EBP Compendium: Summary of Clinical Practice Guideline

Brain Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine
Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature from 1998 through 2002
Cicerone, K. D., Dahlberg, C., et al. (2005).
Archives of Physcial Medicine and Rehabilitation, 86(8), 1681–92.

AGREE Rating: Highly Recommended

Description:

This guideline provides recommendations for the cognitive rehabilitation of individuals with traumatic brain injury (TBI) or stroke. This is an update of a previous guideline published by Cicerone et al. in 2000. The target audience of this guideline is healthcare professionals involved in the management of individuals with acquired brain injury. Recommendations are provided and defined as Practice Standards, Practice Guidelines, or Practice Options based on the strength and the quality of the supporting evidence. A recommendation for a Practice Standard is based on at least one well-designed class I study with support from class II or class III evidence that directly addresses treatment effectiveness. A Practice Guideline recommendation is based on one or more class I studies with methodological limitations or well-designed class II studies that directly address treatment effectiveness. A recommendation for a Practice Option is based on class II or class III studies that directly address treatment effectiveness.

Recommendations:

• Treatment
  • Cognition (TBI Patients)
    • General Findings - “There is insufficient evidence to support the use of specific interventions for attention deficits during acute rehabilitation” (p. 1683). Further research is warranted to determine the differential effects on various components of attention and the effects of cognitive intervention combined with pharmacological treatment.
    • Compensatory Attention Treatments - Strategy training for attention deficits exhibited by subjects with TBI should be considered in post-acute rehabilitation (Practice Standard). 
    • Compensatory Memory Treatments
      • Srategy training for individuals with mild memory impairments is recommended and may include use of internal strategies or use of external memory notebooks.
      • Use of external assistive devices (e.g. pagers, voice organizers) appears to benefit individuals with moderate to severe memory impairments.
      • "[T]raining in the use of external compensations (including assistive technology) with direct application to functional activities" is recommended for individuals with moderate or severe memory impairment (Practice Guideline) (p. 1685). 
    • Computer-Assisted Training
      • The committee recommends that “computer-based interventions be considered as an adjunct to treatment when there is therapist involvement” (Practice Option) (p. 1684).
      • Repeated practice using computer-based interventions without therapist involvement is not recommended. 
    • Metacognitive Treatments
      • Treatments for executive functioning deficits that “promote internalization of self-regulation strategies through self-instruction and self-monitoring, should be considered" (Practice Option) (p. 1686).
      • Additionally, "[t]here is evidence that the incorporation of self-management techniques enhance the use, maintenance and perceived helpfulness of a memory notebook” (p. 1685). However, the authors conclude that “there is insufficient evidence to make specific recommendations regarding interventions to improve self-awareness after TBI or stroke” (p. 1686). 
    • Specific Skill/Functional Training
      • Interventions directed at the acquisition of specific skills "appear effective for increasing specific behaviors rather than improving memory function" (p. 1685).
      • "[T]raining in the use of external compensations (including assistive technology) with direct application to functional activities" is recommended for individuals with moderate or severe memory impairment (Practice Guideline) (p. 1685).
  • Cognition (Stroke Patients)
    • General Findings - Evidence from class I studies “provide additional support for the practice standard recommending cognitive linguistic therapies during acute and postacute rehabilitation” (Practice Standard) (p. 1684). 
    • Compensatory Memory Treatments
      • Evidence from class I studies supports the use of strategy training for individuals with mild memory impairments after TBI or stroke (p. 1685).
      • "[T]raining in the use of external compensations (including assistive technology) with direct application to functional activities" is recommended for individuals with moderate or severe memory impairment (Practice Guideline) (p. 1865).
    • Visual Neglect Treatment - Evidence from class I and class Ia studies demonstrate the “efficacy of visual scanning training for visual neglect” in subjects with stroke (Practice Standard) (p. 1683).
  • Speech (Stroke Patients)
    • Apraxia Treatment - Specific gestural or strategy training for apraxia after left hemisphere stroke is… recommended as a new practice standard during acute rehabilitation” (Practice Standard) (p. 1684).
  • Language
    • General Findings - The authors conclude that “interventions for specific language impairments, such as reading comprehension and language formulation, are effective after left hemisphere stroke or TBI” (p. 1684).
    • Computer-Based Treatment (Stroke Patients) - Computer-based interventions may be "considered as an adjunct to treatment when there is therapist involvement; sole reliance on repeated exposure and practice on computer-based tasks without some involvement and intervention by a therapist is not recommended” (Practice Option) (p. 1684).
• Service Delivery
• Dosage (Stroke Patients)
  • General Findings - Treatment intensity should be "considered as a key factor in the rehabilitation of language skills after left hemisphere stroke" (Practice Guideline) (p. 1684).
• Setting (TBI Patients)
  • General Findings - The implementation of comprehensive-holistic cognitive rehabilitation programs are recommended for treating individuals with moderate to severe TBI in the post acute phase (Practice Guideline).
• Format (Stroke Patients)
• Group-Based Treatment - “There is evidence that group communication treatment can produce clinically meaningful improvements in language function, including improved functional communication, beyond the effects of social contact alone” (p. 1684).

Keywords: Brain Injury; Stroke; Cognitive Rehabilitation

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Added to Compendium: November 2010