Cognitive Rehabilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence

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TBI leads to impairment in sensory, motor, language, and emotional processing, and also in cognitive functions such as attention, information processing, executive functions, and memory. Cognitive impairment plays a central role in functional recovery in TBI. Innovative methods such as music therapy to alleviate cognitive impairments have been investigated recently. The role of music in cognitive rehabilitation is evolving, based on newer findings emerging from the fields of neuromusicology and music cognition. Research findings from these fields have contributed significantly to our understanding of music perception and cognition, and its neural underpinnings.

From a neuroscientific perspective, indulging in music is considered as one of the best cognitive exercises. A preliminary study examining the effect of NMT in cognitive rehabilitation has reported promising results in improving executive functions along with improvement in emotional adjustment and decreasing depression and anxiety following TBI. The potential usage of music-based cognitive rehabilitation therapy in various clinical conditions including TBI is yet to be fully explored. There is a need for systematic research studies to bridge the gap between increasing theoretical understanding of usage of music in cognitive rehabilitation and application of the same in a heterogeneous condition such as TBI.

Traumatic brain injury TBI , an injury to the brain from an external agent or force, is one of the leading causes of disability in multiple domains of functioning. TBI may cause transient or long lasting impairment in neurological and neuropsychological functioning 1. Injury may be primary or secondary in nature.

Primary injury is the direct impact of the external agent causing injury to the brain.


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Secondary injury is due to disordered autoregulation or any other pathophysiological changes within the brain following the injury. Hypoxic or ischemic injuries which may be a primary or secondary injury affect recovery. Depending upon the site of injury focal or diffuse and severity of the injury mild, moderate, or severe , impairment is observed in the physical, psychological, and social domains of functioning. These impairments may be transient or long lasting in nature 2 — 5.

The TBI sequelae includes physical sequelae which may be in the form of motor dysfunctions, hemiplegia, visual impairment, auditory impairment, deficits in gait etc; psychological sequelae in the form of deficits in cognitive functions and emotional problems; social sequelae in the form of loss of family or friends, or changes in the social relationship, changes in routine activities, loss of job or loss of work-related skills, inability to acquire new skills, and financial problems. It is the psychological and social consequences of TBI that are far more disabling and burdensome to the individual, the caregivers as well as the society at large 3 , 6 — 8.

The psychological and social sequelae may be observed immediately after the injury or after lapse of time. This may or may not be in concurrence with physical disability. Physical dysfunctions are easily detectable and often not a major problem in mild injury. The severity of TBI is associated positively with severity of psychosocial functioning.

Cognitive Rehabilitation Therapy for Traumatic Brain Injury : Evaluating the Evidence

Cognitive deficits such as deficits in attention, information processing, planning, decision-making, memory, language, and emotional processing have significant impact on personal and socio-occupational functioning. Cognitive deficits are considered to play a central role in TBI and contribute significantly to functional recovery 4 , 9. In the past three and half decade, cognitive remediation CR has emerged as one of the best available treatment methods to restore cognitive functions and facilitate compensatory strategies to overcome cognitive deficits following TBI or other acquired brain injury conditions 10 — The terms rehabilitation and remediation conveys specific approach to treatment, although the two terms have been interchangeably used in literature to discuss treatment strategies aiming at skills development in patients needed to perform tasks that are difficult to perform due to cognitive deficits.

In a technical sense, rehabilitation involves a wide array of interventions offered by a multidisciplinary team. CR comes under the umbrella of a broader treatment approach, i. Cognitive rehabilitation includes methods such as remediation, compensation, and holistic or multimodal programs 6 , Cognitive rehabilitation is a confluence of therapeutic activities based on brain—behavior relationships. Functional improvement is achieved by re-establishing or reinforcing previously learned adaptive patterns of behavior, facilitating improvement in cognitive functions through compensatory mechanisms and sometimes facilitating new patterns of activity through external compensatory mechanisms.

