Cognitive rehabilitation therapy

Effects of cognitive rehabilitation therapy, assessed using fMRI.

Specialty| neurology/psychiatry

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Cognitive rehabilitation therapy refers to a wide range of evidence-based interventions[1][2][3][4] aiming to restore or compensate for impaired cognitive functioning. Impaired cognitive functioning in patients is typically caused by neurological conditions such as traumatic brain injury, neurodegenerative diseases as well as stroke.[5] The primary goal of cognitive rehabilitation is to improve daily functioning and independence in individuals who have been cognitively impaired, targeting memory, attention, executive function and language/communication to improve an individual's quality of life. The strategies of cognitive rehabilitation therapy are rooted in improving neuroplasticity, and involves an individualized program of specific skills training and practice plus metacognitive strategies. Metacognitive strategies include helping the patient increase self-awareness regarding problem-solving skills by learning how to monitor the effectiveness of these skills and self-correct when necessary.

In cognitive rehabilitation therapy, trained therapists and psychologists create an individualized plan, depending on personal needs and goals, to restore cognitive function as possible. Cognitive rehabilitation therapy aims to improve the core underlying cognitive processes that are lacking due to mental illness or brain injuries, and is different from cognitive behavioral therapy, which focuses on treating mental health disorders.

Cognitive rehabilitation therapy is a subset of Cognitive Rehabilitation (community-based rehabilitation, often in traumatic brain injury; provided by rehabilitation professionals) and has been shown to be effective for individuals who had a stroke in the left or right hemisphere,[6] or brain trauma.[7] Cognitive rehabilitation is done after the patient is medically stable in cases there is injury. Individuals who have impaired cognitive functioning due to childhood lack of support or learning opportunities may also benefit from cognitive rehabilitation therapy.[8]

## Contents

* 1 Mechanisms and evidence
* 2 Treatment types
* 2.1 Restorative CRT
* 2.1.1 Cognitive remediation therapy
* 2.2 Compensatory CRT
* 3 Assessments
* 4 See also
* 5 References

## Mechanisms and evidence

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].

## Treatment types

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.

### Restorative CRT

Restorative cognitive rehabilitation, also known as retraining cognitive rehabilitation, repairs lost and damaged cognitive abilities using repetitive, targeted exercises to retrain the brain, using specialized computerized and manual cognitive exercises[15]. This is based on the assumption that the plasticity of the brain can accommodate higher levels of cognitive behavior and skills through regular task practice[16]. Restorative task practice involves exercises targeting various areas of cognition, including learning and memory/attention, problem solving, attention and having complex thoughts. Techniques used in restorative cognitive rehabilitation include simple exercises practicing active recall or expanding vocabulary in manual exercises, but is usually done with commercially available software; The software packages Cogpack, Pss CogRehab, and PositScience are among others in showing greatest success in patients.

#### Cognitive remediation therapy

A computer-assisted type of cognitive rehabilitation therapy called cognitive remediation therapy has been used to treat schizophrenia/psychosis, anorexia nervosa, ADHD, and major depressive disorder.[17][18][19][20][21] Cognitive remediation therapy is a type of restorative rehabilitation.

### Compensatory CRT

Compensatory rehabilitation aims to help the patient develop the skill to use tools and aids to overcome the impairment they're faced with (e.g., patients with impaired memory can compensate by writing down what they need to remember).

## Assessments

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]

