506 S.A.

Raskin

Perhaps one of the most important factors to any the training and how these systems react to experi-
rehabilitation approach is the need for generalization ence such as the training procedures. The fourth is that
[6]. One of the first authors to specify an approach to experience-dependent changes interact. In addition, of
generalization was Gordon [7]. He suggested that the course, some plastic changes reflect compensation,
first level of generalization was that gains from reha- while others reflect recovery, and the treatment must
bilitation should hold true in the same setting with specifically be designed with one or the other in mind.
the same materials on separate occasions. The sec- In other words, in some cases the plasticity is one of
ond is that improvement on the training tasks is also an intact cortical region taking on the tasks once medi-
observed on a similar but not identical set of tasks. ated by the damaged region. In other cases, it is now
The third level of generalization is that the functions suggested that damaged regions can actually recover
gained in training are shown to transfer to functions in and resume previous functions.
day-to-day living.
Sohlberg and Raskin [8] suggested a set of gener-
Sensory and Motor Functions
alization principles or strategies that could be broadly
adapted in both research and clinical practice. These
One area of treatment that has shown considerable
principles, drawn primarily from the applied behav-
promise is constraint-induced (CI) therapy [13]. CI
ioral literature [9] and from the cognitive psychol-
therapy is a prescribed, integrated, and systematic
ogy literature on transfer of training [10], are to (1)
therapy designed to induce a patient to use a more-
actively plan for and program generalization from the
impaired upper extremity for many hours a day for
beginning of the treatment process, (2) identify rein-
several weeks (depending on the severity of the initial
forcements in the natural environment, (3) program
deficit). Some of the important elements are that the
stimuli common to both the training environment and
therapy requires repetitive, task-oriented training for a
the real world, (4) use sufficient examples when con-
significant period of time (several hours a day for 10
ducting therapy, and (5) select a method for measuring
or 15 consecutive weekdays). The use of a generaliza-
generalization.
tion procedure to transfer gains made in the research
These methods are thought to promote generaliza-
laboratory or clinical setting to the patient’s real-world
tion through known learning and transfer of training
environment is essential. Finally, the hallmark of this
paradigms [11]. The process by which generaliza-
therapy is constraining the patient to use the more-
tion itself occurs, of course, varies according to the
impaired upper extremity during waking hours over the
treatment approach. Compensation techniques affect
course of treatment, sometimes by restraining the less-
generalization by bypassing defective cognitive func-
impaired upper extremity in a mitt or cuff. For a review
tions and allowing the person to apply strategies in
of CI therapy, see [12, 14].
a large number of settings. Restorative approaches
Another new approach to motor deficits is loco-
are thought to actually change the cognitive process,
motor training (LT) [15]. This is an approach to gait
thereby allowing the process to be more effective in
rehabilitation that provides truncal support while giv-
any setting.
ing manual sensory signals on a moving treadmill.
Participants are supported in a harness over a tread-
mill. The theoretical basis is that the spinal cord has
Lessons from Plasticity
the capacity to integrate the afferent input and respond
with an appropriate motor output through a network of
Kolb and Whishaw [12] have identified several impor-
spinal interneurons. In one study the amount of body
tant principles of plasticity that can be used to inform
weight support that was required was reduced from 40
rehabilitation approaches. The first is that changes in
to 0% over a period of weeks [16].
the brain can be shown at many levels, including cellu-
lar, synaptic, systems, or in vivo levels. The second is
that the brain can be altered by a wide range of experi- Cognitive Domains
ences and that experience-dependent changes can be
long lasting. The third is that training studies must Cognitive training has been studied most extensively
be aware of the specific systems being targeted by in individuals with traumatic brain injury, although
28 Current Approaches to Cognitive Rehabilitation
recent studies have also demonstrated efficacy in indi-
viduals with schizophrenia [17], mild cognitive impair-
ment [18], and reading disabilities [19]. For cognitive
deficits, treatment seems most effective when a combi-
nation of compensatory and restorative approaches is
used. Although it seems both simpler and more expe-
dient to use compensation initially, to some extent,
the severity of the cognitive impairment is believed
to affect the extent to which compensation is sponta-
neously adopted. Moderately impaired individuals are
most likely to compensate, whereas mildly impaired
individuals may be unaware of a need to compensate,
and severely impaired individuals may lack the skill
and insight to implement compensatory behavior with-
out substantial training and support. It is also important
to recognize that the use of a particular compensa-
tion may have a negative trade-off. Compensatory
behaviors should optimize and not hinder utilization of
available resources, including the residual capacity of
the injured system. Implementation of compensatory
behaviors should also consider the consequences for
the individual and for others in the individual’s envi-
ronment.
