20Q: Cognitive Rehabilitation Therapy (CRT) for Adults with Traumatic Brain Injury (TBI)

From the Desk of Ann Kummer

I am so excited to introduce this 20Q article to you on cognitive rehabilitation therapy (CRT) for adults with traumatic brain injury (TBI). As you may know, the goal of CRT is to help individuals to relearn cognitive skills that have been lost or altered as a result of damage to brain. It also involves helping the affected individual compensate for lost cognitive functions that cannot be redeveloped.

In this article, Jennifer Ostergren, PhD, CCC-SLP, ASHA-F answers key questions regarding the foundations of CRT. She also explains how CRT can be used to target various cognitive functions following TBI, including processing, memory, executive function, and communication.

Dr. Ostergren is an Associate Dean of the College of Health and Human Services at California State University, Long Beach (CSULB). She is uniquely qualified to answer questions regarding CRT because she has almost 20 years of clinical experience in the rehabilitation of adults with neurogenic cognitive-communication disorders due to TBI. She has developed curriculum and has taught a graduate course on this topic. In addition, she is a national presenter and has published several articles on CRT—two of which received the Editor’s Choice Award from Contemporary Issues in Communication Sciences and Disorders for significant contribution in the field. Most importantly, Dr. Ostergren is the author of a very informative text entitled: Cognitive Rehabilitation Therapy for Traumatic Brain Injury: A Guide for Speech-Language Pathologists.

This 20Q article provides some key facts and useful information from Dr. Ostergren regarding this very interesting and important topic. It will be of great interest to all speech-language pathologists who work with adolescents and adults who have cognitive and/or communication deficits secondary to TBI.

Now...read on, learn and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

20Q: Cognitive Rehabilitation Therapy (CRT) for Adults with Traumatic Brain Injury (TBI)

Jennifer Ostergren

1. Let’s begin with the following basic question: What is cognitive rehabilitation therapy (CRT)?

Although there are many definitions of CRT, one commonly utilized definition is that of the Brain Injury Interdisciplinary Special Interest Group (BI-ISIG) of the American Congress of Rehabilitation Medicine (ACRM), which states,

Cognitive rehabilitation is a systematic, functionally oriented service of therapeutic cognitive activities, based on an assessment and understanding of the person’s brain-behavior deficits. Services are directed to achieve functional changes by (1) reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or (2) establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems” (Harley et al., 1992, p. 63; Institute of Medicine [IOM], 2011).

Another definition I find helpful in describing CRT is the United States Department of Veterans Affairs, which stated that cognitive rehabilitation is,

One component of a comprehensive brain injury rehabilitation program. It focuses not only on the specific cognitive deficits of the individual with brain injury, but also on [his or her] impact on social, communication, behavior, and academic/vocational performance. Some of the interventions used in cognitive rehabilitation include modeling, guided practice, distributed practice, errorless learning, direct instruction with feedback, paper-and-pencil tasks, communication skills, computer-assisted retraining programs, and use of memory aids” (Benedict et al., 2010, as cited in Institute of Medicine, 2011, p. 78). 

2. Is CRT new?

No, actually CRT dates back to World War I when soldiers and civilians received treatment for war-related traumatic brain injuries.  In the 1970s, CRT gained momentum as a result of improvements in medical services that increased survival rates for those with severe TBI. By the 1980s, CRT was a common part of rehabilitative service offered in many rehabilitation settings.  In recent years, research evidence in this area continues to grow, due in part to military conflicts that have resulted in increases in military service members with TBI, but also due to advances in our understanding about mild TBI, concussion, and sports-related brain injury. 

3. Is CRT effective for use with adults with TBI? 

Yes, there is now overwhelming evidence to demonstrate positive efficacy and effectiveness of CRT for adults with TBI (Cicerone et al., 2011, 2005, 2000; Rohling, Faust, Beverly, Demakis, & Rao, 2009). 

