Cognitive rehabilitation aims to help recover mental functions impaired by brain injury through restoration, substitution, and restructuring approaches. Computerized cognitive rehabilitation (CACR) uses computer programs and exercises to retrain impaired cognitive skills. It provides personalized feedback and reinforcement through tasks of increasing difficulty. Research shows CACR improves attention, memory, and executive functions in patients with brain injuries, learning disabilities, schizophrenia, substance abuse disorders, depression, and multiple sclerosis compared to control groups. CACR appears as effective as traditional face-to-face rehabilitation with similar costs. Issues include variability in brain injury characteristics and rehabilitation programs across studies.
2. What is cognitive rehabilitation ?
Treatment designed to help people recover from mental functions that are
lost or impaired following a brain injury .
Different rehabilitation approaches:
1. Restoration: Cognitive training and retraining strategies meant to
strengthen and restore one function
2. Substitution: Compensatory devices that help to replace a lost function
3. Restructuring:
Environmental restructuring: Changing family demands placed on the
individual
Using educational and vocational facilities
Following the patients in their environment (Sohlberg & Mateer, 2001)
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3. What is not
• Cognitive rehabilitation concerns information processing
Cognitive rehabilitation = cognitive retraining = cognitive remediation
• Psychotherapy influences patient’s image on self and surroundings
• Psychoactive drugs targets brain receptors
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4. What is computerised cognitive
rehabilitation (CACR) ?
A computer is used as a high tech tool for retraining impaired cognitive skills of
neurologically- and psychiatrically-based problems (Bracy, 1999)
Requirements: clinically stable patients -able to concentrate 20 min
accurate cognition assessment
The key elements include:
1. Intrinsic motivation –task performance is in itself rewarding
2. Guided practice in computer-based training exercises
3. Supportive, one-on-one ,training sessions
4. Task engagement through contextualization
5. Personalized feedback
6. Positive reinforcement (Medalia, J & Revheim, 1999; Castelnuovo, Prione, Liccione, &
Cioffi,2003)
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5. Historical Development
Introduction of game-like programs in cognitive rehabilitation of brain-injured
individuals (Lynch,1983)
First software program designed to train
Attention Reaction time Perceptual motor skills
Memory Problem solving Reasoning (Lynch, 1992).
• Program software designed to exercise visual perception, attention, and
memory capacity (Gianutsos, 1992)
• NeurXercise: Cognitive training videogame-like program for individuals
suffering from brain-injuries (Podd & Seeling, 1992)
A battery of interrelated cognitive-training set of programs (Bracy, 1983)
developed into a Psychological Software Service (PSS)
o Neuroscience Center of Indianapolis (NSC): First evidence-based cognitive
rehabilitation clinic
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6. Building Block Theory
The training tasks unfold in a hierarchically fashion.
Level 1: Exercises address basic cognitive processes, such as:
- Receptors, nerve pathways and primary cortical areas function
properly
Level 15: Exercises grow in complexity and build on previous levels.
-integrate perceptions
Level 24:
-retrieve stored information (Bracy O.L., 1986)
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7. Computer assisted cognitive
rehabilitation clinic
NeuroScience Center of Indianapolis (NSC) clinical services are based
on PSSCogRehab program developed by Dr. Bracy
It contains 8 software modules; 64 computerized tasks.
Applications: Assessment, diagnostics, report writing , and
rehabilitation therapy
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8. Empirical support for PSSCogRehab
Brain injuries
o Patients with severe closed head injury received 20 hours over 4 to 6 weeks
o PSSCogRehab displayed significant improvements from pre- to post-
treatment and in comparaison to non-computerised control group
o (Batchelor, Shores, Marosszeky, Sandanam, & Lovarini, 1988).
o Patients with brain injury received CACR /Control matched group received
only speech and occupational therapies.
o Both higher on post neuropsychological measures on attention, memory, visuo-
spatial ability, and problem solving.
o No differences between groups (Chen, Thomas, Glueckauf, & Bracy, 1997)
Learning
o 80 children
o Computer assisted programs for education and cognitive rehabilitation
targeting intellectual functioning (9 weeks)
o Significant advancement on problem solving skills, attention, and visuo-
spatial tests (Bracy, Oakes, Cooper, Watkins, Brown, & Jewell, 1999)
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9. Empirical support for PSSCogRehab
Schizophrenia and schizoaffective disorder:
o N=65 ; randomly assigned
Experimental group: Computer-based training on attention, memory,
and executive functions & work therapy (i.e. paid work with supportive
aids)
control group: Only work therapy
Measures: Cognitive abilities & feedback on work performance
Experimental group improved on WM, affect recognition, and
executive function
1 year follow-up
o Maintanance: WM, affect recognition and executive functioning
o Increased value on job market
(Bell, Bryson, Greig, Corcoran, & Wexler, 2001; Bell, Zito, Greig, & Wexler, 2008).
