1 s2.0 S0003999305003308 Main

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REVIEW ARTICLE
Evidence-Based Cognitive Rehabilitation: Updated Review of

the Literature From 1998 Through 2002
Keith D. Cicerone, PhD, Cynthia Dahlberg, MA, CCC-SLP, James F. Malec, PhD,
Donna M. Langenbahn, PhD, Thomas Felicetti, PhD, Sally Kneipp, PhD, Wendy Ellmo, MS, CCC-SLP,
Kathleen Kalmar, PhD, Joseph T. Giacino, PhD, J. Preston Harley, PhD, Linda Laatsch, PhD,
Philip A. Morse, PhD, Jeanne Catanese, MA, CCC-SLP
ABSTRACT. Cicerone KD, Dahlberg C, Malec JF, Langenbahn DM, Felicetti T, Kneipp S, Ellmo W, Kalmar K, Giacino
JT, Harley JP, Laatsch L, Morse PA, Catanese J. Evidencebased cognitive rehabilitation: updated review of the literature
from 1998 through 2002. Arch Phys Med Rehabil 2005;86:
1681-92.
Objective: To update the previous evidence-based recommendations of the Brain Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine for cognitive rehabilitation of people with traumatic brain
injury (TBI) and stroke, based on a systematic review of the
literature from 1998 through 2002.
Data Sources: PubMed and Infotrieve literature searches
were conducted using the terms attention, awareness, cognition, communication, executive, language, memory, perception,
problem solving, and reasoning combined with each of the
terms rehabilitation, remediation, and training. Reference lists
from identified articles were reviewed and a bibliography listing 312 articles was compiled.
Study Selection: One hundred eighteen articles were initially selected for inclusion. Thirty-one studies were excluded
after detailed review. Excluded articles included 14 studies
without data, 6 duplicate publications or follow-up studies, 5
nontreatment studies, 4 reviews, and 2 case studies involving
diagnoses other than TBI or stroke.
Data Extraction: Articles were assigned to 1 of 7 categories
reflecting the primary area of intervention: attention; visual
perception; apraxia; language and communication; memory;
executive functioning, problem solving and awareness; and
comprehensive-holistic cognitive rehabilitation. Articles were
abstracted and levels of evidence determined using specific
criteria.
Data Synthesis: Of the 87 studies evaluated, 17 were rated
as class I, 8 as class II, and 62 as class III. Evidence within each
area of intervention was synthesized and recommendations for
practice standards, practice guidelines, and practice options
were made.
From JFK-Johnson Rehabilitation Institute, Edison, NJ (Cicerone, Kalmar, Ellmo,

