Recomendações para Melhores Práticas na CRT.docx

7/29/2019 Recomendaes para Melhores Prticas na CRT.docx

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Recomendaes para Melhores Prticas na CRT - documentoproduzido pela Sociedade de Reabilitao Cognitiva, 2004

A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-A Sociedade para Reabilitao Cognitiva, Inc.Malia K, P Lei, Sidebottom L, Bewick K, S Danziger,Schold E-Davis, Martin Scull-R, K & Murphy Vaidya AInovao prtica em Terapia Cognitiva Reabilitao

Pgina 2As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-1AGRADECIMENTOSSomos gratos s seguintes pessoas para a sua reviso independente e

comentrios sobre este documento:Dave ArciniegasYehuda Ben-YishayRita Cola-CarrollRosamond GianutsosCharlotte LoughHeidi RubinBarbara Wilson

Pgina 3As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-2NDICESumrio Executivo3O objetivo deste documento4Seo Um: A Framework1. Perspectivas Histricas

52. Definindo CRT83. Indivduos envolvidos na CRT9Seo II: Avaliao e Tratamento4. Avaliao125. Restaurao e Compensao166. A importncia da integrao com outros aspectos da Multidisciplinar

Equipe20
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7. Fatores psicossociais218. Funcionalmente Oriented239. Modelos

2510. Educao2911. Formao processo3212. Estratgias3513. Treinamento de Atividades Funcionais3714. Conscincia38

15. Reportagem41Seo Trs: a base de evidncias para o Programa de CRT16. Introduo4317. A base de evidncias4418. CRT tratamento pode ajudar com problemas emocionais e Psicossocial4619. CRT tratamento pode ter um efeito significativo sobre Estruturas Cerebrais4720. Determinar se CRT obras uma questo complexa4721. CRT tem validade de face49Referncias teis50

Pgina 4As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao

A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-3Sumrio ExecutivoOs efeitos a longo prazo de dificuldades cognitivas aps uma leso cerebral so umaestabelecida fato. A Sociedade para Reabilitao Cognitiva est empenhada emdesenvolver e assegurar as melhores prticas no campo da CognitivaReabilitao.Este documento foi produzido num momento em que so diferentes organizaesproduo de Diretrizes e Normas para a reabilitao neurolgica. Tem como objectivoapresentar a base para a melhor prtica, num aspecto da presente, a saber, CognitiveReabilitao, para que os planejadores, gestores, profissionais, pessoas com crebro

leso, e suas famlias podem determinar o que necessrio.A parte principal do documento constitudo por 81 Recomendaes, sob


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uma variedade de temas, que foram concebidos para cobrir exaustivamenteprtica clnica em uma variedade de configuraes de leses cerebrais adquiridas. Estesrecomendaes so suportados com provas sob a forma de opinio de especialistas.Alm disso, a seco foi includa para permitir que o leitor a ganhar um rpidoviso geral das melhores prticas. Isto apresentado na forma de uma base de dados.

Apesar de no ser completa, esta base de dados um bom ponto de partida paraqualquer umque precisa explorar isso com mais detalhe. Todas as referncias so includas na suatotalidade.

Pgina 5As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-4O objetivo deste documentoOs efeitos cognitivos da leso cerebral, e as implicaes para o futuroqualidade de vida, tem sido bem documentada na literatura (Turner-Stokes,2003). Agora um facto que os problemas cognitivos so um dosmais incapacitante consequncias a longo prazo de leso cerebral.A Academia Nacional de Neuropsicologia (NAN) nos Estados Unidos temproduziu uma declarao de posio em breve CRT (2002). No Reino Unido,Real Colgio de Mdicos e da Sociedade Britnica de ReabilitaoMedicina produziram Diretrizes para tanto leso cerebral aguda psreabilitao e reabilitao acidente vascular cerebral, o que salientar a importncia dacompreender e lidar com os problemas cognitivos (Turner-Stokes, 2003;

Royal College of Physicians, 2004).Reabilitao Cognitiva Terapia (CRT) central para a reabilitao de leses cerebraissucesso. No entanto, ainda h debate sobre quais tratamentos funcionam melhor,as condies em que, e para o qual os pacientes. Como resultado, tem havido umanmero de meta-revises, algumas das quais esto em curso, do vasto e sempreexpanso literatura publicada neste domnio (Chestnut, 1999; NIHCD, 1999;Cicerone et al, 2000;. Cappa et al, 2003;. Frattali et al, 2003).. Estas opiniesfazer um resumo da evidncia cientfica disponvel.H tambm uma necessidade de ter em conta opinio de especialistas. A Sociedade paraReabilitao cognitiva (SCR) consiste de um Conselho de Administrao e umConselho Consultivo,

composto por um grande nmero de especialistas na rea de reabilitao cognitiva., portanto, adequado e oportuno que a Sociedade para CognitivaReabilitao (SCR) produz este documento: "Recomendaes para MelhorPrtica. "Este documento deve ser considerado um" trabalho em progresso ", queser atualizado conforme novas evidncias publicado. Baseia-se na clnicaexperincia apoiada pela evidncia publicada.O objetivo deste documento :Fornecer uma lista completa de recomendaes de boas prticas baseadasem evidncias publicadas e opinio de especialistas.Para actuar como um recurso mais detalhada do que foi produzido como resultado deo meta-revises, tomadas de posio e documentos diretrizes.

Para ajudar a melhorar a prtica clnica em uma ampla variedade de configuraes quefornecer CRT.


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Por favor contacte-nos com seus comentrios e sugestes:[email protected]

Pgina 6As recomendaes de SCR para Melhores Prticas

em Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-5PRIMEIRA SEO: QUADRO1. Perspectivas HistricasRecomendao 1.1:Programas de reabilitao de leses cerebrais deve incluir cognitivaavaliaes e tratamentos (CRT).Recomendao 1.2:CRT deve ser includo em todas as fases da reabilitao, do comapara a comunidade, de forma adequada as necessidades do indivduo comleso cerebral.Recomendao 1.3:Pessoal a trabalhar dentro de reabilitao de leses cerebrais devem ser treinados paraentender a cognio e seu impacto sobre a sua prpria profissionalentradas.CRT se desenvolveu como resultado de um conhecimento crescente sobre a longo prazoefeitos da leso cerebral. CRT foi usado pelo exrcito britnico e alemosuas tentativas de reabilitar tropas durante as duas Guerras Mundiais (Pentland etal, 1989;. Poser et al, 1996)..Desde a Segunda Guerra Mundial, CRT tornou-se parte integrante da leso cerebral

reabilitao:A histria do CRT velha e nova. Primeira Guerra Mundial e II levou aconsidervel desenvolvimento dos mtodos de reabilitao de todos os tipos. Contudona dcada de 1970 e 1980, o campo da CRT experimentou a maior mudana.Esta revoluo foi estimulado primeira pesquisadores porque a reabilitao eterapeutas tornou-se interessado em psicologia cognitiva, que tinha idoatravs de um perodo de rpido crescimento na dcada de 1960. Alm disso, distintocertafiguras como Alexander Luria avanou um nmero de idias importantes sobreneurocognio e o tratamento de deficincias cognitivas.Parente, R. & Herrmann, D. (1996). Reciclagem cognio. Aspen, Maryland, p. 1.

"Embora o TCE pode resultar em incapacidade fsica, a mais problemticaconseqncias envolvem cognio do indivduo, emocional ecomportamento. O consenso recomenda que a reabilitao "de pessoas comTCE deve incluiu a avaliao cognitiva e comportamental e interveno.Institutos Nacionais de Sade Declarao de Conferncia de Consenso deDesenvolvimentoReabilitao de Pessoas com TCE. Convocada em 1998. Coloque a pressionar em 1999.

Pgina 7As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-6
mailto:[email protected]:[email protected]:[email protected]


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Prejuzos cognitivos na memria, raciocnio, ateno, julgamento e autoconscincia so obstculos importantes no caminho para a independncia funcionale um estilo de vida produtivo para a pessoa com uma leso cerebral. . . tornou-sedramaticamente evidente para profissionais, pacientes e suas famlias que cognitivadeficincias, que interagem com perturbao de personalidade, estavam entre os

determinantes mais crticos dos resultados da reabilitao definitiva. Portantoreabilitao cognitiva tornou-se um componente integral da leso cerebralreabilitao.Academia Nacional de Neuropsicologia declarao de posio sobre ReabilitaoCognitiva.Maio de 2002. wwwnanonline.org.At a dcada passada, a CRT no foi abordado nos livros didticos ou feito oobjeto de conferncias profissionais. Nos ltimos anos, vrios hospitais ao redoro pas estabeleceu CRT como parte de suas ofertas de tratamento. Existe agorauma organizao profissional, a Sociedade de Reabilitao Cognitiva que temestabeleceu requisitos de certificao para profissionais de CRT.

