Proof of efficacy and universal standards for cognitive rehabilitation have been lacking in the cognitive rehabilitation literature. Effectiveness of Rehabilitation for Cognitive Deficits offers the new World Health Organization International Classification of Functioning (WHO ICF) model that defines several levels of rehabilitation including: improvement of neural functioning in the brain, reduction of cognitive impairment, such as visual neglect and attention deficits, and improvement in functionally important activities and social interactions. This book provides a comprehensive review of what works well, the clinical challenges, and projects the future of cognitive rehabilitation. The book is divided into seven sections, each further divided into several related chapters. The first section delves into the context in which rehabilitation takes place, both historically and theoretically. The second through fifth sections describe in detail the core processes that are targeted in cognitive rehabilitation: attention, memory, spoken language, and executive disorders. The sixth section investigates the evolving cognitive rehabilitation theories that have been propelled by “the decade of the brain” and new imaging capabilities. The final section describes outcomes in cognitive rehabilitation in persons with traumatic brain injury, stroke, and early stage dementia.
Section One focuses on the basis for cognitive rehabilitation. The authors provide a theoretical model developed by WHO that allows for careful, data-driven assessment of individuals and program evaluation. In Section Two, the authors describe types of attention deficits and attention interventions. The current practice of patient-specific hypothesis testing (PSHT) that combines research with a customized approach to treatment based on patient variables appears to be successful in the amelioration of attention deficits in brain injured adults. The authors also discuss key components to attention training remediation, such as rating scales that address functional attention and frequency of occurrence of attention breakdown; measurement of attention in every day tasks, such as driving; and, obtaining caregiver reports. Overall, these chapters appear quite relevant because they capture the nature of attention difficulties while describing methods for quantifying change based on treatment. Sections Three, Four and Five focus on rehabilitation of memory, spoken language, and executive functioning after attention has been treated and improved. The authors provide useful visual models that can be easily transformed into action plans that document weekly and long-term gains. Variables that are important for evaluation of such treatments include timing, functionality, and generalization. The authors describe the challenge in rehabilitation of cognitive functioning, of transforming changes from the clinic setting into higher levels of activity, participation, and maintenance. Unfortunately, it appears that memory remediation works best for those patients with mild impairments; there is no compelling evidence yet for effective improvement of profound memory impairment. Additionally, there is insufficient proof that medication improves executive functioning in brain injured adults. Although methylphenidate has been borrowed from the ADHD treatment regimen to improve dopaminergic/noradrenergic systems, research studies examining how this medication may improve executive functioning in adults with acquired brain injuries have not been conclusive. Similarly, more confirmatory findings are needed to prove the efficacy of the use of amantadine, bromocriptine and L-dopa for memory/behavior change.
In Section Seven, the authors look critically at measurement of patient change and program success. While meta-analyses are favored in this evaluation research, the authors caution that such analyses may lack methodological rigor, due to the likely collapsing of variables and omission of select data. Lack of consistency and standardization across outcome measures add additional problems in efficacy measurement. Finally, there is a need to directly impact the generalization of findings of outcome measures to more functional tasks, such as activities of daily living (ADL’s), attention in the community, and skills in the home. While the patient may perform adequately on a neuropsychological measure or in a treatment encounter, there is no guarantee that this performance will be linked to functional improvement in real life situations.
This volume provides a blueprint for where to start with efficacy research, what pitfalls to avoid, and what direction is needed to launch new and comprehensive studies. The authors advocate that rehabilitation centers should collaborate to enhance reliability across techniques, consistent methodology, and outcome measurement. Newer studies are examining models that may assist in addressing levels of brain injury, instead of relying on one model for all levels and types of injury.
The success of compensatory strategies, such as memory aids, in improving memory, and additionally, reducing anxiety, is encouraging for those engaged in traumatic brain injury rehabilitation. One flaw of the book is the lack of emphasis on psychosocial interventions that appear to be effective and crucial components to facilitate the adjustment of the brain injured individual, and of family members who must assume new caregiver roles.
Effectiveness of Rehabilitation for Cognitive Deficits will interest clinical researchers who are investigating models of cognitive rehabilitation, neuropsychologists who work with brain injured clients, interdisciplinary team members who must strive to conceive reasonable treatment goals, as well as directors of rehabilitation teams who must convince third party payors to provide and extend treatment for those with brain injury who are making gains. The positive message of this book is that now there are actuarial methods to assist in the determination of how great these gains are, and how they can be made even greater. The Editors are to be commended for their process-oriented perspective and their support of the need to quantify change routinely.
