Cognitive Rehabilitation Therapy (CRT)

What is cognitive rehabilitation therapy?

After brain injury, it is common to experience some combination of changes in your thinking and behavior. These changes may affect your daily life in all kinds of ways: your relationships with loved ones, your ability to return to school or work, and your ability to independently manage household responsibilities like cooking, paying bills, doing the laundry, etc. These difficulties may prevent you from being able to safely carry out basic everyday tasks and routines without assistance.

Cognitive Rehabilitation may improve your everyday functioning by helping you regain or strengthen weak skills. It can also teach you strategies and new ways of functioning to help you better manage your daily life responsibilities in spite of your brain injury related difficulties. Many times, treatment involves a combination of both of these approaches. Cognitive Rehabilitation for people with TBI usually addresses one or more of the following areas:

• Attention and/or slowed thinking
• Learning and memory
• Higher level thinking skills
• Social interaction and communication skills
• Visual scanning and perceptual difficulties

What is cognitive rehabilitation therapy like?

Before starting a Cognitive Rehabilitation program, often a neuropsychologist will perform an assessment of your cognitive abilities to identify what aspects of thinking are most problematic.  This assessment can also identify current strengths that can be used to help you compensate for (work around) your difficulties. Results of testing help determine what your cognitive rehabilitation program will focus on.  A typical program should include one or more of the following interventions:

• Attention training involves the use of computer-based activities and/or paper and pencil tasks to directly improve or strengthen attention skills.  There is also usually a focus on training in the use of strategies (ex: working in a distraction free environment, do one task at a time, allow for rest breaks) that can help improve performance on tasks.
• Rehabilitation of memory problems involves teaching compensatory strategies to help you remember to perform important tasks (ex: taking medication, going to appointments), recall important details (ex: steps in a task, items in a list, facts from a story), and learn new information and tasks. Memory training is discussed in more detail here (include link to memory training factsheet).
• Rehabilitation for higher level thinking skills may involve training in formal problem solving, planning, organization and goal management strategies, as well as practicing these skills in real world environments and on everyday tasks.  The therapist often provides a lot of education and direct feedback about a patient’s performance as part of training to help increase self-awareness and the ability to monitor and adapt behavior as needed to achieve goals.
• For people with behavior problems or difficulties communicating or interacting appropriately in social situations, treatment is often carried out in a group setting.  Goals may focus on helping improve your ability to manage your feelings and behavior.  It may help you learn to communicate better with others.  Computerized activities may be also be used to help improve your ability to recognize other people’s emotions.  Family members may be included as part of this type of treatment.  The Social Skills Training factsheet in the treatment hub provides more information on this type of training.
• Visual scanning and visuoperceptual training may use a combination of computer based, paper and pencil and functional tasks.  Repeatedly practicing structured visual scanning exercises can improve how quickly and accurately you complete tasks like reading, writing, typing or making sure no cars are coming before crossing a street.  Usually there is also a focus on using strategies (ex: line markers, line numbering, increased line spacing, etc), to help accommodate for scanning difficulties. 

Once area(s) of difficulty are identified as treatment targets, you will work closely with your health care provider to identify appropriate goals for treatment, including the tasks and activities that are meaningful and relevant to your everyday life.  For example, say you are experiencing memory problems, and have a personal goal of being able to independently perform household tasks and routines.  Some tasks you may need to remember include taking your medications, feeding the dog, running errands, and attending your doctor appointments.  Here, cognitive rehabilitation may involve training in the use of different memory compensation tools and strategies.  However, what works for one person might not work for everyone.  In the beginning of treatment, your therapist may have you practice using different types of aids and/or strategies to help find the ones that work best for you.  In the above example, this might include a variety of traditional external aids like daily planners, pillboxes, post-it notes, to-do lists, and/or electronic devices such as alarms, timers, smartphone apps, smart home devices/virtual assistants, and other digital tools.

Once you decide which tools and strategies are best suited for you, your cognitive rehabilitation therapist will train you in how to use them, and will provide you with a lot of guidance, support and practice until you become independent in using them. You may also be assigned “homework” that requires you to practice using the tools and strategies on your own in different tasks or environments outside of treatment sessions. 

How strong is the evidence for cognitive rehabilitation therapy?

There is a lot of evidence demonstrating the effectiveness of cognitive rehabilitation for people with TBI.  Direct training of impairments in attention and visual scanning has been shown to help improve performance in those areas.  In other areas, such as memory, problem solving, social skills, and social communication, there is strong evidence that training in the use of compensatory strategies can improve performance in everyday tasks and enhance overall cognitive and functional outcomes.  Interventions that combine direct training and compensatory strategy training may both improve task performance and promote generalization to daily life.  Using tools and techniques that work for you can be life changing. Becoming more independent in everyday tasks may lead to a greater sense of control over your life.  This in turn may help improve your mood and overall quality of life.  

There are currently a number of evidence-based practice recommendations for the treatment of TBI-related cognitive impairment based on four systematic literature reviews by Dr. Keith D. Cicerone et al [anchor link to references below], with the latest review publishing in 2019.

Where can I find more information?

• What About Cognitive Rehabilitation Therapy?
  From BrainLine
• Learning to Remember - Tips on memory strategies.
  From BrainLine
• Memory Strategies After TBI
  From BrainLine
• Cognitive Problems After Traumatic Brain Injury
  From the Model Systems Knowledge Translation Center
• Best Practices in Cognitive Rehabilitation for Children and Youth
  From BrainLine

What do patients say?

“I just learned over the years various coping mechanisms. … I keep Post-its in business. I buy thousands and thousands of Post-its. If I have something coming up I’ll write a note and put it on my mirror. I know in the morning I go to brush my teeth there is it, ‘Don’t forget your 11 o’clock appointment.’”  - Retired NFL player George Visger
 

• In this video, retired NFL player George Visger discusses what memory strategies work for him.
• Jason Cowper and Tonya Howell share their stories of coming to terms with changes in their memory, and strategies they use to compensate for these changes.

Organizations

Brain Injury Association of America

National Brain Tumor Society

National Multiple Sclerosis Society

American Stroke Association

Alzheimer's Association | Alzheimer's Disease & Dementia Help

Parkinson's Foundation

American Congress of Rehabilitation Medicine (ACRM)