Parente, R. & Herrmann, D. (1996). Reciclagem cognio. Aspen, Maryland, p. 5.Ele j no pode ser dito que a reabilitao cognitiva um "novo campo".Sohlberg, MM & Mateer, CA (2001). Reabilitao cognitiva:Uma abordagem integrativa neuropsicolgica. A imprensa Guilford, p. ix.Cognitivo reciclagem tem sido aceite uma interveno teraputica noreas de psicolingstica e educao especial para dificuldades de aprendizagem emcrianas e adultos h vrias dcadas.Berrol, S. (1990). Problemas na reabilitao cognitiva. Arch Neurol 47, 219-220.A Sociedade Britnica de Medicina de Reabilitao (BSRM) enfatiza aimportncia dos dficits cognitivos aps o TCE: "A aquisio de novos conhecimentosehabilidades particularmente difcil quando h dficits cognitivos. Todos aqueles quesoenvolvidos com o paciente que tem uma leso cerebral deve entender cognitivadeficincias e como eles alteram o que o paciente capaz de compreendercumprir e alcanar ".Reabilitao aps leso cerebral traumtica. (1998). BSRM. Relatrio do Grupo deTrabalho.Reabilitao cognitiva fundamental para qualquer programa de tratamento projetadopara otraumtica cerebral feridos individual.

Reabilitao Cognitiva. (1994). Rattock, J. & Ross, a BPCh. 21 em Neuropsiquiatria do TCE. (Eds.) Prata JM, Yudofsky SC, e Hales, RE,American Psychiatric Press Inc.,Washington, DC.95% dos centros de reabilitao que sirvam as necessidades das pessoas com lesocerebralfornecer alguma forma de reabilitao cognitiva, incluindo combinaes deindividual, de grupo e terapias baseadas na comunidade.Cicerone, KD et al. (2000). Evidncias baseadas reabilitao cognitiva: recomendaespara a prtica clnica.Arch Phys Med Rehabil 81, 1596-1615.

O Helios relatrios do programa de boas prticas em vrios estgios de ps leso,"como


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pacientes mostram sinais de recuperar a conscincia que eles devem ser transferidospara

Pgina 8As recomendaes de SCR para Melhores Prticas

em Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-7um hospital de reabilitao, onde um programa estruturado de atividades nos promove a reabilitao de habilidades cognitivas, mas tambm impededeteriorao do comportamento. ' Este trabalho recomendado para continuar nopostar fase aguda: 'cognitivo, avaliao emocional e social einterveno ", e para o estgio pr-profissional: 'No psycho-social/preestgio profissional, a nfase na construo de autonomia social, cognitivo,treinamento emocional e social ".Diretrizes para boas prticas. O Helios Programa. (1996). Grupo de Trabalho sobreLeso CerebralReabilitao do Setor de Reabilitao Funcional da Unio Europeia programa Helios II.Os estados BSRM: 'cognitivas, problemas emocionais e comportamentais soseguinte extremamente comum adquiriu leso cerebral. . . onde cognitivadeficincia est causando dificuldades de gesto ou limitar a respostareabilitao, aconselhamento especializado deve ser procurado e, se necessrio, opaciente encaminhado a um programa de reabilitao formal focada em amenizar oconseqncias de seus dficits cognitivos direta ou indiretamente. "Diretrizes para Reabilitao seguinte adquiriu leso cerebral em adultos em idade detrabalhar. (2003). 7

Rascunho.Produzido pelo Grupo BSRM Trabalho. Seo 7.5.2.O programa deve basear-se nos resultados de fsico, cognitivo, executivo,comunicao, as avaliaes psicossociais e funcionais, de acordo comos efeitos pretendidos.Crebro do Sul Thames Injury Association Reabilitao,Padres Mnimos recomendados para reabilitao de leso aguda do crebro Post.(2000). Padro 4.2.O programa tem de basear-se nos resultados de fsico, cognitivo,comunicao, as avaliaes psicossociais, funcionais e ambientais.

Turner-Stokes L. (2002). Governao Clnica em Medicina de Reabilitao.O estado da arte em 2002. Reabilitao Clnica 16 (supl. 1): 1-58. Apndice 1:Normas para especialista em-paciente e servios comunitrios de reabilitao, p. 41,Standard 5.1.Reabilitao cognitiva deve estar disponvel, porque, s vezes, mais diretatentativas de remediar habilidades funcionais (por exemplo, cozinhar, higiene) sodevido frustrada de disfuno cognitiva subjacente.Vogenthaler, D. (1987). Uma viso geral da leso na cabea:Suas consequncias e reabilitao. Leso Cerebral 1 (1): 113-127.O Brain Injury Grupo de Interesse Especial do Congresso Americano deMedicina de Reabilitao (ACRM BI-ISIG) foi criado em 1994 para examinar a

papel da psicologia na CRT. O grupo identificou o papel positivo e valor deCRT.


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Bergquist, TF & Malec, JF (1997). Psicologia: a prtica atual e as questes de formaoemtratamento da disfuno cognitiva. Neurorehabilitation 8, 49-56.

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As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-82. Definindo CRTRecomendao 2.1: essencial ter uma definio clara do CRT, a fim de direcionar oavaliao e tratamento actividades.A fim de definir CRT, essencial ter uma idia clara do que o termo"Cognio" refere-se a:O que chamamos de cognio um conjunto complexo de habilidades mentais queincluiateno, percepo, compreenso, aprendizagem, lembrando problema,resoluo de problemas, raciocnio e assim por diante. Estes atributos mentaispermitem-noscompreender o nosso mundo e para funcionar dentro dele. Depois de uma lesocerebral, uma pessoanormalmente perde uma ou mais dessas habilidades. Reabilitao cognitiva a arteea cincia de restaurar esses processos mentais aps a leso no crebro.Parente, R. & Herrmann, D. (1996). Reciclagem cognio. Aspen, Maryland, p.1.Esta definio geral d uma viso geral do que CRT, mas a definio em

uso mais comum foi publicada pelo Congresso Americano deMedicina de Reabilitao, Brain Injury Grupo de Interesse Especial (ACRM BI-SIG)em1997:CRT uma "sistemtica, servio funcionalmente orientado de teraputica cognitivoatividades e uma compreenso de dficits comportamentais da pessoa. Serviosso direcionados para alcanar mudanas funcionais por: Reforar, o fortalecimento ou o estabelecimento de padres previamente aprendidosde comportamento, ou

Estabelecer novos padres de atividade cognitiva ou mecanismos para

compensar a deficincia sistemas neurolgicos. 'Bergquist, TF & Malec, JF (1997). Psicologia: a prtica atual e treinamentoproblemas no tratamento da disfuno cognitiva. Neurorehabilitation 8, 49-56.Esta definio foi aprovada pela Comisso de Credenciamento deFacilidades de reabilitao (CARF) e pela Academia Nacional deNeuropsicologia (NAN), em sua declarao de posio sobre Reabilitao Cognitiva(Maio de 2002).

Pgina 10As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-9


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3. Indivduos envolvidos na CRTRecomendao 3.1:Prestao CRT cruza fronteiras disciplinares. Tentativas deve serfeito para utilizar as habilidades trazidas a este campo por uma variedade deindivduos que receberam a sua formao em assuntos relacionados.

Praticantes de CRT deve ser licenciado / qualificado em um relevantedisciplina.Recomendao 3.2:Relevante e extensa formao ps-graduada na CRT deve serpreenchido por todos os indivduos que prestam o servio CRT.As referncias a seguir apiam a viso de que a CRT um multi-disciplinarprestao e no , nem deve ser, o nico domnio de qualquer disciplina nico:Estes servios (reabilitao cognitiva) so fornecidos pela faculdade educadaindivduos que, em sua maior parte, tenham completado um currculo de cinciassociais(Ou seja, psicologia, sociologia, educao especial).

Raymond, MJ (1994). Consulta neuropsicolgica em reabilitao.New Jersey Rehab, edio de maro, pp 18-27.Porque suas razes so interdisciplinares, os praticantes de CRT vemdiversas reas.Parente, R. & Herrmann, D. (1996). Reciclagem cognio. Aspen, Maryland, p. 5.Com vistas a eficcia, os dfices cognitivos devem ser tratados dentro de umaprograma neurorehabilitation abrangente que incorpora uma ampla variedadede modalidades de tratamento. Fisiatria e fisioterapia, individualaconselhamento, intervenes familiares, questes profissionais e comunidade re-entradatodos precisam ser abordadas. A no ser que todos estes esto integrados no tratamentoresultados do programa, bem sucedido do processo de reabilitao posta em causa.Rattok, J. & Ross, BP (1992). Uma Abordagem Prtica para CognitiveReabilitao. Neurorehabilitation, 2 (3): 31-37.Uma vez que os dficits cognitivos em pacientes com TCE pode prejudicar aprendizadode habilidades emtodas as disciplinas, cabe a equipe para desenvolver oportunidades como muitos comopossvel, em que as dificuldades cognitivas so o foco do tratamento, e aincorporar estratgias corretivas em todos os encontros teraputicos para maximizaraprendizado e resultado.Waxman, R. & Gordon, WA (1992). Grupo-Administrado Remediao Cognitiva para

Pacientes com leso cerebral traumtica. Neurorehabilitation, 2 (3): 46-54.