4. Are there certain individuals with TBI for which CRT is not recommended? 

The majority of studies on CRT have been conducted in the post-acute phases, and in particular the chronic phase of recovery after a TBI. This is likely because researchers design experiments of this nature to better rule out spontaneous recovery as the source of change due to CRT.  As such, research evidence for use of CRT with individuals in the acute phase of recovery is limited. 

5. What about individuals with post-traumatic amnesia (PTA) after TBI.  Would they benefit from CRT? 

The period of PTA is commonly described as, “an interval during which the patient is confused, amnesic for ongoing events, and likely to evidence behavioral disturbances” (Levin, O’Donnell, & Grossman, 1979, p. 675).  CRT is generally not recommended while individuals who are experiencing PTA (PTA, Ponsford et al., 2014).  Rather, intervention for individuals with TBI who are experiencing PTA includes environmental modifications and strategies to reduce agitation and improve orientation. 

6. What are the general treatment recommendations for CRT in adults with TBI? 

In implementing CRT, general treatment recommendations include (Bayley et al., pp. 302–303): 

• Tailoring treatment to the patient’s neuropsychological profile, premorbid cognitive characteristics, and goals for life activities and participation. 
• Focusing on activities that are meaningful to the patient, in the person’s own environment and applicable to the person’s life 
• Incorporating strategies to generalize 
• Reassessing of on a regular basis using standardized functional outcomes that measure the effectiveness of the intervention you provide 

I have found the first two recommendations to be the guiding principle of my many years working with individuals with TBI. The very first paragraph of my book on the topic of CRT (Ostergren, 2017) starts with a quote from author Stephen Shore, who said about individuals with autism, “If you’ve met one person with autism – you’ve met one person with autism" (as cited in Kolarik, 2016, p. 479).  I have found the same to be true for individuals TBI. The diversity among individuals who experience a TBI is infinite, as are the ways in which the trauma associated with TBI can occur. No two individuals or their injuries are exactly alike.  Understanding this is a cornerstone to CRT, as no two interventions using CRT will be exactly the same either. 

7.  Why are you only discussing CRT for adults with TBI? Children also experience TBI.  Do they not benefit from CRT? 

My omission of children in this discussion is deliberate, not because children with TBI are not a worthy and important topic.  To the contrary, they absolutely are, and in fact children are a large subset of those who experience TBI.  However, there are two distinct evidence foundations for CRT for children with TBI versus CRT for adults with TBI.  There is a danger in collapsing these two foundations and assuming that research evidence that supports CRT with adults generalizes to it use with children.  Hence, I am careful to separate the two.  My expertise is that of adults, but clinicians interested in CRT will also find research evidence for its use in children.  This is just not covered within the scope of these twenty questions. 

8. Are there certain ways to categorize and describe CRT approaches? 

Yes, I generally describe the treatment approach either restoration, calibration, and/or compensation CRT.  Restoration CRT seeks to improve, strengthen, or normalize an impaired cognitive function (IOM, 2011). Methods within restoration CRT involve repetition and drill or exercise-like activities that target a cognitive process, gradually increasing in difficulty and demand (IOM, 2011). The Society of Cognitive Rehabilitation refers to this type of treatment as process training, noting that the purpose is to “stimulate poorly functioning neurologic pathways in the brain in order to maximize their efficiency and effectiveness . . . using new undamaged pathways (redundant representation) and, sometimes, old particularly damaged pathways” (Malia et al., 2004, p. 32). This frame views the act of restorative treatment as overcoming damage related to TBI. 

Compensation CRT seeks to provide alternative strategies for completing everyday activities, despite residual cognitive deficits (IOM, 2011). Compensation approaches are divided into internal and external strategy compensation (IOM, 2011; Malia et al., 2004). External strategies are those that rely on items external to the individual, such as alarms, notebooks, notes, calendars, and so forth. Internal strategies are those internal processes such as mnemonics, visualization, word association, and so forth (Malia et al., 2004). 

