-
J Head Trauma Rehabil 1999;14(3):277-307© 1999 Aspen Publishers,
Inc.
277
N DECEMBER 1998, the Agency for Health
Effect of Cognitive Rehabilitationon Outcomes for Persons
withTraumatic Brain Injury:
A Sys temat ic Rev iew
Special Article
Nancy Carney, PhDAssistant ProfessorDepartment of Emergency
Medicine
Randall M. Chesnut, MDDirectorNeurotrauma and Neurosurgical
Critical
CareDepartments of Neurological Surgery and
Emergency Medicine
Hugo Maynard, PhDProfessorDepartment of Emergency
MedicineDivision of Medical Informatics and
Outcomes Research
N. Clay Mann, PhDAssistant ProfessorDepartment of Emergency
Medicine
Patricia Patterson, PhDAssistant Professor of Nursing
Mark Helfand, MDAssociate ProfessorDivision of Medical
Informatics and
Outcomes ResearchOregon Health Sciences UniversityPortland,
Oregon
Address correspondence to N. Carney, Oregon HealthSciences
University, 3181 SW Sam Jackson Park Road,Portland, OR
97201-3098.
This study was supported by Contract no. 290-97-0018,awarded by
the Agency for Health Care Policy and Re-search (AHCPR). The
authors are solely responsible forthe content of this article, and
the opinions do not nec-essarily represent the views of the
AHCPR.
The authors acknowledge Oregon Health Sciences Uni-versity
Neurotrauma Research Group, the Fourth An-nual Aspen
Neurobehavioral Conference, the Brain In-jury Support Group of
Portland, and Mark Ylvisaker,PhD.
We evaluated evidence for the effectiveness of cognitive
rehabilitation methods to improve outcomes forpersons with
traumatic brain injury (TBI). A search of MEDLINE, HealthSTAR,
CINAHL, PsycINFO, andthe Cochrane Library produced 600 potential
references. Thirty-two studies met predetermined inclusioncriteria
and were abstracted; data from 24 were placed into evidence tables.
Two randomized controlledtrials and one observational study
provided evidence that specific forms of cognitive rehabilitation
reducememory failures and anxiety, and improve self-concept and
interpersonal relationships for persons withTBI. The durability and
clinical relevance of these findings is not established. Future
research utilizingcontrol groups and multivariate analysis must
incorporate subject variability and must include
standarddefinitions of the intervention and relevant outcome
measures that reflect health and function. Keywords: cognitive
rehabilitation, evidence based, systematic review
I Care Policy and Research (AHCPR) pub-lished an evidence report
on rehabilitation ofpersons with traumatic brain injury (TBI),1
produced by the Evidence-Based PracticeCenter (EPC) at Oregon
Health Sciences Uni-versity. Five key questions addressing
thephases of recovery from TBI were used todirect a systematic and
exhaustive search ofthe literature for studies containing
evidencefor effectiveness of specified interventions.
-
278 JOURNAL OF HEAD TRAUMA REHABILITATION/JUNE 1999
Standards for grading the quality of evidence,consistent with
those used by the U.S. Pre-ventive Services Task Force,2 were
used,based on the assumption that the strongestevidence is found in
well-designed random-ized controlled trials (RCTs).
One class of intervention identified forevaluation was cognitive
rehabilitation. Thepurpose of this article is to present the
find-ings of the evidence report with respect tocognitive
rehabilitation. We have three goals:
1. To articulate the evidence for effective-ness of this
intervention, using methodsand standards with demonstrated
utilityin other areas of medical research3;
2. To illustrate controversies about the useof such standards in
evaluating TBI reha-bilitation, particularly when applied
tocognitive rehabilitation;
3. To compose reasonable recommenda-tions for practice and for
future re-search.
DEFINITION AND CLASSIFICATION OFCOGNITIVE REHABILITATION
A standard, widely used definition of cogni-tive rehabilitation
that serves inter- or trans-disciplinary clinical and research
purposesdoes not exist. For this review, a conceptfounded in
Goldstein’s4 schema of cognitionwas used: Cognition operates as an
integratedsystem consisting of performance fields andvarious
functions within these fields. Thefields include attention, memory
and learn-ing, thinking or mental organization, affectand
expression, and executive functions. De-pending on many factors,
brain injury may af-fect overall performance and may have
differ-ential effects on performances within thesefields. A
traditional and perhaps limited5 defi-nition of cognitive
rehabilitation is that it is aset of therapies used to help improve
dam-aged intellectual, perceptual, psychomotor,and behavioral
skills.6 It is a system of inter-
ventions designed to increase daily functionalabilities by
improving or augmenting deficitsin processing and interpreting
information7
or by modifying the environment.5
Therapeutic strategies of cognitive rehabili-tation have been
classified as restorative orcompensatory. Restorative cognitive
rehabili-tation (RCR) is based on the theory that re-petitive
exercise can restore lost function.7
Compensatory cognitive rehabilitation (CCR)strives to develop
internal substitutes5 and/orexternal prosthetic assistance for
dysfunc-tions.8 Although this distinction is widelyused in study
publications, it is recognizedthat, in clinical practice, the two
strategies donot exist independent of each other. Ylvis-aker5
argues against the fundamental validityof the distinction, stating
that (a) strategic be-havior is a component of normal cognition,(b)
helping people with TBI to acquire com-pensatory behaviors and
equipment is help-ing them to become more strategic, and,therefore,
(c) the compensatory interventionis restorative, in that it
operates to restore thiscomponent of normal cognition.
Strategic behavior can be highly individual;its acquisition may
involve setting personalgoals, specifying methods for meeting
thegoals, experimenting with methods, and re-formulating goals,
requiring daily changes inprotocol, all of which are a part of the
inter-vention. The question is, What, exactly, is theintervention
or set of interventions? Giventhe apparent necessity for
individualizedtreatment that may change daily, how shouldcognitive
rehabilitation be operationally de-fined?
DEFINITION AND CLASSIFICATION OFOUTCOMES
Ylvisaker’s5 argument raises a similar prob-lem with defining
and measuring outcomes.The clinical practice of highly
individualizedtreatment in TBI rehabilitation has generated
-
Special Article 279T
able
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ests
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280 JOURNAL OF HEAD TRAUMA REHABILITATION/JUNE 1999
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-
Special Article 281
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-
282 JOURNAL OF HEAD TRAUMA REHABILITATION/JUNE 1999
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tive
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ve e
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n
-
Special Article 283
a vast catalog of outcomes and their mea-sures. Table 1
summarizes the results of thestudies in this review that used
laboratorytests of cognition to measure treatment ef-fects. Tests
are organized within six cognitivedomains, as defined by Lezak,9 as
well as a cat-egory for test batteries, one for miscellaneoustests
and those developed by a clinic for thepurpose of program
evaluation (clinic-spe-cific tests). In 23 studies, 91 individual
mea-sures of outcome were used, of which ap-proximately 25% are
clinic-specific. Thissimple tabulation suggests that, as with
thedefinition of the intervention, there is no stan-dard set of
outcome measures for TBI reha-bilitation that can be used across
clinics toevaluate both patient progress and
programeffectiveness.
Note that the category with the highestproportion of positive
effects is clinic-specifictests, suggesting that a study conducted
in apractice setting that has generated a uniqueprotocol for
program evaluation is morelikely to show a positive result of its
treat-ment. Such studies, if they met the predeter-mined inclusion
criteria, were used as evi-dence in this review, contrary to the
advice ofmembers of the Aspen Neurobehavioral Con-ference,10 who
requested that studies be ex-cluded if the clinicians who designed
and op-erate the practice are also the researcherswho designed and
conducted the evaluation.