The goal of cognitive rehabilitation is to help patients with cognitive deficits to adapt to their disability to improve overall functioning. Evidence exists to support benefits of CR in improving cognitive functions such as attention, memory aphasia, functional communication, and unilateral spatial neglect 11 , 12 , Systematic reviews on a total of intervention studies on CR in TBI and other acquired brain injury have concluded that there is substantial evidence to support benefits of CR in TBI 13 , The outcome was influenced by moderating variables such as the specific cognitive function targeted in intervention, duration between injury to treatment onset, the type of injury, and age of patients included in the intervention studies Interventions to remediate cognitive deficits have often employed either paper—pencil or computer-based tasks that would enable direct training of the cognitive function as well as metacognitive training methods i.

The most often evaluated treatment approach in the published literature aims to directly retrain the cognitive function that is impaired via cognitive drills and exercises targeting the specific cognitive function Repeated practice on carefully designed exercises is considered to facilitate recovery of the damaged neural circuits and restoration of function such as attention, memory, executive functions, etc.

The tasks mediated by these circuits would then lead to a near normal or normal level of functioning as comparable to the functioning due to an intact brain without any injury 16 , 26 — A careful examination of literature on CR in acquired brain injury indicates a lack of high-quality evidenced-based research studies and fraught by lack of generalizability of improvement on cognitive functions targeted in the treatment sessions to real-life situations 23 , 29 — Many innovative methods to treat TBI sequelae have been developed over the years.

Music therapy is one such method. Music-based intervention methods have shown promising results in rehabilitating movement, gait-related problems It has shown positive results in reducing the levels of anxiety, depression, agitation and in inducing stable mood state. Enhanced adaptive behavior following music-based intervention has been observed even during recovery from coma and later in both adult and children population 33 — Music-based intervention has led to improvement in speech production and sensory perceptions 40 , Studies suggest that use of musical intervention facilitates early responsiveness in patients which in turn foster cognitive rehabilitation in the early acute phase following TBI The more recent frontier is music-based CR in various neurological and neurosurgical conditions 33 , The application of music in CR is although a recent endeavor, the potential of music in this area of rehabilitation was put forth much earlier This very nature of music to reduce stress and enhance emotional health has started receiving scientific evidence from studies examining the neurochemical changes that occur when listening to or engaged in music actively.

The two important markers of stress regulated by the hypothamalic-pituitary-adrenal axis HPA or HTPA , the beta endorphin and cortisol levels have been observed to decrease significantly with music intervention 45 — A recent review has examined the scientific work supporting therapeutic effect of music using neurochemical changes as evidence.

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The authors of this review work compile the evidences in four different domains viz. It is also hypothesized that listening to music facilitates neurogenesis or the regeneration and repair of cerebral nerves by adjusting the secretion of steroid hormones, finally leading to neural plasticity Intensely pleasurable music or anticipation of a peak emotional experience whilst listening to music is known to engage the very same areas involved in other real-life emotions such as mesolimbic, the reward area of the brain, the nucleus accumbens, and an increase in dopamine levels 50 — In fact evidence-based approach to understanding the benefits of music, especially in the area of neurological rehabilitation has been a recent endeavor 54 , The neurochemical marker of neural plasticity, viz.

A paradigm shift in the field of music therapy has been significantly influenced by the growth in the areas of neuromusicology, music cognition, and neurochemistry of musical process. The shift in music therapy from a social science and interpretive models to neuroscientific models has been set forth In the field of neuroscience today, music is considered as a powerful tool to understand brain functions and music—brain—behavior interactions.

Music engages a host of cognitive processes such as acoustic analysis, information processing, sensory motor integration, learning, memory, decision making, emotion, and creativity. In other words, music can stimulate complex cognitive, affective, and sensorimotor processes in the brain that can be generalized and transferred to non-musical therapeutic applications 56 — Scientific evidence linking music and cognitive functions is more than impressive, thanks to the findings from the emerging field of music cognition and neuromusicology. Indulging in music is considered as an exercise of cognitive flexibility.