Giacino, Catanese); Craig Hospital, Englewood, CO (Dahlberg); Rusk Institute of
Rehabilitation Medicine, New York, NY (Langenbahn); Mayo Medical Center and
Medical School, Rochester, MN (Malec); Beechwood Rehabilitation Services, Langhorne, PA (Felicetti); Marianjoy RehabLink, Wheaton, IL (Harley); Community
Skills Program, Counseling and Rehabilitation Inc, Marlton, NJ (Kneipp); University
of Illinois, Chicago, IL (Laatsch); and Neurobehavioral Services of New England,
Portland, ME (Morse).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to Keith D. Cicerone, JFK-Johnson Rehabilitation Institute, 2048
Oak Tree Rd, Edison, NJ 08820, e-mail: kcicerone@solarishs.org.
0003-9993/05/8608-9612$30.00/0
doi:10.1016/j.apmr.2005.03.024
Conclusions: There is substantial evidence to support cognitive-linguistic therapies for people with language deficits
after left hemisphere stroke. New evidence supports training
for apraxia after left hemisphere stroke. The evidence supports
visuospatial rehabilitation for deficits associated with visual
neglect after right hemisphere stroke. There is substantial evidence to support cognitive rehabilitation for people with TBI,
including strategy training for mild memory impairment, strategy training for postacute attention deficits, and interventions
for functional communication deficits. The overall analysis of
47 treatment comparisons, based on class I studies included in
the current and previous review, reveals a differential benefit in
favor of cognitive rehabilitation in 37 of 47 (78.7%) comparisons, with no comparison demonstrating a benefit in favor of
the alternative treatment condition. Future research should
move beyond the simple question of whether cognitive rehabilitation is effective, and examine the therapy factors and
patient characteristics that optimize the clinical outcomes of
cognitive rehabilitation.
Key Words: Brain injuries; Cognition disorders; Practice
guidelines; Rehabilitation; Stroke.
2005 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and
Rehabilitation
HE BRAIN INJURY interdisciplinary Special Interest
Group (BI-ISIG) of the American Congress of RehabilitaT
tion Medicine (ACRM) previously conducted an evidencebased review of the literature through 1997 about cognitive
rehabilitation for people with traumatic brain injury (TBI) or
stroke.1 That review led the BI-ISIG to make several specific
recommendations concerning the clinical practice of cognitive
rehabilitation and its effectiveness in TBI and stroke patients.
Since publication of our initial findings, several additional
systematic reviews of cognitive rehabilitation have been published. A task force under the auspices of the European Federation of Neurological Societies2 used similar methods and
reviewed many of the same studies referenced in our initial
report. That task force concluded that there is substantial evidence to support attention training in the postacute phase after
TBI (but not during the period of acute recovery) and compensatory memory training for subjects with mild memory impairments. Evidence of the effectiveness of pragmatic conversational therapy after TBI was based on a limited number of
studies with small samples, and was in need of confirmation.
Several methods of rehabilitation for spatial neglect were found
to be effective, as was the treatment of apraxia with compensatory strategies. As part of a broader effort by the Academy of
Neurologic Communication Disorders and Sciences to develop
practice guidelines for treating cognitive-communication disorders after TBI, Sohlberg et al3 examined the evidence for the
effectiveness of direct attention training after TBI. They conArch Phys Med Rehabil Vol 86, August 2005
1682
UPDATE ON COGNITIVE REHABILITATION, Cicerone
cluded that there was evidence of improvement in attentionbased skills with direct training, although the interpretation of
studies was limited by factors such as subject heterogeneity and
the lack of replications. Two Cochrane reviews have examined
cognitive rehabilitation for attention deficits4 or memory deficits5 after stroke, but only class I studies were included. Lincoln et al4 concluded there was some evidence that training
improves alertness and sustained attention but insufficient evidence of improved functional independence after stroke. Majid et al5 identified a single study that met their criteria for
inclusion and found insufficient evidence to support or refute
the effectiveness of cognitive rehabilitation for memory problems after stroke.
Several systematic reviews6-8 found evidence that cognitive
rehabilitation, including visual scanning training, improves
spatial neglect after right hemisphere stroke, but also found that
there is limited or insufficient evidence for the duration of
treatment effects or relevance to everyday functioning.6,8 Systematic reviews of treatment for aphasia have reached conflicting conclusions. Robey9 conducted a meta-analytic review of
55 studies of clinical outcomes after aphasia rehabilitation.
These were generally observational studies, rather than randomized controlled trials (RCTs). Outcomes for treated subjects were superior to outcomes for untreated subjects in all
stages of recovery, particularly when treatment was begun in
the acute stage of recovery, and the extent of treatment effects
was positively associated with the amount of treatment. There
were too few studies to permit an examination of the differential effects of treatments for different types of aphasia. Cappa
et al2 found some evidence for the effectiveness of aphasia
therapy, again based largely on class II and III studies. In
contrast, a Cochrane review10 of aphasia rehabilitation identified only 12 RCTs suitable for the authors review, none of
which were considered of adequate methodologic quality to
warrant complete description and analysis. The main conclusion reached in that review was that aphasia therapy after
stroke has not been shown to be clearly effective or ineffective
within an RCT.
These systematic reviews have generally found some evidence to support the effectiveness of cognitive rehabilitation
after TBI or stroke, but have also recognized the need for better
specification of treatment effects and increased methodologic
rigor, and have sometimes limited their conclusions on these
grounds. We recognize that clinical guideline development is
an ongoing process that should include an updated review of
the literature within 5 years of the initial recommendations.
The BI-ISIG recently completed an updated evidence-based
review and made recommendations that incorporate the literature published from 1998 through 2002. This article summarizes those findings and recommendations. In this article, we
concentrate on describing class I studies. Class II and III
studies are discussed when they provide unique or contradictory information. A more complete discussion of these studies
is in the full report of the BI-ISIG committee (online at http://
www.acrm.org).
METHODS
We followed prior methodology for identifying relevant
literature, reviewing, and classifying, and developing recommendations. These methods are described in more detail in our
initial publication.1 For the current review, we searched
PubMed and Infotrieve for articles published between 1998 and
2002, using the terms attention, awareness, cognitive, communication, executive, language, memory, perception, problem
solving, and reasoning combined with each of the terms rehabilitation, remediation, and training. We elected to include
Arch Phys Med Rehabil Vol 86, August 2005
RCTs published before 1998 that were not included in our first
review, but not other studies. Two such articles were identified
and included in this review. This resulted in the identification
of 312 articles. The abstracts or complete articles were reviewed to eliminate articles according to the following exclusion criteria: (1) articles not addressing intervention, (2) theoretical articles or descriptions of treatment approaches, (3)
review articles, (4) articles without adequate specification of
interventions, (5) articles that did not include participants primarily with a diagnosis of TBI or stroke, (6) studies of pediatric subjects, (7) single-case reports without empirical data,
(8) nonpeer-reviewed articles and book chapters, (9) articles
describing pharmacologic interventions, and (10) articles not
written in English. One hundred eighteen articles were included this screening process. Thirty-one studies were excluded after further detailed review (14 studies without data, 6
articles representing duplicate publications or follow-up studies, 5 articles that were nontreatment studies or experimental
manipulations, 4 reviews, and 2 single-case studies of subjects
with diagnoses other than TBI or stroke). Studies providing
follow-up to previously reviewed treatment studies were not
fully evaluated or classified as new treatment studies, but
findings from these studies were reviewed and are discussed
here when appropriate.
Eighty-seven studies were fully reviewed and evaluated,
with the level of evidence determined based on criteria used in
our prior review.1 Well-designed, prospective RCTs were considered class I evidence; studies using a prospective design
with quasirandomized assignment to treatment conditions
were designated as class Ia studies. Given the inherent difficulty in blinding rehabilitation interventions, we did not consider this as criterion for class I or Ia studies. Class II studies
consisted of prospective, nonrandomized cohort studies; retrospective, nonrandomized case-control studies; or multiplebaseline studies that permitted a direct comparison of treatment
conditions. Clinical series without concurrent controls, or single-subject designs with adequate quantification and analysis
were considered class III evidence. Articles were reviewed and
classified by at least 2 committee members. Disagreements
between the 2 primary reviewers (as happened with 7 articles)
were first addressed by discussion between reviewers to correct
minor sources of disagreement, ant then by obtaining a third
review.
Of the 87 studies, 17 were rated as class I, 8 as class II, and
62 as class III. The overall evidence within each predefined
area of intervention was synthesized and recommendations
were derived from the relative strengths of the evidence. The
level of evidence required to determine practice standards,
practice guidelines, or practice options was based on the
decision rules applied in our initial review (appendix 1). All
recommendations were reviewed by the entire committee to
ensure consensus.
Remediation of Attention Deficits
We identified 5 studies on remediation of attention deficits
after TBI. Two were class I prospective randomized studies11,12 comparing attention treatment with alternative treatments; 1 was a class II study13 that compared attention treatment with no treatment; and 2 were class III studies.14,15
Sohlberg et al11 used a crossover design to compare the
effectiveness of attention process training (APT) brain injury
education and support for 14 patients with acquired brain
injury. Self-reported changes in attention and memory functioning, as well as improvement on neuropsychologic measures
of attention-executive functioning, were greater after APT than
after therapeutic support. The second class I study12 taught 22
patients with severe TBI to compensate for slowed information