## See also

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

## References

1. ↑ Cicerone, Keith D.; Dahlberg, Cynthia; Kalmar, Kathleen; Langenbahn, Donna M.; Malec, James F.; Bergquist, Thomas F.; Felicetti, Thomas; Giacino, Joseph T. et al. (December 2000). "Evidence-based cognitive rehabilitation: Recommendations for clinical practice". Archives of Physical Medicine and Rehabilitation 81 (12): 1596–1615. doi:10.1053/apmr.2000.19240. ISSN 0003-9993. PMID 11128897.
2. ↑ Cicerone, Keith D.; Dahlberg, Cynthia; Malec, James F.; Langenbahn, Donna M.; Felicetti, Thomas; Kneipp, Sally; Ellmo, Wendy; Kalmar, Kathleen et al. (August 2005). "Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 1998 Through 2002". Archives of Physical Medicine and Rehabilitation 86 (8): 1681–1692. doi:10.1016/j.apmr.2005.03.024. ISSN 0003-9993. PMID 16084827.
3. ↑ Cicerone, Keith D.; Langenbahn, Donna M.; Braden, Cynthia; Malec, James F.; Kalmar, Kathleen; Fraas, Michael; Felicetti, Thomas; Laatsch, Linda et al. (April 2011). "Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 2003 Through 2008". Archives of Physical Medicine and Rehabilitation 92 (4): 519–530. doi:10.1016/j.apmr.2010.11.015. ISSN 0003-9993. PMID 21440699.
4. ↑ Cicerone, Keith D.; Goldin, Yelena; Ganci, Keith; Rosenbaum, Amy; Wethe, Jennifer V.; Langenbahn, Donna M.; Malec, James F.; Bergquist, Thomas F. et al. (March 2019). "Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014". Archives of Physical Medicine and Rehabilitation 100 (8): 1515–1533. doi:10.1016/j.apmr.2019.02.011. ISSN 0003-9993. PMID 30926291.
5. ↑ 5.0 5.1 "Cognitive Rehabilitation Therapy for Traumatic Brain Injury: What We Know and Don't Know about Its Efficacy". ECRI Institute. 2011-01-21. https://www.ecri.org/Documents/Technology-Assessment/Cognitive_Rehabilitation_Therapy_ECRI_Institute_012111.pdf. "Approaches to cognitive rehabilitation therapy are generally separated into two broad categories: restorative and compensatory."
6. ↑ 6.0 6.1 Keith D. Cicerone; Cynthia Dahlberg; James F. Malec; Donna M. Langenbahn; Thomas Felicetti; Sally Kneipp; Wendy Ellmo; Kathleen Kalmar et al. (August 2002). "Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 1998 Through 2002". Archives of Physical Medicine and Rehabilitation (xxx: Elsevier) 86 (8): 1681–1692. doi:10.1016/j.apmr.2005.03.024. PMID 16084827. http://www.archives-pmr.org/article/S0003-9993(05)00330-8/abstract. Retrieved 2011-01-22. "The overall analysis of 47 treatment comparisons, based on class I studies included in the current and previous review, reveals 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.".
7. ↑ Soderback I.; Ekholm J. (1992). "January–March). Medical and social factors affecting behavior patterns in patients with acquired brain damage: a study of patients living at home three years after incident". Disability and Rehabilitation 14 (1): 30–35. doi:10.3109/09638289209166424. PMID 1586757.
8. ↑ Samuel, Ravi (October 2008). "Cognitive rehabilitation for reversible and progressive brain injury". Indian Journal of Psychiatry 50 (4): 282–284. doi:10.4103/0019-5545.44752. ISSN 0019-5545. PMID 19823615.
9. ↑ Zencius A.; Wesolowski M.; Burke W.H. (1990). "January–March). A comparison of four memory strategies with traumatically brain-injured clients". Brain Injury 4 (1): 33–38. doi:10.3109/02699059009026146. PMID 2297598.
10. ↑ Burke W.H.; Zencius A.H.; Weslowski M.D.; Doubleday F. (1991). "Improving executive function disorders in brain-injured clients". Brain Injury 5 (3): 241–252. doi:10.3109/02699059109008095. PMID 1933075.
11. ↑ 11.0 11.1 Perrotta, Davide (2026-03-23). "A phenomenological epistemology of unconscious mechanisms in cognitive-behavioral therapy: From theoretical insights to practical applications." (in en). Journal of Theoretical and Philosophical Psychology. doi:10.1037/teo0000365. ISSN 2151-3341. https://doi.apa.org/doi/10.1037/teo0000365.