Attention
Impairments in attention, concentration, distractibil-
ity, and reduced processing speed are among the most
commonly reported cognitive impairments. People
with neurological disorders may take more time to
complete tasks, have difficulty concentrating in noisy
or busy environments, experience problems doing
more than one thing at once, or forget what they were
about to say or do.
Spatial neglect, presumed to be based on an atten-
tional deficit, is one area that has shown the possi-
bility of remediation. The spatial imbalance of stroke
patients with unilateral neglect resulting from right
ischemic lesions was reported to be alleviated through
the presentation of simple auditory alerts [20]. The the-
oretical basis was data suggesting that the non-spatial
alertness system is predominantly right-lateralized and
receives ascending projections from subcortical sys-
tems that are generally still intact in cases of neglect.
A similar rationale was used in the development
of another training strategy for neglect, known as
limb activation training, in which patients with left
507
unilateral neglect are encouraged to make small move-
ments of the left arm [21].
For more complex aspects of attention, one obvi-
ous approach to helping people with attention deficits
is to make environmental modifications, such as reduc-
ing noise or visual distraction, performing only a single
task at a time, breaking down tasks into smaller steps,
and reducing the impact of stress or fatigue. These sug-
gestions may not only help the person improve their
ability to manage the external environment but also
help their internal emotional state by removing feelings
of being overwhelmed.
More controversial, although actually more rigor-
ously investigated are the direct retraining techniques
for working with individuals with attentional impair-
ments. Some of the earliest work to demonstrate
positive findings in cognitive rehabilitation involved
systematic intervention focused on attentional systems
[22] and the literature on the rehabilitation of attention
is now substantial [23].
The major premise of direct intervention approaches
is that attentional abilities can be improved by exer-
cising one or more particular aspects of attention.
Treatment has usually engaged patients in a series
of repetitive drills or exercises designed to provide
opportunities for practice on tasks with increasingly
greater attentional demands. Repeated activation and
stimulation of attentional systems are hypothesized to
facilitate changes in cognitive capacity.
Although a wide variety of treatment tasks have
been used in experimental studies of attention train-
ing, the Attention Process Training [24] and Attention
Process Training II [25] materials developed by
Sohlberg et al. have been used in many clinical set-
tings. These materials are hierarchically organized
tasks designed to exercise sustained, selective, alter-
nating, and divided attention. Tasks make increasingly
greater demands on complex attentional control and
working memory. Examples of tasks are listening for
descending number sequences, alphabetizing words in
a sentence or dividing attention between two simul-
taneous tasks. A version for children has also been
developed (Pay Attention!) and used successfully with
children with attention deficits [26].
A major concern about attention training exercises
has been the problem of generalization. For many func-
tions, therapy is clearly most effective when the patient
practices skills in the manner and setting in which they
will be used. However, merely practicing naturalistic
508
tasks may not be effective in and of itself. Mast natural-
istic activities are multidimensional and rely on a vari-
ety of different underlying cognitive processes, such as
divided attention, memory, and planning. Thus, utiliz-
ing a simpler approach that focuses on one process at
a time can be beneficial.
Overall, of all the areas of cognitive processing
that have been addressed in the cognitive rehabilita-
tion literature, some of the most compelling findings
have been in the realm of improvement of attentional
impairments [27]. Improvements have been shown
not only on attentional abilities but in demonstrable
functional improvements [28].