processing and the experience of information overload in
daily tasks. Participants were randomly assigned to receive
either time pressure management (TPM) or an alternative treatment of generic concentration training. Participants receiving
TPM showed significantly greater use of self-management
strategies and greater improvement of attention and memory
functioning than did participants who received the alternative
treatment.
Although the precise nature of the interventions in these 2
class I studies differ, they share a common emphasis on the
development of strategies to compensate for residual cognitive
deficits (strategy training) rather than attempting to directly
restore the underlying impaired function (restitution training). The results of these 2 studies and of an additional small
class II study13 are therefore consistent with a strategy training
model for attention deficits after TBI, and reinforce the conclusions made in our initial review.1
Clinical recommendations. In the current review, there is
evidence from 2 class I studies11,12 with 36 subjects that
supports the effectiveness of attention training for subjects with
TBI during the postacute period of rehabilitation. Considering
this evidence, along with our previous recommendation based
on 2 class I studies with 57 subjects,1 the committee recommends that strategy training for attention deficits exhibited by
subjects with TBI be considered as a practice standard during
the postacute period of rehabilitation. Results of studies in this
area suggest greater benefits on complex tasks requiring the
regulation of attention, rather than on basic aspects of attention
(eg, reaction time or vigilance). These results are consistent
with the emphasis on strategy training to compensate for attention deficits in functional situations. There is insufficient
evidence to support the use of specific interventions for attention deficits during acute rehabilitation.
Recommendations for future research. Evidence from 1
class I study11 suggests that cognitive remediation has differential effects on various components of attention; therefore,
more research is needed to clarify the differential effects of
interventions. The finding that cognitive interventions influence the regulation of attention can be contrasted with pharmacologic treatment, which may exert its primary effect on
basic processing speed.16 This suggests that a combination of
cognitive and pharmacologic interventions may produce the
greatest overall improvement in attention deficits after TBI,
although this has not been evaluated through controlled
research.
Remediation of Visuospatial Deficits
We reviewed 11 studies in the area of rehabilitation of
visuoperceptual deficits. The majority of these involved rehabilitation of unilateral visual neglect, and 1 involved the restitution of visual fields. The 13 studies included 3 class I17,18 or
Ia19 studies, 3 class II studies,20-22 and 5 class III studies.23-27
Two class I or Ia studies involved the rehabilitation of visual
neglect after stroke. The class Ia study19 was a prospective
controlled trial that replicated a prior class II study.28 Training
for neglect produced improvement on standard neglect tests
and a functional measure evaluating generalization, compared
with general cognitive stimulation. Niemeier18 found systematic cueing of visual scanning to be superior to conventional
rehabilitation (which did not produce improvement).
Kasten et al17 examined computer-based treatment of partial
blindness resulting from optic nerve damage or postchiasmal
lesions. The training was intended to restore the underlying
neurologic and visual functions and reduce the extent of the
damaged visual fields (ie, restitution training). The training
1683
resulted in significant enlargement of the visual field in 95% of

the subjects, which remained stable 2 years later.29
One class II22 and 1 class III25 study replicated class I
demonstrations that visual scanning is an effective treatment
for visual neglect. Additional class II20 and class III23,24,26,27
studies introduced forced activation of the affected limb in
conjunction with visual scanning training as a treatment for
visual, and possibly sensory, neglect.
Clinical recommendations. Two class I18 or Ia19 studies of
41 subjects with cerebral stroke replicated the effectiveness of
visual scanning in treating unilateral neglect, consistent with
the 6 class I studies involving 286 subjects from our prior
review.1 These class I studies demonstrating the efficacy of
visual scanning training for visual neglect strongly support that
this type of intervention as a practice standard. Inclusion of
limb activation or electronic technologies for visual scanning
training is recommended as a new practice option, pending
confirmation of efficacy through more rigorous investigation.
A class I study17 provided evidence that computer-based
restitution training can reduce the extent of damaged visual
fields due to postchiasmal lesions, and produce subjective
improvements in visual functioning. We previously noted1 that
the observed reductions in visual field defects were insufficient
to explain the associated reduction in functional impairments,
and that functional improvement was associated with increased
compensation rather than change in the underlying visual field
deficit. We recommend that interventions intended to reduce
the extent of damaged visual fields be considered a practice
option, pending replication by independent investigators.
Recommendations for future research. Class I studies
verifying the usefulness of technologies that might increase the
availability of visual scanning treatment, such as computer
projection22 and the Useful Field of View test25 introduced in
class II and III studies, should be conducted. Class II and III
studies demonstrating positive results for limb activation in
conjunction with visual scanning treatment for neglect merit
verification through class I research.
The evidence that visual restitution training may actually
result in regeneration of the visual fields makes it increasingly
difficult to dismiss this possibility, even though it runs counter
to conventional neurologic wisdom. This method merits further
independent and rigorous investigation in other centers. Such
studies should attempt to differentiate between the contribution
of visual restitution training intended to have an impact directly
on visual field restrictions and the contribution of compensatory mechanisms (eg, improved scanning) to improved
functioning.
Prospective, controlled (class I) studies of interventions to
improve more complex visuospatial abilities required for functional activities (eg, meal preparation, driving) are recommended. Such interventions were explored through class II and
III studies with positive results in our previous review, but
further investigation of such interventions is noticeably absent
in this update.
Remediation of Apraxia
There was a new area of focus with 2 class I30 or Ia31 studies
of rehabilitation for apraxia. Apraxia, the inability to do learned
and purposeful activities such as dressing, can result in selfcare deficits and dependence on caregivers. Smania et al31
compared the effectiveness of gestural training and object use
in 13 subjects with limb apraxia after left hemisphere stroke
with conventional aphasia therapy. Despite an equal amount of
treatment, the group receiving conventional therapies showed
no improvement, while the apraxia treatment produced improvement in both ideational and ideomotor apraxia. DonkerArch Phys Med Rehabil Vol 86, August 2005
1684
voort et al30 conducted a multisite study of subjects with

