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TBI Health and Wellness
Some things to know and understand about Cognitive Rehabilitation.
Everyone knows about physical rehab. That's when physical and occupational therapists, and others on the rehab team work to teach physical skills - like walking, dressing, using a wheelchair or a walker, or learning to write again. Strengthening, stretching, and endurance are also parts of physical rehab. There is little doubt that these things help people to become more independent. But what about cognitive rehab? Does therapy for your memory, for thinking, and for communicating work? Has anybody even studied it enough to know? Some researchers – one of whom is a Craig Hospital staffer -- tried to answer this question. Here's what they learned...
What is cognition? It is the process of "knowing." It includes the ability to choose, understand, remember and use information in your daily life. A cognitive disability may affect how well you can do your activities of daily living. It can make it harder for you to adapt to new situations or problems. Cognitive rehab should help lessen these problems.
But, does cognitive rehab work? Yes. That is what some researchers found. Here's a summary of some specific areas that they looked at in depth:
Language & Communication: In this area the researchers found something very encouraging: language and communication problems can keep improving for a long time after the injury. This is true for spelling, arithmetic, and speaking. People can also keep on improving in their ability to understand things they have read. Working with a speech therapist can help. Speech therapists can help people with TBIs see which areas they are good at and which areas need more practice. They can also teach compensations - new ways of doing old things - that help persons with TBI make up for some of their language problems. Finally, the practice and feedback that speech therapists give in therapy sessions can lead to better conversation skills in social situations too.
Memory: For memory problems, use of internal strategies (going over something
to remember in your mind) or using notebooks or daytimers may help people with TBI
remember better. Real-life compensations work best using things like computers, pagers or notebooks. When therapists and families help train and remind people with TBI to use these things, they work even better.
Problem Solving: Teaching people with TBI strategies to solve problems works. For example, they could be asked to think of a particular problem they've had -- like finding transportation or housing in their community. Next, they can be encouraged to think of all possible ways to solve their problem. Then, they could choose one solution and think about how well it worked in a real life situation. Researchers found that people with TBI who were taught "tricks" like this for problem-solving improved a lot. And, they learned how to handle things in everyday life better. Patients who did not get this kind of practice did not improve.
Attention problems: Everyone agrees that being able to pay attention is important. It's an area that affects how well people with TBI do when they go back to work or school. To try to improve attention skills, therapists might use computer activities
which ask people with TBI to respond only in a particular situation. For example,
the activity might ask the person with a TBI to press a computer key when he or she sees the number "3" on a computer screen. Or, it might ask them to press a buzzer when they hear a certain sound or see a certain picture, shape, or design.
This kind of therapy didn't work very well. Why? First, people with attention training
get better on the computer activity, but it didn't necessarily transfer to other
real life activities. Instead, researchers believe it is practice on attention to
real life activities that helps. The practicing that comes with doing the same activities
over and over seemed to make a difference. Second, when the researchers compared the people with computer training to those who got another kind of therapy, they found that more of those with the different therapy did even better.
That different therapy was called Skills Training. Guess what: Skills Training is based on none other than practice! Patients just practice a skill over and over until they master it. And, the more that their practice relates to something functional or useful - like driving, reading or writing, or following instructions - the better.
So, the most common way to help people with TBI improve their attention is by practicing.
It helps when therapists monitor their patients' performance and give them ideas and feedback. They also found that attention training seems to work best when people are trying to learn new, difficult functional tasks or re-learn old, complex tasks. Think about driving, for example. Driving is a complex skill. It requires attention to many things in the car and on the road at the same time. Practicing attention exercises that relate to driving can improve both driving itself, and attention-to-driving skills.
Now, if you happen to be someone who did have attention training on a computer during your rehab, don't worry. Chances are that your own rehab was also made up of lots of practicing and practicing, and more practicing. And, practice does lead to improvement. Ask any concert pianist or Olympic skier.
How do we figure out all these things about attention, language and communication, memory, and problem solving? There are three articles that reviewed the research
on how well therapy works. The first article reviewed more than 170 research
studies about rehab for people with stroke and TBI. They identified the things that the research showed to be helpful and then summarized what they found. The article
is "Evidence-based cognitive rehabilitation: recommendations for clinical practice",
found in the medical journal, Archives of Physical Medicine and Rehabilitation,
Volume 81, December 2000. A second article reviewed 87 studies in "Evidence-Based
Cognitive Rehabilitation: Updated Review of the Literature from 1988 Through 2002",
in the Archives of Physical Medicine and Rehabilitation, Volume 86, August
2005. Most medical libraries have these articles. The first author's
name is Keith Cicerone, and the second author of these articles is our TBI Model Systems' own Cynthia Dahlberg, Speech and Language Pathologist.
A third article, which was reported on in newspapers and television, was first printed in a magazine called Neuropsychology. It was published in 2001 (Volume 15, Number 2, pages 199-210) and is called "Effectiveness of Attention Rehabilitation after an Acquired Brain Injury: a Meta-Analysis. The authors are Norman W. Park and Janet L Ingles.
The Bottom Line: Several things do have a good chance of making a difference. People with TBI, their families and friends can work on them together in the months and years after they have finished their inpatient rehab. Improvements in
real life activities can continue long after the injury.
Communication: Language and communication can improve for a long time after the injury. What you learn in therapy will translate to real-life conversations. Bottom line: Those ongoing speech therapy sessions probably are worth your time! Involve yourself in conversations with others.
Memory: The magic word is "compensation." Your memory may never be what you want it to be, but you can try to "outsmart" it with tricks that help you compensate. Bottom line: Try things like notepads, reminders, palm pilots, etc. And, having a very strict routine that you follow can be very helpful.
Problem solving: Thinking through problems can help -- especially when it is a real-life problem that needs to be solved. Bottom line: Specify the problem. Determine what the options are. Listen to others' advice. Choose a solution. Evaluate the results.
Attention: Practice, repetition, and feedback all can help you learn to be more attentive, especially for complex, real-life tasks. However, practicing attention skills on a computer program by yourself probably will not help improve attention in real life situations. Bottom line: Participate in real life situations that require you to pay attention, and practice, practice, practice. Have someone with you to give you feedback.
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