July 15, 2008 Features

Traumatic Brain Injury and Cognitive Rehabilitation

Current Approaches to Research, Reimbursement, and Clinical Treatment

For the first time since World War II—and unfortunately for the same reason—people are becoming aware of traumatic brain injury (TBI) as a public health concern. Reporters are filing stories of injured veterans and their rehabilitation, politicians are discussing the need for TBI-related services, and software companies are aggressively marketing devices and programs to "build brain muscles" after injury. At the same time, basic research in neuroscience shows the brain's incredible plasticity and its potential to respond to treatment. In many ways, this should be the best of all times for individuals with TBI to receive state-of-the-art services.

Ironically, reimbursement for cognitive rehabilitation has never been more difficult to obtain. Reimbursement difficulties stem from the lack of providers and lack of provider training in best practices for rehabilitation. Although cognitive rehabilitation is covered by many state health plans, it often is denied by private insurers (see Brain Injury Association of America's cognitive rehabilitation position statement [PDF].) This difficulty is also due in part to the effect of sources such as the Cochrane Collaboration, an international group that typically considers only randomized controlled trials (RCTs) as valid evidence. The requirement for RCTs leads to the impression that good evidence is lacking for the efficacy of cognitive rehabilitation.

Many groups, such as the Brain Injury Association of America, ASHA, and the American Occupational Therapy Association, as well as state advocacy groups, are working to publicize evidence in support of cognitive rehabilitation. The TBI writing committee of the Academy of Neurologic Communication Disorders and Sciences has worked for more than seven years to review the literature and generate practice guidelines for the rehabilitation of cognitive-communication disorders in individuals of all ages with TBI (for a list of the committee's publications, go to the Academy of Neurologic Communication Disorders and Sciences Web site). The case of a client, J.B., illustrates how the guidelines might be applied.

Case Illustration

J.B., a 38-year-old male, had a high school diploma and an associate of arts degree in social sciences from a community college. He presented with moderate cognitive impairments at one month post-TBI sustained in an auto accident. He was discharged from sub-acute rehabilitation with a referral to outpatient treatment.

Considered within the framework of the International Classification of Functioning, Disability, and Health, J.B.'s major impairments were in working memory, declarative learning, and executive function (including emerging awareness of deficits and insufficient control of both behavior and attention to meet the demands of his prior workplace). Positive environmental factors included an employer willing to give J.B. a try at his old job, as long as the employer didn't have to create necessary modifications herself, and three hours per day of job coaching through the Department of Vocational Services. Positive personal factors included his motivation to return to work, outgoing personality, interest in social interactions, and physical mobility.

J.B. worked as the assistant manager of a dairy department in a grocery store. His responsibilities included checking and stocking shelves, creating a list of orders each day, monitoring expiration dates on products, and interacting with customers to find specific items.

His first day back at work was a disaster. He lost track of his place when stocking shelves, having been distracted by the background noise of customers moving about and talking. Customers complained that he started odd and intrusive conversations, and they had difficulty breaking away to continue shopping. He couldn't remember the locations of all of the products, which change periodically as new products are introduced, and couldn't help a customer find goat cheese; he then became frustrated and lost his temper. His boss was shocked at his difficulty at work, as the accident did not change J.B.'s appearance and he had no medical or physical needs. The job coach completed a detailed work assessment and asked for help in coming up with strategies for J.B. to be successful in this position.


What types of intervention does the evidence support in this case? The following are a few ideas.

Direct Attention Training

J.B. needs to improve his ability to focus on the stocking task and resist distractions. The existing evidence supports direct training on the task itself, with a hierarchical progression of increasing attention demands from simple to complex distracters (M. Sohlberg et al., 2003). There is little evidence that attention training generalizes to novel tasks, so J.B. must be trained on the task he will perform at work.

External Memory Aids

There is no direct evidence to support memory "retraining exercises," or the use of internal memory strategies like mnemonics, for individuals like J.B., so these are not recommended.

J.B. could benefit from the use of an external memory aid such as a map of product locations in the dairy department, perhaps as part of a notebook or portable digital assistant that also allows him to jot down the names of products that need restocking. The existing evidence supports the use of both high- and low-technology aids to support memory in individuals with declarative learning impairments, and also in individuals with problems in executive memory (i.e., the ability to use strategies to search memory) (Sohlberg et al., 2007). These aids must be ecologically relevant and acceptable to the individual.