Memory
Approaches to remediation of memory and new learn-
ing are among the oldest in the cognitive rehabilitation
literature. Some approaches are based on techniques
that help ordinary individuals remember better and
some are specifically based on what is known fol-
lowing a particular injury or illness. Most recently,
approaches from cognitive science and learning theory
have been applied to memory rehabilitation, includ-
ing those attempts to improve memory ability, provide
compensatory approaches through externally or inter-
nally focused manipulations, and maximize likelihood
of learning and remembering in individuals with mem-
ory impairments. The particular approach taken in
any one case depends on the nature and severity of
the deficit, the degree of insight, the goals of the
patient, the environmental demands and expectations,
and other factors.
Environmental Modification
Environmental modification may decrease the need
for retrieval of specific information from memory.
Included in this category are environmental cues, such
as large signs posted in the home to remind the person
where items are located or how a machine or appli-
ance is operated. These types of modifications can
be used in the home, work, or school environment.
Modifications can also include removing environmen-
tal dangers, such as disabling a stove.
S.A. Raskin
Cues and checklists are a somewhat more active
approach. Cues can be specific pieces of informa-
tion provided by a family member or a less specific
cue such as an alarm that is set to remind the per-
son when to take a medication. Several sophisticated
cuing devices have been created for prospective mem-
ory impairments, including Neuropage [29] which uses
a central computer and a paging company to page the
patient automatically when a task needs to be com-
pleted. Neuropage has been demonstrated to signifi-
cantly improve the ability of people with brain injury
to complete tasks [30] and to reduce stress related to
careers [31].
Compensatory approaches have focused primarily
on the use of datebooks or notebooks [32]. There are
many studies that document the efficacy of using exter-
nal aids for the management of memory disorders [33].
A number of studies emphasized the importance of
individualizing the training and the selection of the
external aid used and the need to provide direct, sys-
tematic instruction in the use of the external aid [34,
35]. In the latter study, the use of external aids was
found to be effective when compared to supportive
therapy, although the results were not significantly
different at follow-up.
Vanishing Cues
There are also several recent techniques designed to
maximize learning. Research in both learning theory
and cognitive neuroscience has yielded valuable new
insights into the best approaches for training new skills
in individuals with memory impairments. The method
of vanishing cues, for example, was designed to take
advantage of spared priming effects in amnesic sub-
jects. Maximum cuing is used initially, and the amount
of cuing is slowly reduced over repeated trials, simi-
lar to backward chaining techniques. Glisky et al. [36]
have used this technique in several studies in which
they have shown improvement in specific functional
skills (e.g., operating a computer) and maintenance
of skills over time. Despite some transfer of learn-
ing to highly similar job contexts, learning continues
to be highly task-specific. Huntin and Parkin [37],
however, did find an advantage for the method of van-
ishing cues over rote learning (standard anticipation) in
learning computer-related words and their definitions.
28 Current Approaches to Cognitive Rehabilitation
This result might reflect differences in the subject
population and warrants further research.
Errorless Learning
Most strategies to aid memory are based, in part, on
repetition and spared procedural learning, particularly
in individuals with severe amnesia. One important
finding in this area is the demonstration of improved
performance with errorless learning [38, 39]. In a
series of studies, individuals with severe amnesia
learned more quickly and accurately when they were
not permitted to make incorrect guesses. Using stem-
completion tasks, subjects with severe memory impair-
ments were required to generate words that began with
a particular word stem. In an errorless learning con-
dition, the word was given and the subjects were told
to write it down first. On subsequent trials, only correct
responses were written down. In the errorful condition,
subjects were allowed to generate guesses, including
errors. Improved recall was seen in the errorless learn-
ing condition, presumably because individuals with
amnesia have impaired explicit and episodic memory;
errors are thus not recalled as errors, and, by virtue of
repetition, are actually primed for later recall. Errorless
learning was also shown to be superior on tasks appli-
cable to everyday life, such as recalling names or
programming an electronic aid.
