Evidence-based cognitive rehabilitation: recommendations for clinical practice.

OBJECTIVE: To establish evidence-based recommendations for the clinical practice of cognitive rehabilitation, derived from a methodical review of the scientific literature concerning the effectiveness of cognitive rehabilitation for persons with traumatic brain injury (TBI) or stroke. DATA SOURCES: A MEDLINE literature search using combinations of these key words as search terms: attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, reasoning, rehabilitation, remediation, and training. Reference lists from identified articles also were reviewed; a total bibliography of 655 published articles was compiled. STUDY SELECTION: Studies were initially reviewed according to the following exclusion criteria: nonintervention studies; theoretical, descriptive, or review papers; papers without adequate specification of interventions; subjects other than persons with TBI or stroke; pediatric subjects; pharmacologic interventions; and non-English language papers. After screening, 232 articles were eligible for inclusion. After detailed review, 61 of these were excluded as single case reports without data, subjects other than TBI and stroke, and nontreatment studies. This screening yielded 171 articles to be evaluated. DATA EXTRACTION: Articles were assigned to 1 of 7 categories according to their primary area of intervention: attention, visual perception and constructional abilities, language and communication, memory, problem solving and executive functioning, multi-modal interventions, and comprehensive-holistic cognitive rehabilitation. All articles were independently reviewed by at least 2 committee members and abstracted according to specified criteria. The 171 studies that passed initial review were classified according to the strength of their methods. Class I studies were defined as prospective, randomized controlled trials. Class II studies were defined as prospective cohort studies, retrospective case-control studies, or clinical series with well-designed controls. Class III studies were defined as clinical series without concurrent controls, or studies with appropriate single-subject methodology. DATA SYNTHESIS: Of the 171 studies evaluated, 29 were rated as Class I, 35 as Class II, and 107 as Class III. The overall evidence within each predefined area of intervention was then synthesized and recommendations were derived based on consideration of the relative strengths of the evidence. The resulting practice parameters were organized into 3 types of recommendations: Practice Standards, Practice Guidelines, and Practice Options. CONCLUSIONS: Overall, support exists for the effectiveness of several forms of cognitive rehabilitation for persons with stroke and TBI. Specific recommendations can be made for remediation of language and perception after left and right hemisphere stroke, respectively, and for the remediation of attention, memory, functional communication, and executive functioning after TBI. These recommendations may help to establish parameters of effective treatment, which should be of assistance to practicing clinicians.

[Endotracheal tube cuff pressure. Monitoring during general anesthesia]. / Pressione della cuffia del tubo endotracheale. Monitoraggio durante anestesia generale.

BACKGROUND: To value changes of endotracheal tube cuff pressure during anaesthesia with N2O, using standard tubes or Brandt-system tubes. METHODS: Endotracheal cuff pressure during anaesthesia in three groups of patients has been monitored: Group 1 (n. 41): endotracheal tube with low-pressure cuff using N2O/O2 (2:1 or 1:1); Group 2 (n. 55): Brandt's double cuff-tubes using N2O/O2 (2:1 or 1:1); Group 3 (n. 20-control group): tubes with low-pressure cuff using O2/air. Values of pressure (M +/- DS: p < 0.05) have been compared with ANOVA, Bonferroni's method (p < 0.017). RESULTS AND CONCLUSIONS: Brandt's double cuff-tubes (G2) succeed in avoiding uncontrolled increase of cuff-pressure during anaesthesia with N2O. Standard low-pressure tubes (G1) shown increase of cuff pressure during anaesthesia with N2O which is absent using no N2O (G3).

Varieties of deficit unawareness after brain injury.

The failure to recognize the existence of disease is known as anosognosia. This article provides a brief discussion of the evolution of this concept and reviews some qualitative differences in the manner in which the disavowal of neurogenic impairment is expressed. Theoretical explanations for the unawareness of deficit after neurologic illness include motivational-symbolic, cognitive subsystem, and supraordinate system theories. Observations from a clinically derived, structured awareness interview are presented, suggesting three factors that may underlie patients' apparent lack of awareness of deficits after traumatic brain injury. These include diminished awareness of deficits secondary to impaired cognition, especially memory and reasoning deficits; psychological reactance and denial of deficits; and a relatively "pure" inability to recognize areas of impaired functioning as a direct consequence of brain injury. The causes of unawareness are likely to be complex and multiply determined in any given patient, although it may be possible to identify primary, secondary, and even tertiary contributions according to specific behavioral and phenomenological characteristics. The ability of patients to modify their perceptions and acknowledgment of deficits after objective feedback may have particular diagnostic value and clinical utility in this regard.