Although practitioners agree that the de-sired outcome of
cognitive rehabilitation isimprovement in daily function, many of
thecommonly used outcome indicators, repre-sented in Table 1, are
intermediate measures,rather than health outcomes. For example,
acognitive rehabilitation study may identify“attention” as the
primary dysfunction for pa-tients, apply an intervention designed
to im-prove attention, and use a common labora-tory test, such as
the Paced Auditory SerialAttention Task, or PASAT,11 as a measure
ofimprovement. The question is, Do high
scores on the PASAT accurately predictwhether the patients’
attention performanceswill function adequately in the context
ofwork or social situations in which distractionand other demands
are present? More gener-ally, do the measures used to assess the
effec-tiveness of cognitive rehabilitation predictimprovement in
real-life function?
CAUSAL PATHWAY
Fig 1 shows a causal pathway linking cogni-tive rehabilitation
to potential benefits. Weused this causal pathway to circumscribe
oursearch for evidence of effectiveness of anintervention in the
face of little or no defini-tion of the intervention and no
standard mea-sure of effectiveness. Arc 1 represents the di-rect
effect of cognitive rehabilitation onhealth outcomes—outcomes that
can be feltor experienced by the patient in daily life. Inthe
context of a systematic review, “direct”evidence comes from
comparative studiesthat examine the effect of cognitive
rehabili-tation on measures of these outcomes. Arc 2
Fig 1. Causal pathway for cognitive rehabilitation.Note: *PASAT,
Paced Auditory Serial AdditionTask; WAIS-R, Wechsler Adult
Intelligence Scale—Revised; See Table 1 for measures of
cognitiveabilities.
-
284 JOURNAL OF HEAD TRAUMA REHABILITATION/JUNE 1999
represents the direct effect of cognitive reha-bilitation on
measures of employment, suchas return to work and job retention.
“Indi-rect” evidence refers to a causal chain that re-lies on
intermediate measures. In Fig 1, thefirst link in this chain is
between the interven-tion and intermediate measures of improve-ment
(Arc 3); this link corresponds to thequestion, Does cognitive
rehabilitation im-prove scores on intermediate measures ofcognitive
function, such as the PASAT, theWechsler Adult Intelligence
Scale—Revised(WAIS-R), etc.? The next links in the causalchain
correspond to the question, Do inter-mediate measures used to
assess the effective-ness of cognitive rehabilitation predict
im-provement in real-life function (Arc 4) andemployment (Arc
5)?
METHODS
A previous publication12 documents themethods used to conduct
the review. The fol-lowing summarizes the important aspects ofthe
process:
1. Two panels of technical experts, one lo-cal and one national,
worked with theresearch team to define key questions,research
parameters, and outcome mea-sures, and to specify the causal
path-ways. Relevant health outcomes were:• Activities of daily
living (ADL)• Long-term measure of disability (re-
striction or lack [resulting from animpairment] of ability to
perform anactivity in the manner or within therange considered
normal for a humanbeing)
• Long-term measure of impairment(loss or abnormality of
psychological,physiological, or anatomical structureor
function)
• Independence, relationships, familylife, satisfaction
• Long-term financial burden
2. Search strategies derived from the ques-tions were used to
acquire relevant lit-erature from MEDLINE (1976–1997),HealthSTAR
(1995–1997), CINAHL(1982–1997), PsycINFO (1984–1997),and the
Cochrane Library.
3. Of 3,098 abstracts read by two indepen-dent reviewers, 600
applied to the ques-tion of cognitive rehabilitation.
4. Exclusion criteria were:• not TBI (eg, carbon monoxide
poi-
soning),• pediatric,• pharmacological intervention,• case
report,• instrument development,• alcohol/drug abuse as an
outcome,• stroke,• editorial or no data,• acute care intervention
(eg, surgical),
and• foreign language.
One hundred fourteen articles passed thisscreen.
5. Inclusion criteria were:• data specific to the question,•
sound scientific methods,• rehabilitation as an intervention,•
independent variable specific to the
question,• dependent variable specific to the
question.6. Level of evidence was determined, us-
ing the following system:• Class I—Well-designed randomized
controlled trials (RCTs)• Class II[a]—RCTs with design flaws
and multicenter or population-basedlongitudinal (cohort)
studies
• Class II[b]—Nonrandomized con-trolled trials, case-control
studies, andwell-designed case series
• Class III—Case reports, uncontrolledcase series, and expert or
consensusopinion
-
Special Article 285
7. Key studies were critically appraised,and data from them were
abstracted andplaced into evidence tables.
1S
Of the 114 potential references identifiedfor inclusion by the
literature search, 53 metthe predetermined eligibility criteria.
Fromreference lists of reviewed articles and peerrecommendations,
an additional 20 articleswere identified, resulting in a total of
73 full-text articles that were retrieved and read. Ofthose, 41
were excluded. Of the excluded ar-ticles, 3 were reviews, 5 were
studies withfewer than 5 subjects, 1 was retrospective,and 25
studies were descriptive. Five studiesmeasured independent or
dependent vari-ables outside the scope of this research ques-tion,
and two studies compared clients whowere referred for treatment
with those re-ferred for testing. Although excluded as evi-dence
about effectiveness, the descriptiveand observational data from
these researchefforts were used in the review process toprovide a
foundation for understanding andinterpreting the evidence.
The remaining 32 articles were abstractedand are presented in
the following categories:
11 randomized controlled trials• 5 measuring relevant health
outcomes
(Table 2)• 6 measuring intermediate outcomes
(Table 3)4 comparative studies• 1 measuring employment
outcomes
(Table 4)• 3 measuring intermediate outcomes
(Table 5)8 studies of the relationship between inter-
mediate tests and employment (Table 6)9 observational studies• 1
measuring relevant health outcomes
(Table 7)• 8 measuring intermediate outcomes
DIRECT EVIDENCE
Does cognitive rehabilitation improvehealth outcomes (Arc
1)?
Randomized controlled trials
Five randomized controlled trials13–17 usedmeasures of relevant
health outcomes to com-pare the effects of specific forms of
cognitiverehabilitation with alternative treatments orwith no
treatment (see Table 2). Comparisongroups were provided with
unstructured ses-sions, computer game sessions, or nonthera-peutic
attention. In one study,14 two distinctinterventions were compared;
each groupwas trained in one of the skills and was testedfor both.
Treatment time in four of the studiesranged from 10 to 20 hours;
the fifth16 pro-vided 96 hours of treatment. Follow-up forone
study17 occurred at 6 months and for asecond study13 at 1 month for
6 of the sub-jects; the other studies did not include follow-up
testing.
As seen in Table 2, the studies varied in set-ting, populations,
size, client chronicity, andmeasures of severity of injury. One
hundredthirty-seven clients were observed in thesetrials; 69
received the targeted treatments.
Measures used in these studies, which ap-proximated important
health outcomes, werethe Functional Independence Measure(FIM),15
Observed Everyday Memory Failures(EMFs), Rabideau Kitchen
Evaluation Revised(RKE-R),14 Katz Adjustment Scale (KAS),16 anda
variety of inventories designed to measureanxiety, communication,
and relationships.13
In addition, these studies used neuropsycho-logical test
batteries and other intermediatemeasures of cognitive function to
evaluatetreatment effect.
