Statement - The Evidence for Cognitive Rehabilitation

Lynn Turkstra, PhD, CCC-SLP
Associate Professor, Department of Communicative Disorders, University of Wisconsin, Madison

Cognitive impairments are a common consequence of traumatic brain injury (TBI). These include impairments in memory and attention, as well as in "higher level" thinking such as integrating information and making inferences. As a result, many individuals with TBI struggle in school, at work, in social situations, and in the community. Cognitive impairments are a far greater influence on long-term outcome than the broken bones and other physical aspects of an injury, yet until the war in Iraq they rarely were discussed in public.

For many years, the conventional wisdom was that nothing could be done to reduce the long-term cognitive impairments of individuals with TBI. When an injury occurred in childhood, most people believed that a full recovery would occur-the child would "grow out of" the injury and go on to develop normal cognitive function. For adults, many believed that after six months there was no further hope of recovery. Each of these statements has proven to be untrue.

There is growing evidence that cognitive rehabilitation is effective for individuals with TBI; that is, it can make a meaningful difference in academic, employment, social, and community outcomes for children and adults with TBI. Several professional associations-including the Academy of Neurologic Communication Disorders-have examined the evidence for cognitive rehabilitation and generated evidence-based practice guidelines for clinicians. These reviews have provided strong support for many rehabilitation techniques, and also show us where further research is needed.

There are noteworthy themes in the evidence for cognitive rehabilitation. First, intervention must be delivered in high doses. A one-hour therapy session each week is much less likely to result in meaningful change than a comprehensive program that engages the individual for several hours.

Second, therapy must be tailored to the needs of the individual. There is no evidence that "cookbook"-type approaches are helpful when they do not focus on the person's strengths, limitations, and needs in everyday life.

Third, therapy must be delivered in the contexts in which the skills and strategies will be used. For many reasons, individuals with TBI often are unable to transfer learned skills from one context to another, so therapy must begin by using context.

Fourth, recovery is not over at six months post-injury. There is growing evidence from animal and human studies that intervention can be effective even many years later, particularly when therapy is delivered at high doses. The brain is plastic-that is, it is capable of change over time with the appropriate stimulation. Individuals with TBI differ in the time post-injury at which they are fully ready to engage in rehabilitation. Reimbursement, however, is likely to be exhausted within the first several weeks after injury.

As the evidence on cognitive rehabilitation grows, we appear to be faced with a paradox. We have learned that high-frequency, individually tailored intervention can be effective months or years after injury. We know that successful rehabilitation engages the client in personally meaningful activities that include key elements of the context in which skills will be used. We know that children do not recover completely from early brain damage, but might have progressive difficulties as higher-level cognitive skills are required. By contrast, current funding typically extends only weeks or at best a few months after injury. Frequency is dictated by administrative concerns rather than evidence. Intervention often takes place in contexts removed from those in which the individual functions in daily living. Budget cuts have virtually eliminated time for clinicians to work with significant others in that patient's life, or communicate effectively with other providers to ensure a continuum of care.

As clinicians and clinician-scientists, we aim for best practices in patient care. In order to meet the long-term needs of individuals with TBI, that means advocating for our patients and for system change, as well as for the dissemination of the most current practice information to the general public; individuals with TBI and the important people in their lives; and providers.