Cognitive Rehabilitation: Practice and ImplementationJenna Bisignano

Objectives Understand the process of cognitive rehabilitation

and what populations it most successful for Learn cognitive interventions to use in practice for

individuals with cognitive disabilities Identify the use of cognitive rehabilitation in a sub-

acute setting Understand collaboration with other disciplines in

order to implement the best plan of care for patients Integrate cognitive techniques into everyday practice

What is cognitive rehabilitation therapy?“Cognitive Rehabilitation Therapy (CRT) is the process of relearning cognitive skills that have been lost or altered as a result of damage to brain cells or chemistry”A treatment that combines both medical and therapeutic services, specifically aimed at restoring as many cognitive functions as possible while proposing different compensatory strategies to help individuals live with cognitive deficitsBased upon scientific theories that have been derived from various disciplines including cognitive neuroscience, neuropsychology, neurolinguistics and language and cognitive developmentIf skills cannot be relearned, new ones can be taught to enable the patient to compensate for his or her loss in cognitive functionhttp://www.societyforcognitiverehab.org/patient-family-resources/what-is-cognitive-rehab.php

History of CRT 1920s- the first use of CRT was seen post World War I veterans

returning home in Germany The German government created a “school for soldiers” which was a

hospital for injured soldiers Assessments and evaluations of psychological skill performance were

performed to determine deficits of soldiers 1963-Alexander Luria provided the first writings of CRT in Russia for

post Word War II soldiers Focused on the rehabilitation of soldiers in the neurosurgical unit in the

mountains for Russia His model included an assessment of neurocognitive functioning,

analysis of various adaptive mechanism and evaluation skills to help preclude the deficits

CertificationLevel 1

certification: Must be a Qualified Independent

Practitioner according to the American Congress of Rehabilitation Medicine's Guidelines for Cognitive Rehabilitation standards

Must have appropriate credentials for an independent practice in their discipline according to state licensing agencies appropriate to their profession

Level 2 certification:

Those who are unable to practice their profession independently, and require supervision by a Qualified Independent Practitioner.

The Qualified Independent Practitioner is accountable for the design, implementation and ongoing quality and appropriateness of evaluation and treatment services delivered to clients.

Qualifications for certificationsLevel I

Certification: Minimum of a master's degree in an

allied rehabilitation field from a regionally accredited institution where the degree is a prerequisite for licensure or certification (e.g., Psychology, Speech)

OR Minimum of a bachelor's degree in

an allied rehabilitation field from a regionally accredited institution where the degree is sufficient for licensure, certification or registration (e.g., Occupational Therapy)

For Level II Certification:

Bachelor's or master's degree in an allied rehabilitation field from a regionally accredited institution where the degree is insufficient for licensure, certification or registration

OR When such licensure,

certification or registration is not available

The process of CRT Educate the patient about cognitive weaknesses

and strengths- awareness of the deficits Process training to develop skills through

retraining- resolving the problem Strategy training- utilizing the environment to

work on compensatory strategies Functional activities training- applying education,

process and strategy into everyday life – real life improvements

Individuals that could benefit from CRT

Hypoxic brain injury Stroke Dementia and other

cognitive disorders Psychiatric or other

mental disorders

Multiple Sclerosis Optic neuritis Memory loss Epilepsy Aneurysm

Role of Occupational Therapy in CRT in acute care Typically for individuals with a sudden onset such as

stroke or TBI Evaluate the performance of safety awareness and

independence in self-care activities Preparatory activities to facilitate balance and

stability Family and caregiver education Home program may be developed, with

client/caregiver training as needed

Role of Occupational Therapy in CRT in a skilled nursing facility

Follow up with acute care interventions when the incident is severe

Intensive, daily therapy to improve all aspects of function

Interventions to address attention, problem solving, and perceptual deficits, and to manage impulsive behavior

Functional cognitive activity interventions Communication

Writing thank you cards Using a calendar or day planner Developing/using a memory book Using a telephone, computer Creating a list of important numbers

Healthcare Schedule upcoming appointments

Functional cognitive activities Medication management

Setting up a pill box Leisure

Board games, card games, puzzles Following written directions for a craft or game Reading the newspaper Using the TV guide

Functional cognitive activities Meal Preparation

Follow a recipe Following instructions in food

box Understanding food labels Meal planning

Money management Using money to pay for

purchase Pay bills online or write checks Manage bank accounts Ordering from a take out menu Ordering from a a catalogue

Functional cognitive activities Shopping

Clipping relevant coupons Developing grocery lists Budgeting Estimation of costs

Community Tasks Ordering from a menu in a restaurant Going to the store Riding public transportation Arranging transportation

