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Evidence-based cognitive rehab: updated review of the literature from 1998-2002, by Cicerone.docx

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Kris Romero

Evidence-based cognitive rehab: updated review of the literature from 1998-2002, by Cicerone alot of evidence to support cognitive rehab for ppl with TBI. Ex/ strategy training for mild memory impairment/post acute attention deficits, and interventions for functional communication deficits  further research needs to done to determine if cog rehab is effective and examine the therapy factors and pts characteristics that optimize the clinical outcomes of cog rehab INTRO - spatial neglect after RH stroke cog rehab such as visual scanning improve functioning but not sure if this helps everyday functioning. - aphasia treatment is inconclusive when looking at RCT studies - when treatment begins in the acute stage of recovery and the more extensive the treatment the more positively associated is the treatment effects Methods: - 31 studies were excluded becaz they were without data, duplicate/follow up, nontreatment studies/non- experimental, reviews, or single case studies of ppl with TBI or stroke Class organization of studies: CLASS I: well designed, prospective RCT CLASS Ia: prospective, quasi-randomized assignment to treatment CLASS II: prospective, non-randomized cohort studies; retrospective, non-randomized case control studies; or multiple baseline studies CLASS III: clinical series without concurrent controls, or single subject design w/adequate quanitification and analysis Definition of levels of recommendations: 1. Practice standards: based on at least 1 class I study with an adequate sample, w/support from class II or III. Directly addresses treatment effectiveness and provide good evidence that the treatment be used in acquired neurocog impairment and disability. 2. Practice guidelines: based on 1 or class I studies with methodologic limitations, or well designed class II with adequate samples, that directly looks at treatment effectiveness. Provide probable evidence that the treatment is effective with these pts. 3. Practice options: based on class II or III studies that look at treatment effectiveness.Allows recommendations that the treatment may be effective for the pt. Remediation of attention deficits: -using attention process training, they found that self reported changes in attention/memory functioning, and greater improvement on neuropsych measures of attention-executive functioning than after therapeutic support - Time pressure management also helped improve use of self management strategies and greater attention/memory functioning than alternate treatment ** both these strategies use strategy training (compensation) rather than restitution training (restoring the underlying impaired function). - Clinical recommendation: Practice standard- strategy training for attention deficits administered during the postacute rehab for ppl w/TBI. -Further research: combo of cognitive and pharma intervention may produce the greatest overall improvement in attention deficits after TBI. Needs controlled research Remediation of visuospatial deficits: mainly unilateral neglect - training for neglect produced improvement on standard neglect tests and a functional measure evaluating generalization compared w/general cog stimulation - systematic cueing of visual scanning was better than conventional rehab -computer based treatment of partial blindness resulting from optic nerve damage or postchiasmal lesions. It tried to restore underyling neurologic and visual functions, and reduce visual field damage. It enlarged the visual field in 95% of subjects and remained this way for 2 years, -Clinical recommendation: A/ Practice standard- visuospatial rehabilitation- visual scanning training in treatment of visual neglect B/ Practice guideline- i. Scanning training: impo even critical element for ppl with severe visuospatial impairment that includes visual neglect after RH stroke ii. Isolated microcomputer exercises to treat unilateral left neglect: not recommended as it isn’t effective C/ Practice options: i. Systematic training of visuospatial/organizational skills: used on ppl with visual perceptual deficits, without visual neglect after RH stroke during acute rehab. Not recommended for ppl with LH stroke or TBI who don’t exhibit unilateral spatial attention. ii. Inclusion of limb activation or electronic technologies for visual scanning training: maybe included in treatment for visual neglect after RH stroke iii. Computer based interventions intended to produce extension guided treatment: considered for ppl with TBI or stroke. Form of restitution training to help ppl with postchiasmal lesions. Produces subjective improvement in visual functioning. -Further research: look at restitution training involving computer based interventions Remediation of apraxia: - apraxia: the inability to do learned and purposeful activities. Ex/ dressing - found that strategy training integrated into occupational therapy (OT) was more effective in improvingADL function than the conventional OT at the end of 8 weeks of training. Strategy training involved using internal/external compensations for apraxic impairment while doingADL activities. -Clinical recommendations: A/ Practice standard: specific gestural or strategy training for apraxia after LH stroke during acute rehab. These are better than conventional sensorimotor or aphasia therapies. Remediation of language and communication deficits: - more intensive treatment for global aphasics reached sig improvement in all language modalities - Contraint-induced movement therapy (CIMT) im
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