Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014

Objective To conduct an updated, systematic review of the clinical literature, classify studies based on the strength of research design, and derive consensual, evidence-based clinical recommendations for cognitive rehabilitation of people with TBI or stroke. Data Sources Online Pubmed and print journal searches identified citations for 250 articles published from 2009 through 2014. Study Selection 186 articles were selected for inclusion after initial screening. 50 articles were initially excluded (24 healthy, pediatric or other neurologic diagnoses, 10 non-cognitive interventions, 13 descriptive protocols or studies, 3 non-treatment studies). 15 articles were excluded after complete review (1 other neurologic diagnosis, 2 non-treatment studies, 1 qualitative study, 4 descriptive papers, 7 secondary analyses). 121 studies were fully reviewed. Data Extraction Articles were reviewed by CRTF members according to specific criteria for study design and quality, and classified as providing Class I, Class II, or Class III evidence. Articles were assigned to 1 of 6 possible categories (based on interventions for attention, vision and neglect, language and communication skills, memory, executive function, or comprehensive-integrated interventions). Data Synthesis Of 121 studies, 41 were rated as Class I, 3 as Class Ia, 14 as Class II, and 63 as Class III. Recommendations were derived by CRTF consensus from the relative strengths of the evidence, based on the decision rules applied in prior reviews. Conclusions CRTF has now evaluated 491 papers (109 Class I or Ia, 68 Class II, and 314 Class III) and makes 29 recommendations for evidence-based practice of cognitive rehabilitation (9 Practice Standards, 9 Practice Guidelines and 11 Practice Options). Evidence supports Practice Standards for attention deficits after TBI or stroke; visual scanning for neglect after right hemisphere stroke; compensatory strategies for mild memory deficits; language deficits after left hemisphere stroke; social communication deficits after TBI; metacognitive strategy training for deficits in executive functioning; and comprehensive-holistic neuropsychological rehabilitation to reduce cognitive and functional disability after TBI or stroke

Proceedings from the Ice Hockey Summit III: Action on Concussion

Objectives The Ice Hockey Summit III provided updated scientific evidence on concussions in hockey to inform these five objectives: (1) describe sport related concussion (SRC) epidemiology, (2) classify prevention strategies, (3) define objective, diagnostic tests, (4) identify treatment and (5) integrate science and clinical care into prioritized action plans and policy. Methods Our action plan evolved from 40 scientific presentations. The 155 attendees (physicians, athletic trainers, physical therapists, nurses, neuropsychologists, scientists, engineers, coaches and officials) voted to prioritize these action items in the final Summit session. Results (1) establish a national and international hockey data base for SRCs at all levels; (2) eliminate body checking in Bantam youth hockey games; (3) expand a behavior modification program (Fair Play) to all youth hockey levels; (4) enforce game ejection penalties for fighting in Junior A and professional hockey leagues; (5) establish objective tests to diagnose concussion at point of care (POC); and (6) mandate baseline testing to improve concussion diagnosis for all age groups. Conclusions Expedient implementation of the Summit III prioritized action items is necessary to reduce the risk, severity and consequences of concussion in the sport of ice hockey

Rethinking the need and ability to achieve cognitive structure: Measurement and theory issues

Quantifying individual differences in clients\u27 needs and abilities to implement cognitive structure might be beneficial for clinicians working within a cognitive behavioral perspective. Although there is a substantial body of literature on epistemic processes, a general agreement about the best measures is lacking. A primary purpose of Study One was to simultaneously evaluate pertinent measures in an effort to determine best items and to create a combined instrument. Psychometric analyses were carried out on three measures of the need for cognitive structure—the Personal Need for Structure scale (PNS; Thompson et al., 1992), Need for Cognitive Structure scale (NCS; Bar-Tal, 1994), and Need for Closure Scale (NFCS; Webster & Kruglanski, 1994)—and two measures of the ability to achieve cognitive structure—the Ability to Achieve Cognitive Structure scale (ARCS; Bar-Tal, 1994) and Personal Fear of Invalidity scale (PFI; Thompson et al., 1992). These measures were then combined into a new measure called the Cognitive Processing Styles Inventory (CPSI) and a large-scale factor analysis was performed. The results only partially supported Webster and Kruglanski\u27s (1994) proposed facets of the need for closure: Preference for Order, Preference for Predictability, Decisiveness, Discomfort with Ambiguity, and Closed-Mindedness but their proposed pattern of item loadings on these factors was not supported. Using the NCS, AACS, and CPSI scales, Study Two evaluated Kruglanski and Bar-Tal\u27s theories on the influence of need and ability to achieve structure on stereotype use, vigilance, hypervigilance, functional and dysfunctional impulsivity, impressional primacy effects, decisional certainty, and effortful processing. Overall, Bar-Tal\u27s theory on the moderating effects of AACS on NCS was poorly supported. Additionally, no support was found for the influence of need or ability to achieve structure on stereotype use. In many cases, AACS alone did better than NCS or the NCS x AACS interaction in accounting for the variance in the dependent variables. On average, the CPSI scales did as well or better than the NCS and AACS scales in accounting for variance in the dependent variables of interest. Theoretical implications of this research are discussed and recommendations are provided for use of the CPSI