apraxia from left hemisphere stroke. Subjects were randomized
to receive either strategy training integrated into occupational therapy (OT) or conventional OT. The main principle of
the strategy training program was the use of internal or external
compensations for the apraxic impairment during the performance of activities of daily living (ADLs).32 The emphasis of
conventional treatment was on sensorimotor impairments. During the first 8 weeks of their inpatient stay, all subjects received
15 to 19 hours of treatment, with no difference in the amount
of treatment provided in the 2 conditions. Strategy training was
more effective in improving ADL function than the conventional OT at the conclusion of the 8 weeks of training. At
5-month follow-up, there were no differences between the 2
groups; apparently because of the continued improvement in
the subjects who had received (and in some cases were still
receiving) conventional treatment. The investigators suggested
that patients receiving conventional therapy needed more therapy to improve their ADL functioning.
Clinical recommendations. Two class I30 or class Ia31
studies of 126 subjects with left hemisphere stroke provide
evidence that apraxia can be treated effectively and may facilitate improvement in functional ADLs during the initial period
of inpatient rehabilitation, compared with conventional sensorimotor or aphasia therapies. Specific gestural or strategy training for apraxia after left hemisphere stroke is therefore recommended as a new practice standard during acute rehabilitation.
Remediation of Language and Communication Deficits
The remediation of neurogenic communication disorders is
an active area of research, with 40 studies identified in the
current review that addressed a range of language-related impairments. There were 3 class I studies,33-35 1 class Ia study,36
1 class II study,37 and 35 class III studies.38-72 Most of this
research involved subjects with left hemisphere stroke (35
articles with a total of 253 stroke subjects). Three studies in
which the subjects were primarily people with stroke also
included subjects with TBI.38-40 There were also 4 singlesubject studies of people with TBI.42-45 There was 1 study41 of
6 subjects with TBI for a total of 16 subjects with TBI in 8
research articles during this review period.
Denes et al33 evaluated the effect of intensity of treatment for
17 subjects with global aphasia at an average of 3 months
postonset, using a functional stimulation approach to therapy.
More subjects with intensive treatment reached significant improvement in all language modalities. This concept was supported by 3 class III articles reporting improved functional
communication after chronic stroke46 and improved naming
ability of subjects with stroke or TBI40,43 with increased intensity of treatment. Constraint-induced movement therapy
(CIMT) to improve language skills after left hemisphere stroke
was evaluated in a class I study of 17 subjects with chronic
aphasia.35 CIMT was described as massed practice of verbal
responses that was designed to constrain patients to the systematic practice of speech acts with which they had difficulty.
The results demonstrated significant benefit of CIMT compared
with conventional aphasia therapy.
Elman and Bernstein-Ellis34 evaluated the effectiveness of
group communication treatment after left hemisphere stroke.
All participants were at least 6 months postinjury and were
stratified according to their initial aphasia severity. They were
randomly assigned to receive either group communication
treatment or deferred treatment. Group communication treatment focused on initiating conversations and conveying a message, understanding the communication disorder, being aware
of personal goals and progress, and having confidence in being
able to communicate in personally relevant situations. To control for the effect of social contact, the control subjects participated in social activities (eg, movement classes, church activities) while their group communication treatment was deferred.
Participants who received the group communication treatment
showed significantly more improvement in functional communication. In an effort to evaluate a cost-effective and functional
treatment program, Worrall and Yiu36 compared a home-based,
functional communication program provided by trained volunteers with non-language-based recreational treatment and no
treatment conditions, for people with chronic aphasia. Between-group comparisons revealed significant improvement
from the functional communication program compared with no
treatment, but not compared with recreational activities.
There is evidence supporting the use of cuing techniques and
semantic analysis to improve naming ability by people with
aphasia and TBI,43,44,46,52,53,56,57,65,69,71 to improve writing
skills in patients with chronic aphasia,46-51,61,67,68 and to improve sentence production in patients with agrammatic aphasia.39,59,64,70 These studies, along with the studies from the last
review,1 support the efficacy of treating naming disorders in
people with chronic aphasia, but there is still no clear evidence
that one method is more effective than another.
A class III study by Wiseman-Hakes et al41 supported the
effectiveness of group treatment to improve pragmatic communication skills for 6 subjects with TBI. However, 1 class III
single-subject study42 failed to demonstrate the effectiveness of
pragmatic training, primarily because of the limited contextual
aspects of the treatment.
Clinical recommendations. The results from 3 class I studies33-35 of treatment of language deficits in 58 subjects after left
hemisphere stroke are consistent with the results from 3 class
I studies with 169 subjects from our prior review,1 and provide
additional support for the practice standard recommending
cognitive linguistic therapies during acute and postacute rehabilitation for such subjects. There is evidence that group communication treatment can produce clinically meaningful improvements in language functioning, including improved
functional communication, beyond the effects of social contact
alone.34,41
Two class I studies with 34 subjects33,35 and 3 class III
studies40,43,46 with 44 subjects support the concept that increased intensity of treatment for subjects with aphasia results
in improved communication skills. We recommend that treatment intensity be considered as a key factor in the rehabilitation of language skills after left hemisphere stroke, as a new
practice guideline.
Several class III studies provide additional support for the
established practice guideline that interventions for specific
language impairments, such as reading comprehension and
language formulation, are effective after left hemisphere stroke
or TBI.
Two class III studies53,65 suggest that independent computer
use may serve as an adjunct to clinician-directed treatment of
word retrieval. Based on these findings, the committee recommends as a practice option that computer-based interventions
be considered as an adjunct to treatment when there is therapist
involvement; sole reliance on repeated exposure and practice
on computer-based tasks without some involvement and intervention by a therapist is not recommended.
Recommendations for future research. Given the overall
evidence to support the effectiveness of language interventions
after left hemisphere stroke, additional research should be
directed at specific parameters of treatment related to effectiveness. Several studies suggest that more intense treatment, in-
cluding massed practice, produces significant benefits; this area

merits further controlled investigation.
Several studies from this and our prior review suggest that
intervention provided in the home or community by trained
volunteers can improve language functioning.36,73,74 We identified several additional studies that addressed training for
volunteers75 or caretakers76 to support the conversation of
partners with aphasia; however, we excluded those studied
from formal review because they did not directly treat the
people with aphasia. This may represent a valuable adjunct or
alternative to traditional treatments, particularly for chronic
aphasia, that merits further controlled investigation.
There remains a compelling need for controlled studies of
interventions to improve pragmatic communication in people
with TBI.
Remediation of Memory Deficits
Studies of the remediation of memory deficits have continued to address the use of compensatory strategies, as well as a
growing interest in evaluating the application of assistive technology. We reviewed 13 studies in this area, including 3 class
I77,78 or Ia79 studies, 2 class II studies,80,81 and 8 class III
studies.82-89
Two class I studies77,78 addressed the effectiveness of training strategies in memory rehabilitation. Kaschel et al77 evaluated the use of a simple visual imagery technique for the
rehabilitation of participants with mild memory impairment
after acquired brain injury. Visual imagery was compared with
the standard approach to memory treatment in 7 different
rehabilitation centers (eg, practical guidelines to improve memory, use of notebooks and calendars). Both the visual imagery
and standard conditions were preceded by 3 months of notreatment baseline; this was followed by memory training for
30 sessions over 10 weeks, with follow-up assessment 3
months later. Significant improvement was apparent for the
imagery condition, and was restricted to the therapeutic interval and recall of verbal material, consistent with predictions.
The improvements associated with visual imagery training
were paralleled by positive changes in relatives ratings of
patients memory functioning and were maintained at 3-month
follow-up.
Ownsworth and McFarland78 investigated the remediation of
everyday memory impairment using a diary combined with
self-instructional training. The addition of the self-management
strategy to diary use was associated with better maintenance of
strategy use and greater decline in memory problems. The
results are consistent with a previous single-subject study90 and
also suggest that some forms of compensatory strategy training
may be beneficial to patients who are many years postinjury.
These class I studies from this review are consistent with the
conclusions from our prior review, indicating that compensatory memory strategy training is effective for patients with
relatively mild memory impairment.
One class Ia study79 extended the results of a previous class
II study91 investigating the effectiveness of a portable pager
(NeuroPage) to improve independence in people with memory
and planning problems. During the intervention period, the
pager was used to address specific problems in daily functioning that were identified by patients or relatives. Significant
improvements in participants completion of everyday tasks
resulted, compared with no-treatment and baseline conditions.
Use of a pager appears to be particularly beneficial for people
who must complete certain tasks on a regular basis, and is
facilitated by its ease of use and relevance to patients selfidentified needs.87 Five additional class III studies84-86,88,89
investigated the application of some form of external compen-
1685
sation for memory impairments using assistive technology (eg,