One study applied the errorless learning paradigm
to a more complex cognitive skill, that of social prob-
lem solving [40]. Sixty individuals with schizophrenia
or schizoaffective disorders were randomly assigned to
experimental treatment or control groups. The experi-
mental group participated in a social problem-solving
training module. This training module included three
components. The first was “receiving” skills (identi-
fying problematic social interactions on a videotape),
the second was “processing” skills (identifying three
basic solutions to the problem), and the third was
“sending” skills (practice in applying the solution in
a role play). Throughout the training the instructor
slowly faded cues to facilitate errorless learning. The
control group received similar content but without
errorless conditions. The experimental training group
demonstrated significantly better retention of appropri-
ate social problem-solving skills at 3 months follow-up
on the assessment of personal problem-solving skills.
509
Distributed Practice
Another technique of this type used to aid new learning
is derived from studies of distributed practice. These
studies suggest that learning is facilitated by having
review that occur over a longer period of time, for
example, 1 h every day for a week rather than 7 h in
1 day. This schedule seems to allow time for memory
consolidation [41, 42]. There is some evidence to sug-
gest that distributed practice has a greater effect on the
cortical network that supports retrieval [43].
Prospective Memory Training
One particularly encouraging approach to direct
retraining has been prospective memory training [44].
In a study by Raskin and Sohlberg [45], subjects with
traumatic brain injury were required to execute actions
at future designated times. As subjects became more
proficient, the length of time between task assign-
ment and task execution was systematically increased.
Results supported the ability to increase subjects’
prospective memory span. In addition, two measures
of generalization were used. Subjects improved on
both naturalistic probes and performance in daily life
(measured with a diary method). A similar spaced-
retrieval approach was used by Kurtz et al. [46] to treat
attention and prospective memory impairments in indi-
viduals with schizophrenia and by Kinsella et al. [47]
in individuals with Alzheimer’s disease.
Other Techniques
Some direct retraining approaches use repeated expo-
sure and practice to try to facilitate learning. However,
there is little evidence to suggest that this approach
is helpful for memory remediation [48]. In general,
treatments are aimed at problems with encoding, such
as elaboration [49] or visual imagery [50]. But there
is some evidence that these strategies may actually
reduce the cognitive resources available to the individ-
ual [51].
Metacognitive strategies to improve learning have
been used with some success. These strategies use for-
mal routines to help the person identify and structure
material to be learned. For example, Lawson and Rice
510
[52] used executive strategy training in a single case
study. This involved identifying the problem, selecting
a strategy, using the strategy, and then monitoring the
outcome.
Academic Strategies
Academic therapies are focused on aiding in the recall
of written material. In the PQRST (preview, question,
read, state, test) method the individual is taught to go
through a series of stages when reading (preview the
material, generate questions, read, state the answers to
the questions, test your recall) [53].
TEACH-M is an instructional package designed by
Ehlhardt et al. [54]. The acronym stands for task analy-
sis, errorless learning, assessment, cumulative review,
high rates of correct practice, and metacognitive strat-
egy. They demonstrated its efficacy in four individuals
with severe memory deficits. These individuals were
able to use these seven steps to successfully learn an
e-mail procedure.
Language
Rehabilitation of language deficits generally targets
the area of deficit. Thus, therapies are specific to
phonological aspects of language, syntactic aspects of
language, or semantic aspects of language. In addition,
treatment can focus on the initiation or elaboration of
verbal responses, such as in verbal fluency. Pragmatics
is sometimes subsumed under language therapies and
has to do with social rules of communication, such as
turn-taking.
Treatments aimed at phonology of language are
generally used with people who exhibit anomic
aphasia. These treatments include semantic feature
analysis, semantic cueing, and phonological cuing.
Semantic feature analysis aims to activate the seman-
tic network of a particular word. For example, if a
person with aphasia is having difficulty retrieving a
word, s/he might be asked to describe distinguishing
features of the concept that the word represents. The
goal is to have spreading activation of the entire seman-
tic network that surrounds the target word and thus to
activate the target word itself [55]. In semantic cue-
ing treatment, the clinician might provide antonyms,
S.A. Raskin
synonyms, categories, or pictures to help guide the per-
son toward the target word, and in phonological cuing
the therapist provides cues based on sound, such as
rhymes. For a review on the relative efficacy of these
therapies, see [56].
