Cognitive Rehabilitation
Kam Gardner, MS, CCC-SLP, Speech-Language Pathologist at Kaiser Permanente, has reviewed this page for content accuracy.
For people who have suffered concussions, persistent post-concussion symptoms (PPCS) may include a range of cognitive impairments which can hinder activities of daily living (ADLs). Types of cognitive deficits range widely and differ from person to person, but they all tend to impair the individual’s capacity to process information. Cognitive rehabilitation therapy (CRT) aims to help concussion patients overcome cognitive deficits; the following list of cognitive impairments may help you recognize whether CRT might be helpful to you.
Auditory Processing Deficits: I am experiencing new difficulties understanding what people are telling me.
Perceptual Organization Deficits: I am having difficulty identifying objects around me, even though my vision isn’t fuzzy? (i.e., recognizing a cup as a cup rather than a cone-like object with a hole?
Distractibility: I can no longer stay focused, even if I’m supposed to be. Voices and noise in the environment interrupt my focus, and I have difficulty completing simple tasks.
Memory Deficits: I am having trouble remembering names, dates, faces, or information that I used to bring to mind effortlessly.
Procedural Memory Deficits: Can I recall how to fax documents, and can I remember the steps to make a pot of coffee?
Visual-Motor Integration Deficits: Do I have difficulty moving my hands where I want them to go? (i.e., drawing a figure-eight or catching a ball).
Fine Motor Coordination Deficits: Am I experiencing difficulty texting, tying shoelaces, or turning a doorknob?
Processing Speed Deficits: Am I feeling sluggish, as if I used to be able to complete so many tasks, but now I can only get through one? Does the world seem to be on fast forward?
Math Calculation Deficits: Am I struggling with seemingly simple calculations? I can not mentally calculate math problems that require regrouping without paper and pencil, or I have difficulty counting money and calculating percentages when shopping.
Executive Function Deficits: Am I overwhelmed by tasks I ordinarily would have been able to balance? (i.e., cooking multiple dishes at once, etc.) Am I having difficulty judging the safety of certain behaviors? (i.e., being overly cautious or not careful enough).
Answering these questions for yourself may help you decipher if CRT would benefit you; however, being open with your primary care physician (PCP) about your new cognitive challenges should be your first step after a suspected concussion. If there is one person you should complain to, it is your PCP. Another suggestion would be to report your complaints to any of your other medical providers.
What is cognitive rehabilitation therapy?
Cognitive rehabilitation in theory
CRT begins by helping a person recognize their strengths and weaknesses, then follows with various types of training. Process training focuses on retraining and practicing skills to resolve problems. Strategy training “focuses on compensating for impairments by using a variety of internal and external strategies,” for instance, keeping a memory notebook (external because you have the notebook to refer to and internal because writing it down could improve memory). Functional activities training focuses on teaching you ways to employ skills in everyday life. Practitioners work with the person’s goals in mind; thus, all forms of training are highly individualized.
Two flavors to suit your goals
Training goals may be restorative or compensatory, and one or both may apply to an individual’s experience. Practitioners use restorative therapies to help someone recover cognitive abilities and compensatory therapies to help them cope with daily struggles. Restorative therapies work by harnessing brain plasticity, a process of reforming neuronal circuitry. Since our brains have this ability to change and remodel, practicing specific skills theoretically will increase the brain’s ability to perform each skill and improve functionality. For example, practicing multitasking should improve your capacity to multitask.
Compensatory training works by finding strategies to accommodate a particular deficit. It may sound like this method should be a last resort, however, bear in mind that sometimes it takes more resources than you have to work through the process restorative therapies require. Neither is better than the other since both produce results, and no judgments should be applied if you work around your impairments. However, if you aim to reach more independent functionality, restorative therapies are more appropriate.
Generally, restorative methods produce broad-ranging results while compensatory ones solve a problem with your daily life. Restoring attentional capacity, for example, means you can concentrate more fully during any activities throughout your day-benefiting your life in a holistic manner. Compensating for reduced attentional capacity might mean taking periodic breaks during work or otherwise limiting your exposure to stimulation (i.e., wearing noise-canceling headphones). Therefore, compensatory training would be more oriented towards handling a specific problem than attaining a more comprehensive recovery. Since concussion patients can have so much to handle, both types of cognitive rehabilitation might be beneficial.
When should you look into CRT?