voice organizers).84,85,89
Clinical recommendations. Two class I studies77,78 with
41 participants demonstrated the effectiveness of memory strategies for subjects with mild memory impairments after TBI or
stroke, including reducing memory failures. These findings are
consistent with the previous 4 class I studies1 with 91 subjects
and support the use of strategy training for subjects with mild
memory impairment as a practice standard. These interventions
may consist of internal strategies (eg, visual imagery) as well
as compensation through the use of notebooks or diaries. The
benefits of specific intervention strategies may be evident in
discrete aspects of memory performance, for example, visual
imagery to facilitate verbal recall.77 There is evidence that the
incorporation of self-management techniques enhances the use,
maintenance, and perceived helpfulness of a memory notebook.78 There is also evidence that interventions to promote the
use of external memory aids can benefit people with TBI who
are many years postinjury.78
The use of externally directed assistive devices such as
pagers and voice organizers appears to benefit people with
moderate to severe memory impairments, including evidence
from 1 class Ia79 study that included subjects for whom previous interventions were ineffective. These interventions facilitate completion of everyday activities that subjects have selfidentified as relevant. The use of external memory aids and
assistive devices may require extensive training,1 or may need
to remain under the direction of someone other than the person
with memory impairment.79,86 As with our previous recommendation on the use of interventions directed at the acquisition of specific skills, these interventions appear effective for
increasing specific behaviors rather than improving memory
function. Based on current evidence and in conjunction with
the evidence from our previous review, training in the use of
external compensations (including assistive technology) with
direct application to functional activities is recommended as a
practice guideline in subjects with moderate or severe memory
impairment after TBI or stroke.
Recommendations for future research. Findings from 1
class I study77 are notable for suggesting that a specific intervention has a differential impact on different aspects of memory functioning. This finding requires replication. The effectiveness of various assistive technologies to compensate for
severe memory impairment should be investigated through
additional prospective, controlled studies.
Remediation of Executive Functioning, Problem-Solving,
and Awareness
The area of executive functioning includes several integrative cognitive processes by which people monitor, manage, and
regulate the orderly execution of goal-directed ADLs. We
reviewed 9 studies concerned with executive functioning, problem solving, and awareness, including 1 class I study,92 1 class
Ia study,93 and 7 class III studies.94-100
The class I study92 evaluated the effectiveness of a problemsolving intervention, goal management training (GMT), on
successful task completion. Participants received either 1 hour
of GMT or 1 hour of motor skills training. GMT was associated
with improved performance on paper-and-pencil measures intended to simulate everyday activities. The fact that the entire
treatment in this trial was limited to a single hour of instruction
limits the translation of these findings in terms of the clinical
application and effectiveness of the intervention.
One class Ia study addressed the internalization of selfregulation strategies. Medd and Tate93 examined the effectiveness of a cognitive-behavioral program of anger management
1686
that involved self-awareness and self-instructional training.

Efforts were made to increase participants awareness of anger
via training to recognize their cognitive, physical, and emotional reactions. Results showed a significant decrease in the
outward expression of anger for the treatment group compared
with controls, suggesting improved emotional self-regulation
as a result of treatment. One class III study95 evaluated a group
treatment program developed to enhance self-regulation skills
and self-awareness in 21 patients with acquired brain injury.
After treatment, participants reported greater awareness of deficits and increased use and effectiveness of strategies in their
daily life.
In the Medd and Tate study,93 there was no change in
participants awareness of anger problems with the treatment.
Three class III case studies specifically addressed techniques
for improving awareness by promoting internal control of
behavior: one via self-monitoring techniques96 and the others
using observer feedback and self-evaluation.97,98 Several of
these studies suggest that behavioral improvement is not contingent on increased self-awareness.93,99,100
Clinical recommendations. One class I study with 30 participants supports the effectiveness of interventions for problem-solving deficits,92 although the direct application to clinical practice is constrained by the limited extent of the
intervention. A class III study95 demonstrated improved strategy application and psychosocial functioning after training in
problem solving. These findings are consistent with a class Ia
study with 37 participants from our prior review,1 and reinforce
the practice guideline recommending the training of formal
problem-solving strategies and their application to everyday
situations and functional activities of people with TBI.
Our previous review recommended that cognitive interventions that promote internalization of self-regulation strategies
through self-instruction and self-monitoring, be considered a
practice option for the remediation of deficits in executive
functioning.1 Two class III studies94,95 support this recommendation and 1 class Ia study93 suggests that these techniques may
be used to improve emotional self-regulation in patients with
TBI. In addition, 3 class I studies indicate that self-instructional
training is an effective component of interventions for the
remediation of deficits in attention,12 visual neglect,18 or
memory.78
The effectiveness of interventions directed at patients poor
awareness of deficits has been addressed by 1 class Ia study93
and 6 class III studies.95-100 Given the small number of uncontrolled studies and inconsistency of methods and results in this
area, there is insufficient evidence to make specific recommendations regarding interventions to improve self-awareness after
TBI or stroke.
Recommendations for future research. Future studies
may incorporate treatment for problems of emotional control
and psychosocial skills, particularly as these reflect components of problem-solving and self-regulation interventions. The
effectiveness of interventions that attempt to promote the internalization of strategies needs to be addressed through prospective, controlled studies. Our previous review noted the
potential use of external strategies for the rehabilitation of
executive problems,101 and this approach might have promise
in the treatment of patients with marked difficulties in their
planning and organization of everyday activities.79 Despite the
importance that is commonly attributed to awareness as a
mediator of rehabilitation outcomes, there continue to be few
studies of interventions in this area.
Comprehensive-Holistic Cognitive Rehabilitation