Treatments aimed at the syntactic level of lan-
guage include syntax stimulation. The most widely
used syntax stimulation treatment is the Helm Elicited
Program for Syntax Stimulation (HELPSS) [57]. In
this program, the treatment sessions are hierarchically
structured and the goal is to elicit verbal productions of
specific syntactical structures. The therapist might, for
example, read a short story that ends with a question
and then a response sentence that follows a particu-
lar syntax. The clinician then reads the same passage
but now asks the person with aphasia to provide the
response sentence.
Some of the oldest therapies have been aimed at
treating expressive aphasia by improving the gener-
ation of verbal output. Melodic intonation therapy
[58] puts a focus on the melodic line and rhythm
of speech and is based on the theory that this will
recruit the non-language hemisphere. Promoting apha-
sic’s communicative effectiveness (PACE) therapy [59]
was designed to use the exchange of ideas between
the therapist and the person with aphasia. PACE is
based on the pragmatic rule of reciprocity whereby
the two individuals participate in a conversation as
equals. The four principles of PACE are the exchange
of new information (typically cards are used and
the individual turns over a card and must explain
what appears on the card), equal participation, free
choice of communicative channels, and functional
feedback.
Some recent promising studies have been mod-
eled after constraint-induced therapy [60]. Constraint-
induced language therapy (CILT) is designed to elim-
inate the potential learned non-use of individuals (the
theory that if individuals start to use compensations,
to avoid language, the non-use of language becomes
learned) with aphasia [61, 62]. CILT incorporates the
principles of repetition, intensity, salience, and speci-
ficity of treatment. The idea of constraint in this case
is the limiting of the person’s responses to speech by
using visual barriers that prevent any communication
through gesture, drawing, facial expression, etc [63].
The therapy is hierarchically organized so that at first
only a single word is required and then full sentences,
etc. Results suggested improvements generalized to
28 Current Approaches to Cognitive Rehabilitation
daily life. In one study, CILT was demonstrated to be
superior to PACE [51].
Dyslexia and Developmental Reading Disorders
There has been considerable interest of late in behav-
ioral rehabilitation approaches to reading disorders
based on the theory that dyslexia arises from phono-
logical processing deficits. Shaywitz and colleagues
[64] examined 77 children identified as poor read-
ers. The children were placed in one of three groups.
The first was an experimental intervention that pro-
vided 50 min/day of explicit and systematic tutoring
about letters, phonemes, and letter–sound linkages.
This was based on theories that posterior reading
systems might be plastic to interventions that are
phonologically mediated. The second group received
typical school interventions. The third group was a no-
intervention control. Compared to pre-treatment, those
children in the experimental group improved reading
accuracy, reading fluency, and reading comprehension.
Moreover, they demonstrated increased activation in
left hemisphere regions on fMRI.
Richards and Berninger [65] provided children with
dyslexia with a 3-week instructional program. This
program provided explicit instruction and was time-
sensitive. Instruction was given in linguistic aware-
ness, grapheme–phoneme associations, decoding and
spelling, and a writer’s workshop. Children who
received training demonstrated improvement in read-
ing and changes in functional connectivity on fMRI
such that after training the children with dyslexia were
not significantly different than good readers in left
inferior frontal gyrus activation.
A commercial product, Fast ForWord, which uses
acoustically modified speech has also been used in
studies of rehabilitation of children with dyslexia.
This is a computer-based program for rehabilitat-
ing reading, with seven training exercises that focus
on oral language, discrimination and listening, as
well as phonological processing and listening com-
prehension. Children with dyslexia have demonstrated
improvement in reading accuracy and brain activa-
tion changes using this program [66]. In one study
[67], 20 children were given this behavioral train-
ing in auditory processing and oral language training.
These children showed improved reading performance
and fMRI demonstrated increases in temporo-parietal
511
cortex and left inferior frontal gyrus. However, other
studies have failed to find a specific effect of Fast
For Word compared to other behavioral interventions
[68].