Does premorbid depression influence post-concussive symptoms and neuropsychological functioning?

We examined the contribution of premorbid affective disturbance to persistent post-concussive symptoms and neuropsychological functioning following a mild traumatic brain injury. No differences were observed on self-reported post-concussive symptoms, MMPI scales, or neuropsychological measures between two case-matched groups of patients with and without a history of pre-injury depression. Clinicians are urged to use caution in attributing post-concussive symptoms or neuropsychological deficits to the presence of a pre-existing affective disorder.

Disturbance of social cognition after traumatic orbitofrontal brain injury.

A patient with traumatic orbitomedial frontal lobe damage demonstrated good neurocognitive recovery but a lasting, profound disturbance of emotional regulation and social cognition. Initial neuropsychological findings included a complete anosmia, mildly reduced fluency and disturbed motor regulation. The impairments of fluency and motor regulation resolved, and formal measures of "frontal lobe" functioning were generally intact. However, she remained impaired on tasks requiring the interpretation of social situations, which mirrored her impairment in real life functioning. This disturbance in social cognition appeared related to difficulty appreciating and integrating the relatively subtle social and emotional cues required for the appropriate interpretation of events. The patient's presentation represents an intermediate position between patients with profound neurobehavioral deficits and patients with impaired real-life social cognition despite intact neuropsychological performance following orbitofrontal damage. Variations in the orbitofrontal behavioral syndrome may be related to extent of lesion, time post injury and the course of recovery in different patients.

Cognitive rehabilitation: learning from experience and planning ahead.

Cognitive rehabilitation has evolved to be a common clinical practice, despite questions regarding the scientific basis for its effectiveness. A selective interpretation of existing studies suggests that non-specific treatment factors play an important role in the efficacy of cognitive rehabilitation. Some future directions for the science and practice of cognitive rehabilitation are discussed.

Neuropsychological rehabilitation of mild traumatic brain injury.

A significant minority of patients who have sustained a mild traumatic brain injury (MTBI) may exhibit persistent disability. There have been few attempts to describe and evaluate the effectiveness of neurorehabilitation for these patients. We conducted a retrospective analysis of the results of a neuropsychological rehabilitation programme for 20 patients with MTBI. Based upon the ability to resume productive functioning after treatment, 10 patients were determined to exhibit a good outcome and 10 patients were considered to exhibit a poor outcome. Patients with good outcome exhibited significant pre-post-treatment improvements on both neuropsychological measures of cognitive functioning and self-reported post-concussive symptoms. Patients with poor outcome demonstrated little improvement in either area, and in some cases showed a decline in functioning. The results are consistent with the view that there may be significant variability in recovery and response to treatment after MTBI. There is a continued need to identify which patients may benefit from neurorehabilitation, develop specially tailored interventions, and conduct controlled, prospective studies in this area.

Attention deficits and dual task demands after mild traumatic brain injury.

Attention deficits are a prominent aspect of cognitive dysfunction after mild traumatic brain injury (MTBI). Patients frequently complain of distractibility and difficulty attending to more than one thing at a time, and several neuropsychological studies have found evidence for a specific attention deficit without general neuropsychological impairment. The present study examined the nature of attentional disturbance after MTBI using an extended version of the 2 and 7 Test, which introduced two conditions reflecting patients' subjective complaints: the ability to perform with background 'noise', and while simultaneously attending to a secondary task. The dual task demands produced a significant slowing in processing speed for both the MTBI patients and control subjects. However, the relative decline in processing speed appeared much greater for the patients with MTBI, and they differed from control subjects only in this condition. The results are consistent with findings that patients with MTBI exhibit relatively subtle cognitive deficits which are apparent primarily under conditions which require effortful or controlled cognitive processing and exceed their available cognitive resources. Thus, the attentional deficits apparent during dual task demands may represent decreased cognitive, and perhaps neural, efficiency which reflects MTBI patients' subjective complaints and functional impairments.

Current perceptions of rehabilitation professionals towards mild traumatic brain injury.