In comprehensive-holistic cognitive rehabilitation, we included studies that investigated interventions directed at multiple aspects of dysfunction, often addressing a combination of
cognitive, emotional, motivational, and interpersonal impairments, in the context of an integrated and programmatic treatment approach. We reviewed 1 class I,102 1 class II,103 and 5
class III studies104-108 of comprehensive-holistic programs of
cognitive rehabilitation. The class I study by Salazar et al102
evaluated the efficacy of cognitive rehabilitation for 120 people
with moderate to severe TBI within a single, military medical
referral center. Of 273 consecutively hospitalized patients, 120
patients met eligibility criteria and participated in the study.
They were, on average, about 38 days postinjury. Patients were
randomly assigned to receive either multidisciplinary, in-hospital cognitive rehabilitation109 or a limited home program110
consisting of individual education and encouragement from a
psychiatric nurse. Return to work rates were 90% for the
cognitive rehabilitation group and 94% for the home group; the
authors noted these extraordinarily high return-to-work rates
and suggested that participants high preinjury education and
level of functioning, significant degree of spontaneous recovery, and ready availability of (military) employment after injury might have limited the ability to detect any differential
benefits from the cognitive rehabilitation program. A subgroup
analysis of 75 participants with more severe injuries (those
unconscious for 1h) showed a significant benefit from the
cognitive rehabilitation program. While this study does not
provide strong support for comprehensive-holistic cognitive
rehabilitation, the significant subject selection bias and restricted setting markedly limit the ability to generalize these
findings to most areas of rehabilitation practice.
A principle contribution of the class III studies is their
relevance to understanding the impact of comprehensive-holistic cognitive rehabilitation on social participation and community integration after TBI. Four studies104-107 with a total of 270
patients evaluated programs based on the principles of neuropsychologic rehabilitation. Most of the participants were people with severe TBI who had received clinical treatment for at
least 3 months-in many cases, several years-after injury. Between 39%104 and 62%107of patients were engaged in community-based employment after treatment, and 49% made clinically significant gains in community integration.106
Clinical recommendations. The single class I study102 of
120 subjects with TBI did not provide support for comprehensive cognitive rehabilitation compared with basic education
and reassurance in the early stages of recovery from TBI;
patients with more severe injuries, however, did show greater
benefit with the more intense, structured treatment program.
However, the ability to generalize from the results of this study
is severely constrained by the restricted nature of the population, unique (military) setting, and limited course of treatment.
Four class III studies104-107 with 265 subjects support the
clinical effectiveness of comprehensive-holistic programs of
cognitive rehabilitation for improving community integration, social participation, and productivity after TBI or
stroke. There is also evidence that gains in community
functioning can be achieved by patients 1 or more years
postinjury,106 and that gains from treatment are maintained
for several years after rehabilitation.105,111,112 These studies
support our previous conclusion1 that treatment in postacute
programs of comprehensive-holistic cognitive rehabilitation
is recommended as a practice guideline in treating people
with moderate to severe TBI. The integration of cognitive
and interpersonal interventions is characteristic of compre-

Table 1: Differential Treatment Effects of Cognitive Rehabilitation
(CR) Compared With Alternative Treatment or Control Conditions
Based on All Class I Studies
Nature of Treatment
Comparison
No. of
Comparisons
No. of
Patients
Percentage of
Comparisons
Showing
Differential
Benefit in Favor
of CR
CR vs other cognitive or
psychosocial treatment
CR vs pseudotreatment
CR vs conventional rehabil
CR vs no treatment
Total
10
15
14
8
47
290
582
587
342
1801
60.0
66.7
92.9
100.0
78.7
hensive-holistic cognitive rehabilitation programs. There is

also evidence that psychosocial interventions may facilitate
the effectiveness of treatments directed at specific cognitive
impairments after TBI11 or stroke.64 These findings are
consistent with our prior recommendation that the integration of individualized cognitive and interpersonal therapies
be considered a practice option.
Recommendations for future research. There is a particular need in this area to confirm the positive findings from class III
studies using controlled trials. This might best be addressed
through practical clinical trials that select clinically relevant, alternative interventions for comparison, represent a diverse population of study participants, and use a broad range of relevant
health outcomes.113 The continued use of observational methods
is also encouraged, particularly to identify the types of patients
who are most appropriate for, and likely to benefit from, comprehensive-integrated cognitive rehabilitation.114
Comparison of Cognitive Rehabilitation and Alternative
Interventions
The question of effectiveness of cognitive rehabilitation
must be answered in relation to available alternative treatments. For each of the 46 class I studies included in this and
our prior review, we examined the nature of the alternative
treatment conditions and classified them as no treatment,
conventional rehabilitation, pseudotreatment, a psychosocial intervention, or an alternative cognitive intervention.
1687
We defined conventional rehabilitation as the provision of

standard physical, OT, and/or speech therapy in accordance
with routine procedures in a traditional rehabilitation setting. We defined pseudotreatment as providing participants
with mental or social stimulation without specific therapeutic intent (eg, recreational computing, leisure activities, repetitive mental exercises). Psychosocial interventions were
defined as individual or group psychotherapy or emotional
support. Studies that compared different types of specific
cognitive interventions (eg, attention training compared
with memory training) were considered to provide an alternative cognitive intervention in comparison with the intervention under investigation. We relied on the original authors description of the alternative treatment to make these
classifications, although on several occasions we had to rely
on our judgment regarding the nature of the comparison. We
used only studies that reported direct statistical comparisons
between treatments in this analysis. For studies that compared cognitive rehabilitation with more than 1 alternative
treatment, cognitive rehabilitation was compared separately
with each of the alternatives. For the purpose of this analysis, we collapsed studies using psychosocial or other
cognitive interventions as the alternative treatment. This
resulted in the comparison of 47 treatment conditions, representing 1801 patients (table 1).
It is clear that cognitive rehabilitation provides clinical
benefits, compared with not receiving any treatment, and
substantial benefits compared with conventional rehabilitation. Cognitive rehabilitation produced greater improvement
than pseudotreatment, psychosocial treatment, or an alternative cognitive intervention in about two thirds (64%) of
the study comparisons. Overall, cognitive remediation resulted in a significant benefit compared with the alternative
condition in about 79% of all treatment comparisons (see
table 1). There were 22 treatment comparisons involving
616 patients primarily with TBI. In those studies, 18 of the
22 (81.8%) comparisons demonstrated a differential benefit
in favor of cognitive remediation. Among the 25 treatment
comparisons involving 1185 patients primarily with stroke,
19 (76%) demonstrated a differential benefit favoring cognitive remediation. In no case was there evidence that the
alternative condition was superior to cognitive rehabilitation.
Table 2: Evidence-Based Recommendations for Cognitive Rehabilitation: Practice Standards