Executive Functions
Executive functions are arguably the most difficult
cognitive processes to define for the purposes of
rehabilitation efforts. In general, rehabilitation efforts
involve moving from simple structured activities with
significant external cuing and support to more com-
plex, multistep activities in which external support
is gradually reduced and internal support or self-
direction is required. Unfortunately, these techniques
have been evaluated in only a small number of
studies.
Compensatory Strategies
Frequently treatment of executive function deficits
rely on compensatory strategies, such as posting rou-
tines in an obvious spot, restructuring the environ-
ment, or teaching task-specific routines. Often these
strategies first involve considerable cuing from a
therapist but then this is gradually decreased over
time.
Behavioral Treatments
Behavioral treatments have been employed both to
modify behavioral dyscontrol and to improve initia-
tion and drive. Alderman et al. [69] have demonstrated
effective use of a particular behavior modification
technique, response cost, in assisting individuals to
gain greater inhibitory control over their behavior.
In this technique, the patient is given a number of
tokens, which are subsequently exchanged for tangi-
ble rewards. However, in the interim, the individual is
prompted to give the staff one token and state the rea-
son for its loss whenever a target behavior (negative)
is observed. The procedure enables salient feedback to
be extracted from the environment, places a minimal
load on memory, and increases awareness.
512
Sohlberg et al. [70], for example, demonstrated
that an individual with severe frontal lobe impair-
ment and marked initiation problems responded dif-
ferentially with different types of cuing. During a
group activity the patient was provided with a cue,
at which time he was to ask himself whether he was
initiating conversation. He was also provided with
some didactic training around the nature of commu-
nication and the importance of appearing involved
and interested in the activity. His verbal interactions
during the group session increased from a baseline
period, during which no cues were given, to the fol-
lowing treatment phase, during which prompts were
withdrawn.
There have also been many studies using a com-
pensatory approach to the rehabilitation of executive
control. This might include teaching task-specific rou-
tines such as grooming and dressing procedures, or
preparation of simple meals. Geyer [71] prepared a
handout for teaching such task-specific routines for
this purpose.
Direct Training
Direct training approaches include structured exercises
that provide multiple opportunities for initiating, plan-
ning, and carrying out goal-directed activities. The
goal of the treatment is for the patient to take on
increasing responsibility for carrying out multistep
plans and activities. It is important that the treatment
be linked to a solid and specific theory of executive
functions and known anatomical substrates [72].
Training that targets working memory has shown
efficacy in children with attention-deficit hyper-
activity disorder [73] and training generalized to
improved performance on nontrained working mem-
ory tasks. Children were given computerized visual
spatial working memory tasks over a period of 14
weeks. Furthermore, after training, brain activity in
middle and inferior frontal gyrus was significantly
increased [74].
Approaches focused on multi-tasking, which is
related to divided and alternating attention, also have
shown some promise. Stablum et al. [75] demonstrated
improvements in dual-task performance with practice
over 5 weeks. Generalization was demonstrated by
gains noted on the PASAT and a self-report measure.
S.A. Raskin
Metacognitive Strategies
Metacognitive approaches to executive dysfunction
focus on increasing insight, self-awareness, and self-
regulation. Verbal self-regulation strategies are based
on the observation that it is possible to regulate ones
own behavior through self-talk. Stuss et al. [76] used a
verbal self-regulation approach in an individual with
motor impersistence who could not maintain a sim-
ple movement over time. The patient did learn to alter
his behavior, although he needed cues to initiate and
maintain the self-regulation strategy.
Another kind of intervention at this level involves
teaching self-instructional procedures. Cicerone and
Wood [77] reported successful treatment with such a
procedure of a patient who exhibited planning abil-
ity and poor self-control 4 years after a brain injury.
They used as a training task a modified version of
the Tower of London. Training involved three dis-
tinct phases: overt verbalization, overt self-guidance,
and covert internalized self-monitoring. To promote
generalization following the program, the client was
presented with a structured interpersonal problem and
asked to solve it by applying principles learned in
the self-instructional training. The results supported
the clinical efficacy of verbal mediation training.
Additional work with a focus on greater generaliza-
tion has been carried out by Cicerone and Giacino
[78], which demonstrated that verbal mediation strate-
gies can lead to improved performance in daily life.