As the name suggests, calibration CRT seeks to refine awareness and self-measurements of cognitive performance (e.g., thinking about thinking) and use that information to shape behavior after a TBI. Calibration approaches are common within treatment that focuses on the broader construct of metacognition and executive function. Generally, they will target both offline and online awareness skills. 

These are general categories of CRT, but in reality the distinction between approaches is not always clear as these descriptions suggest.  CRT approaches are varied and often attempt to accomplish a similar goal (improving recall, attention, problem solving, communication, and so forth in daily activities) using differing approaches (restoration, compensation, calibration, or combinations thereof).  Further, many treatment programs use more than one approach simultaneously. 

9. Can CRT be provided in group format? 

Yes, and in fact group therapy (either alone or in combination with individual therapy) is a common form of CRT (Hammond et al., 2015). Examples of group-based intervention include group CRT to address: 

• Social skills 
• Memory 
• Emotional self-regulation 
• Goal attainment 
• Problem solving 
• Communication 
• Attention and concentration 
• Sleep hygiene ​

10. Is assistive technology part of CRT for TBI? 

Yes, an increasingly prominent element of CRT for individuals with TBI is assistive technology for cognition (ATC) (Ostergren & Montgomery, 2014). ATC can significantly enhance the independence and quality of life for individuals with TBI (Sohlberg, 2011; Sohlberg & Mateer, 2001b). It can also help to reduce the demands that are placed on caregivers. 

11. Is CRT provided by speech-language pathologists (SLPs)? 

Yes, SLPs provide CRT and are well prepared to do so.  According to ASHA’s scope of practice, an SLP’s roles and responsibilities in the area of cognitive-communication disorders includes “training discrete cognitive processes, teaching specific functional skills, developing compensatory strategies and support systems, providing caregiver training, and providing counseling and behavioral support services” (ASHA, 2005, para. Roles).  This is not, however, the only area of rehabilitation provided by SLP for individuals with TBI. To the contrary, there are many facets of rehabilitation following TBI (not solely CRT), and several parallel roles of SLPs who work with individuals with TBI, including in the areas of speech, swallowing, and alternative and augmentative communication (AAC), to name a few.  We are also not the only professionals that offer CRT for individuals with TBI.  Other disciplines who also provide CRT include occupational therapists, recreation therapists, psychologists, and others. 

12. You mentioned cognitive-communication disorders in the scope of practice for SLPs.  What is the relationship to communication, cognition, and CRT? 

Many decades of research have consistently shown communication impairments after TBI to be both common and enduring in nature. Cognition impairments are also a cardinal feature of TBI, including impairments in attention, memory, executive function, and social cognition.  Communication and cognition are inescapably interconnected, as are the domains of cognition to one another.  It is at this intersection where cognitive-communication disorders exists following TBI.  Contemporary views on impairments of this nature in individuals with TBI (particularly those with closed-head injury) hold that the communication difficulty following TBI occurs either secondary to cognitive disruptions common to TBI (e.g., due to attention, memory, executive function impairments) or interdependently of these disrupted processes (McDonald, Togher, & Code, 2014; Murdoch, 2010).   These are described by ASHA as cognitive-communication disorders, which encompass “difficulty with any aspect of communication that is affected by disruption of cognition” (ASHA, 2005, para. 1) 

13. Are CRT and cognitive intervention reimbursable? 

Yes, and as per a recent ASHA bulletin on the topic (ASHA, n.d.), effective January 1, 2018 there is a new Current Procedural Terminology (CPT) for cognitive intervention that will replace the previous CPT code in this area.  This new code will be CPT 97127, described in the codebook as: 

CPT97127 - Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact. 

The Centers for Medicare & Medicaid Services (CMS) will not recognize CPT code 97127 for Medicare payment. Instead, CMS created the following G-code to report cognitive treatment services, also effective January 1, 2018, as follows: 

G0515 - Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes 

14. What areas of cognition are addressed by CRT? 

CRT can be used to target deficits in attention, memory, executive function, and social cognition.  This is also generally how the research literature parses out the categories of CRT evidence. 