There has been long-standing controversy in the medical literature and increasing interest within the rehabilitation field in mild traumatic brain injury and postconcussion syndrome. The Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine conducted an opinion survey to analyze the perceptions of rehabilitation professionals towards patient's with these problems. The survey initially compared response patterns of rehabilitation personnel to two earlier identical surveys made with a group of neurosurgeons and a group of neuropsychologists. As a group, rehabilitation professionals tend to have perceptions of mild traumatic brain injury that are similar to those of neuropsychologists. The survey also included a group of questions developed to analyze specific issues among rehabilitation professionals related to symptomatology, persistence, and treatment. The most salient findings concluded that rehabilitation providers: (1) want a grading system associated with the term to designate injury severity, symptom severity, and level of functional impairment; (2) most frequently use neuropsychologists in assessment and treatment of these patients; (3) report cognitive deficits as the most common symptom, followed by irritability and somatic complaints; (4) when medications are used, most frequently use antidepressants; (5) typically follow these patients anywhere from six to 18 months postinjury; and (6) report that most patients make a complete functional recovery, though there is a substantial proportion (about 25%) who do not. Implications drawn from the survey include that there is a need to better define the term and its associated features and that there is a substantial group of patients who remain at least partially functionally disabled and present a major challenge to the rehabilitation community.

Monitoring rate of recovery to predict outcome in minimally responsive patients.

Existing methods of assessing neurobehavioral responsiveness in severely brain-injured patients are limited by their inability to recognize subtle clinical changes over time. This study evaluates the Coma Recovery Scale (CRS), developed for use during acute rehabilitation. The CRS was designed to detect subtle changes in neurobehavioral status and to predict outcome in patients with sever alterations of consciousness. Acceptable levels of concurrent validity were established with the Disability Rating Scale ([DRS], r = -.93) and the Glasgow Coma Scale ([GCS], r = .90). The CRS was also found to have adequate interrater reliability (kappa = .83). Twenty-eight minimally responsive patients, unable to communicate or follow commands reliably, were evaluated on the CRS, the DRS, and the GCS. Although initial scores on all three scales were significantly correlated with outcome at discharge, change scores were more predictive of outcome. In addition, CRS change scores correlated higher with outcome (r = -.78, p less than .01) than DRS and GCS change scores. These findings indicate that the CRS is a sensitive measure of neurobehavioral responsiveness and suggest that rate of change during acute rehabilitation may be an important outcome predictor.

Confabulation following aneurysm of the anterior communicating artery.

Nine subjects with aneurysms of the anterior communicating artery (ACoA) and 17 subjects with other intracranial hemorrhages (ICH) were evaluated for confabulatory responses under two naturally occurring conditions: (1) when subjects were not oriented to person, place, month and year, (2) when subjects were fully oriented. Confabulation was observed in all 9 of ACoA patients both during disoriented and oriented periods. In contrast, 7/17 of the other ICH patients showed signs of confabulation while disoriented, whereas only one continued to display confabulatory tendencies while fully oriented. Confabulation was more severe in the ACoA group. These data suggest that the confabulation observed in the other ICH group may be secondary to an acute confusional state while the prolonged confabulation in ACoA patients may be a manifestation of a more primary cerebral disorder.

Planning disorder after closed head injury: a case study.

Disturbances of executive functioning after traumatic brain injury represent significant obstacles to social and vocational recovery and may require specific remedial intervention. We report the treatment of a client with impaired planning ability and poor self-control after closed head injury. Intervention consisted of a self-instructional procedure that required him to verbalize a plan of behavior before and during execution of the training task and gradually faded overt verbalization. There was systematic reduction of off-task behaviors and problem-solving errors over the eight weeks of training. Pre- and postmeasures showed significant changes consistent with increased planning ability. Self-control ratings of everyday behaviors improved with explicit training to promote generalization. Training of plan-ahead and self-verbalization strategies appears effective for remediation of executive functioning after traumatic brain injury. Generalization to real-life situations can be observed with extended training.

Effects of frontal lobe lesions on hypothesis sampling during concept formation.

Thirty-two subjects with unilateral cerebral tumors were assessed for the use of hypotheses and cognitive strategies during a visual discrimination task. Subjects with frontal lobe lesions attained fewer concepts and used fewer appropriate hypotheses than subjects with tumors confined to the posterior hemisphere, although there was no difference in total hypotheses used. Lose-stay errors were committed with greater frequency among patients with frontal lobe lesions, although not all subjects with frontal lobe tumors exhibited this error tendency. The results of hypothesis sampling and a second visual discrimination transfer task suggested that the frontal lobe deficit was related to difficulty in attending to multiple cues and in monitoring feedback to segregate relevant from irrelevant sources of information.