As noted by Onsworth et al. [79], such improvements
in self-regulatory strategies can lead to an increased
awareness of deficits and a more realistic anticipatory
awareness of situations where patients may experience
difficulty.
Von Cramon et al. [80] described positive results
in a series of patients with frontal lobe dysfunction.
Their training procedure enabled patients to reduce
the complexity of a multistage problem by breaking
it down into more manageable proportions. Problem-
solving training incorporated four modules. The first
was generation of goal-directed ideas, the second
was systematic and careful comparison of informa-
tion provided by a problem to be solved, the third
consisted of tasks requiring simultaneous analysis
of information from multiple sources and the fourth
focused on improving abilities to draw inferences.
Inferential thinking was operationalized as the ability
28 Current Approaches to Cognitive Rehabilitation
to predict the goals of another person from an
action.
In another study that used the strategy of break-
ing down a complex problem into smaller portions,
Marshall et al. [81] used a formalized modeling of
effective problem solving by a therapist. They reported
that the individuals with brain injury, following train-
ing, asked more useful questions, adopted new strate-
gies for solving problems that were not presented
during training, and showed less random guessing.
A similar series of studies aimed at metacognitive
skills fall under the approach of goal management
training (GMT) [82]. This technique uses a general
purpose algorithm to teach individuals five stages of
problem solving (stop, define the task, list the steps
needed, learn the steps, and check your performance).
In a controlled study, Levine et al. [63] demonstrated
the superiority of GMT to motor skills training when
comparing two groups of individuals with brain injury.
This has also been applied to naturalistic tasks such as
meal preparation.
As with other areas of treatment discussed, the use
of metacognitive strategies and self-instructional pro-
grams for individuals with acquired frontal injuries is
just beginning to be formally evaluated. It is encour-
aging, however, that positive outcomes have been
reported and that there are numerous reports of success
with such approaches in a variety of clinical popu-
lations. The executive disorders encompass a broad
range of cognitive and behavioral difficulties. Effective
strategies for such patients require an appreciation for
each person’s cognitive profile, self-regulation capac-
ity, and level of awareness, so that appropriate specific
individual therapies can be designed and generaliza-
tion can be targeted.
In this vein, Gordon et al. [83] describe a compre-
hensive day treatment program that is based on specific
targets and methods for the treatment of executive
dysfunction including cerebral organization, cognitive-
behavioral theory of problem solving, and learning
theory.
Normal Aging
Many authors have pointed out the benefits obtained
from providing multimodal approaches to cognitive
remediation (e.g. [84]). One example of this is the
513
Advanced Cognitive Training for Independent and
Vital Elderly (ACTIVE) therapies [85]. These thera-
pies apply the principles of cognitive remediation to
healthy older adults in an attempt to delay or pre-
vent the development of cognitive disabilities. This
program consists of three cognitive training modules
that target specific cognitive abilities (memory, reason-
ing, speed of processing). Large randomized controlled
trials have demonstrated that each of the three treat-
ments specifically improves that cognitive domain.
More recent studies have also demonstrated delays in
the decline of health-related quality of life specifically
due to the speed-training intervention [86].
Virtual Reality
Virtual reality is a computer-generated environment
that the user can interact with. There are four types
of virtual environments at present. These are head-
mounted displays, augmented environment, Fish Tank
environment, and projection-based environment. The
head-mounted display allows the user to feel com-
pletely immersed with all of the external environment
blocked from view. However, some users may expe-
rience unpleasant side effects, such as motion sick-
ness. In augmented virtual reality systems, both the
computer-generated images and the rest of the envi-
ronment are visible. Fish Tank systems have the vir-
tual environment displayed on a computer screen. In
projection-based paradigms a full wall has a projection
of the virtual environment. Researchers have described
virtual reality as creating complex real-world environ-
ments with laboratory control of the variables being
displayed.