In two studies, treatment produced statis-tically significant
effects on relevant out-come measures. In one,17 individuals
trainedin the use of notebooks and equipped withwristwatch alarm
cues had fewer EMFs than
-
286 JOURNAL OF HEAD TRAUMA REHABILITATION/JUNE 1999
Tab
le 2
.R
and
om
ized
co
ntr
olle
d t
rial
s o
f co
gnit
ive
reh
abili
tati
on
–hea
lth
ou
tco
mes
(A
rc 1
)
Sou
rce
No
vack
(199
6)
Sch
mit
ter-
Edge
com
be
(199
5)
Nei
stad
t(1
992)
Ru
ff (
1990
)
Hel
ffen
stei
n(1
982)
Inte
rven
tio
n/t
reat
men
t gr
ou
p
Res
tora
tive
an
d c
om
pen
sato
ryH
iera
rch
ical
, str
uct
ure
d C
AC
R w
ith
ther
apis
t su
pp
ort
an
d e
xte
rnal
cu
es
Co
mp
ensa
tory
No
teb
oo
k tr
ain
ing
wit
h w
rist
wat
ch a
larm
cue
Res
tora
tive
Fun
ctio
nal
Ski
lls G
rou
p (
T1)
tra
ined
info
od
pre
par
atio
n
Res
tora
tive
an
d c
om
pen
sato
ryC
AC
R a
nd
ex
tern
al a
ids
(no
teb
oo
ks,
cale
nd
ars,
sch
edu
les,
tim
ers,
etc
.)
Co
mp
ensa
tory
Inte
rper
son
al P
roce
ss R
ecal
l (IP
R)
Vid
eota
pe
of
soci
al in
tera
ctio
n, v
iew
ing
of
tap
e, f
eed
bac
k, c
orr
ecti
on
s an
dp
ract
ice
Co
mp
aris
on
gro
up
/2
nd
tre
atm
ent
gro
up
Un
stru
ctu
red
.M
emo
ry/r
easo
nin
g ta
sks,
gam
es, c
om
pu
ter
gam
es
Gro
up
ses
sio
ns
for
pro
ble
m s
olv
ing,
dis
cuss
ion
of
soci
alis
ola
tio
n, f
rust
rati
on
s
Per
cep
tual
Ski
lls G
rou
p(T
2) t
rain
ed in
par
qu
etry
blo
ck a
ssem
bly
.Ea
ch g
rou
p t
rain
ed in
on
esk
ill, t
este
d f
or
bo
th s
kills
Psy
cho
soci
al f
un
ctio
nin
gan
d A
DLs
No
nth
erap
euti
c at
ten
tio
n(w
ith
no
fee
db
ack
on
inte
rper
son
al f
un
ctio
n-
ing)
Du
rati
on
of
inte
rven
tio
n
30 m
in s
essi
on
s5
d/w
k20
ses
sio
ns
10 h
r to
tal
60 m
in s
essi
on
s2
d/w
k8
wks
16 s
essi
on
s16
hr
tota
l
30 m
in s
essi
on
s3
d/w
k6
wks
9 h
r to
tal
3 h
r/d
4 d
/wk
8 w
k96
hr
tota
l
1 h
r/d
20 d
20 h
r to
tal
Fo
llo
w-
up
No
ne
6 m
on
ths
No
ne
No
ne
1 m
o (
on
6su
bje
cts)
Sett
ing/
po
pu
lati
on
Acu
te in
pat
ien
t re
hab
ilita
-ti
on
Co
nse
cuti
ve a
dm
issi
on
so
ver
3 yr
Ou
tpat
ien
t vo
lun
teer
s
Bo
sto
n S
cho
ol o
fO
ccu
pat
ion
al T
her
apy,
Tu
fts
Un
iver
sity
.Su
bje
cts
recr
uit
ed f
rom
10 h
ead
-inju
ry p
rogr
ams,
8 re
sid
enti
al, 2
ou
tpat
ien
t
Un
iver
sity
of
San
Die
goO
utp
atie
nts
Po
pu
lati
on
no
t sp
ecif
ied
Bra
in I
nju
ry P
roje
ctW
oo
dro
w W
ilso
nR
ehab
ilita
tio
n C
ente
r
con
tin
ues
-
Special Article 287
Sou
rce
No
vack
(199
6)
Sch
mit
ter-
Edge
com
be
(199
5)
Nei
stad
t(1
992)
Ru
ff (
1990
)
Hel
ffen
stei
n(1
982)
N
T -
22C
- 22
T -
4C
- 4
T1
- 23
T2
- 22
T -
12C
- 12
T -
8C
- 8
Ch
ron
icit
y
T -
5.9
wk
(3.3
)C
- 6.
4 w
k(4
.9)
T -
77.7
mo
(46.
8)C
- 86
.8 m
o(6
7.7)
7.9
yr (
6.6)
T -
44.3
mo
(25.
6)C
- 52
.2 m
o(1
9.2)
No
t sp
ecif
ied
Seve
rity
21-G
CS
≤ 8
3-m
od
erat
eG
CS
+ p
osi
tive
CT
20-8
day
s co
ma
+ p
osi
tive
CT
T -
139.
3 D
RS
(2.2
)C
- 14
0.5
DR
S(2
.6)
≤ 10
WA
IS-R
Blo
ck D
esig
nsc
aled
sco
reLe
ss t
han
per
fect
sco
reo
n p
rete
stR
KE-
R
T -
25.5
co
ma
day
s (1
6.4)
C -
48.3
co
ma
day
s (2
8.3)
Esti
mat
ed t
ob
e m
ild t
om
od
erat
e
Ou
tco
mes
/an
aly
sis
Dig
it S
pan
& M
enta
l Co
ntr
ol s
ub
test
s o
fW
MS
Co
mp
ute
r-b
ased
mea
sure
s o
f re
acti
on
tim
e(R
T)
Neu
rop
sych
olo
gica
l Bat
tery
FIM
on
24
of
44 s
ub
ject
s M
AN
OV
A/A
NC
OV
As,
t-t
ests
Lab
ora
tory
Rec
all (
Ind
ex f
rom
WM
SLo
gica
l Mem
ory
1 &
2, V
isu
al R
epro
du
c-ti
on
1 &
2)
RB
MT
pro
file
sco
reEv
eryd
ay M
emo
ry Q
ues
tio
nn
aire
Ob
serv
ed E
very
day
Mem
ory
Fai
lure
s(E
MFs
)Sy
mp
tom
Ch
eckl
ist
90A
NC
OV
As
Par
qu
etry
Blo
ck D
esig
nR
abid
eau
Kit
chen
Eva
luat
ion
Rev
ised
(RK
E-R
)W
AIS
-R B
lock
Des
ign
su
bte
stA
NO
VA
s, t
-tes
ts
Kat
z A
dju
stm
ent
Scal
e (K
AS)
Sel
f-Rep
ort
and
Fam
ily R
epo
rtM
AN
OV
A/A
NC
OV
A
Stat
e T
rait
An
xie
ty S
cale
(ST
AS)
Ten
nes
see
Self
-Co
nce
pt
Scal
e (T
SCS)
Inte
rper
son
al C
om
mu
nic
atio
n I
nve
nto
ry(I
CI)
Inte
rper
son
al R
elat
ion
ship
Rat
ing
Scal
e(I
RR
S)In
dep
end
ent
Ob
serv
er R
epo
rt S
cale
Vid
eota
pe
An
alys
isA
NC
OV
As
Res
ult
s
No
Tre
atm
ent
Effe
ct∆
for
FIM
AD
LsT
= 2
9.3
C =
29.