15. You have provided general examples thus far of CRT. Can you break down CRT into these areas of cognition it addresses starting with attention? 

Two approaches with solid research evidence in the area attention deficits after TBI are: Dual Task Training (DTT) and Attention Processing Training (APT).  APT is an approach that is likely familiar to SLPs who have provided CRT for individuals with TBI.  It was developed in 1987 by Sohlberg and Mateer.  There are currently three versions commercially available for purchase: APT I, APT II (specifically for mild cognitive impairment), and APT III (computerized version) (Sohlberg & Mateer, 2001a; Sohlberg, Johnson, Paule, Raskin, & Mateer, 2005; Sohlberg & Mateer, 2010). Traditionally, APT has been described as a restorative approach, given that it targets repeated practice of specific attentional systems, “hypothesized to facilitate cognitive change” (Sohlberg & Mateer, 2001a, p. 134). Recent iterations of the APT have also incorporated compensatory strategy and metacognitive training (Ponsford et al., 2014, APT III manual).  I therefore generally describe recent versions of the APT as encompassing all three frames of CRT: restoration, compensation, and calibration.  APT targets all levels of attention (sustained, selective, alternating, and divided attention) and the executive control of attentional systems, using the following guiding principles: 

• Grounding treatment in hierarchical organization and theoretical models of attention 
• Providing opportunity for practice and repetition 
• Using client data to drive treatment decisions 
• Individualizing treatment and promoting generalization to relevant real-world tasks 

DTT specifically targets dual-tasking, which is sometimes referred to as divided attention, but commonly defined as the ability to perform two things at once (Posner & Peterson, 1990). DTT combines the use of calibration and restoration CRT.  Restorative aspects of DTT seek to address attention system deficits through training specific aspects of attention performance, in a hierarchical manner. More recent aspects of DTT also address self-reflection, performance feedback, and other instructional tasks that seek to enhance attentional awareness (Couillet et al., 2010; Evans et al., 2009). 

16. What about information processing speed. I understand this is an aspect of cognition that can also be impaired in individuals with TBI.  Does CRT address this? 

Yes, after a TBI, slowed mental processing is common (Mathias, Wheaton, & Becker, 2007).  One approach with research evidence in this area is Time Pressure Management (TPM).  TPM uses compensation CRT to provide training in the use of specific strategies to prevent or reduce time pressures due to slowed mental processing speed (Fasotti et al., 2000; Winkens, Van Heugten, Fasotti, & Wade, 2009). TPM also uses calibration CRT to (1) bring awareness to slowed mental processes after a TBI, (2) highlight the relationship of slowed mental processing to time pressures in daily activities, and (3) foster an understanding of the relationship between compensation and persisting deficits of this nature (Ponsford et al., 2014, pp. 324–325). 

17. What about memory impairments and CRT? 

The strongest research evidence for CRT for memory deficits following TBI is in the area of compensation CRT, both internal and external, especially for those with mild to moderate memory impairments (Velikonja et al., 2014).  In recent years, some researchers have also suggested the importance of including metacognitive CRT (calibration) to improve metamemory in individuals with TBI (Kennedy, 2006). Environmental supports are also useful, especially for those with more severe memory impairment (Velikonja et al., 2014).  The research literature also has a number of instructional practices that can be used to promote learning for those with memory impairments, including the use of the principles of distributed practice, effortful processing of information/stimuli, and teaching strategies that constrain errors, such as errorless learning and spaced retrieval (Velikonja et al., 2014).  Of note, restoration CRT in the area of memory “show[s] no evidence in enhancing sustained memory performance” beyond trained tasks (Velikonja et al., 2014, p. 382). This includes paper-and-pencil tasks and those executed via computer-based repetitive drills and practice. Guidelines in this area recommend that restorative approaches “only be considered to develop adjunct memory rehabilitation strategies with evidence-based instructional and compensatory strategies, and only if developed in conjunction with a clinician with a focus on strategy development and transfer to functional tasks” (p. 382). 