Creatively working with various dynamic features of music such as pitch and rhythm is known to involve attentional networks and executive functions. Temporal cues in music and rhythm engage not only the motor system but play a crucial role in arousal, orientation, and sustenance of attention.

Rhythmic patterns synchronize with the internal oscillators in accordance with its temporal regularity, thereby having its effect on attentional processes 63 — Similarly, music provides a temporal—metrical structure that facilitates perceptual grouping and chunking of the information being processed or learnt as well as can be used as a mnemonic device in memory formation. Listening to polyphonic music has shown to engage neural circuits underlying multiple forms of working memory, attention, semantic processing, target detection, and motor imagery, in turn indicating that music listening engages brain areas that are involved in general functions rather than music-specific areas Music also engages all limbic and paralimbic brain areas, which are crucial in evoking, maintaining, and modulating emotion 51 , 68 , It seems plausible that engaging in music would not only stimulate the various centers of the brain including the emotion areas but music can also be systematically used in altering and regulating the cognitive processes involved, which can be further generalized to non-musical domains of functioning.

So much so, musicians are considered as the best model to study neural plasticity due to the effects of intense training involving sensorimotor training such as music 70 , A schematic representation of the effect of music on the functioning of the brain and the various domains of functioning affected in TBI addressed by music therapy is presented as Figure 1. Figure 1. Schematic representation of the effect of music on neural, cognitive, neurochemical functions, and how music therapy which involves musical-based activities active and passive has effect on various domains of functions known to be affected following traumatic brain injury.

Findings from the field of neuroscience have provided an edifice leading to the development of a science-based approach to music therapy practice and research. This has been termed as neurologic music therapy NMT.

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This dynamic model was conceptualized to develop a systematic epistemology for translational research, linking scientific findings in neurological, psychological, and physiological foundations of music cognition and production to rehabilitation of functions in the non-music domain. NMT techniques are standardized in its terminology and application, thereby lending itself for systematic research studies. Standardized techniques and application procedures had eluded music therapy in the past 43 , 44 , NMT techniques, hitherto have been designed to address three areas of functioning, viz.

A brief overview on the specific techniques developed toward remediation of cognitive functions is listed in Table 1. Table 1. Brief overview on the techniques of NMT under each of the cognitive domain targeted for intervention. First of all, CR via NMT begins with the first of a systematic neuropsychological evaluation to outline the specific area that requires therapeutic attention. Following this, the therapeutic goals and objectives are set.

Then, the non-musical exercises in the traditional CR approach are enriched with the techniques of NMT. The final goal is to facilitate transference of improved cognitive function to non-musical domains of functioning and everyday functioning. This is targeted by providing home-work exercises with the aim of enabling generalization to everyday situation 44 , CR is the most recent domain to be addressed via NMT. The systematic approach in this direction has spurred from the evidence that music and rhythm engage not just the motor system but also cognitive functions. The present paper will limit its focus on the third area of functioning, the cognitive functioning specific to its application TBI.

Despite the strong evidence linking music and its effect on cognition and emotion, by far, scientific evidence for effectiveness of music as to improve cognition in TBI is surprisingly weak with only a few studies and no randomized controlled trials. A review on music therapy literature indicates that only a handful of research have examined music therapy for CR in neurological conditions and far lesser studies carried out in TBI 33 , 81 — A systematic review on music therapy in acquired brain injury examined seven studies which were either randomized or quasi-randomized controlled trials with a total of participants showed that rhythmic auditory stimulation RAS was effective in improving gait parameters including gait velocity, stride strength, cadence, and gait symmetry in acquired brain injury conditions.

This review study could not comment on the effect of music therapy on other outcomes such as upper extremity motor function, speech, pain perception, and behavioral agitation and cognitive orientation due to insufficient data This meta-analytic study examining effectiveness of music therapy for acquired brain-injured conditions found only a handful of randomized controlled group studies and none of the studies included in the final data analysis examined CR in TBI So far, there has been only one study examining remediation of executive functions in TBI using music therapy.