Pgina 11As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-10Wilson (2002), ilustra claramente o reconhecimento de que existe uma necessidade deincorporar a informao a partir de uma ampla variedade de fontes, se houver algumaesperana deobteno de um modelo significativo de CRT. Cruzando fronteiras disciplinares um

maneira em que este objetivo pode ser promovido.O Brain Injury Grupo de Interesse Especial Interdisciplinar da American


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Congresso de Medicina de Reabilitao especifica a formao necessria paraprofissionais qualificados em reabilitao cognitiva, incluindo:Trabalho do curso documentado, experincia relevante e treinamento formal nacompreenso do funcionamento neurolgico, comportamental e cognitivo eformao especializada na reabilitao de distrbios cognitivos.

ISIG cabea Leso de ACRM. (1992). Diretrizes para a reabilitao cognitiva.Neurorehabilitation 2 (3): 62-67.A Sociedade para Reabilitao Cognitiva um rgo no-disciplina especfica,que procura reunir todos que est fornecendo, ou que est interessadoem, CRT. O SCR reconhece que as profisses diferentes tm diferentes habilidadesque pode ser trazida para o campo para o benefcio dos clientes / pacientes.Recomendao 3.3:A pessoa com leso cerebral deve ser visto como um elemento integranteda equipe.Recomendao 3.4:A pessoa com leso cerebral deve ser envolvido no cognitiva

esforo tratamento nos seguintes aspectos:a) A justificativa para a formao deve ser aprovado pelo indivduob) Os mtodos e os materiais a serem utilizados para o treino cognitivo deve sercompreendidos e aceitos pelo indivduoc) A necessidade de motivao persistente para participar deve ser aceito peloindividual.Estes autores do documento que os clientes que eram participantes ativos em seuobjetivoconfigurao e monitoramento do progresso mostrou realizao de objetivo superior emanuteno.Webb, PM & Glueckhauf, RL (1994). Os efeitos de envolvimento direto noestabelecimento de metas sobre resultados da reabilitao parapessoas com leses cerebrais traumticas. Reabilitao Psicologia 39, 179-188.

Pgina 12As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-11Recomendao 3.5:O sistema familiar / apoio da pessoa com leso cerebral desempenha um

papel importante na interveno e devem ser activamente envolvidosdurante todo o tratamento.A evidncia clnica e dados de investigao indicam uma relao entre ocapacidade da famlia de se adaptar e lidar com o trauma e sucesso do paciente emreabilitao. Isto , no h uma relao dinmica entre o paciente efamlia de tal forma que a leso tem um impacto dramtico sobre o sistema familiar, eresposta da famlia leso tem um impacto sobre o resultado do tratamento. Assim,h uma necessidade crtica para o desenvolvimento de intervenes eficazes detratamento da famlia.Maitz, EA & Sachs, PR (1995). Tratar famlias de indivduos com leso cerebraltraumtica de

uma famlia de sistemas de perspectiva. Cabea J Trauma Rehabil 10 (2): 1-11.Reabilitao sucesso. . . depende de uma verdadeira colaborao com o cliente


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e os membros da famlia ou de outras pessoas de apoio significativas na vida do cliente.. .Colaborao (1) facilita a identificao de objetivos teraputicos que importaaos indivduos afetados pela leso cerebral, (2) molda a intervenoprocesso para que ele ir trabalhar para indivduos reais em contextos do mundo real,

(3)reconhece que os outros membros da famlia do que a pessoa com a leso tambmprecisa de suporte, e (4) pode melhorar o processo de pesquisa para a reabilitaodesenvolver e avaliar intervenes eficazes.Sohlberg, MM & Mateer, CA (2001). Reabilitao Cognitiva. Guilford, NY, pp 401-404.

Pgina 13As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-12CLUSULA SEGUNDA: AVALIAO E TRATAMENTO4. AvaliaoRecomendao 4.1:Uma bateria normal de avaliao deve ser administrada em cadadefinindo que fornece CRT.Recomendao 4.2:A bateria de avaliao deve fornecer informaes suficientes paraformulam hipteses sobre os prejuzos cognitivos subjacentes edficits que interferem com o funcionamento cognitivo da pessoa.

Recomendao 4.3:Os resultados da avaliao de bateria dever permitir que o terapeutapara tomar decises sobre quais tratamentos so necessrios, em vezque apenas a descrever os problemas.Por exemplo, no considerado como apropriado para uma configurao de reabilitaoseum teste de memria, por exemplo, apenas diz ao examinador que o paciente tem umdficit de memria verbal de tantos pontos ou desvios-padro, mas sim oteste de memria deve habilitar o examinador para decidir qual aspecto daprocesso de memria est a falhar e, portanto, onde o alvo da terapia.Recomendao 4.4:

Em contextos de reabilitao, padronizados avaliaes psicomtricas,questionrios, entrevistas estruturadas, e observaes comportamentaistoda uma gama de configuraes funcionais devem ser usados semdando maior nfase a uma qualquer abordagem.Recomendao 4.5: essencial para a referncia cruzada dos resultados dos testes com os outrose com testes feitos em diferentes departamentos (onde esta possvel) e com o teste feito em dias diferentes ou em diferentesmomentos do dia.

Pgina 14As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao


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A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-13Com alguma experincia, padres tpicos de dficits e foras podem ser facilmenteidentificados a partir de uma tal bateria, na maioria dos pacientes. Onde tais padresno so claras, em seguida, consultoria especializada deve ser procurada, geralmente de

umneuropsiclogo ou neuropsiquiatra.Recomendao 4.6:Sempre que os resultados da avaliao possveis devem ser compartilhadas com ocrebro lesado pessoa. Eles devem ser explicadas em termos de que oindividual pode compreender e explicitamente relacionadas com osproblemas funcionais que tenham sido identificados.Recomendao 4.7:Um plano de tratamento cognitivo deve ser elaborado com o crebrolesado, como resultado direto das avaliaes. Acordodeve ser tomada sobre este entre o terapeuta eo crebro lesado

pessoa.Recomendao 4.8:Reavaliao deve ser realizada em intervalos regulares, a fimpara monitorar e relatar o progresso.Preciso ter em conta de teste e reteste preconceitos, mas admite-se que h uma falta de baterias repetveis. A filosofia de trabalho na repetio do teste deveser a de demonstrar ao cliente / paciente que ele ou ela est fazendo progresso.s vezes, isso vai significar utilizando testes que podem ter um reteste vis. No entanto,isto sublinha a importncia do uso de questionrios, estruturadoentrevistas e observaes comportamentais, juntamente com testes formais.Neuropsicolgica, ou formal, as avaliaes so necessrias, mas no suficientespara o estabelecimento de nveis de funcionamento na vida cotidiana:O exame clnico neuropsicolgico uma ferramenta til, mas limitado. Completoapreo por seus diagnsticos preditivos, pontos fortes e reabilitao orientador-e fraquezas est to relacionado com a formao clnica do examinador comoa percia tcnica e administrao dos vrios testes. . . .Os resultados dos testes do alguma indicao de desempenho intelectual gerale uma idia geral de disfuno relativa no neuropsicolgicamedidas utilizadas. No entanto, existem muitas formas de inteligncia oucompetncia que no so bem aproveitado por at mesmo um muito completoexame neuropsicolgico. Estes incluem a inteligncia social ou a

capacidade de conviver bem com outras pessoas, trabalhar susceptibilidade, capacidadededesejo, cansao de fazer bem, responsabilidade, etc Estas so todas as capacidades que

Pgina 15As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-14pessoas que possuem pode ser esperado para exacerbar ou minimizar o impactode certas deficincias cognitivas. . . .

A relao exata destas pontuaes para o nvel final de psicossocialajuste e de atividades especficas de interveno ainda est longe de bem


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entendi ... Se vamos fazer recomendaes sobre oreintegrao de um indivduo para o dano cerebral comunidade seguinte,com base nos resultados do teste, precisamos ter uma melhor compreenso de como anossaprocedimentos de teste atuais se relacionam com tais aspectos de funcionamento como

trabalhodesempenho e independncia nas atividades da vida diria.Prigatano, GP, pepping, M. & Klonoff, P. (1986). Cognitivo, personalidade epsicossocialfatores na avaliao neuropsicolgica de pacientes lesionados cerebrais. Ch. 7 emClinicalNeuropsicologia da interveno. (Eds.) BP Uzzell & Y. Gross. Martinus NijhoffPublishing,Boston.Avaliao contnua valioso e desejvel. O uso consistente de procedimentosque gerar resultados significativos permite o acompanhamento quantitativo dos

resultados. Opessoa com leso cerebral pode ser ensinado para tabular suas prprias partituras emgrficos fornecidos para o indivduo. Especialmente desejvel a entrada de notasem uma planilha estruturada que produz uma visualizao grfica dos resultados.As pessoas com leso cerebral que aprendem a fazer isso pode adquirir vocacionalmentehabilidades valiosas.Rosamond Gianutsos. (2005). Comunicao pessoal.Recomendao 4.9:Sempre que possvel, os resultados da avaliao e do plano de tratamentodeve ser explicado, discutido e acordado com o cuidador ououtro significativo.Recomendao 4.10:Os resultados da avaliao devem ser usados pela equipe de terapia paraajud-los a fazer um prognstico para o que eles podem alcanar com opessoa com leso cerebral. Isso deve ser claramente indicado por escrito,com justificativas, para a pessoa crebro lesado e suacuidador ou parente. Estes formam as "metas de resultados."Recomendao 4.11:Os objetivos do tratamento deve ser especificado como um resultado da avaliao.Estes devem incluir metas de resultados, metas de longo prazo e de curtoobjetivos de longo prazo. Estes devem ser acordadas com a pessoa com crebro

leso.