2
No
tre
atm
ent
effe
ct o
n 4
or
5m
easu
res.
Tre
atm
ent
gro
up
had
few
er E
MFs
than
co
ntr
ol g
rou
p a
t p
ost
trea
tmen
t.∆
for
mea
n n
o. o
f EM
FsT
= –
23.3
7C
= –
7.75
No
tre
atm
ent
effe
ct a
t fo
llow
-up
No
tre
atm
ent
effe
ct o
n R
KE-
R∆
for
RK
E-R
T1
= 7
.92
T2
= 2
.68
Per
cep
tual
Ski
lls G
rou
p (
T2)
sco
red
sign
ific
antl
y h
igh
er t
han
Fu
nct
ion
alSk
ills
Gro
up
(T
1) o
n P
arq
uet
ry B
lock
Des
ign
No
tre
atm
ent
effe
ct∆
for
mea
ns
on
KA
S gl
ob
al s
cale
sco
res
ran
ged
fro
m:
T =
4, C
= 1
(So
cial
Ob
stre
per
ou
s-n
ess,
Sel
f-Rep
ort
) to
:T
= –
0.6,
C =
–0.
4 (A
cute
Psy
cho
tici
sm, F
amily
/Rep
ort
).
Tre
atm
ent
effe
ct o
n 1
var
iab
le f
rom
STA
S an
d 3
var
iab
les
fro
m T
SCS.
Tre
atm
ent
effe
ct o
n I
RR
S sc
ale,
an
dIn
dep
end
ent
Ob
serv
er R
epo
rt S
cale
(gro
up
mea
ns
no
t p
rovi
ded
)
Leve
l
I I I I II (
a)
Tab
le 2
.C
on
tin
ued
-
288 JOURNAL OF HEAD TRAUMA REHABILITATION/JUNE 1999
Tab
le 3
.R
and
om
ized
co
ntr
olle
d t
rial
s o
f co
gnit
ive
reh
abili
tati
on
—in
term
edia
te o
utc
om
es (
Arc
3)
Sou
rce
Th
om
as-
Sto
nel
l(1
994)
Tw
um
(199
4)
Nie
man
n(1
990)
Ru
ff (
1989
)
Inte
rven
tio
n/t
reat
men
t gr
ou
p
Res
tora
tive
an
d c
om
pen
sato
ryC
AC
R w
ith
th
erap
ist
inte
rven
tio
nT
each
war
e
Res
tora
tive
Imag
ery
Tra
inin
g sp
ecif
ic t
o v
erb
al t
ask
ou
tco
me
mea
sure
sV
erb
al L
abel
ing
Tra
inin
g sp
ecif
ic t
o v
isu
alta
sk o
utc
om
e m
easu
res.
Tes
t st
imu
li p
rese
nte
d u
nti
l rec
all w
asp
erfe
ct o
r u
nti
l 6th
tri
al.
Del
ayed
rec
all t
este
d a
t 30
min
Res
tora
tive
Co
mp
ute
r an
d n
on
com
pu
ter
atte
nti
on
rem
edia
tio
n
Res
tora
tive
an
d c
om
pen
sato
ryC
AC
R a
nd
ex
tern
al a
ids
(no
teb
oo
ks,
cale
nd
ars,
sch
edu
les,
tim
ers,
etc
.)
Co
mp
aris
on
gro
up
/2
nd
tre
atm
ent
gro
up
Tra
dit
ion
al t
her
apy,
com
mu
nit
y sc
ho
ol
pro
gram
s
Fou
r gr
ou
ps:
no
tra
inin
g,ve
rbal
tra
inin
g, im
ager
ytr
ain
ing,
bo
th t
rain
ings
Res
tora
tive
an
d c
om
pen
-sa
tory
mem
ory
tra
inin
g
Co
mp
ute
r an
d v
ideo
gam
es, c
op
ing
skill
s,h
ealt
h, d
iscu
ssio
n,
ind
epen
den
t liv
ing,
art
Du
rati
on
of
inte
rven
tio
n
1 h
r/d
2 d
/wk
8 w
k16
hr
tota
l
Sin
gle
trai
nin
gse
ssio
n
2 h
r/d
2 d
/wk
9 w
k36
hr
tota
l
5 h
r/d
4 d
/wk
8 w
k16
0 h
r to
tal
Fo
llo
w-
up
No
ne
No
ne
2 w
k
No
ne
Sett
ing/
po
pu
lati
on
Hu
gh M
acM
illan
Reh
abC
entr
e—T
oro
nto
Po
pu
lati
on
no
t sp
ecif
ied
To
wso
n S
tate
Un
iver
sity
Ref
erra
l so
urc
es n
ot
spec
ifie
d. A
ll h
adn
euro
psy
cho
logi
cal
eval
uat
ion
s b
y st
ate
DV
R
Ou
tpat
ien
ts—
U.C
. San
Die
go H
ead
In
jury
Cen
ter.
Co
nta
cted
th
rou
ghh
osp
ital
s, c
om
mu
nit
yco
llege
s, a
nd
S.D
. Hea
dIn
jury
Fo
un
dat
ion
Un
iver
sity
of
San
Die
goP
op
ula
tio
n n
ot
spec
ifie
d
con
tin
ues
-
Special Article 289T
able
3.
Co
nti
nu
ed
Sou
rce
Rya
n (
1988
)
Ker
ner
(198
5)
Inte
rven
tio
n/t
reat
men
t gr
ou
p
Res
tora
tive
an
d c
om
pen
sato
ryEx
tern
al m
nem
on
ics,
en
cod
ing
stra
tegy
pra
ctic
e, p
erso
nal
ized
em
oti
on
alte
chn
iqu
es, r
ehea
rsal
, CA
CR
, syn
thes
is o
fal
l in
gro
up
pra
ctic
e
Res
tora
tive
CA
CR
Co
mp
ute
r M
emo
ry R
etra
inin
g G
rou
p(C
MR
G)
Co
mp
aris
on
gro
up
/2
nd
tre
atm
ent
gro
up
Gam
es, p
sych
oso
cial
sup
po
rt, a
rt, g
rou
pd
iscu
ssio
ns,
sel
f-ex
pre
ssio
n, r
elax
atio
nex
erci
ses
Tw
o c
om
par
iso
n g
rou
ps:
1. C
om
pu
ter
Co
ntr
ol
Gro
up
(C
CG
)U
sed
co
mp
ute
rs t
ocr
eate
gra
ph
ics.
2. N
o-E
xp
osu
re C
on
tro
lG
rou
p (
NEC
G)
Du
rati
on
of
inte
rven
tio
n
5.5
hr/
d4
d/w
k6
wk
24 s
essi
on
s13
2 h
r to
tal
45 m
in s
essi
on
s12
ses
sio
ns
4.5
wk
9 h
r to
tal
Fo
llo
w-
up
No
ne
15 d
CM
RG
on
ly
Sett
ing/
po
pu
lati
on
Un
iver
sity
of
Vir
gin
iaSc
ho
ol o
f M
edic
ine
Wo
od
row
Wils
on
Reh
abili
tati
on
Cen
ter
Po
pu
lati
on
no
t sp
ecif
ied
DeA
nza
Co
llege
Po
pu
lati
on
no
t sp
ecif
ied
Sou
rce
Th
om
as-
Sto
nel
l(1
994)
Tw
um
(199
4)
N
T -
6C
- 6
T1
- 15
T2
- 15
T3
- 15
T4
- 15
Ch
ron
icit
y
Ran
ged
fro
m3
mo
nth
s to
4 ye
ars
Ave
rage
13.