This preliminary study using a quasi experimental design examined the immediate effect of NMT in a group-setting on patients with brain injury. The treatment group received four brief sessions of NMT lasting for 30 min duration and each session targeted one of the following functions: attention, memory, executive functions, and emotional adjustment. The control group participants comprised of patients with TBI This brief single session intervention did not bring about significant changes in attention and memory The study did not examine sustenance of improved functions over time. The findings emphasize the need for longer duration of intervention especially for cognitive functions such as attention and memory.

There is a gap between theoretical understanding of potential role of music as a CR method and systematic evaluation of its efficacy in TBI patients. With exponential growth in the scientific evidence in linking music and cognitive functions, the gap in application of music in CR in TBI would definitely be a temporary phenomenon. So far, the set-back in carrying out such research studies may be due to the very abstract nature of music and limited understanding of the link between music and specific cognitive functions. A clearer understanding of music engaging a host of cognitive process has been possible over the past two to three decades with the emergence of scientific evidence from the fields of neuromusicology and music cognition.

Until this time, there was an overpowering view of music as a therapeutic method for enhancing well-being with greater emphasis on emotional components in therapy. In addition, the difficulty may have been due to the very heterogeneous nature of TBI with varied cognitive profile.

NMT methods have been successful in designing methods and techniques to address specific cognitive functions, even by circumventing the emotional component of music in the therapeutic setting. It would not be too long before the effectiveness of NMT methods to improve cognitive functions is systematically evaluated in TBI as well as other neurological and neurosurgical conditions.

What About Cognitive Rehabilitation Therapy? | BrainLine

A ubiquitous phenomenon like music and systematic techniques such the NMT can be main-stream holistic treatment method in TBI and other clinical conditions. The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Rehabilitation after traumatic brain injury.

Med J Aust —5. McDonald S.

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Impairments in social cognition following severe traumatic brain injury. J Int Neuropsychol Soc 19 — Morton MV, Wehman P. Psychosocial and emotional sequelae of individuals with traumatic brain injury: a literature review and recommendations. Brain Inj 9 — Bond MR. Assessment of the psychosocial outcome after severe head injury. Ciba Found Symp 34 — Pubmed Abstract Pubmed Full Text.

Draper K, Ponsford J. Cognitive functioning ten years following traumatic brain injury and rehabilitation. Neuropsychology 22 — Traumatic brain injury: future assessment tools and treatment prospects. Neuropsychiatr Dis Treat 4 — A brief review of traumatic brain injury rehabilitation. Ann Acad Med Singapore 36 1 — McAllister TW. Neurobehavioral sequelae of traumatic brain injury: evaluation and management. World Psychiatry 7 1 :3— Association between cognitive performance and functional outcome following traumatic brain injury: a longitudinal multilevel examination. Neuropsychology 26 — Traumatic brain injury rehabilitation: state of the science.

Am J Phys Med Rehabil 85 — CrossRef Full Text.

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Evidence-based cognitive rehabilitation: updated review of the literature from through Arch Phys Med Rehabil 86 — Arch Phys Med Rehabil 92 — Effectiveness of cognitive rehabilitation following acquired brain injury: a meta-analytic re-examination of Cicerone et al. Neuropsychology 23 The efficacy of cognitive rehabilitation in patients with traumatic brain injury. Arch Neurol 47 —2. Evidence-based cognitive rehabilitation: recommendations for clinical practice. Arch Phys Med Rehabil 81 — Diller L, Gordon WA.

Interventions for cognitive deficits in brain-injured adults. J Consult Clin Psychol 49 — Gordon WA. Methodological considerations in cognitive remediation. Neuropsychological Rehabilitation. Edinburgh: Churchill Livingstone Inc. Strategic aspects of neuropsychological rehabilitation. Wilson BA. Cognitive rehabilitation: how it is and how it might be. J Int Neuropsychol Soc 3 — Prigatano GP. J Int Neuropsychol Soc 3 —9. A randomized controlled trial of holistic neuropsychologic rehabilitation after traumatic brain injury.