Pgina 16As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-15Recomendao 4.12:Todos os objetivos devem ser escritos como metas SMART e claramentedocumentada.O acrnimo SMART garante que as metas so:

S - Especfico, M - Mensurvel, A - atingveis, R - Realista / recursos, e T -Oportuna e Tempo ligados.


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Isso fornece a estrutura para a pessoa crebro lesado e permite tanto a pessoae para monitorar o progresso de ver melhorias. Voc deve ter uma claraobjetivo de cada sesso ou atividade, ou seja, exatamente o que a pessoa deve sercapaz de fazer at ao fim da sesso. Um objectivo algo que pode serde forma clara e precisa, que voc pode observar a pessoa que faz. Estado

claramente o que deve ser alcanado, em que condies especficas, at quando, eo nvel de resposta correcta necessria. Seja realista ao estabelecer essas metas eobjetivos. No desenvolver objetivos em um nvel to elevado que voc eopessoa sentir-se frustrados. Rever seus objetivos e se eles so muito altos,modific-los.Cada um dos componentes representados pelo acrnimo SMART deve serapresentar, caso contrrio, a meta no vai acontecer.McMillan & T fascas C. (1999). Planejamento gol e reabilitao neurolgica.Reabilitao Neuropsicolgica 9, 345-361.

Pgina 17

As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-165. Restaurao e CompensaoRecomendao 5.1:Tratamentos CRT deve abranger as tentativas de restaurao de Lostfuno ao mesmo tempo, como uma estratgia de ensino compensatrios paraminimizar os prejuzos cognitivos.Recomendao 5.2:

A pessoa com leso cerebral nunca deve ser dito que a sua idadefunes cognitivas podem ser totalmente restaurado, pois eles devem ser avisadosque o objectivo maximizar ou otimizar essas habilidades, ao mesmo tempo aprendernovas maneiras de fazer as coisas para minimizar os problemas(Compensao).O argumento sobre a possibilidade de superar o problema neurolgico oucompensar isso est em curso h um par de dcadas. Isto no deveser visto como um "ou / ou" a situao. mais apropriado para combinar com oabordar as necessidades de cada cliente / paciente.Pode ser visto a partir da definio ACRM CRT que diz respeito a ambascompensando dificuldades cognitivas e com a restaurao perdida cognitiva

funes. Na verdade, este um tema que encontra eco nos trabalhos de muitospublicadosautores, por exemplo:Embora a cognio tem sido estudada por um longo tempo, os procedimentos paraassistirna restaurao das funes cognitivas s agora esto sendo desenvolvidos.No mnimo, deveramos ser capazes de ajudar as pessoas a identificar as suas perdas.Alm disso, as pessoas podem ser ajudadas a chegar a um acordo com o problema etrabalhando mtodos para lidar com isso. Finalmente, podem ser feitas tentativas pararestaurarperda de funo. Muitas vezes, as pessoas perguntam se o treinamento dirigido a

compensao ou arestaurao da funo. A resposta mais prudente "ambos".


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Gianutsos, R. (1980) O que reabilitao cognitiva?Jornal da Reabilitao, julho / agosto / setembro, pp 36-40.Estratgias cognitivas gerais teraputicos consistem em ensinar compensatriahabilidades e crebro reciclagem. Atravs da prtica e repetio, deficincia cognitivafunes podem ser reforadas. Isto pode ocorrer por reforo de competncias de

fundaotais como a ateno / concentrao, tempo de reao, processamento visual, eocapacidade de organizar novas informaes. Esses blocos bsicos de construo. . . podeserintegrados mais complexos comportamentos funcionais (vestir, cozinhar,equilibrar um talo de cheques e operao de um automvel). Lpis e papeltarefas, programas de software de computador, vdeo e comentrios so usados paradesenvolver essas habilidades.Raymond MJ (1994) consulta neuropsicolgica em reabilitao.New Jersey Rehab, edio de maro, pp 18-27.

Pgina 18As recomendaes de SCR para Melhores Prticasem Terapia Cognitiva Reabilitao A Sociedade para Reabilitao Cognitiva (2004) www.cognitive rehab.org.uk-17CRT "um processo pelo qual as pessoas com leses cerebrais trabalham em conjuntocom a sadeprofissionais de servios e outros para remediar ou aliviar os dficits cognitivosdecorrente de uma leso neurolgica.Wilson, B. (2002). Rumo a um modelo abrangente de reabilitao cognitiva.

Reabilitao Neuropsicolgica 12 (2): 97-110.Evidence for experience dependent plasticity of the brain, including cellregeneration, means that rehabilitation can aim at reinstituting impairedcognitive function, as well as at training compensatory strategies for thefunction.'Robertson, IH (1999). Setting goals for cognitive rehabilitation. Curr Opin Neurol12(6): 703-8.Sometimes we try to restore lost functioning, or we may wish to encourageanatomical reorganisation, help people use their residual skills moreefficiently, find an alternative means to the final goal (functional adaptation),use environmental modifications to bypass problems or use a combination of

estes mtodos.Wilson, B. (2002). Towards a comprehensive model of cognitive rehabilitation.Neuropsychological Rehabilitation 12(2): 97-110.There is an increasing body of evidence and opinion demonstrating thatrestoration approaches are valid:Interventions to improve neural network and cognitive function may involveparticular types of experience and stimulation (eg, complex environments)with experience-dependent changes demonstrable in the biology of neuralconnections, small blood vessels and even the organisation of brain layers.National Institutes of Health Consensus Development ConferenceStatement Rehabilitation of Persons with TBI. Convened in 1998. Put to press in 1999.

Theoretically direct retraining of impaired cognitive functions appears to bepossvel. If accomplished such training would be of substantial help to


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pacientes.From the NIH report. Prigatano, GP (1998). Cognitive Rehabilitation:An impairment oriented approach embedded in a holistic perspective.My first point is that restoration is an appropriate goal for the beginning oftherapy because it just might work. To the extent that it does work, it will

obviate the need for alternative treatments and reduce the total need forrehabilitative services. To those who are concerned about the ethics ofholding out false hope, I would propose that we should question theproprieties of ruling out hope. . . . the point is, who really has the knowledgeto justify the elimination of hope?Gianutsos, R. (1991). Cognitive rehabilitation: Neuropsychological speciality comes ofage.Brain Injury 5(4): 353-368.Cognitive exercise helps change the brain itself. It seems almost self evidentthat this should be the case . . . systematic cognitive activation may promotedendritic sprouting in the victims of stroke or head injury; this in turn facilitates

Pgina 19The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk18the recovery of function . . . it is logical that the more broad based a cognitiveworkout regimen the more general the effects.Goldberg, E. (2001) The Executive Brain, OUP, p. 204.Retraining tasks do more than just restore lost functions; they also can be

instrumental in helping patients to develop compensatory strategies and viceversa. This illustrates that restoration and compensation approaches are notmutually exclusive:This study looked at two groups of patients, 15 in each group. Grupo 1received four 45-minute session over 4 weeks in computer tasks on a visualremediation-training task without instruction in compensatory training. Grupo2 had four 45-minute sessions over 4 weeks, consisting of instruction in theuse of three internal compensation strategies (verbalisation, chunking andpacing). 80% of both groups used compensatory strategies. Therefore manypeople following brain injury will develop these themselves whilst doing theappropriate training tasks. It is therefore appropriate and beneficial to use

retraining tasks.Dirette, DK, Hinojosa, J. & Carnevale, GJ (1999).Comparison of remedial and compensatory interventions for adults with acquired braininjuries.J Head Trauma Rehabil 14(6): 595-601.Restorative training focuses on improving a specific cognitive function,whereas compensatory training focuses on adapting to the presence of acognitive deficit. Compensatory approaches may have restorative effects atcertain times. Some cognitive rehabilitation programs rely on a single strategy(such as computer assisted cognitive training), while others use an integratedor interdisciplinary approach. A single program can target either an isolated

cognitive function or multiple functions concurrently. . . . Compensatriadevices, such as memory books and electronic paging systems, are used


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both to improve particular cognitive functions and to compensate for specificdficits. Training to use these devices requires structured, sequenced andrepetitive practice.National Institutes of Health Consensus Development Conference StatementRehabilitation of Persons with TBI. Convened in 1998. Put to press in 1999.

Recommendation 5.3:Whichever mix of restoration and compensation approaches areused, the therapy needs to be systematic, structured, andrepetitive according to the needs of each particular client/patient.The training must be progressive and adapted to each training subject. Otraining schedule must be repetitious and intense.From the NIH report. Prigatano, GP (1998). Cognitive Rehabilitation:An impairment oriented approach embedded in a holistic perspective.