Virtual reality has been used as a tool to reme-
diate a range of neurologic and psychiatric condi-
tions [87]. These include spatial inattention, attention-
deficit hyperactivity disorder, post-traumatic stress dis-
order, arm movements after stroke, traumatic brain
injury, and pain. Advantages of virtual reality therapies
include increased patient motivation, adaptability, data
storage, and reduced medical costs [88].
A review of virtual reality use in the reha-
bilitation of people with brain injury [89] shows
that studies have focused on executive dysfunction,
memory impairments, spatial ability impairments,
attention deficits, and unilateral visual neglect. For
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rehabilitation of memory impairments, virtual reality
environments have been used to improve procedural
learning, which is reported to generalize to real-world
performance [90].
Another area of increased interest is the use of vir-
tual reality for children with ADHD [91]. Rizzo and
his colleagues have created a virtual reality classroom
that has an embedded continuous performance task. In
addition, there are simulated and “real-world” auditory
and visual distracters [92].
Brain–Computer Interface
There has been considerable popular interest in
the idea of a brain–computer interface that can be
used for rehabilitation purposes. In a review by
Birbaumer and Cohen [93], the majority of these
non-invasive brain–computer interfaces (BCIs) have
been used for individuals with motor deficits follow-
ing spinal cord injury or stroke. While there have
been some promising studies using invasive proce-
dures with animals in the laboratory, there is still
a lack of proven clinical utility. BCIs are typically
based on one of several possible neurophysiologi-
cal rhythms, such as electroencephalographic oscilla-
tions. For the most part, non-invasive human studies
use biofeedback of EEG oscillations or event-related
potentials.
Human rehabilitation studies have demonstrated
some limited but promising findings. In individu-
als who have paralysis from spinal cord lesions, a
single case study suggested that the individual was
able to activate electrostimulation of arm and hand
muscles by controlling EEG readings, but it did not
seem to generalize to daily life [94]. Similarly, stud-
ies in humans using single motor or parietal neuron
spike patterns were not applicable to activites of daily
living [95].
Several groups have also tried to restore motor func-
tions following chronic stroke. In a series of studies
utilizing MEG, magnetic sensors over the sensorimo-
tor regions of the lesioned hemisphere are used for
training. Then a prosthetic hand is attached to the par-
alyzed hand and the person is trained to use visual
feedback to move the hand by increasing sensorimotor
rhythms (or mu rhythms) over the lesioned hemi-
sphere [96]. Although positive reports of movement
S.A. Raskin
have been given, training often takes a long time and
the movement tends to be slow and not naturalistic.
Conclusions
Some of the most exciting new works in the field of
rehabilitation are based on models of cortical plas-
ticity. Robertson and Murr [97] have argued that the
extent and nature of neural recovery following targeted
intervention will depend largely on the severity of the
injury. Thus, in the case of a large lesion, there may
not be sufficient residual connectivity with which to
re-establish a fully functioning network. In these cases,
then, treatment should be targeted at the compensatory
recruitment of alternative brain regions or the use of
compensatory strategies.
In a similar vein, there is some evidence to sug-
gest that patients with brain injury require training
that is tailored to their specific level of functioning.
For example, an analysis of individual differences in
a study of attention training using the APT training
by Sohlberg and colleagues [98] indicated differences
in treatment efficacy depending on a patient’s initial
vigilance level. Only individuals who had poor vigi-
lance levels showed improvements in basic attentional
skills, while only individuals with better vigilance
levels showed improvement on the more demanding
attentional or working memory tasks. Further work is
required to establish predictors of training efficacy and
future studies should delineate specific patient profiles
in order to determine who is likely to benefit.
Research in rehabilitation is increasingly being
required to follow evidence-based guidelines, as it has
been noted many times that it tends to be limited
by the heterogeneity of subjects, methods, and out-
come measures. While randomized controlled studies
are assumed to provide the best evidence of efficacy,
it is also accepted that in clinical practice it might be
necessary to combine standard treatment protocols and
individualized treatments [99].
As the field of cognitive neuroscience provides
more evidence for the specific kinds of practice and
experience-dependant learning that lead to most effec-
tive cortical plasticity, it should also be possible to
target rehabilitation efforts to maximize these potential
changes.