CRT has many variables: providers, settings, focus, and treatment formats. Many different types of professionals deliver services described as CRT. These providers are typically credentialed and licensed by their professions and state boards. They include, but may not be limited to:. Treatment may also be delivered in a variety of formats individual, group therapy, day treatment program , and intensities intensive inpatient rehabilitation, daily outpatient, or weekly.

Ideally, cognitive assessment to evaluate level of alertness, orientation to surroundings, and memory of recent events begins from the moment someone with a brain injury is admitted to the hospital. With moderate or severe cognitive impairments, individuals may receive CRT during an inpatient rehabilitation program and then be discharged to an outpatient setting for further treatment. The treatment team and discharge coordinator typically make recommendations about the treatment setting and type of provider that will be most effective in working with the kinds of cognitive problems that the individual displays.

The program may include functional activities such as planning outings into the community, or work or school re-entry. Comprehensive programs like this may be staffed by providers from multiple disciplines. More targeted therapy may be delivered by a single provider.

For example, a person with cognitive issues related to language processing following directions, using written strategies for memory and organization may focus on speech-language pathology services. Someone working on the cognitive skills for driving or home management may receive occupational therapy.

The professional who delivers the service may describe the treatment as CRT or in terms unique to that profession. People who sustain a concussion or mild TBI without being hospitalized may have a more difficult time being referred for CRT and having treatment covered by insurance. Without medical documentation of the problem, insurers may decline to make referrals or pay for CRT.


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  4. Because of the variability in patients and the CRT they may receive, research studies, to date, have not identified a single most effective treatment. Families and providers can work together to challenge insurance denials if they occur. Families can appeal denials, and ask the professional to provide detailed reports of functional progress made by the patient or articles demonstrating the effectiveness of the technique being used.

    Professional associations such as the American Speech-Language-Hearing Association provide assistance to speech-language pathologists and their patients by writing letters supporting CRT. Cognitive rehabilitation therapy may be like the proverbial elephant — it feels different to different people depending on their circumstances and perspective. But, as patients and families will attest, CRT is as fundamental a need in TBI recovery as physical rehabilitation — and for some, even more essential to their quality of life.

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    8. The National Academies Press. Doctors will keep suggesting you go to therapy to rehabilitate the parts of your brain that you are struggling with however the best method to improve brain function is to practice repetitive actions such as those brain games or memorization skills. Another method to use is association techniques such as visual cues, notes, reminders on your phone, imploring the help of friends and family to remind you of certain things until you automatically strengthen those parts of your brain again.

      Also, try alternative methods of therapy, yoga, music therapy, art, and meditation can help as well. If you can stay away from medications that are unnecessary try to improve brain function before turning to them as the medication is usually a coverup relief for the real underlying issue and does nothing to actually resolve or strengthen your cellular communication in the brain.

      I am not a professional, however, these methods will not harm you and something out of the blue might catch you by surprise by working. I'm trying to apply a cognitive therapy for musicians to in prove dystopian and reduce muscle cramp.. I am going to apply a therapy.. I was referred by my neurologist after a fall for cognative memory to a speech therapist.

      I had been tested by both. The therapist told me to do Saduku games and keep a daily calendar which I already had been doing I am having lots of trouble remembering even to look at the daily calendar, pay my bills, remember words, events, etc. The therapist says I don't really need any more since she gave me the two things to do. Is that what Cognative therapists do? Or is she just unqualified?? I am a licensed speech-language pathologist in the state of Texas I and would recommend you look for a more specialized speech-language pathologist. A well qualified therapist should be able to offer compensatory strategies for immediate assistance, such as a calendar, but also activities to target neuroplasticity.

      Hi Jacqueline, sorry to hear you are struggling with your memory. I have a pretty awful memory myself, so I know how frustrating that can be! It sounds like the speech therapist you saw may not have very much experience in cognitive rehabilitation. You are clearly having difficulty with these daily tasks, and a good speech therapist should be able to help you get a little closer to your prior level of function.



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