Pgina 20The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk19The treatment consists of hierarchically organised treatment tasks andprovides exercises, which require repetitive use of the impaired cognitivesystem in a created, progressively more demanding sequence. . . .Luria theorised that recovery of function can occur through new learnedconnections established through cognitive retraining exercises specificallytargeted at the source of problems for the basic processes that have beeninterrompidas. . . . In the process specific approach to cognitive rehabilitation,

practice or drills are simply a means of attacking deficient cognitive capacity;the exercises do not have any inherent value in and of themselves. . . .The process specific approach is different from general stimulation in that aconstellation of related tasks, all of which target the same component of aparticular cognitive process, are systematically and repetitively administered. .. .Repetition is perhaps the hallmark of the process specific approach tocognitive rehabilitation. This orientation is based, in part, on the Lurianconcept, which states a direct retraining of cognitive processes can result in areorganisation of higher level, thought processes. In order to do this,however, multiple trials providing stimulation and activation of the target

process are required to achieve neurologic reorganisation. The notion is thatthe repeated taxing of the same neurological system facilitates and guides thereorganisation of function. Thus the process specific approach requiresimplementation of repetitive exercises within the planned program that placesdemands on the patient to perform an impaired skill.

As soon as the patient has mastered a particular exercise or group ofexercises, higher-level treatment tasks targeting the same cognitivecomponent need to be available so that the continued stimulation andactivation of the objective cognitive processes can occur. The final principle ofprocess specific therapy is a reminder that the ultimate measure of success intherapy lies with improvement in living and work status rather than change on

Os resultados dos testes.Sohlberg, MA & Mateer, CA Introduction to cognitive rehabilitation and practice.


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Paper on the net (www.pacelearningrx.com/cognitiverehab.html).

Pgina 21The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy

The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk206. The Importance of Integration with other aspects of theMulti-disciplinary teamRecommendation 6.1:CRT cannot be seen as a stand alone therapy, but must form

part of the multi-disciplinary approach.Cognitive Rehabilitation is central to any treatment program designed for thetraumatically brain injured individual. Although specific cognitive exerciseshave their own unique place as training tools, when used in isolation, they areof doubtful value in aiding a traumatically brain injured person to attain truefuncionalidade. However, when utilised as part of a comprehensiveinterdisciplinary program of rehabilitation for TBI, they can be crucial andefficacious components of treatment.Cognitive Rehabilitation. (1994). Rattock, J. & Ross, BP Ch. 21 in Neuropsychiatry ofTBI.(Eds.) Silver, JM, Yudofsky SC & Hales, RE, American Psychiatric Press Inc.,Washington,DC.There are five principles that guide the implementation of the therapies to bediscussed below (medical care, physical therapy, speech therapy,

occupational therapy, cognitive rehabilitation, psychological counselling,behaviour management, art, and music therapy, therapeutic recreation). Elesso os seguintes: Implement these various practices as early after the injury as isvivel. Research has shown that doing so enhances eventualresultado. Provide the services in an holistic manner. Provide services in an interdisciplinary manner. Various therapies must focus on both the micro deficits and macro deficits simultaneously. While it is important to remediate specificcognitive problems within a laboratory/treatment setting, it is equally

important to focus on the client's functional domain (ie, daily livingactivities). Therefore, attempts to remediate a cognitive problemshould occur on both 'fronts' simultaneously. The design and implementation of the various therapeutic regimensshould emanate from a comprehensive, systematic, interdisciplinaryevaluation process.Vogenthaler, D. (1987). An overview of head injury: Its consequences andrehabilitation.Brain Injury 1(1): 113-127.



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The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk217. Fatores psicossociaisRecommendation 7.1:CRT should incorporate work on the patient's awareness and

psychosocial skills (eg, coping, anxiety, mood, self-esteem, self-concept, motivation, locus of control, adjustment).The neuropsychological rehabilitation of traumatically head-injured peoplecan best be achieved by a holistic and integrated program. Such a programmust co-ordinate cognitive remedial interventions with efforts to improvefunctional skills and interpersonal functions, providing specialised methods ofclinical management designed to ameliorate problems stemming from poorcompliance, lack of adequate malleability, lack of sufficient awareness andlack of acceptance of one's existential situation.Ben-Yishay, Y. & Gold, J. (1990). Therapeutic milieu approach to neuropsychologicalreabilitao. Ch. 11 in Neurobehavioural sequelae of traumatic brain hope. (Ed.)

Wood RL, Taylor and Francis, London.Cognitive and affective impairments are related to the achievement ofrehabilitation goals during the early stages after TBI and stroke.Prigatano GP & Wong JL. (1999). Cognitive and affective improvement in braindysfunctional patients who achieve inpatient rehabilitation goals. Arch Phys MedRehabil 80: 77-84.'When emotional and motivational disturbances become the focus ofrehabilitation as well as cognitive impairments, improved psychosocialoutcomes have been reported.' He then describes three aspects of this:patients' overall energy to sustain mental effort on cognitive tasks,insight/self-awareness, speed of information processing. He states that allthree of these are very important to remediate following TBI. . . .When the direct retraining of an underlying cognitive impairment is attempted,it should be recalled that both cognitive and affective functions are intimatelyinterconnected. Consequently they must be addressed simultaneously tomaximise their usefulness for the patient. . . .Training must help patients to adjust to whatever permanent disabilities theyhave sustained and provide them with appropriate methods for doing so fromboth cognitive and psychotherapeutic perspectives.From the NIH report. Prigatano, GP (1998). Cognitive Rehabilitation:An impairment oriented approach embedded in a holistic perspective.

Description is provided of the holistic model of treatment that addressescognitive, social, emotional and functional aspects of brain injury together:'Clinically the holistic model makes sense and despite its apparent expense,in the long term it is probably cost effective.'Wilson, B. (2002). Towards a comprehensive model of cognitive rehabilitation.Neuropsychological Rehabilitation 12(2): 97-110.

Pgina 23The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk

22The term cognitive rehabilitation covers any intervention strategy or technique


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that enables patients and their families to come to terms with, manage or toreduce acquired cognitive deficits.Rehabilitation after TBI. (1998).British Society Rehabilitation Medicine (BSRM) Working Party Report.Sohlberg and Mateer (2001) suggest that the term 'cognitive rehabilitation is

too narrow and it is better to talk about rehabilitation of individuals withcognitive impairments.' Wilson agrees that 'this seems a sensible suggestionas it implies that people with cognitive impairment may have additionalproblems that should also be addressed in rehabilitation programmes'.Wilson, B. (2002). Towards a comprehensive model of cognitive rehabilitation.Neuropsychological Rehabilitation 12(2): 97-110.

Pgina 24The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk238. Functionally OrientedRecommendation 8.1:CRT treatment goals are tailored to enhance the individual's abilityto function as independently as possible in the least restrictivecriao. The end result of CRT must be to improve quality of lifeand real life skills.Treatment aims shall be directed towards enhancing the overall outcome. TodosCRT endeavors shall be tailored to enhance the functional abilities of theclient to promote the client's ability to live as independently as possible in the

least restrictive environment. Treatment goals are directed towardsmaximizing independence in skills needed for daily life and the ability to enjoyvida.Ideally, all rehabilitative efforts aim towards returning the individual with TBI toa comunidade. For some, this means return to work and familyresponsabilidades. For others, this means living in the community with neededservices and supports.All CRT treatment is directed towards maximizing the level of independencethrough helping the individual maximize their remaining cognitive skills, alongwith the use of cognitive compensatory strategies and practical application ofdaily living skills using these strategies.

Wilson stresses the need for CRT to focus on functional competence as theponto final.Wilson, B. (2002). Towards a comprehensive model of cognitive rehabilitation.Neuropsychological Rehabilitation 12(2): 97-110.CRT is: 'The systematic use of instruction and structured experience tomanipulate the functioning of cognitive systems such as to improve the qualityor quantity ofcognitive processing in a particular domain. Cognitivorehabilitation is, therefore, a specialised component of more generalrehabilitation, the aim of which is the maximisation of the functionalindependence and adjustment of the brain-damaged individual.Robertson, I. (1999). Setting goals for cognitive rehabilitation.

Current Opinion in Neurology 12, 703-708.CRT is 'the therapeutic process of increasing or improving an individual's


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capacity to process and use incoming information so as to allow increasedfunctioning in everyday life.'Sohlberg, MM & Mateer, CA Introduction to cognitive rehabilitation and practice.Paper on the net (www.pacelearningrx.com/cognitiverehab.html).