Awareness and distress after traumatic brain injury: A relative\u27s perspective

Objective: To examine the relationship between relatives\u27 distress level and their ratings of impaired awareness for persons with traumatic brain injury (TBI). Design and Outcome Measures: Participants were 25 patients with TBI, 16 with probably dementia, and 15 with memory complaints but no dementia. Participants completed the Barrow Neurological Institute Screen for Higher Cerebral Functions. Relatives of all patients completed the Patient Competency Rating Scale (Relative Form). Relatives also rated their distress level on a scale from 0 (no distress) to 10 (severe distress) and then rated the patient\u27s level of awareness of their difficulties, also on a scale from 0 (not aware) to 10 (completely aware). Setting: Clinical neuropsychology outpatient service of a neurological institute and medical center. Results: For relatives of patients with TBI, a significant correlation of -0.52 (P = .006) was found. Correlations for the dementia and memory complaint groups were -0.62 (P = .03) and -0.39 (P = .20), respectively. Conclusions: The presence of brain dysfunction associated with neuropsychological disturbances appears to influence the magnitude of the relationship between the distress level of family members and their ratings of impaired awareness in persons with TBI. © 2005 Lippincott Williams & Wilkins, Inc

Cognitive functioning before and after surgical resection for hypothalamic hamartoma and epilepsy

OBJECTIVE: To determine whether patients with hypothalamic hamartoma (HH) improve in their cognitive functioning after neurosurgical resection of their HH and explore what variables correlate with cognitive outcome. METHODS: Thirty-two patients underwent preoperative and postoperative neuropsychological testing. The age range of patients was between 3.3 and 39.3 years (mean 12.2 years, SD 7.0). The average time interval between surgery and postoperative neuropsychological testing was 23.4 months (range 5.1-47.2 months). Tests administered varied on the basis of the patient\u27s age and clinical condition. RESULTS: As a group, measures of overall intelligence showed improvement postsurgery, with associated improvement in processing speed. Memory scores did not demonstrate consistent improvement or decline. Duration of epilepsy, age at surgery, and level of neurocognitive functioning prior to surgery were correlated with postsurgical cognitive status. Patients who had mental retardation but were testable generally showed the greatest gains. CONCLUSIONS: Despite the great variability in level of cognitive impairment in patients with HH and refractory epilepsy, level of intelligence may show mild to moderate improvements postsurgery if no surgical complications occur. The variables that predict cognitive outcome are not fully delineated, but testable individuals with the greatest presurgical cognitive impairment and those with the shortest duration of epilepsy appear to make the greatest gains in intellectual functioning. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that single surgical resection for HH was associated with improvement in some subset measures of intellectual functioning, but not memory. Factors that predict better outcomes cannot be determined

Subjective reports of fatigue during early recovery from traumatic brain injury

Objective: To determine whether patients with traumatic brain injury (TBI) report higher levels of fatigue than do normal controls and to identify demographic and cognitive correlates of self-reported fatigue. Design: Prospective study. Setting: Inpatient neurorehabilitation unit in a medical center and neurological institute. Participants: Forty-seven neurorehabilitation inpatients with TBI. Main Outcome Measures: Barrow Neurological Institute (BNI) Fatigue Scale and BNI Screen for Higher Cerebral Functions. Results: Patients reported significantly greater levels of fatigue compared to the levels reported by normal controls, although fatigue was found to be unrelated to injury severity, number of days from injury to assessment, cognitive impairment, and gender. Inspection of individual items revealed no significant differences between severe versus moderate versus mild TBI groups. However, being able to last the day without taking a nap (ie, item 10) was found to be the most sensitive item associated with fatigue in the TBI group. Conclusions: Results of this study suggest the need to integrate activities and interventions to increase endurance in patients with TBI during early rehabilitation. Accommodating regular rest breaks and increasing restful sleep should be a focus of inpatient neurorehabilitation units. © 2005 lippincott Williams & Wilkins, Inc