Intervention
Visuospatial rehabilitation
Cognitive-linguistic therapies
Specific interventions for functional
communication deficits, including pragmatic
conversational skills
Specific gestural or strategy training for apraxia
Memory strategy training
Strategy training for attention deficits
Recommendations
Recommended for persons with visuoperceptual deficits associated with visual

neglect after right hemisphere stroke
Recommended during acute and postacute rehabilitation for persons with language
deficits secondary to left hemisphere stroke
Recommended for persons with TBI
Recommended for persons with apraxia after left hemisphere stroke during acute
rehabilitation
Recommended for persons with mild memory impairments from TBI, including the
use of internalized strategies (eg, visual imagery) and external memory
compensations (eg, notebooks)
Recommended during postacute rehabilitation for persons with TBI. Insufficient
evidence exists to distinguish the effects of specific attention training during
acute recovery and rehabilitation from spontaneous recovery or from more
general cognitive interventions.
1688

Table 3: Evidence-Based Recommendations for Cognitive Rehabilitation: Practice Guidelines
Intervention
Scanning training
Cognitive interventions for specific language

impairments such as reading comprehension and
language formulation
Treatment intensity
Use of external compensations with direct application
to functional activities
Training in formal problem-solving strategies and their
application to everyday situations and functional
activities
Comprehensive-holistic neuropsychologic rehabilitation
Isolated microcomputer exercises to treat unilateral left

neglect
Recommendations
Recommended as an important, even critical, element for persons

with severe visuoperceptual impairment that includes visual neglect
after right hemisphere stroke
Recommended after left hemisphere stroke or TBI
Should be considered as a key factor in the rehabilitation of language

skills after left hemisphere stroke
Recommended for persons with severe memory impairment after TBI
or stroke
Recommended during postacute rehabilitation for persons with stroke
or TBI
Recommended during postacute rehabilitation to reduce cognitive and
functional disability for persons with moderate to severe TBI or
stroke
NOT recommended; does not appear effective
DISCUSSION
This updated review of the literature regarding cognitive
rehabilitation included 17 class I studies of 291 patients with
TBI and 247 patients with stroke, with 16 of the 17 studies
providing evidence for the effectiveness of cognitive rehabilitation. Five class I studies provide evidence for the effectiveness of remediation for visual inattention17-19 or apraxia30,31 in
patients with stroke, and 4 studies support the effectiveness of
interventions for communication deficits after stroke.33-36 One
of these studies36 supported the use of volunteers to improve
communication skills after chronic aphasia, compared with no
treatment, but failed to demonstrate benefits when compared
with social recreation.
Among studies addressing the remediation of cognitive impairments after TBI, 2 class I studies11,12 support the training of
compensatory strategies to improve attention during the postacute period of rehabilitation. Two class I studies support the
use of memory strategy training, including the development of
internalized strategies77 and use of a memory notebook or
diary,78 for patients with mild memory deficits resulting from
TBI. An additional class I study79 indicated that an external
cueing system may benefit patients with persistent, severe
impairments of memory and planning as a result of TBI or
stroke. A class I study92 supports the use of interventions to
improve problem-solving abilities. An additional class Ia
study93 suggests that treatment to improve emotional selfregulation may benefit TBI patients; this study contributes to
the evidence supporting the internalization of self-regulatory
strategies after TBI. The studies that have demonstrated effective rehabilitation of attention, memory, and executive func-
Table 4: Evidence-Based Recommendations for Cognitive Rehabilitation: Practice Options

Intervention
Systematic training of visuospatial and organizational skills
Inclusion of limb activation or electronic technologies for

visual scanning training
Computer-based interventions intended to produce extension
of damaged visual fields
Computer-based interventions as an adjunct to clinicianguided treatment
Sole reliance on repeated exposure and practice on
computer-based tasks without some involvement and
intervention by a therapist
Interventions that promote internalization of self-regulation
strategies through self-instruction and self-monitoring
Integrated treatment of individualized cognitive and

interpersonal therapies
Recommendations
May be considered for persons with visual perceptual deficits,

without visual neglect, after right hemisphere stroke as part
of acute rehabilitation. NOT recommended for persons with
left hemisphere stroke or TBI who do not exhibit unilateral
spatial inattention.
May be included in treatment of visual neglect after right
hemisphere stroke
May be considered for persons with TBI or stroke
May be considered for cognitive and linguistic impairments
NOT recommended
May be considered for persons with deficits in executive

functioning after TBI, including impairments of emotional selfregulation, and as a component of interventions for deficits in
attention, neglect, and memory
May improve functioning within the context of a comprehensive
neuropsychologic rehabilitation program, and facilitate
effectiveness of specific interventions
tioning deficits after TBI used different interventions, but they