12. ↑ Pressman, Helaine Tobey (2007-02-01). "Traumatic Brain Injury Rehabilitation: Case Management and Insurance-Related Issues". Physical Medicine and Rehabilitation Clinics of North America. Traumatic Brain Injury: New Directions and Treatment Approaches 18 (1): 165–174. doi:10.1016/j.pmr.2006.11.006. ISSN 1047-9651. PMID 17292818. https://www.sciencedirect.com/science/article/pii/S1047965106000878.
13. ↑ 13.0 13.1 Bäckman, Julia; Kravchenko, Olly; Halvorsen, Matthew; de Schipper, Elles; Ivanova, Ekaterina; Kaldo, Viktor; Isacsson, Nils Hentati; Eide, Thorstein Olsen et al. (2026-03-09). "Genome-Wide Association Study of Symptom Change Following Cognitive Behavioral Therapy for Common Mental Disorders" (in en). American Journal of Medical Genetics Part B: Neuropsychiatric Genetics. doi:10.1002/ajmg.b.70015. ISSN 1552-4841. PMID 41804033. https://onlinelibrary.wiley.com/doi/10.1002/ajmg.b.70015.
14. ↑ 14.0 14.1 Cicerone, Keith D.; Goldin, Yelena; Ganci, Keith; Rosenbaum, Amy; Wethe, Jennifer V.; Langenbahn, Donna M.; Malec, James F.; Bergquist, Thomas F. et al. (August 2019). "Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014". Archives of Physical Medicine and Rehabilitation 100 (8): 1515–1533. doi:10.1016/j.apmr.2019.02.011. ISSN 0003-9993. PMID 30926291. https://linkinghub.elsevier.com/retrieve/pii/S0003999319301947.
15. ↑ Samuel, Ravi (2008). "Cognitive rehabilitation for reversible and progressive brain injury" (in en). Indian Journal of Psychiatry 50 (4): 282–284. doi:10.4103/0019-5545.44752. ISSN 0019-5545. PMID 19823615.
16. ↑ Taphoorn, Martin JB; Klein, Martin (March 2004). "Cognitive deficits in adult patients with brain tumours". The Lancet Neurology 3 (3): 159–168. doi:10.1016/S1474-4422(04)00680-5. ISSN 1474-4422. PMID 14980531. https://linkinghub.elsevier.com/retrieve/pii/S1474442204006805.
17. ↑ "Successful computer-assisted cognitive remediation therapy in patients with unipolar depression: a proof of principle study". Psychol. Med. 37 (9): 1229–38. Sep 2007. doi:10.1017/S0033291707001110. PMID 17610766.
18. ↑ Wykes T (May 2007). "Cognitive remediation therapy in schizophrenia: randomised controlled trial". Br J Psychiatry 190: 421–7. doi:10.1192/bjp.bp.106.026575. PMID 17470957.
19. ↑ Wykes T (Aug 2007). "Cognitive remediation therapy (CRT) for young early onset patients with schizophrenia: an exploratory randomized controlled trial". Schizophr. Res. 94 (1–3): 221–30. doi:10.1016/j.schres.2007.03.030. PMID 17524620.
20. ↑ "Cognitive remediation in ADHD: effects of periodic non-contingent alerts on sustained attention to response". Neuropsychol Rehabil 16 (6): 653–65. Dec 2006. doi:10.1080/09602010500200250. PMID 17127571.
21. ↑ "A cognitive remediation programme for adults with Attention Deficit Hyperactivity Disorder". Aust N Z J Psychiatry 36 (5): 610–6. Oct 2002. doi:10.1046/j.1440-1614.2002.01052.x. PMID 12225443.
22. ↑ McKay Moore Sohlberg; Catherine A Mateer (2001). Cognitive rehabilitation: an integrative neuropsychological approach. Guilford Press. p. 4. ISBN 978-1-57230-613-4. https://books.google.com/books?id=ddeYbfy5Ue8C.
23. ↑ 23.0 23.1 Andrew Tilghman (2011-01-01). "Military insurer denies coverage of new brain injury treatment". USA Today. https://www.usatoday.com/news/military/2011-01-01-brain-injury-insurer_N.htm. "In an internal 2009 study, the Tricare Management Agency found that cognitive rehabilitation therapy is scientifically unproved and does not warrant coverage as a stand-alone treatment for brain injuries."
24. ↑ Letter to The Honorable Robert Gates from Senator Claire McCaskill (January 19, 2011)

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