18. What is the difference between internal and external compensation CRT for individuals with TBI? 

Internal compensation includes strategies such as visualization/visual imagery, repeated practice, retrieval practice, and self-cueing, while external compensation includes aids and devices, such as diaries, notebooks, customized memory books, organizers, planners, and pagers (Velikonja et al., 2014).  For both external and internal compensation, CRT approaches proceed in a similar fashion, first with the selection an applicable compensatory strategy, followed by teaching and instruction in the use and purpose of that strategy, then with training in the application of that strategy across various tasks and situations in a controlled context, and lastly with practice of that strategy in natural and novel circumstances (Ostergren, 2017). 

19. Similarly, can you offer some examples of CRT for executive function? 

Approaches with solid research evidence in the area of CRT for executive function deficits after TBI including metacognitive treatment, such as Goal Management Training (GMT) (and TPM, described previously), as well as Strategic Memory and Reasoning Training (SMART) and Constructive Feedback Awareness Training (CFAT). 

GMT is based on theories of sustained attention as integral to supporting executive function (Stuss & Levine, 2002; Stuss & Alexander, 2007), such that lapses in sustained attention result in “slips of intention” that impair executive function and task performance.  GMT uses calibration and compensation CRT to instruct individuals with TBI to monitor performance, identify these slips in intention, and implement strategies to reduce their impact on executive function. 

SMART uses calibration CRT to improve impairments in gist reasoning that lead to difficulties in executive function.  Within the context of SMART, gist reasoning is defined as “the ability to synthesize complex information, whether written, auditorily presented, or visually depicted, into abstracted meanings that are not explicitly stated” (Chapman, 1995, as cited in Vas, Spence, & Chapman, 2015). The essential tenants of SMART are to teach strategies that help the individuals with TBI to: 1) filter incoming information and discard irrelevant information, 2) integrate and combine important facts within incoming information, and 3) process incoming information from different perspectives that lead to cognitive flexibility and innovative thinking (Vas et al., 2011). 

CFAT uses calibration CRT to improve both offline and online awareness through structured opportunities and direct feedback that help individuals with TBI evaluate their performance, discover errors, and compensate for deficits (Ownsworth, Fleming, Desbois, Strong & Kuipers, 2006).  It includes educating an individual with TBI about the nature and characteristics of deficits and their impact, providing them with feedback about their performance, and offering structured opportunities for self-reflection and self-prediction about performance. 

20. Last, but not least, can you discuss CRT for communication difficulties after a TBI? 

Given the nature of cognition, communication, and cognitive-communication disorders, all of the approaches already discussed have the potential to improve cognitive-communication deficits following TBI by targeting the underlying cognitive aspects of communication.  In specifically targeting social communication, Finch and colleagues noted that research evidence is greatest to support context-sensitive approaches, such as Social Communication Training (SCT), delivered predominantly in group-based service models (Finch et al., 2016). Theoretical frames within SCT vary, but in general, more recent group-based SCT employs predominantly calibration and compensation CRT. Commonalities among SCT techniques, include “feedback, self-monitoring, modeling, behavioral rehearsal, role-play, and social reinforcement” (Struchen, 2014, p. 216).  Some of the approaches in this area have manuals available for purchase such as TBI Express Communication Training and Group-Interactive Structured Treatment (GIST) Social Competency Training.  A few additional recommendations in this area of social communication include (Togher et al., 2014, pp. 356–357). 

• Opportunities to rehearse communication skills, “in situations appropriate to the context in which the individual will live, work, study, and socialize” 
• Education and training of communication partners 
• Provision of and training in appropriate alternative and augmentative communication 
• Patient-identified goals that are measured at the level of participation in everyday social life

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