Occupational therapy versus cognitive rehabilitation therapy

Occupational therapy

Help people across the lifespan participate in everyday ‘occupations’ that they want and need to do and are meaningful through the use of therapeutic use of activities

Cognitive rehabilitation

Restorative and compensatory treatment with the intent to improve the cognitive system to function in a wide variety of activities using different strategies

Cognitive Rehab for Multiple Sclerosis Patients Cognitive impairment is a major symptom of MS and has a negative

impact on patients’ quality of life After 6 months of cognitive rehabilitation patients were asked to take

these tests again and their scores increased significantly Selective reminding test Spatial recall test Symbol digit modalities test Paced auditory serial addition test Word list generation F-A-S test Subtests of WAIS-III Boston naming test Trail making test

The study showed a significant improvement related to learning and visual memory, executive function

Cognitive Rehab for individuals with dementia General cognitive stimulation and reality

orientation approaches consistently produce improvements in general self-reported quality of life and well-being

Researches performed a study regarding the use of contextualized individual cognitive rehabilitation, emphasizing collaborative goal-setting resulted in achieving self-rated competence and satisfaction with personally meaningful activities of daily living

Interventions for individuals who suffered a stroke Begin treating patients as early as possible in

order to have a better outcome for individuals with neurological damage

Focus interventions on direct cognitive skills training instead of broad generalization with a broader long term goal in mind Training for visual spatial neglect

Participation in everyday life activities provides the most succesful outcome measure

Interdisciplinary team work CRT is practiced by a wide range of professionals

in rehabilitation medicine, nursing, physical and occupational therapy, speech-language pathology, psychology, and neurology

Body structures and functions (impaired memory) as a result of disease or injury limit one’s ability participate in everyday meaningful activities

Collaboration with academic colleagues in other disciplines can facilitate functional outcomes for the individual

Interdisciplinary approach in practice

Interdisciplinary approach Study done to test if stroke patients could successfully

complete a self medication program using an interdisciplinary cognitive rehabilitation approach

Team made up of a nurse and speech-language pathologist to set up a self-medication program

81% of the stroke patients successfully completed the self medication program, compared to 36% of the debilitated patients

An interdisciplinary approach to medication management for cognitively impaired stroke patients holds promise

Cognitive rehabilitation for individuals with traumatic brain injuries

The intention of rehabilitation following a traumatic brain injury is to improve physical, cognitive, and psychosocial functioning; to promote independence, and to facilitate community integration

Cognitive rehabilitation targets cognitive and psychosocial functioning directly and can improve physical functioning indirectly

Sufficient evidence exists supporting the efficacy and effectiveness of cognitive rehabilitation, which has become the treatment of choice for cognitive impairments and leads to improvements in cognitive and psychosocial functioning

Summery The goal of cognitive rehabilitation is to improve the person’s

ability to perform cognitive tasks, cope with affective distress, and increase self-confidence, self-efficacy, and self- awareness

This is achieved by Retraining previously learned skills and residual abilities Teaching compensatory strategies Making environmental modifications to the person’s domestic and

vocational setting Facilitating adjustment to the cognitive disability by increasing

awareness These approaches are often combined to optimize the effects

of treatment

References AOTA. (2016). Occupatioanl Therapy’s Role in Adult Cognitive Disorders. Retrieved from:

https:// www.aota.org//media/Corporate/Files/AboutOT/Professionals/WhatIsOT/PA/Facts/ Cognition%20fact%20sheet.pdf 

Bahar-Fuchs, A., Clare, L., & Woods, B. (2013). Cognitive training and cognitive rehabilitation for persons with mild to moderate dementia of the Alzheimer’s or vascular type: a review. Alzheimers Res Ther, 5(4), 35.

Gich, J., Freixanet, J., García, R., Vilanova, J. C., Genís, D., Silva, Y., & ... Ramió-Torrentà, L. (2015). A randomized, controlled, single-blind, 6-month pilot study to evaluate the efficacy of MS-Line!: a cognitive rehabilitation programme for patients with multiple sclerosis. Multiple Sclerosis Journal, 21(10), 1332-1343. doi:10.1177/1352458515572405

The Society for Cognitive Rehabilitation. (2013). What is Cognitive Rehabilitation Therapy? Retrieved from: http

://www.societyforcognitiverehab.org/patient-family-resources/what-is-cognitive-rehab.php Tsaousides, T., & Gordon, W. A. (2009). Cognitive rehabilitation following traumatic brain

injury: assessment to treatment. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 76(2), 173-181.