2m
on
ths
fro
mre
turn
to
con
scio
us-
nes
s to
trea
tmen
t
Seve
rity
Rec
ove
red
to
7o
r 8
on
Ran
cho
scal
e
≥ 3
wee
ksco
ma
Ave
rage
WA
IS-
R I
Q =
80
Ou
tco
mes
/an
aly
sis
Tea
chW
are
Scre
enin
g M
od
ule
Stan
dar
diz
ed N
euro
psy
cho
logi
cal T
est
Bat
tery
AN
CO
VA
S u
sed
to
tes
t gr
ou
pd
iffe
ren
ces
Ver
bal
Tas
k M
ean
No
. Wo
rds
Rec
alle
d,
Del
ayed
Rec
all,
& T
rial
s to
Per
fect
Vis
ual
Tas
k M
ean
No
. Wo
rds
Rec
alle
d,
Del
ayed
Rec
all,
& T
rial
s to
Per
fect
MA
NO
VA
Res
ult
s
Tre
atm
ent
effe
ct o
n 8
of
18n
euro
psy
cho
logi
cal s
ub
test
s. G
rou
pm
ean
s n
ot
pre
sen
ted
Tre
atm
ent
effe
ctIm
ager
y gr
ou
p s
core
s h
igh
er t
han
Ver
bal
on
all
verb
al t
asks
. Ver
bal
gro
up
sco
res
hig
her
th
an I
mag
ery
on
all i
mag
ery
task
s.D
iffe
ren
ce in
mea
ns
bet
wee
nIm
ager
y an
d N
o I
mag
ery
Gro
up
on
:1.
Im
med
iate
rec
all:
+8
2. D
elay
ed r
ecal
l: +
1.5
3. T
rial
s to
cri
teri
on
: –2.
5D
iffe
ren
ce in
mea
ns
bet
wee
n V
erb
alLa
bel
ing
and
No
Ver
bal
Lab
elin
gG
rou
p o
n:
1. I
mm
edia
te r
ecal
l: +
52.
Del
ayed
rec
all:
+.7
53.
Tri
als
to c
rite
rio
n: –
2.25
Leve
l
I I
con
tin
ues
-
290 JOURNAL OF HEAD TRAUMA REHABILITATION/JUNE 1999T
able
3.
Co
nti
nu
ed
Sou
rce
Nie
man
n(1
990)
Ru
ff (
1980
)
Rya
n(1
988)
Ker
ner
(198
5)
N
T -
13C
- 13
T -
20C
- 20
T -
10C
- 10
CM
RG
- 12
CC
G -
6 NEC
G- 6
Ch
ron
icit
y
T -
41.0
C -
37.1
Ran
ged
fro
m1
to 7
yea
rs
T -
54.5
mo
nth
sC
- 57
.3m
on
ths
≥ 3
mo
nth
s
Seve
rity
Co
ma
T -
15 d
ays
C -
20 d
ays
GO
AT
T -
94.4
(5.
5)C
- 90
.7 (
6.8)
DR
ST
- 13
2.9
(9.0
)C
- 13
5.2
(7.0
)
T -
32.1
co
ma
day
s (2
1.4)
C -
48.8
co
ma
day
s (2
6.4)
Each
gro
up
had
5 m
ilds
(DR
S >
134
/14
4) a
nd
5m
od
erat
es(D
RS
≤ 13
4/14
4)
Mem
ory
ind
exra
tin
g se
vere
to m
ild
Ou
tco
mes
/an
aly
sis
Att
enti
on
Tes
t d
2P
ASA
TD
ivid
ed A
tten
tio
n T
est
Tra
ils B
RA
VLT
Blo
ck S
pan
Lea
rnin
gSD
NT
B s
ub
test
sM
AN
OV
A
San
Die
go N
euro
psy
cho
logi
cal B
atte
ryFo
rms
A a
nd
BM
AN
OV
A
BV
RT
, Rey
CFT
, Tay
lor
Co
mp
lex
Fig
ure
,Se
lect
ive
Rem
ind
ing
Tes
t, R
uff
Tra
il, W
MS
Logi
cal M
emo
ry s
ub
test
MA
NO
VA
Mem
ory
In
dex
(M
I) s
cale
d &
sta
nd
ard
sco
res
Acq
uis
itio
n R
ecal
l (A
R)
scal
ed &
sta
nd
ard
sco
res
t-te
sts
Res
ult
s
No
tre
atm
ent
effe
ct
No
tre
atm
ent
effe
ct
No
tre
atm
ent
effe
ct
Tre
atm
ent
effe
ct o
n 5
of
12 m
easu
res
∆ A
R (
scal
ed)
for
CM
RG
= –
4.33
, fo
rC
CG
= 0
.00
∆ M
I (s
cale
d)
for
CM
RG
= –
5.92
, fo
rC
CG
= 0
.50,
fo
r N
ECG
= 0
.66
∆ M
I (s
tan
dar
d)
for
CM
RG
= –
5.58
,fo
r C
CG
= 0
.50,
fo
r N
ECG
- 0.
33Si
gnif
ican
t in
crea
se f
or
CM
RG
was
no
t m
ain
tain
ed a
t fo
llow
-up
Leve
l
I I I I
T =
tre
atm
ent
gro
up
, C =
co
ntr
ol g
rou
p. N
um
ber
s in
( )
are
sta
nd
ard
dev
iati
on
s. N
egat
ive
valu
es in
dic
ate
gain
.
-
Special Article 291T
able
4.
Co
mp
arat
ive
stu
dy
of
cogn
itiv
e re
hab
ilita
tio
n—
emp
loym
ent
(Arc
2)
Sou
rce
Pri
gata
no
(198
4)
Inte
rven
tio
n/t
arge
t
Res
tora
tive
an
d c
om
pen
sato
ryIn
ten
sive
, co
ord
inat
ed, m
ult
idis
cip
linar
yC
R. S
tres
ses
awar
enes
s o
f d
efic
its,
com
pen
sato
ry s
kills
dev
elo
pm
ent.
Sta
ffin
clu
des
clin
ical
neu
rop
sych
olo
gist
,sp
eech
pat
ho
logi
st, o
ccu
pat
ion
alth
erap
ist,
ph
ysic
al t
her
apis
t, r
esea
rch
psy
cho
logi
st
Co
mp
aris
on
No
neu
rop
sych
olo
gica
lre
hab
ilita
tio
n p
rogr
am(N
RP
).O
ther
inte
rven
tio
ns
no
tsp
ecif
ied
Du
rati
on
of
inte
rven
tio
n
4 d
/wk
6 h
r/d
6 m
o62
4 h
r to
tal
Fo
llo
w-
up
Bet
wee
n33
mo
an
d3
mo
,d
epen
din
go
n w
hen
the
per
son
ente
red
the
pro
gram
and
was
dis
char
ged
Sett
ing/
po
pu
lati
on
T: T
BI
clie
nts
wh
oen
tere
d P
resb
yter
ian
Ho
spit
al N
RP
bet
wee
n 2
/80
an
d 8
/82
and
sta
yed
at
leas
t 6
mo
nth
s.C
: TB
I fi
les
of
refe
rral
s to
NR
P b
etw
een
2/8
0 an
d 8
/82
wh
o d
id n
ot
ente
r th
ep
rogr
am w
ere
retr
osp
ec-
tive
ly e
xam
ined
Sou
rce
Pri
gata
no
(198
4)
N
T =
18
C =
17
Ch
ron
icit
y
T -
21.6
mo
nth
sC
- 13
.6m
on
ths
Seve
rity
No
t sp
ecif
ied
Ou
tco
mes
/an
aly
sis
1. W
AIS
-R V
erb
al I
Q, P
erfo
rman
ce I
Q,
Vo
cab
ula
ry, B
lock
Des
ign
, Dig
it S
ymb
ol.