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10. Website-based cognitive
rehabilitation
Neuropsycholine (NPO)
o Internet-based application for assessment, diagnosis, and treatment of
injury
o Upgrades are automatic
o Subscribers have unlimited use of the software to assess, diagnose, write
clinical reports and treat an unlimited number of patients
Challenging Our Minds was developed for children
http://www.challenging-our-minds.com/tour/sample1/t03t01.php
Currently used for rehabilitation treatment in over 300 facilities
o 4 US Military Bases and 5US Veteran's Administration Medical Centers
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11. CACR randomised controlled trials
Alzheimer’s Disease (N= 14 mildly cognitive impaired)
o 10 X 30 minutes of interactive computerized training for memory of
objects and routes in a standard residence
o Results: superior performance than control group-chat with a
psychologist (Schreiber, Schweizer, Lutz ,Kalveram, & Jäncke, 1999)
• Attention (N = 77 first grade with ADD symptoms)
o Captain’s Log program: 36 exercises - auditory and visual sustained
attention and impulse control
o Results: significantly less attention problems than control (Rabiner, Desiree,
Skinner, & Malone, 2010).
• ADHD ( N = 4 severe ADHD)
o 64 training sessions with Captain’s Log
o Decreased hyperactive behaviour (Slate, Meyer, Burns, & Montgomery, 1998).
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12. CACR randomised controlled trials
Substance-abuse disorders
o Residential care patients (N=160; randomly assigned)
o CACR plus standard treatment condition OR computer-based typing
tutorial plus standard treatment.
o Follow up at 3, 6, 9 and 12 months.
o Results: CACR group were more engaged in treatment
Adherence to treatment was superior and
Longer abstinence time (Fals Stewart &Lam, 2010)
Opioid-dependent outpatients
o Interactive program therapy plus with voucher-based contingency OR
only therapy implemented by clinician
o Results: Improvement compared to only therapy implemented by clinician
(Bickel, Marsch, Buchhalter, & Badger, 2008)
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13. CACR randomised controlled trials
Depression (N=12 with recurrent MDD)
o Computerized treatment (first-time used; Elgamal et al, 2007).
o Results: Improvement on attention, verbal learning, memory, psychomotor
speed and executive function compared to healthy control group
o However, depressive symptoms persisted over the trial
Multiple sclerosis (mild disabilities)
o Results: Treatment group (CACR for attention, information processing, and
executive functions) performed better than control group (no
rehabilitation program) after 3 months (Mattioli, Chiara, Deborah ,Giovanni, &
Ruggero, 2010)
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14. CACR versus face-to-face
rehabilitation
Study comparing CACR and face-to-face rehabilitation
Target: attention, reaction time, learning, visuospatial skills, and problem
solving
Control: age, gender, education, dominant hand, IQ, and time elapsed since
injury
Results: no differences on living without anybody ‘s help, driving, and
school/home return
Study also examined the cost: cost was similar for both groups.
Time was longer for CACR group and cost per hour was higher for FTF
group (Schoenberg, Ruwe, Dawson, McDonald, Houston, & Forducey, 2008)
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15. Issues
Brain injured patients with cognitive deficits need clear instructions;
unfriendliness in software may reinforce the patient's maladaptive
behaviour and affect the rate of learning
Engaging clients in learning tasks can be quite challenging:
schizophrenia impacts motivation (Schoenberg, Ruwe, Dawson, McDonald,
Houston, & Forducey, 2008)
Methodological issues in brain injuries research : variability in
preinjury characteristics of the sample, severity and site of injury, time
between injury moment and beginning of treatment ;
Variability in data collections: intervention variability in terms of
frequency, intensity, and duration.
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16. CACR and computer-assisted
psychotherapy
Commonalities:
Assessment procedure
Treatment based on learning theory, cognitive psychology, neuropsychology
Addressing the emotional state that may interfere with
rehabilitation process
Differences:
-Rehab: treatment involve exercises from occupational domain designed to address fine
motor manipulation, manipulations of blocks into various pattern, visual-spatial
analysis
-Psychotherapy: face-to-face interventions, strategies focus on changing how you think
and behave.
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17. References
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severely closed-head-injured patients using computer-assisted and noncomputerized treatment
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00012
Bell, M. D., Zito, W., Greig, T., & Wexler, B. E. (2008). Neurocognitive enhancement therapy with
vocational services: Work outcomes at two-year follow-up. Schizophrenia Research, 105(1-3), 18-29.
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