Behavior Management

There are two contexts in which J.B. might need strategies to support positive interactions: when he becomes angry and loses his temper, and in conversation with customers. The existing evidence suggests that both could be addressed with either antecedent behavior management strategies, such as creating verbal scripts and routines (e.g., an "escape" routine when he is losing his temper, greeting routines for customers), or consequence-oriented management such as reinforcement of either positive behaviors or low rates of negative behaviors (Ylvisaker, Turkstra, & Coelho, 2005). Both have supporting evidence, but there is a trend toward increasing use of antecedent-based management in TBI; individuals with TBI often have impaired reasoning, declarative learning, and behavioral control, so punishment might lead to frustration and failure without improving behavior. Antecedent-based management has been critiqued because it entails providing supports that might not be present in all contexts. It is important, therefore, that supports be systematically withdrawn over time to foster independence in diverse contexts (Ylvisaker, Turkstra, & Coelho, 2005).

Learning New Skills

J.B. will require training to use his new memory aid, behavioral routines, and scripts. The research evidence suggests that individuals like J.B. with declarative learning impairments learn best when training capitalizes on intact procedural memory skills (Ehlhardt et al., 2008). Declarative learning may be achieved in a single trial, includes learning from errors, may be consciously directed and generalized, and is enhanced by strategies such as elaboration and semantic association. By contrast, procedural learning requires multiple repetitions, is probabilistic (i.e., retention is a function of repetition of the correct response), and is dependent on surface features of the learning context rather than semantic associations.

Learning of simple procedural tasks also is more effective if training trials are spaced out over time, rather than massed in a single session. For J.B., these factors might mean training him to use one external aid that he has with him at all times, so it "generalizes" across contexts, and doing this by asking him questions that will prompt access of the aid multiple times at increasing time intervals.

Awareness and Metacognitive Skills

J.B. realized that his first day back at work was a disaster. Individuals with cognitive impairments similar to J.B.'s may realize in retrospect what went wrong, but have trouble figuring out why or what to do so it won't happen again. There is solid evidence that incorporating metacognitive strategies when teaching highly complex activities—such as keeping track of dairy products on the shelves and stocking new items in the appropriate place—effectively capitalizes on J.B.'s preserved ability to learn procedures (Kennedy et al., 2008). Several RCTs, group, and single-subject designs demonstrate the effectiveness of breaking complex tasks into smaller steps and directly teaching individuals using step-by-step procedures. Steps that include self-checking or self-questioning enhance the likelihood that usefulness of the process will be maintained (Kennedy et al., 2008).

Because his TBI is so recent, it is not surprising that J.B. is less aware of his disability than those who have lived with TBI for years. However, early intervention that is practical and instantiated in his job—using tools to help compensate for the loss of executive functions—will help J.B. better understand his limits and abilities.

Who Delivers the Services?

Cognitive rehabilitation for individuals with TBI is a collaborative effort that engages many professionals and disciplines. The primary providers of cognitive rehabilitation are speech-language pathologists and occupational therapists. Neuropsychologists make a critical contribution in assessment and treatment planning, as described in documents generated by the Joint Committee on Interprofessional Collaboration of ASHA and Division 40 (neuropsychology) of the American Psychological Association.

Vocational rehabilitation providers also play an important role, although access to services may be limited in some parts of the country. Social workers and case managers facilitate access to services and community supports for individuals with TBI and their families. In school settings, cognitive rehabilitation may also involve teachers and other administrative personnel, particularly in training procedural strategies and for management of behavior. It is easy to see why this process can be overwhelming for individuals with TBI and other stakeholders. As one client said, "I'm supposed to be the CEO but I have no 'E'!"

Since 2004, ASHA has been working to combat insurance companies' denial of cognitive rehabilitation services provided by SLPs. When BlueCross and BlueShield Association (BCBSA, an association for 41 independently owned Blues plans) declared that cognitive rehabilitation was "investigational" and therefore not reimbursable, ASHA expressed its objections and provided research to BCBSA; in addition, ASHA solicited patients whose claims had been denied to collaborate in challenging the denials through the state insurance independent review organization process. As a result, an independent review in Montana overturned the denial of claims by a 38-year-old TBI survivor, setting a precedent for reimbursing such claims. ASHA also held a press conference at the National Press Club in 2007 featuring TBI survivors and SLPs to call attention to a national survey showing that reimbursement issues limit access to rehabilitation. 

For more information about reimbursement for TBI, contact Janet McCarty at jmccarty@asha.org

Lyn S. Turkstra, is associate professor in the Department of Communicative Disorders at the University of Wisconsin at Madison. Contact her at lsturkstra@wisc.edu.