Pgina 25The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk24The final principle of process specific (cognitive rehabilitation) therapy is areminder that the ultimate measure of success in therapy lies withimprovement in living and work status rather than change on test scores.Sohlberg, MM & Mateer, CA . Introduction to cognitive rehabilitation and practice.Paper on the net(www.pacelearningrx.com/cognitiverehab.html).In short cognitive rehabilitation should focus on real life functional problems, itshould address associated problems such as mood or behavioural problemsin addition to the cognitive difficulties and it should involve the person withbrain injury, relatives and others in the planning and implementation ofcognitive rehabilitation. Within the discussion on what to focus of traumamakes the point that the end point is functional improvements.Wilson, B. (2002). Towards a comprehensive model of cognitive rehabilitation.Neuropsych Brain Rehabilitation 12(2): 97-110.Recommendation 8.2:Each functional task needs to be analyzed in terms of its

constituent functions, and those functions that are impaired needto be compensated for in order to make possible the normalperformance of that functional task.Recommendation 8.3:The therapist must make explicit to the brain-injured person howthese impairment-based goals link with functional competence.Recommendation 8.4:Opportunities to practice in real life settings should be provided aspart of this process in order to develop generalization and transferde aprendizagem.

Pgina 26The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk259. ModelosRecommendation 9.1:CRT cannot be informed by a single model (such as cognitiveneuroscience), but needs to incorporate models from diverse areasof human function.'Rehabilitation is one of many fields that needs a broad theoretical baseincorporating frameworks, theories and models from a number of differentareas'. Gianutsos (1989) stated, 'Cognitive rehabilitation came of mixed
http://translate.googleusercontent.com/translate_c?depth=1&ei=BnsNUfjjLIye9QTk-4CYAQ&hl=pt-BR&prev=/search%3Fq%3Dcognitive%2Bcourse%2Bfree%26hl%3Dpt-BR%26client%3Dfirefox-a%26hs%3Dd05%26tbo%3Dd%26rls%3Dorg.mozilla:pt-BR:official&rurl=translate.google.com.br&sl=en&u=http://www.pacelearningrx.com/cognitiverehab.html%29&usg=ALkJrhgONCFWEznRHnNNCwXTmbjJYKGfHQhttp://translate.googleusercontent.com/translate_c?depth=1&ei=BnsNUfjjLIye9QTk-4CYAQ&hl=pt-BR&prev=/search%3Fq%3Dcognitive%2Bcourse%2Bfree%26hl%3Dpt-BR%26client%3Dfirefox-a%26hs%3Dd05%26tbo%3Dd%26rls%3Dorg.mozilla:pt-BR:official&rurl=translate.google.com.br&sl=en&u=http://www.pacelearningrx.com/cognitiverehab.html%29&usg=ALkJrhgONCFWEznRHnNNCwXTmbjJYKGfHQhttp://translate.googleusercontent.com/translate_c?depth=1&ei=BnsNUfjjLIye9QTk-4CYAQ&hl=pt-BR&prev=/search%3Fq%3Dcognitive%2Bcourse%2Bfree%26hl%3Dpt-BR%26client%3Dfirefox-a%26hs%3Dd05%26tbo%3Dd%26rls%3Dorg.mozilla:pt-BR:official&rurl=translate.google.com.br&sl=en&u=http://www.pacelearningrx.com/cognitiverehab.html%29&usg=ALkJrhgONCFWEznRHnNNCwXTmbjJYKGfHQhttp://translate.googleusercontent.com/translate_c?depth=1&ei=BnsNUfjjLIye9QTk-4CYAQ&hl=pt-BR&prev=/search%3Fq%3Dcognitive%2Bcourse%2Bfree%26hl%3Dpt-BR%26client%3Dfirefox-a%26hs%3Dd05%26tbo%3Dd%26rls%3Dorg.mozilla:pt-BR:official&rurl=translate.google.com.br&sl=en&u=http://www.pacelearningrx.com/cognitiverehab.html%29&usg=ALkJrhgONCFWEznRHnNNCwXTmbjJYKGfHQ


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parentage including neuropsychology, occupational therapy, speech andlanguage therapy and special education.' McMillan and Greenwood (1993)stated, 'These authors understood that cognitive rehabilitation should not beconfined by one theoretical framework or model.' A description is given of theholistic model of treatment that addresses cognitive, social, emotional and

functional aspects of brain injury together: 'Clinically the holistic model makessense and despite its apparent expense, in the long term it is probably costeffective'. A diagramatic provisional model of CRT is proposed to encompassthe variety of aspects that need to be considered when undertaking CRT.Wilson, B. (2002). Towards a comprehensive model of cognitive rehabilitation.Neuropsychological Rehabilitation 12(2): 97-110.Barbara Wilson's (2002) provisional model of cognitive rehabilitation.

Pgina 27The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk26Recommendation 9.2:Cognitive skills should be considered as a hierarchy.Recommendation 9.3:The following five cognitive skill areas should be comprehensivelyassessed and, wherever necessary, treated.Hierarchical Cognitive ModelAttention & OrientationComunidade

integraoExecutivoPsychosocial FunctionsMetacognition(Awareness &Regulation)ArousalLinguagem,Memory,Visual Processing,Information Processing,

Pgina 28The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk27Attention skills include the following aspects: Sustained, Selective, Alternating,and Divided.Visual Processing skills include the following aspects: Acuity, OculomotorControl, Fields, Visual Attention, Scanning, Pattern Recognition, VisualMemory, and Visual Cognition or Perception.Information Processing skills include the following aspects: Auditory and otherSensory Processing skills, Organisational Skills, Speed, and Capacity of


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Processamento.Memory Skills include the following aspects: Orientation, Episodic,Prospective, Encoding, Storage, Consolidation, and Recall.Executive Skills include the following aspects: Self-Awareness, Goal Setting,Self-Initiation, Self-Inhibition, Planning and Organization, Self-Monitoring, Self-

Evaluation, Flexible Problem Solving, and Metacognition.Recommendation 9.4:Attention skills should be seen as the underlying foundation of allother cognitive skills. Assessment and treatment should alwaysbegin at this level if problems are evident.Recommendation 9.5:It is essential to work on executive skills and awareness at allstages of cognitive development.Recommendation 9.6:It is important to determine whether the commonly reportedmemory difficulties are dependent upon attention or information

processing failures, ie secondary manifestations of impulsivity,attention deficits, and information processing failures or the resultof interactions among these three functions.

Pgina 29The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk28There are four approaches to successful cognitive rehabilitation (Malia &

Brannagan, 2000):1. Educao2. Process Training3. Strategy development and implementation4. Aplicao funcionalRecommendation 9.7:The four approaches to CRT should be used concurrently with allpatients but the relative balance between them will alter accordingto the presenting neurological condition (eg, tumors may notbenefit from process training), stage post-injury, awareness level ofthe patient, and time constraints of the staff.

Pgina 30The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk2910. EducaoRecommendation 10.1:All individuals with brain injury should receive educationappropriate to their abilities and needs. In an inpatient center, thisis usually best done through a formal education group. In settingsor circumstances that preclude this, the therapist should ensurethat the individual receives appropriate education at sufficient


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intensity and with adequate repetition to ensure learning. Ofollowing recommendations do not necessarily apply if it is notpossible or appropriate to run an education group.Recommendation 10.2:Wherever possible, all individuals with brain injury should attend an

education group at least once, so long as their language skills,attention skills and awareness levels permit.Recommendation 10.3:The decision to include in or exclude from an education groupshould be made by mutual consent of the whole team at thetreatment planning or multidisciplinary team meeting, wherever this possvel.Recommendation 10.4:Education should take place in a formal education group and inindividual sessions. It should be seen as an ongoing processrather than only occurring on one occasion

Recommendation 10.5:The education group should take place regularly. In institutions it isoften helpful to run this for one hour each day until the content hasbeen covered (see recommendation 10.8).

Pgina 31The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk30

Recommendation 10.6:The education group should be conducted by therapists withtraining/expertise in running therapeutic groups. recomendadothat two therapists should be involved in the group.Recommendation 10.7:There should be a minimum of 3 and a maximum of 7 patients inany group.Recommendation 10.8:Education should cover the following areas: Neuroanatomy, understanding the own brain injury and what

rehabilitation is all about.

Cognitive problems following brain injury. Emotional problems following brain injury, how to cope with the

changes one experiences and developing a new sense of self.Recommendation 10.9:Generally, the brain-injured person should be fully apprised of hisor her cognitive problems, the fact that he or she has had a braininjury and the likely prognosis for the individual cognitively, at theearliest stage possible. If this is not done, there should be a clearand compelling reason.This will often be started during the assessment phase, but will certainly becompleted immediately after assessment. This aspect of education is

considered to be an ongoing process which aims to help the patient todevelop appropriate self-awareness, heighten self-esteem, develop


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confidence, develop feelings of personal control, and develop a trusting,working relationship with the therapist.The importance of education cannot be overemphasized. Without goodawareness much of what is subsequently offered will have no lasting effectson the brain-injured person's life once he or she leaves the rehabilitation

ambiente. Education should continue as long as is necessary; in somecases, this may mean years.

Pgina 32The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk31Recommendation 10.10:A range of appropriate materials should be available for the brain-injured person, including books, CD-ROMs, Internet access, andrelevant articles, along with the education group notes.