WM
S M
emo
ry Q
uo
tien
t, L
ogi
cal M
emo
ry,
Vis
ual
Rep
rod
uct
ion
, Ass
oci
ativ
e Le
arn
ing,
Hal
stea
d R
eita
n T
rail
Mak
ing
Tes
t, F
inge
rT
app
ing,
Tac
tual
Per
form
ance
Tes
t.R
uss
ell-N
eure
nge
r A
vera
ge I
mp
airm
ent
Scal
e2.
KA
S R
elat
ive
Scal
e3.
Em
plo
ymen
tA
NC
OV
AS
Res
ult
s
Tre
atm
ent
effe
ct:
1. W
AIS
-R p
erfo
rman
ce I
.Q.
∆ T
= 8
.7, C
= 4
.82.
Blo
ck D
esig
n∆
T =
2, C
= 1
.43.
WM
S M
emo
ry Q
uo
tien
t∆
T =
9.5
, C =
2
Leve
l
II(b
)
T =
tre
atm
ent
gro
up
; c =
co
ntr
ol g
rou
p.
-
292 JOURNAL OF HEAD TRAUMA REHABILITATION/JUNE 1999
Tab
le 5
.C
om
par
ativ
e st
ud
ies
of
cogn
itiv
e re
hab
ilita
tio
n—
inte
rmed
iate
ou
tco
mes
(A
rc 3
)
Sou
rce
Gra
y (1
992)
Bat
chel
or
(198
8)
Wo
od
(198
7)
Inte
rven
tio
n/t
reat
men
t gr
ou
p
Res
tora
tive
CA
CR
tas
ks s
elec
ted
th
atm
ake
dem
and
s o
n a
lert
ing,
wo
rkin
gm
emo
ry, a
lter
nat
ing
atte
nti
on
an
d d
ivid
edat
ten
tio
n. U
sed
fee
db
ack,
rei
nfo
rcem
ent,
visu
al s
tim
uli,
an
d c
uei
ng
Res
tora
tive
CA
CR
dir
ecte
d t
ow
ard
rem
edia
tio
n in
rec
ent
mem
ory
, att
enti
on
/sp
eed
of
info
rmat
ion
pro
cess
ing,
an
dh
igh
er c
ogn
itiv
e fu
nct
ion
ing
Res
tora
tive
vis
ual
tra
inin
g o
f in
form
atio
np
roce
ssin
g u
sin
g C
AC
R
Co
mp
aris
on
gro
up
/2
nd
tre
atm
ent
gro
up
Rec
reat
ion
al c
om
pu
tin
g
Res
tora
tive
co
gnit
ive
ther
apy
dir
ecte
d t
ow
ard
rem
edia
tio
n c
on
sist
ent
wit
h t
reat
men
t gr
ou
p b
ut
del
iver
ed w
ith
ou
tco
mp
ute
rs
C1
- Clie
nts
in s
ame
inp
atie
nt
reh
abili
tati
on
cen
ter
as t
reat
men
t gr
ou
pw
ho
did
no
t re
ceiv
e th
eC
AC
R in
terv
enti
on
C2
- Per
son
s w
ith
ou
t T
BI
Du
rati
on
of
inte
rven
tio
n
T -
75 m
inse
ssio
ns
14 s
essi
on
so
ver
3–9
wk
17.5
hr
tota
lC
- 60
–90
min
sess
ion
s o
ver
3–9
wee
ksM
ean
12.
7 h
rto
tal
4–6
wk
20 h
r to
tal
1 h
r/d
20 d
4 w
k20
hr
tota
l
Fo
llo
w-
up
6 m
o
No
ne
20 d
Sett
ing/
po
pu
lati
on
New
cast
le G
ener
alH
osp
ital
, Cam
bri
dge
Un
iv.,
U.K
.P
sych
olo
gist
s in
ou
tpat
ien
t cl
inic
s, s
taff
of
soci
al s
ervi
ces,
an
dsu
pp
ort
gro
up
s in
Edin
bu
rgh
so
licit
ed f
or
nam
es o
f p
eop
le w
ith
atte
nti
on
def
icit
s d
ue
tob
rain
inju
ry.
Wes
tmea
d H
osp
ital
,A
ust
ralia
Co
nse
cuti
ve r
efer
rals
to
reh
abili
tati
on
med
icin
eu
nit
ove
r 9
mo
nth
Inp
atie
nt
reh
abili
tati
on
cen
ter
St. A
nd
rew
’sH
osp
ital
, U.K
.
con
tin
ues
-
Special Article 293
Sou
rce
Gra
y (1
992)
Bat
chel
or
(198
8)
Wo
od
(198
7)
N
T -
17C
- 14
T -
17C
- 17
T -
10C
1 -
10 C2
-10
Ch
ron
icit
y
T -
79 w
eeks
(151
)C
- 84
wee
ks(1
52)
T -
72.7
day
s(6
6.5)
C -
96.3
day
s(1
04.1
)
T -
27.5
mo
nth
s (5
.8)
C1
- 36.
5m
on
ths
(15.
6)
Seve
rity
T -
8 m
ild t
om
od
erat
e, 9
seve
reC
- 8
mild
to
mo
der
ate,
6se
vere
T -
7.3
com
ad
ays
(6.3
)C
- 7.
0 co
ma
day
s (8
.7)
PT
AT
- 2.
4 m
on
ths
(0.5
)C
1 - 2
.7m
on
ths
(0.4
)A
ll re
qu
ired
full-
tim
e ca
re
Ou
tco
mes
/an
aly
sis
PA
SAT
No
. Co
rrec
t, L
on
gest
Str
ing,
an
dIn
form
atio
n P
roce
ssin
g R
ate
(IP
R)
WA
IS-R
su
bte
sts
Neu
rop
sych
olo
gica
l Bat
tery
22 T
ota
l Tes
tsA
NC
OV
AS
use
d f
or
anal
ysis
WA
IS-R
Ru
ssel
’s W
MS
Bu
sch
ke S
elec
tive
Rem
ind
ing
Tes
tT
aylo
r Fi
gure
PA
SAT
Au
stin
Maz
eA
NC
OV
As
and
t-t
ests
use
d f
or
anal
ysis
Pu
rsu
it R
oto
r, D
igit
Sym
bo
l, C
ho
ice
Rea
ctio
n T
ime,
Sim
ple
Rea
ctio
n T
ime,
Vis
ual
an
d C
ho
ice
Rea
ctio
n T
ime
for
vigi
lan
ce, a
tten
tio
n t
o t
ask,
Att
enti
on
Rat
ing
Scal
e
Res
ult
s
Tre
atm
ent
Effe
ct o
n 2
of
22 t
ests
at
po
sttr
eatm
ent
Tre
atm
ent
effe
ct o
n 6
of
22 t
ests
at
follo
w-u
pG
rou
p m
ean
s n
ot
pre
sen
ted
No
tre
atm
ent
effe
ct
Tre
atm
ent
effe
ct f
or
atte
nti
on
to
Tas
kan
d A
tten
tio
n R
atin
g Sc
ale
fro
mb
asel
ine
to f
irst
fo
llow
-up
Tre
atm
ent
effe
ct f
or
Ch
oic
e R
eact
ion
tim
e fr
om
bas
elin
e to
sec
on
d f
ollo
w-
up
.G
rou
p m
ean
s n
ot
pre
sen
ted
Leve
l
II(b
)
II(b
)
II(b
)
Tab
le 5
.C
on
tin
ued
T =
Tre
atm
ent
Gro
up
, C =
Co
ntr
ol G
rou
p. N
um
ber
s in
( )
are
sta
nd
ard
dev
iati
on
s
-
294 JOURNAL OF HEAD TRAUMA REHABILITATION/JUNE 1999T
able
6.