Intellectual functioning in presurgical patients with hypothalamic hamartoma and refractory epilepsy

Objective: The goal of the work described here was to examine the relationship between intellectual test performance in patients with hypothalamic hamartoma (HH) with refractory epilepsy and their seizure histories, as well as the size and neuroradiographic anatomical features of the HH. It was predicted that the level of estimated intelligence and the pattern of intellectual test performance would significantly correlate with the size of the HH and neuroanatomical features. Method: In this cross-sectional design study, 49 patients with HH between the ages of 5 and 55 years were classified by age at time of examination, as well as pattern of performance on the Wechsler intelligence scales. All patients were included in data analysis irrespective of their ability to participate in psychometric testing. Patients with a prior history of neurosurgical treatment were excluded. Results: For those patients functionally capable of participating in cognitive testing (n = 42), a summary index score, which estimated level of intellectual function (composed of the Vocabulary, Block Design, and Coding subtests of the Wechsler intelligence scales), was significantly correlated only with number of antiepileptic drugs (AEDs) the patient was taking at the time of evaluation (r = -0.66, n = 38, P = 0.05). In contrast, a categorization method addressing the pattern of intellectual test performance (including those patients who were not functionally capable of participating in cognitive testing, n = 49) was significantly correlated with number of AEDs (r = +0.35, n = 48, P = 0.01), size of HH (r = +0.38, n = 49, P = 0.01), presence of precocious puberty (PP: r = +0.41, n = 49, P = 0.01), and anatomical classification of HH (r = +0.39, n = 49, P = 0.01). Conclusions: The findings confirm the wide range of cognitive functioning in the population of patients with HH and refractory epilepsy, and suggest that multiple variables are correlated with intellectual test performance in patients with HH with refractory epilepsy. Although the present cross-sectional design study does not answer the question of whether or not epilepsy severity produces lower intelligence in this patient population, number of AEDs and neuroanatomical features of the HH lesion are identified as being significantly related to cognitive performance in this patient sample. © 2008 Elsevier Inc. All rights reserved

Cognition in epilepsy patients with hypothalamic hamartomas

Many patients with epilepsy caused by hypothalamic hamartomas (HHs) have cognitive impairments during the course of the disease or following neurosurgical treatment. The purpose of this study was to assess cognitive function in these patients, as well as factors influencing preoperative cognitive performance and cognitive outcome after neurosurgical treatment. Using the two largest and most detailed neuropsychology datasets on HH and epilepsy from two centers, we retrospectively report on cognitive functions in 48 patients with structural epilepsy due to HH (mean age ± standard deviation [SD] 20 ± 12 years, range 5–53 years, median 16 years; disease duration mean 17 ± 11 years). Intelligence, verbal learning and recall, and speed and executive functions (processing speed and cognitive flexibility) were assessed before and on average 19 (±11) months after surgery (interstitial radiosurgery: N = 22; neurosurgical resection/disconnection: N = 26). Prior to neurosurgical treatment, 52% of patients showed impaired executive and 62% showed reduced verbal memory functions. A trend for a detrimental effect of higher drug load on cognitive functioning was found. After neurosurgical treatment, intellectual functions for the entire cohort tended to increase. This correlated with improved seizure frequency and decreased number of antiepileptic drugs (AEDs). However, postoperative outcomes for individual patients were highly variable, with significant deteriorations in 17% (processing speed) to 34% (cognitive flexibility and verbal learning), and performance increases in 17% (intellectual functioning) up to 39% (processing speed) of the patients. Higher levels of presurgical performance were significant predictors of cognitive decline after surgery. These results are highly relevant for patient consultation and may help with therapeutic decisions

Surgical resection of hypothalamic hamartomas for severe behavioral symptoms

Hypothalamic hamartomas (HHs) are associated with treatment-resistant epilepsy. Many patients also experience severe and sometimes disabling psychiatric problems. The most common behavioral symptoms consist of paroxysms of uncontrolled anger related to poor frustration tolerance. These can include violence, resulting in disrupted family or school relationships, and legal consequences including incarceration. In a large cohort of patients undergoing surgical resection of HHs for refractory epilepsy, 88% of families described an improvement in overall behavioral functioning [1]. Here, we describe four patients (three males, mean age = 11.9. years) who underwent surgical resection of HHs largely for behavioral indications. Three patients had relatively well controlled seizures, and one had no history of epilepsy. All patients had striking improvement in their psychiatric comorbidity. HH resection can result in significant improvement in behavioral functioning, even in patients with relatively infrequent seizures. Further investigation under approved human research protocols is warranted. © 2010 Elsevier Inc