Pgina 33The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk3211. Process TrainingThe purpose of process training is essentially to stimulate poorly functioningneurological pathways in the brain in order to maximize their efficiency and

eficcia. This will sometimes mean using new undamaged pathways(redundant representations) and, sometimes, old partially damaged pathways.Process training therefore aims to overcome the damage.Process training is not general stimulation or drill training, although this mayhave some benefits they are not specific and may not generalize to real life.Process training relies on two components: Good comprehensive assessment Analysis of the results according to a practical cognitive modelThe analysis should always ask, Why is that problem occurring? until an

impaired component skill or cluster of skills is revealed. A task, or preferably aseries of tasks, is then designed to develop and improve the impaired skills. Se

this approach is successful, then any real life skills that rely on that underlyingimpaired skill should improve as it improves.The analysis should essentially result in the generation of a hypothesis, whichis then tested with appropriate training materials. Formal reassessment helpsto determine the accuracy of the hypothesis.Recommendation 11.1:Process training should be used with the majority of people withbrain injury to work on the hypothesized underlying impairments, atthe same time as working on functional goals.Recommendation 11.2:Process-training approaches must rely on the results of acomprehensive assessment that seeks to help the therapistanalyze the underlying causes of functional breakdowns.


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Recommendation 11.3:Process-training exercises should be extensive. Uma grande variedade deexercises should be available to target particular impairments. Emorder to avoid mere training on a task, Individual process trainingexercises should not usually be repeated an excessive number of

vezes. It is better to work towards generalization of the skill by

Pgina 34The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk33using multiple exercises, each targeting the impairment in slightlydiferentes maneiras.Recommendation 11.4:Process training exercises should be arranged systematically in astructured program that will help lead the person with brain injurytowards accomplishment of a range of functional skills orbehaviors.Recommendation 11.5:Regular reassessment should be completed to ensure that theperson with brain injury is moving towards his or her functionalmetas. The results of this should determine the direction andprogress through the process training exercises.Experience shows that the use of process training materials that have beendesigned on the basis of neuropsychological theories, and arranged into a

structured program format, usually lead to good gains in the majority ofpacientes(Malia et al., 1993, 1995, 1995, 1995, 1996, 1998; Bewick et al., 1995;Raymond et al., 1996, 1996, 1999; Bennett et al., 1998; Fuii et al., 2001).The reasons for progress on these process-training exercises are complex,but the relationship between the following factors is thought to play a majorrole in the success:1. The development of awareness through the exercises.2. The structured programmed approach to the materials.3. Daily concrete feedback and concrete goals.

4. The relatively short time frames to complete blocks of work.5. The development of patient self-confidence.6. The development of patients' feelings of being in control.7. The massed practice available via homework exercises.8. Activation of neurological pathways through appropriately targetedrepetitive cognitive exercises.9. The development and utilization of compensatory strategies tomelhorar o desempenho.10.Process training is a neutral activity and most patients do not feelthreatened by it; this enables them to accept constructive feedbackmore readily.

11.The activities are easily quantifiable and scoreable.12.Results can be easily graphed to demonstrate improvement and


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this, in turn, leads to improved motivation and self-esteem.


The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk34Recommendation 11.6:Process-training exercises should incorporate a strong emphasison developing self-awareness of problems and their implicationspara o futuro. This can be achieved via self-prediction and self-rating scales, as well as daily feedback.Recommendation 11.7:SMART goals should be written for each process training exercise.Recommendation 11.8:Ideally, blocks of process-training exercises should be completedintensively over relatively short time periods, interspersed withreassessment, feedback with the person with brain injury, andreevaluation of the next step.Recommendation 11.9:Intensive work can be enhanced with the aid of process trainingexercises being given for homework sessions, whenever this ispossvel.Recommendation 11.10:Each process training exercise should be scored as soon aftercompletion as possible. The score should be compared with

previous scores on the same exercise and related to self-predictedand self-rated scores. In many cases, it is a good idea to presentthis information in a graphical format. The score should also berelated to the criterion for success specified in the SMART goal.Recommendation 11.11:Process training should be used in conjunction with strategytraining; the process training exercises can be used to show theperson with brain injury how well the implementation of a strategyimproves his or her performance. This, in turn, should be related tothe functional activities training.

Pgina 36The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk3512. EstratgiasIt is not always possible to utilize new neurological pathways in the brain toovercome the problems, so strategies can then be taught to compensate forthe remaining difficulties. Strategies can be divided into two types: externaland internal. External strategies consist of those things that are external to theperson, such as alarms, notebooks, notes, and calendars. Internal strategiesare those mnemonics that cannot be observed by anyone else, such asvisualizations and word associations (Malia & Brannagan, 1997).


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Internal strategies require greater cognitive capacity than external strategiesbecause the strategy has to be remembered at the very time when the personis beginning to struggle with a task, ie, when he or she is becomingoverloaded (Malia & Brannagan, 2004).The independent use of strategies is entirely dependent upon the level of

awareness that the person with brain injury has. If the individual has noawareness, then he or she will not perceive the need to implement a strategy,even when he or she beings to fail on a task. This level of awareness problemtherefore necessitates the use of environmental modification and/or strategiesimplemented by other people. If the brain-injured person has good awareness,he or she can reasonably be expected to implement taught strategiesindependently (Malia & Brannagan, 2004).Recommendation 12.1:Strategy training should be used with the majority of people withbrain injury to minimize the problems they are experiencing.Recommendation 12.2:

The person with brain injury should be advised that he or she mayalways need to use the taught strategies, which will involvelearning a new way of operating.Recommendation 12.3:External strategies are easier to apply than internal strategies.They should therefore be the strategies that are taught first.


The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk36Recommendation 12.4:Strategy training should be matched to the level of awarenessshown by the person with brain injury. As awareness increases,different strategy training should be incorporated.Recommendation 12.5:The value of strategies can be taught very quickly on the processtraining exercises. Process training and strategy training shouldtherefore be incorporated simultaneously in the majority ofrehabilitation programs for individuals.

Pgina 38The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk3713. Functional Activities TrainingRecommendation 13.1:All cognitive rehabilitation tasks should focus on improving real lifeem funcionamento.Recommendation 13.2:Functional activities should be used in two distinct ways: As a vehicle within which to treat the cognitive skill deficits


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To train the person to complete the particular functional task

Goals should be written for each of these approaches.Recommendation 13.3:Functional goals should be selected in close consultation with theperson with brain injury. They should be goals that are valuable

and important to the person with brain injury, rather than to theterapeuta.Recommendation 13.4:Functional activities should be broken down into their componentparts and these should be related to the process training andstrategy training components of the rehabilitation program in eachcaso.

Page 39The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk3814. ConscinciaRecommendation 14.1:Awareness should be considered to be the key to successfulreabilitao. A great deal of the rehabilitation work should aim atdeveloping appropriate awareness of cognitive skills and howthese are important in the direction the person with brain injury willtake in the future.Recommendation 14.2:

The development of appropriate awareness should be directlyworked on, rather than left to chance.Patients' lack of awareness regarding the existence or severity of deficits afterbrain injury represents a particular area of significance and is often a centralconcern for neuropsychological interventions. . . .Clinically the findings suggest that for patients unable to engage in treatmentdue to their unawareness of deficits, priority needs to address the patient'sawareness deficits and resistance in therapy. One of the most common andcostly errors of treatment may be the failure to confront the patient'sunawareness. . . .Therapist actions that can facilitate collaboration need to be considered in

neuropsychological remediation; schema like Crosson and coworkers (1989)distinction among types of awareness deficits represent a valuable start inneste sentido.Cicerone, KD & Tupper, DE (1991). Neuropsychological rehabilitation treatment oferrors in everyday functioning. Ch. 11 in (Eds.) Tupper, DE & Cicerone, KD, Theneuropsychology of everyday life: Issues in development and rehabilitation. AcadmicoPubl., Kluwer, Boston.Recommendation 14.3:All staff members should be trained to understand awareness, howit links to cognitive skills and what can be done to enhance it. Amodel should be used to guide this process.

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The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk39Intellectual awareness has been achieved when the person is able to

demonstrate that he or she knows what his or her problems are and what theyhave in common, ie, I keep forgetting things people say to me and this isbecause I have had a brain injury. This can be documented through self-rating charts and assessments.Emergent awareness has been achieved when the person is able todemonstrate that he or she knows a problem is happening as it is occurringwithout prompting, ie, on line awareness of a problem. This can only bedocumented through observation of his or her behavior.Anticipatory awareness has been achieved when the person is able topredict or anticipate the situations in which his or her problems are likely toocorrer. This only can be documented through observation of the person's

comportamento. It is only at this stage that the person will be able to implementcompensatory strategies for cognitive deficits unaided. Thus, the developmentof awareness levels needs to be taken into account when setting goals andmaking prognoses about rehabilitation efforts.Crosson, B. et al. (1989). Awareness and compensation in post acute head injuryrehabilitation.Journal of Head Trauma Rehabilitation 4, 46-54.Recommendation 14.4:Education, process training, and strategy training approachesshould all be matched to the level of awareness.Crossons

Crosson's modified model ofmodified model ofconscinciaconscincia(Malia, 1997)(Malia, 1997)Intellectual AwarenessEmergent AwarenessAnticipatoryConscincia

NenhumGrowing AcceptanceFul AcceptanceMnimoMximaMnimoMximaCognitivoExecutivoMetacognitivoHabilidades

Personal happinessSelf esteem etc.