Stu
die
s o
f th
e re
lati
on
ship
bet
wee
n in
term
edia
te t
ests
an
d e
mp
loym
ent
(Arc
5)
Sou
rce
Gir
ard
(199
6)
Cic
ero
ne
(199
6)
Ip (
1995
)
Fab
ian
o(1
995)
Ezra
chi
(199
1)
Fras
er(1
988)
Bro
oks
(198
7)
Sett
ing/
po
pu
lati
on
Cu
rren
t an
d f
orm
er c
lien
ts o
f a
ho
spit
al-b
ased
,in
terd
isci
plin
ary
ou
tpat
ien
t T
BI
pro
gram
Ref
erra
ls t
o n
euro
psy
cho
logy
clin
ic o
f b
rain
inju
ryre
hab
ilita
tio
n p
rogr
am.
Sele
cted
on
bas
is o
f h
avin
g p
arti
cip
ated
inn
euro
reh
abili
tati
on
, hav
ing
neu
rop
sych
olo
gica
lev
alu
atio
n, a
nd
bei
ng
avai
lab
le f
or
follo
w-u
p.
Co
nse
cuti
ve r
efer
rals
fo
r re
hab
ilita
tio
n t
o b
rain
inju
ryu
nit
of
a h
osp
ital
bet
wee
n 1
988
and
199
4
Co
nse
cuti
ve r
efer
rals
to
3 p
ost
acu
te r
ehab
ilita
tio
nfa
cilit
ies
Min
imu
m le
ngt
h o
f co
ma
24 h
r, m
inim
um
ch
ron
icit
y 1
yr Co
nse
cuti
ve p
arti
cip
ants
in N
YU
Hea
d T
rau
ma
Pro
gram
ove
r 4
year
sSa
mp
le c
ho
sen
on
bas
is o
f n
ot
bei
ng
able
to
ret
urn
to
wo
rk f
or
1 ye
ar p
ost
inju
ry a
nd
will
ingn
ess
to p
arti
ci-
pat
e in
pro
gram
Co
nse
cuti
ve o
utp
atie
nt
refe
rral
s w
ho
wer
e em
plo
yed
pri
or
to in
jury
Co
nse
cuti
ve a
dm
issi
on
s to
Dep
artm
ent
of
Neu
rosu
r-ge
ry, I
nst
itu
te o
f N
euro
logi
cal S
cien
ces,
Gla
sgo
w, U
K
N
Init
ial -
152
6 m
on
th f
ollo
w-u
p -
114
12 m
on
th f
ollo
w-u
p -
69
20 70 94 59 48 134
Ch
ron
icit
y
3 ye
ars
(ran
ge6
mo
to
12
yr)
7.8
mo
(ra
nge
3–20
mo
)
3.1
yr
59 m
o (
42.6
)
34.6
5 m
o(2
7.49
)
No
t sp
ecif
ied
Ran
ged
fro
m 2
to 7
yea
rs
Seve
rity
No
t sp
ecif
ied
Mild
20%
mild
27%
mo
der
ate
53%
sev
ere
(bas
ed o
n G
CS)
Seve
re20
day
s av
erag
e le
ngt
h o
fco
ma
(20.
2)
Mo
der
ate
to s
ever
e36
.2 d
ays
in c
om
a (3
1.42
)
Ave
rage
GC
S fo
r 35
wh
ore
turn
ed t
o w
ork
= 1
3A
vera
ge B
CS
for
13 w
ho
did
no
t re
turn
to
wo
rk =
11 Co
ma
du
rati
on
≥ 6
ho
urs
,o
r P
TA
> 2
day
s, o
r su
rger
yfo
r in
trac
ran
ial h
emat
om
aco
nti
nu
es
-
Special Article 295T
able
6.
Co
nti
nu
ed
con
tin
ues
Sou
rce
Naj
enso
n(1
980)
Sett
ing/
po
pu
lati
on
Co
nse
cuti
ve d
isch
arge
s fr
om
Lo
wen
stei
n R
ehab
ilita
tio
nH
osp
ital
, Ra’
anan
a, a
nd
Tel
Avi
v U
niv
ersi
ty S
cho
ol o
fM
edic
ine,
Isr
ael f
rom
1/1
1/74
to
1/4
/7
N
147
Ch
ron
icit
y
No
t sp
ecif
ied
Seve
rity
Co
ma
du
rati
on
ran
ged
fro
m ≤
1 d
ay (
n =
21)
to
≥30
day
s (n
= 2
1)
Sou
rce
Gir
ard
(199
6)
Cic
ero
ne
(199
6)
Inte
rmed
iate
tes
ts
28 t
ests
an
d s
ub
test
s:Sy
mb
ol D
igit
Wri
tten
an
d O
ral
Hal
stea
d-R
eita
n T
rails
A &
BW
AIS
-R V
erb
al s
ub
test
s (6
)P
erfo
rman
ce s
ub
test
s (5
)W
MS-
R V
erb
al M
emo
ry, V
isu
alM
emo
ry, G
ener
al M
emo
ry,
Att
enti
on
/Co
nce
ntr
atio
n,
Del
ayed
Rec
all
Wis
con
sin
Car
d S
ort
ing
Tes
tT
he
Bo
okl
et C
ateg
ory
Tes
tW
ide
Ran
ge A
chie
vem
ent
Tes
t(W
RA
T-R
)
13 n
euro
psy
cho
logi
cal t
ests
Dig
it S
pan
Fo
rwar
d &
Bac
kwar
d T
rails
A &
BC
on
tin
uo
us
Per
form
ance
Tes
to
f A
tten
tio
nP
ASA
TLo
gica
l Mem
ory
I &
II
CV
LTR
ey C
FT I
mm
edia
te a
nd
Del
ayed
Rec
all
WC
ST P
erse
vera
tio
nC
ateg
ory
Tes
tM
azes
Ver
bal
Flu
ency
Hea
lth
/em
plo
ym
ent
ou
tco
mes
McA
ule
y O
utc
om
e Sc
ale
Mea
sure
s p
rod
uct
ive
ou
tco
me
inh
om
e, s
cho
ol,
wo
rk.
Scal
e ra
nge
s fr
om
1 (
no
tp
rod
uct
ive)
to
6 (
mo
re p
rod
uc-
tive
th
an p
rem
orb
id le
vel)
Go
od
Ou
tco
me
Gro
up
(G
O):
Clie
nts
wh
o r
esu
med
res
po
nsi
bili
-ti
es e
qu
ival
ent
to p
rem
orb
idst
atu
s, o
r o
ther
, les
s d
eman
din
g,p
rod
uct
ive
acti
vity
(n
= 1
0).