Accepting you’ve lost something can be highly challenging, but recognizing that it isn’t your fault may help. Cognitive deficits may seem like an abstract notion, but the everyday difficulties they engender are concrete and disabling. You don’t need to have everything going wrong to get help; you don’t even need to understand what’s wrong. If you find yourself wondering, “am I just imagining it?” or, “won’t they think I’m faking it?” please know that your perceptions are based on facts. Just because you can’t see how, it doesn't mean they don’t make sense - now is when you ask for help; don’t wait until you’ve figured it out. Doctors should be equipped to transmute abstract symptomatology into diagnoses; you don’t need to carry that burden. Handling diminished cognitive capacity is such a private process that advocating for yourself might feel wrong in some way. Would you call it wrong for someone else to share those same insecurities? Can you extend that same empathy to yourself? Others experience these same symptoms after a concussion; you aren’t alone in the symptoms concussed people might conceal. As phrased by a Concussion Alliance community member,
“Challenges with staying focused were some of my biggest frustrations, because it felt like I was trapped running in place. It felt like I put in a lot of effort, and I didn't have much to show for it. I used the word "thing" too commonly because I'd be stumbling over what to call the specific item I was referring to and felt awkward fumbling for a few seconds trying to remember the correct vocabulary. "Thing" was a bit faster and safer to revert to…I felt like my brain was always a step behind, and I couldn't think as quickly and clearly as I wanted to.”
Another community member described their loss of motivation, distractibility by social media, and difficulty cooking meals while in conversation.
These are just a taste of cognitive concussions symptoms, and facing the psychological repercussions for these kinds of deficits can be just as debilitating as the deficits themselves. Being open with a trained professional about every difficulty you face will open doors for you to take steps towards your goals.
What does CRT look like?
Because cognitive deficits, post-concussion symptoms, and other concerns are highly variable and unique to each patient, cognitive rehabilitation therapy may look very different for different people. In order to provide the best care, CRT involves individualized treatment programs that specifically address any cognitive deficits using a network of doctors, therapists, and other specialists. Among the several possible care providers, a patient undergoing CRT may work with any combination of professionals: general practitioners, speech-language pathologists, neuropsychologists, occupational therapists, vocational rehabilitation counselors, neurofeedback practitioners, or psychiatrists. CRT may include many other care providers collaborating to ensure that a concussion patient can return to their pre-injury lifestyle as best as possible.
Below we have listed the roles of some of the specialists in a patient’s typical CRT treatment. Note that this is not a comprehensive list and that the needs and treatments for different patients will vary greatly.
General practitioners
A general practitioner’s role in cognitive rehabilitation therapy is first to notice the symptoms or cognitive deficits a patient is experiencing. The general practitioner plays a vital role in providing a patient with proper care because a patient cannot access CRT or almost any of the associated specialists without a referral from a general practitioner.
Speech-language pathologists
Speech-language pathologists (SLPs), otherwise known as speech therapists, can provide a critical and unique role in early symptom monitoring by tracking patients’ progress in assessments like the Montreal Cognitive Assessment (MoCA). SLPs, in addition to treatment for speech-related impairments, also help patients with deficits in memory, attention, or executive functions, which are the mental skills and processes that control behavior. SLPs work with concussion patients in all stages of injury and recovery from onset of injury until recovery and often work with patients experiencing persistent symptoms or Post-Concussion Syndrome.
Overall, a speech-language pathologist’s role in treating a concussion patient is to address the deficits mentioned above while providing the patient with evaluations of various speech-related and pragmatic social skills (conversational turn-taking and eye-contact, for example). Assessments allow the SLP to track the patient’s progress and make the most effective individualized treatment plan. The SLP often spends more time with the individual than other specialists and can cultivate greater rapport. As such, the SLP may become a central point of contact for their patients, referring them to other specialists as necessary.
Neuropsychologists
Neuropsychologists are responsible for the relationship between the brain and behavior. An important role they play in the recovery process is through assessments, in which they use standardized measures to examine behavioral and cognitive changes. These assessments typically take between two and five hours, after which they will either proceed with treatment and therapy as needed or refer the patient to a rehab therapist, depending on if the neuropsychologist does clinical work. Neuropsychologists can be a crucial aid in making a full recovery, especially for patients with noticeable behavioral changes.
Occupational therapists
An occupational therapist’s primary role in the recovery and rehabilitation process is to ensure the patient can return to work, school, independent living, or otherwise regular activities. Occupational therapists (OTs) work with the patient to understand and evaluate their physical and mental condition, as well as any possible cognitive deficits. Additionally, they assess specific skills patients may need to return to work, school, or other relevant pre-injury activities. Naturally, occupational therapy is highly personalized and typically follows a holistic approach that involves adjusting the patient’s typical or desired environment to tailor it to their needs while gradually returning patients to their original comfort and capabilities.
Vocational rehabilitation counselors
Vocational rehabilitation counselors serve a similar purpose to occupational therapists, for patients who have lost employment due to difficulties from symptoms, cognitive deficits, or ongoing treatments, or for patients with a permanent disability. Vocational rehabilitation counselors create specific, individualized employment plans tailored to patients’ needs to help them re-enter the workforce. Additionally, vocational rehabilitation counselors may recommend various community resources like support groups. They will help patients find or supply them with any tools they need to improve their recovery, such as accommodations for work or school.