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Page 41

The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk

40Recommendation 14.5:Level of awareness of cognitive weaknesses and strengths shouldbe explicitly documented in the treatment plan. CRT therapistsshould encourage other team members to do this as well for eachdomain of function, eg, physical, executive, emotional,communication, and ADLs.Recommendation 14.6:The importance of awareness, why it is often compromisedfollowing brain injury, and what will be done to try to improve it,should all be explained to the person with brain injury as part of hisor her educational program.Even when the person with brain injury achieves anticipatory awareness in therehabilitation environment, he or she may still believe he or she will wake upone day and everything will be fine. This is quite common. Thus, the secondpart of the model deals with the level of acceptance of one's problems. Esteforms part of the journey towards a 'new sense of self,' which is at the core ofevery rehabilitation program (Ben-Yishay & Daniels-Zide, 2000).Recommendation 14.7:The importance of developing a new sense of self should beemphasized to every person with brain injury.

Pgina 42The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk4115. ReportagemRecommendation 15.1:Assessment should result in the production of a document thatclearly lists each of the problems, including the level of severity,and an analysis of the underlying causes of the difficulties. Este

same document should include the predicted length of treatment,the goals to be achieved by discharge and the short-termobjectives to achieve these. This document forms the basis of thetreatment plan.Recommendation 15.2:Treatment plans should be provided for the person with the braininjury, (unless he or she is unable to benefit from it due to severityof cognitive impairment), any caregivers or family members, and allrelevant staff members.Recommendation 15.3:The treatment plan should not be finalized until the person withbrain injury indicates that he or she has understood and agrees too contedo. This may involve some negotiation and/or education.


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Recommendation 15.4:The treatment plan should be written in a manner that is easilycomprehended by the person with brain injury.Recommendation 15.5:Progress notes should be maintained regularly in order to

document any major events which take place during therapy.

Pgina 43The SCR Recommendations for Best Practicein Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk42Recommendation 15.6:The treatment plan is the guide that should be followed indesigning the treatment. If new issues arise, or progress is betteror worse than predicted, then this needs to be annotated on arevised treatment plan.Recommendation 15.7:Progress on the treatment plan should be reviewed regularly withall team members, including the person with brain injury. recommended that this review take place every 2-3 weeks in aninstitutional setting or after a pre-determined number of sessions inother settings, eg, after every 10 treatment sessions.

Pgina 44The SCR Recommendations for Best Practice

in Cognitive Rehabilitation Therapy The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk43SECTION THREE: THE EVIDENCE BASE FOR CRT16. IntroduoA common question asked of CRT is does it work? This is too simplistic a

pergunta. CRT involves multiple facets, and the challenge is to determinewhen and in what way each of these facets works best.A huge amount of effort has been, and continues to be, expended on thesetypes of questions, which is only to the credit of this field, since the samequantity and quality of research does not exist for the following aspects of

brain injury rehabilitation:The value and role of medicine

The value and role of psychology

The value of occupational therapy

The value of physical therapy

The value of speech and language therapy (outside of

dysphasia following stroke)


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Evidence-based practice is an essential component to gaining greaterunderstanding, but it is not the whole story. The people who undertakeevidence-based studies need to have a good understanding of the field,particularly because brain injury rehabilitation is such a complex area (seesection 20). This has not always been the case:

If any methodology is applied without considering the complexities of thephenomena under investigation and other relevant sources of information,inaccurate or incomplete conclusions can easily be made in the name ofcincia. . . . let us not replace careful clinical observation and judgement withstatistics and research design and call it 'good practice.'Prigatano, GP (2000). Letters to the Editor. J of Head Trauma Rehabilitation 15(1): x.My comments are offered as someone who worked with Carney et al. paraprepare the report, (and I) reviewed much of the research. . . . Many of uswould agree that practice should be based on empirical research. . . . oshortcomings (of this review) were exacerbated by the reviewers' lack offamiliarity with the material. I view the evidence-based report on cognitive

rehabilitation as substantially flawed.Kreutzer, JS (2000). Letters to the Editor. J Head Trauma Rehabilitation 15(1): x.The following references illustrate the evidence and expert opinion, as well aspoint out some of the problems with establishing evidence based practice. recommended that the meta-reviews be read in detail to obtain furtherinformao.


The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk4417. Evidence BaseThere is increasing evidence that intervention through retraining or provisionof compensatory memory aids can result in improved cognitive functioning.Wilson (1998). Recovery of functions following non-progressive brain injury.Curr Opin Neurobiol 8(2): 281-7.Since the mid 1980's the effectiveness of CRT has been repeatedly evaluatedand several reviews have documented its efficacy (Butler & Namerow, 1988;Gianutsos, 1991; Glisky & Schacter, 1989; Godfrey & Knight, 1987; Gordon &Hibbard, 1991; Gouvier, 1987; Hayden, 1986; Parente & Anderson-Parente,

1991; Prigatano & Fordyce 1987; Seron & Deloche, 1989; Sohlberg & Mateer,1989; Wehman et al., 1989; Wood & Fussey, 1990). Each of these reviewsattests to the success of one or more methods of CRT.Parente, R. & Herrmann, D. (1996). Retraining cognition. Aspen, Maryland, p.1.A review of the literature for CRT in TBI published from January 1988 toAugust 1998 was conducted by the National Institute for Health ConsensusDevelopment Panel. This review included 11 randomised clinical trials. ONIH statement provides 'state of the art information regarding effectiverehabilitation measures for persons who have suffered a TBI and presents theconclusions and recommendations of the consensus panel regarding thesequestes. Although studies are relatively limited, available evidence supports the

use of certain cognitive and behavioural strategies for individuals with TBI. . . .Cognitive exercises, including computer-assisted strategies, have been used


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to improve specific neuropsychological processes, predominantly attention,and memory and executive skills. Both randomised controlled studies andcase reports have documented the success of these interventions usingintermediate outcome measures. Certain studies using global outcomemeasures also support the use of computer assisted exercises in cognitive

reabilitao. Compensatory devices, such as memory books and electronicpaging systems, are used both to improve particular cognitive functions andto compensate for specific deficits.National Institutes of Health Consensus Development Conference StatementRehabilitation ofPersons with TBI. Convened in 1998. Put to press in 1999.The American Congress of Rehabilitation Medicine (ACRM) conducted ameta-analysis of CRT. Cicerone et al. took 171 articles on cognitiverehabilitation from a referenced set of 655 published articles, assigned themto different categories of cognitive function and to level of evidence (Class I, IIor III, see note below). 29 were class I, 35 were class II, and 107 were class

III. 20/29 of the Class I studies (69%) support clearly the effectiveness ofCRT. 62/64 class I and class II studies combined (97%) showed improvedfunctioning among people receiving CRT.Cicerone, KD et al. (2000). Evidence based cognitive rehabilitation: recommendationsfor clinical practice.Arch Phys Med Rehabil 81, 1596-1615.


The Society for Cognitive Rehabilitation (2004) www.cognitive-rehab.org.uk45Class I = prospective, randomised controlled and well designed studiesClass II = prospective, non-randomised studies, retrospective, non-randomised case control studies, or clinical series with controlsClass III = studies with no controls, or single case studiesIn 1999, a Task Force was set up under the auspices of the EuropeanFederation of Neurological Societies with the aim to evaluate the existingevidence for the clinical effectiveness of cognitive rehabilitation and to providerecommendations for practice based on this evidence:There is enough overall evidence to award a grade A recommendation

(based on Randomly Controlled Trial studies) to some forms of cognitiverehabilitation in patients with neuropsychological deficits in the post acutestage after focal brain lesion (stroke, TBI). These include neglect and apraxiarehabilitation after stroke, attention training after TBI . . . e memriarehabilitation with compensatory training in patients with mild amnesia.Cappa SF et al. (2003). EFNS guidelines on cognitive rehabilitation: reportof an EFNS task force. European Journal of Neurology 10, 11-23.The AHCPR panel formulated five questions addressing the effectiveness ofearly rehabilitation in the acute care setting, intensity of rehabilitation,cognitive rehabilitation, supported employment, and case management. Parathe question on cognitive rehabilitation, 15 randomised controlled trials and

comparative studies that met specified inclusion criteria were placed intoevidence tables. They report that there is evidence from two small studies


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(class I and class III) that a personally adapted electronic device, a notebookand an alarm wristwatch, reduce everyday memory failures for people withTBI. There is evidence from one study (class IIa) that compensatory cognitiverehabilitation reduces anxiety and improves self-concept and relationships forpeople with TBI. Evidence from two studies (class I and class IIb) supports

the use of computer aided cognitive rehabilitation to improve immediate recallon neuropsychological testing, but the clinical importance of this finding hasnot been validated.Chestnut, RM et al. (1999). Rehabilitation for traumatic brain injury. Summary,Evidence Report/Technology Assessm

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