all emphasized strategy training as a general principle (ie,
training patients to compensate for residual deficits, rather than
attempting to eliminate the underlying neurocognitive impairment), and this is reflected in our recommendations. One class
I study102 failed to demonstrate the effectiveness of comprehensive-integrated cognitive rehabilitation after TBI compared
with limited home-based treatment, although methodologic
concerns limit the generalization of these results.
Integrating the results from our previous and current reviews, the committee found evidence to support several of our
initial recommendations, made several new recommendations,
and modified several recommendations (tables 2 4). There is
now a substantial body of evidence demonstrating that patients
with TBI or stroke benefit from cognitive rehabilitation. It is
time to move beyond the simple question of whether cognitive
rehabilitation is effective, and to look more precisely at the
therapy factors and patient characteristics that optimize the
clinical outcomes of cognitive rehabilitation.
General Recommendations for Future Research
Future research on the therapeutic factors that contribute to
successful outcomes will require standardized interventions
and identification of the various components of complex interventions. Considerable heterogeneity exists among treatment
methods reported in the literature, and it is difficult to compare
interventions even when these are purported to represent the
same type of treatment. The need to provide greater specification of the theoretical basis, design, and components of interventions has received increased attention, as a prerequisite to
investigating the effectiveness of rehabilitation.115,116
There is a need to replicate interventions that have already
demonstrated effectiveness, to make increasingly specific predictions about the effects of interventions, and to compare
different techniques for specific deficits. This requires the ability to compare the size of treatment effects across different
studies and types of treatment. Much of the literature has failed
to provide information that would allow for a determination of
effect sizes. This also makes it difficult to determine whether
the statistical improvements associated with specific interventions are clinically significant. We recommend the routine
reporting of effect sizes and related statistics (eg, odds ratios,
reliable change indices) that provide some estimate of the
clinical relevance of changes associated with the interventions
in question.
Clinically, there is consensus that cognitive rehabilitation
should not be focused exclusively on the remediation of impairments, but should reduce disability and help restore social
role functioning. However, most studies have evaluated the
outcome of interventions at the impairment level rather than
their effect on the performance of activities or changes in social
participation. Even when interventions are directed at the remediation of impairments, this is presumably based on the
(implicit or explicit) belief that this will ultimately result in
more effective functioning in meaningful contexts. There is a
persistent need to evaluate the effects of cognitive rehabilitation on relevant, functional outcomes. The selection of outcome measures will also vary, depending on level of analysis
and rationale for specific interventions. We recommend that
primary outcome measures be identified in relation to specific
hypotheses and directly related to the intended effects of treatment.
We recognize that the practice of cognitive rehabilitation
must rely on clinical judgment and the accommodation of
treatment approaches to patients unique presentations and
needs.117 Increased specifications of patient characteristics, in-
1689
terventions, outcomes, and their relationships should facilitate

the translation of research into clinical practice and allow
clinicians to better tailor specific interventions to different
aspects of cognitive dysfunction and patients functional goals.
CONCLUSIONS
We have now systematically reviewed 46 class I studies, 43
class II studies, and 169 class III studies of cognitive rehabilitation for people with TBI or stroke. Our overall analysis of 47
treatment comparisons from class I studies, representing 1801
patients, indicates that cognitive rehabilitation is of significant
benefit when compared with alternative treatments. The resulting recommendations should help guide clinical treatment and
facilitate additional research.
Acknowledgments: The Cognitive Rehabilitation Task Force of
the BI-ISIG of ACRM conducted this work. We would like to acknowledge Joanne Azulay, PhD, Thomas Bergquist, PhD, Douglas
Katz, MD, and Virginia Mills, RPT, for their contributions to the
review and classification of the literature.
APPENDIX 1: DEFINITION OF LEVELS OF

RECOMMENDATIONS
Practice standards
Based on at least 1 well-designed class I

study with an adequate sample, with
support from class II or class III evidence,
that directly addresses the effectiveness
of the treatment in question, providing
substantive evidence of effectiveness to
support a recommendation that the
treatment be specifically considered for
people with acquired neurocognitive
impairments and disability.
Practice guidelines Based on 1 or more class I studies with
methodologic limitations, or welldesigned class II studies with adequate
samples, that directly address the
effectiveness of the treatment in
question, providing evidence of probable
effectiveness to support a recommendation
that the treatment be specifically
considered for people with acquired
neurocognitive impairments and disability.
Practice options
Based on class II or class III studies that
directly address the effectiveness of
the treatment in question, providing
evidence of possible effectiveness to
support a recommendation that the
treatment be specifically considered
for people with acquired neurocognitive
impairments and disability.
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1681

Evidence-Based Cognitive Rehabilitation: Updated Review of

From JFK-Johnson Rehabilitation Institute, Edison, NJ (Cicerone, Kalmar, Ellmo,

UPDATE ON COGNITIVE REHABILITATION, Cicerone

UPDATE ON COGNITIVE REHABILITATION, Cicerone

patients with severe TBI to compensate for slowed information

resulted in significant enlargement of the visual field in 95% of

UPDATE ON COGNITIVE REHABILITATION, Cicerone

voort et al30 conducted a multisite study of subjects with

UPDATE ON COGNITIVE REHABILITATION, Cicerone

cluding massed practice, produces significant benefits; this area

sation for memory impairments using assistive technology (eg,

UPDATE ON COGNITIVE REHABILITATION, Cicerone

that involved self-awareness and self-instructional training.

Comprehensive-Holistic Cognitive Rehabilitation

UPDATE ON COGNITIVE REHABILITATION, Cicerone

hensive-holistic cognitive rehabilitation programs. There is

We defined conventional rehabilitation as the provision of

Table 2: Evidence-Based Recommendations for Cognitive Rehabilitation: Practice Standards

Strategy training for attention deficits

Recommended for persons with visuoperceptual deficits associated with visual

Arch Phys Med Rehabil Vol 86, August 2005

UPDATE ON COGNITIVE REHABILITATION, Cicerone

Cognitive interventions for specific language

Isolated microcomputer exercises to treat unilateral left

Recommended as an important, even critical, element for persons

Should be considered as a key factor in the rehabilitation of language

Table 4: Evidence-Based Recommendations for Cognitive Rehabilitation: Practice Options

Systematic training of visuospatial and organizational skills

Inclusion of limb activation or electronic technologies for

Integrated treatment of individualized cognitive and

Arch Phys Med Rehabil Vol 86, August 2005

May be considered for persons with visual perceptual deficits,

May be considered for persons with deficits in executive

UPDATE ON COGNITIVE REHABILITATION, Cicerone

tioning deficits after TBI used different interventions, but they

terventions, outcomes, and their relationships should facilitate

APPENDIX 1: DEFINITION OF LEVELS OF

Based on at least 1 well-designed class I

UPDATE ON COGNITIVE REHABILITATION, Cicerone

5. Majid MJ, Lincoln NB, Weyman N. Cognitive rehabilitation for

26. Samuel C, Louis-Dreyfus A, Kaschel R, et al. Rehabilitation of

UPDATE ON COGNITIVE REHABILITATION, Cicerone

47. Basso A, Marangolo P, Piras F, Galluzzi C. Acquisition of new

69. Robson J, Marshall J, Pring T, Chiat S. Phonological naming

UPDATE ON COGNITIVE REHABILITATION, Cicerone

Arch Phys Med Rehabil Vol 86, August 2005

104. Malec J. Impact of comprehensive day treatment on societal

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