Neurofeedback practitioners
Neurofeedback practitioners can play a significant role in cognitive assessments and treatment of some psychological post-concussion symptoms, especially in the early stages of recovery. These specialists employ a method similar to biofeedback, using a study known as quantitative electroencephalography. In this process, sensors are placed on the patient’s head to scan their brain waves. Participants watch a screen showing a reward and punishment system, rewarding them when they think “correctly” and punishing them for thinking “incorrectly.” For instance, if the patient needs to work on attention, the sensors would be applied to specific regions of the head, and the patient would be rewarded for concentrating and punished for losing focus. Rewards and punishments might be a movie losing brightness and sound or a butterfly moving up and down while moving across a screen.
The above is not a complete list of the specialists that may provide care for a patient needing cognitive rehabilitation. Because of the uniqueness of care involved with cognitive rehabilitation, it is essential to thoroughly understand one’s symptoms or deficits to receive the best possible treatment.
How do you access cognitive rehabilitation therapy?
Access to CRT specialists such as a speech-language pathologist, neuropsychologist, physical or occupational therapist, etc., requires a general practitioner or primary care physician referral. In most cases, a patient cannot access these services without a referral. Most often, a physician will refer patients to a physical medicine and rehabilitation (PM&R) doctor. At this point, the PM&R doctor will essentially approve a plan of care and will refer the patient to additional experts. However, this may not always be the case, and some physicians may make referrals to specific specialists right away. After getting referred to a concussion clinic, outpatient rehabilitation clinic, therapist, or other CRT providers, the doctors and therapists cooperate to form highly personalized treatment and care.
Apps that healthcare providers use are also available to the public
Some apps can help rehabilitate cognitive deficits; for example, Lumosity, BrainHQ, and Constant Therapy are sometimes prescribed by speech-language pathologist Kam Gardner.
Outpatient clinics
Typically, a physician’s most useful referral is to a concussion clinic or other outpatient rehabilitation clinic with expertise in TBI. PM&R doctors working from outpatient rehabilitation clinics may be highly specialized for CRT. These PM&R doctors could be the best way to provide patients with access or referrals to any other specialists they may need. However, unfortunately, outpatient clinics are under-utilized because general practitioners or primary care physicians are unaware of their specialized services, and patient referrals are either delayed or omitted. For more information, please visit our page on concussion and rehabilitation clinics.
Concerns: referrals and insurance
Because cognitive deficits are often not noticeable and post-concussion treatment is not universal, it may be difficult to get referrals in some instances. Patients who suffer severe brain injuries are referred to outpatient rehabilitation clinics after being hospitalized. However, because concussion patients are not hospitalized, physicians don’t think to refer them to an outpatient rehabilitation clinic. Additionally, even with a referral, some insurance companies may be hesitant to cover expenses associated with CRT, especially without medical documentation or diagnoses of symptoms and cognitive deficits related to the concussion. Because there is no consensus on the best option for cognitive rehabilitation, some insurers may consider CRT experimental and may be reluctant to cover the treatment modality.
Though some of these issues may seem daunting, there are still many ways for patients to get the care they need. Some outpatient or concussion clinics allow for self-referrals, which can get patient treatment without a referral from a general practitioner. Additionally, if insurance will not cover the necessary treatments involved with CRT, there are several ways for a patient to appeal or still get coverage. Brainline has excellent information on how to appeal an insurance denial for CRT that you can access here.
How does CRT compare with CBT?
Since cognitive rehabilitation therapy and cognitive behavioral therapy may be easily confused, it might be helpful to think about what distinguishes these therapies from one another. Comparing these treatments can also underscore particular benefits otherwise missed. Cognitive rehabilitation therapies focus on restoring or compensating for cognitive deficits in attention, memory, or executive functioning. Notice the word rehabilitation; bring back up to health, not necessarily your previous level of function.
Cognitive-behavioral therapy focuses on retraining negative thought patterns, which can cycle to anxious or depressive symptoms causing worsening physical symptoms and more negative thoughts. Notice the word behavior; finding behaviors that aid in reframing negative thoughts. Cognitive-behavioral therapy doesn’t necessarily require a loss of function, unlike cognitive rehabilitation therapy, which either works around or improves cognitive function.
CBT interrupts the cycle at the catastrophic thoughts phase by reframing negative thoughts
The negative-feedback CBT cycle
Both therapies may be beneficial for persistent post-concussion symptoms. However, cognitive behavioral therapy may be more beneficial for those dealing with intruding thoughts, while cognitive rehabilitation therapy would be more helpful for those struggling with cognitive tasks post-concussion.
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