Cognitive rehabilitation therapy

Cognitive rehabilitation builds upon brain injury strategies involving memory,^[9] executive functions, activities planning, and "follow through" (e.g., memory, task sequencing, lists).^[10] Cognitive and affective thoughts (e.g., beliefs, desires) are subconsciously organized into mental frameworks and inferences, distinguishing CRT from other therapeutic approaches by helping patients be able to recognize distorted thinking patterns, where they can then be examined closer.^[11] Neuroplasticity, the brain's ability to form new neural connections, is the basis of cognitive rehabilitation, which calls for repeated targeted practice. Through techniques such as cognitive restructuring, underlying cognitive schemas and automatic thought processes that may hinder normal cognitive function can be modified. ^[11]

There are currently many evidence-based practices that support cognitive rehabilitation therapy, especially in patients who have suffered from traumatic brain injury (TBI) or stroke. When treatment plans incorporates metacognitive strategy training, individuals are trained with the ability to apply skills learned in a real-world context. ^[12]

The effects of cognitive rehabilitation therapy remains understudied, although it can be noted that treatment outcomes vary very widely among patients, with a substantial amount of individuals not achieving sufficient improvement^[13]. It's theorized that genetic differences play a role and may help future rehabilitation strategies to become more targeted and effective, but the existing evidence is inconclusive.^[13] One major limitation of cognitive rehabilitation is that many treatments don't always improve daily functioning even when test performance scores improve^[14]. It is theorized that best results are produced when therapy includes tasks from daily life and focused on real-world function^[14].

Typically, cognitive rehabilitation therapy starts with an assessment of current cognitive abilities to identify areas of strengths and the problematic areas needed to improve. Based on testing results, a neuropsychologist will determine what cognitive rehabilitation interventions to focus on in an individual's program plan.

According to the standard text by Sohlberg and Mateer:^[22]

Individuals and families respond differently to different interventions, in different ways, at different times after injury. Premorbid functioning, personality, social support, and environmental demands are but a few of the factors that can profoundly influence outcome. In this variable response to treatment, cognitive rehabilitation is no different from treatment for cancer, diabetes, heart disease, Parkinson's disease, spinal cord injury, psychiatric disorders, or any other injury or disease process for which variable response to different treatments is the norm.

Nevertheless, many different statistical analyses of the benefits of this therapy have been carried out. One study made in 2002 analyzed 47 treatment comparisons and reported "a differential benefit in favor of cognitive rehabilitation in 37 of 47 (78.7%) comparisons, with no comparison demonstrating a benefit in favor of the alternative treatment condition."^[6]

An internal study conducted by the Tricare Management Agency in 2009 is cited by the US Department of Defense as its reason for refusing to pay for this therapy for veterans who have had traumatic brain injury. According to Tricare, "There is insufficient, evidence-based research available to conclude that cognitive rehabilitation therapy is beneficial in treating traumatic brain injury."^[23] The ECRI Institute, whose report serves as the basis for this decision by the Department of Defense, has summed up their own findings this way:^[5]

In our report, we carried out several meta-analyses using data from 18 randomized controlled trials. Based on data from these studies, we were able to conclude the following:

• Adults with moderate to severe traumatic brain injury who receive social skills training perform significantly better on measures of social communication than patients who receive no treatment.
• Adults with traumatic brain injury who receive comprehensive cognitive rehabilitation therapy report significant improvement on measures of quality of life compared to patients who receive a less intense form of therapy.

The strength of the evidence supporting our conclusions was low due to the small number of studies that addressed the outcomes of interest. Further, the evidence was too weak to draw any definitive conclusions about the effectiveness of cognitive rehabilitation therapy for treating deficits related to the following cognitive areas: attention, memory, visuospacial skills, and executive function. The following factors contributed to the weakness of the evidence: differences in the outcomes assessed in the studies, differences in the types of cognitive rehabilitation therapy methods/strategies employed across studies, differences in the control conditions, and/or insufficient number of studies addressing an outcome.

Citing this 2009 assessment, US Department of Defense, one of the federal agencies not responsible for health care decisions in the US, has declared that cognitive rehabilitation therapy is scientifically unproved and should refer their concerns to the US Department of Health and Human Services, US Budget and Management, and/or the Government Accountability Office (GAO). As a result, it refuses to cover the cost of cognitive rehabilitation for brain-injured veterans.^[23][24] Cost-benefit and cost-effectiveness studies, together with an analysis of personnel and veterans' services for new our emerging groups in head and brain injuries, are recommended.^{[citation needed]}

• Rehabilitation (neuropsychology)
• Cognitive remediation therapy
• Rehabilitation psychology
• Community-based rehabilitation