49CE001171-01).
DISCLOSURES
Potential conflict of interest: Nothing to report.
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