Po
or
Ou
tco
me
Gro
up
(P
O):
Clie
nts
un
able
to
res
um
ep
rem
orb
id le
vel o
f ac
tivi
ty/
resp
on
sib
ility
(n
= 1
0)
Des
ign
/an
aly
sis
Pro
spec
tive
cas
e se
ries
AN
OV
As
and
Ste
pw
ise
Mu
ltip
le R
egre
ssio
n u
sed
for
anal
ysis
Ret
rosp
ecti
veT
-tes
ts
Leve
l
III
III
Res
ult
s
67%
of
sam
ple
was
pro
du
ctiv
eat
fo
llow
-up
, 33%
no
t p
rod
uc-
tive
.6
sco
res
sign
ific
antl
y re
late
d t
oo
utc
om
e at
fir
st f
ollo
w-u
p, 8
at
seco
nd
Wit
h r
egre
ssio
n a
nal
ysis
, 9 t
est
sco
res
(WA
IS-R
Blo
ck D
esig
n,
Dig
it S
ymb
ol,
Pic
ture
Co
mp
le-
tio
n, a
nd
Fu
ll Sc
ale
IQ; S
ymb
ol
Dig
it W
ritt
en a
nd
Ora
l; T
rails
B;
WA
IS-R
Ari
thm
etic
an
d W
RA
T-R
Ari
thm
etic
) an
d 3
dem
ogr
aph
icch
arac
teri
stic
s (m
ech
anis
m o
fin
jury
, in
sura
nce
fu
nd
ing,
an
dp
rem
orb
id s
ub
stan
ce a
bu
se)
acco
un
ted
fo
r 30
% o
f th
eva
rian
ce in
ou
tco
me
GO
clie
nts
had
sig
nif
ican
tim
pro
vem
ent
on
6 o
f 13
neu
rop
sych
olo
gica
l tes
tsP
O c
lien
ts h
ad s
ign
ific
ant
imp
rove
men
t o
n 1
neu
rop
sy-
cho
logi
cal t
est
-
296 JOURNAL OF HEAD TRAUMA REHABILITATION/JUNE 1999T
able
6.
Co
nti
nu
ed
con
tin
ues
Sou
rce
Ip (
1995
)
Fab
ian
o(1
995)
Inte
rmed
iate
tes
ts
16 n
euro
psy
cho
logi
cal t
ests
:W
AIS
-R P
erfo
rman
ce I
QV
erb
al I
Q, F
ull
Scal
e IQ
WM
S-R
Del
ayed
Rec
all
Att
enti
on
/Co
nce
ntr
atio
nG
ener
al M
emo
ry I
nd
exV
erb
al M
emo
ry I
nd
exV
isu
al M
emo
ry I
nd
exH
alst
ead
-Rei
tan
Tra
ils A
& B
Tap
pin
g d
om
inan
t &
no
nd
om
inan
tG
roo
ved
Peg
bo
ard
Tes
td
om
inan
t &
no
nd
om
inan
t
8 su
bte
sts
of
WA
IS-R
Pic
ture
Arr
ange
men
tFu
ll Sc
ale
IQP
erfo
rman
ce I
QSi
mila
riti
esB
lock
Des
ign
Dig
it S
ymb
ol
Pre
dic
tio
n P
oin
tsV
erb
al I
QLe
ngt
h o
f C
om
a
Hea
lth
/em
plo
ym
ent
ou
tco
mes
Dic
ho
tom
ou
s m
easu
res
of
retu
rnto
wo
rk o
r sc
ho
ol (
RT
W/S
),ei
ther
fu
ll o
r p
art
tim
e, f
ollo
win
gh
osp
ital
dis
char
ge
Full-
tim
e em
plo
ymen
t (n
= 2
0)P
art-
tim
e em
plo
ymen
t (n
= 1
5)Su
cces
sfu
l co
llege
att
end
ance
(n
= 8
)Su
pp
ort
ed/s
hel
tere
d e
mp
loym
ent
(n =
11)
Un
emp
loye
d (
n =
40)
Des
ign
/an
aly
sis
Ret
rosp
ecti
ve e
valu
atio
no
f m
edic
al c
har
ts a
nd
follo
w-u
p p
ho
ne
calls
to
ob
tain
RT
W/S
dat
at-
test
s u
sed
fo
rco
nti
nu
ou
s sc
ales
chi-s
qu
are
use
d f
or
no
min
al s
cale
sW
ilco
xo
n r
ank
sum
tes
tu
sed
fo
r o
rdin
al s
cale
slo
gist
ic r
egre
ssio
n u
sed
to e
valu
ate
asso
ciat
ion
of
neu
rop
sych
olo
gica
lte
sts
wit
h R
TW
/S
Ret
rosp
ecti
ve e
valu
atio
no
f m
edic
al c
har
ts a
nd
follo
w-u
p p
ho
ne
calls
to
ob
tain
cu
rren
t em
plo
y-m
ent
dat
aD
iscr
imin
ant
anal
ysis
use
d t
o s
pec
ify
stro
nge
stp
red
icto
rs o
f em
plo
y-m
ent
Leve
l
III
III
Res
ult
s
At
follo
w-u
p, 4
2% h
ad r
etu
rned
to w
ork
/sch
oo
l, 58
% h
ad n
ot
5 o
f 16
neu
rop
sych
olo
gica
l tes
tssi
gnif
ican
tly
rela
ted
to
RT
W/S
At
follo
w-u
p, 8
su
bte
sts
pre
dic
ted
em
plo
ymen
t st
atu
s as
follo
ws:
Full-
tim
e em
plo
yed
: 62%
accu
rate
Par
t-ti
me
emp
loye
d: 5
8%ac
cura
teN
ot
com
pet
itiv
ely
emp
loye
d:
67%
acc
ura
te
-
Special Article 297T
able
6.
Co
nti
nu
ed
con
tin
ues
Sou
rce
Ezra
chi
(199
1)
Fras
er(1
988)
Inte
rmed
iate
tes
ts
38 n
euro
psy
cho
logi
cal s
ub
test
sfr
om
7 in
stru
men
ts:
Ori
enta
tio
n R
emed
ial M
od
ule
(OR
M)
Pu
rdu
e P
egb
oar
dV
isu
al m
easu
res
fro
m R
usk
Inst
itu
te o
f R
ehab
ilita
tio
nM
edic
ine
(RIR
M)
Aca
dem
ic m
easu
res
fro
m M
AT
and
WR
AT
WA
IS-R
Hig
her
ord
er v
erb
al a
nd
con
cep
tual
ski
lls f
rom
RIR
M19
tes
ts o
f fu
nct
ion
al b
ehav
ior
-B
ehav
iora
l Co
mp
eten
ceIn
dex
(B
CI)
9 n
euro
psy
cho
logi
cal t
ests
:T
actu
al P
erfo
rman
ce T
est
(TP
T),
Cat
ego
ry T
est,
Tra
ils B
,H
alst
ead
’s I
mp
airm
ent
Ind
ex,
WA
IS I
Q (
Ver
bal
, Per
for-
man
ce, F
ull
Scal
e), W
AIS
Dig
itSy
mb
ol,
and
Nam
e W
riti
ng
Pro
ced
ure
s
Hea
lth
/em
plo
ym
ent
ou
tco
mes
Vo
cati
on
al S
tatu
s (V
STA
T)
6 m
oaf
ter
com
ple
tio
n o
f p
rogr
am,
rate
d o
n a
10-
po
int
scal