Mary R. T. Kennedy, is associate professor in the Department of Speech-Language-Hearing Sciences at University of Minnesota-Minneapolis. Contact her at kenne047@umn.edu.

cite as: Turkstra, L. S.  & Kennedy, M. R. (2008, July 15). Traumatic Brain Injury and Cognitive Rehabilitation : Current Approaches to Research, Reimbursement, and Clinical Treatment. The ASHA Leader.

Beyond RCTs: Other "Precious Metals"

Randomized controlled trials (RCTs) are the accepted "gold-standard" design for investigating the effects of intervention. However, other experimental designs are typically included in schemes that classify intervention studies (e.g., AAN, 2004). There are several problems with assuming that RCTs should always be considered "gold," and why other designs such as group cohort and single-subject multiple baseline designs—considered "silver" and "bronze—provide substantial evidence of treatment efficacy and effectiveness. RCTs reduce variation in both the population sample and the intervention methodology. Group studies often have exclusion and inclusion criteria that yield a relatively homogeneous sample, and yield only average values for the group. Individuals with TBI are a heterogeneous group, with comorbid conditions that might exclude them from group studies. The results of group studies might not apply to individual clients (Kennedy & Turkstra, 2006; Montgomery & Turkstra, 2003). Thus, silver and bronze designs can greatly contribute to the research evidence and, in particular, provide clinicians with evidence specified to a particular client for a particular kind of intervention.


American Academy of Neurology (2004). Clinical Practice Guideline Process Manual. Prepared for the Quality Standards Subcommittee and the Therapeutics and Technology Assessment Subcommittee, by Edlund, W., Gonseth, G., So, Y., and Franklin, G., (retrieved on June 18, 2006 from www.aan.org).

American Speech-Language-Hearing Association. (1995). Guidelines for the Structure and Function of an Interdisciplinary Team for Persons With Brain Injury. Asha, 37(Suppl. 14, pp. 23).

Ehlhardt, L. A., Sohlberg, M. M., Kennedy, M. R. T., Coelho, C., Ylvisaker, M., Turkstra, L. S., et al. (2008). Evidence-based Practice Guidelines for Instructing Individuals with Acquired Memory Impairments: What Have We Learned in the Past 20 Years? NeuroRehabilitation, In press.

Kennedy, M. R. T., Coelho, C., Turkstra, L., Ylvisaker, M., Sohlberg, M. M., Yorkston, K., Chiou, H. H. & Kan, P. F. (2008). Intervention for executive functions after traumatic brain injury: A systematic review, meta-analysis and clinical recommendations. Neuropsychological Rehabilitation, DOI:10.1080/09602010701748644.

Kennedy, M. R. T., & Turkstra, L. (2006). Group intervention studies in the cognitive rehabilitation of individuals with traumatic brain injury: Challenges faced by researchers. Neuropsychology Review, 16, 151-159.

McCarty, J. (2006, July 11). Cognitive rehabilitation denial overturned. The ASHA Leader, 11(9), 1, 22.

McCarty, J. (2005, March 1). Blues' plans deny coverage for cognitive rehabilitation services. The ASHA Leader, pp. 1, 13.

Montgomery, E., & Turkstra, L. (2003). Evidence-based medicine: Let's be reasonable. Journal of Medical Speech Language Pathology, 11(2).

Shafer, D. N. (2007, Aug. 14). "Hidden disability" of TBI goes public. The ASHA Leader, 12(10), 3, 9.

Sohlberg, M., Avery, J., Kennedy, M. R. T., Coelho, C., Ylvisaker, M., Turkstra, L., et al. (2003). Practice guidelines for direct attention training. Journal of Medical Speech-Language Pathology, 11(3), xix-xxxix.

Sohlberg, M. M., Kennedy, M., Avery, J., Coelho, C., Turkstra, L. S., Ylvisaker, M., et al. (2007). Evidence-based practice for the use of external memory aids as a memory compensation technique. Journal of Medical Speech Language Pathology, 15(1), xv-li.

Wertheimer, J. C,, Roebuck-Spencer, T. M., Constantinidou, F., Turkstra, L. S., Pavol, M. and Paul, D. (2008). Collaboration between Neuropsychologists and Speech-Language Pathologists in Rehabilitation Settings. Journal of Head Trauma Rehabilitation (In press).

Ylvisaker, M., Hanks, R., & Johnson-Green, D. (2003). Rehabilitation of Children and Adults With Cognitive-Communication Disorders After Brain Injury. Asha Supplement, 23, 59–72.

Ylvisaker, M., Turkstra, L. S., & Coelho, C. (2005). Behavioral and social interventions for individuals with traumatic brain injury: a summary of the research with clinical implications. Seminars in Speech and Lang., 26(4), 256-267.


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