Wilson, 2008 PDF

ANRV339-CP04-06 ARI 22 February 2008 16:40
Neuropsychological
Rehabilitation
Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org
Barbara A. Wilson
by University of Utah - Marriot Library on 05/05/13. For personal use only.
Cognition and Brain Sciences Unit, Medical Research Council, Addenbrookes

Hospital, Cambridge CB2 2QQ, United Kingdom;
email: barbara.wilson@mrc-cbu.cam.ac.uk
Annu. Rev. Clin. Psychol. 2008. 4:14162 Key Words

First published online as a Review in Advance on brain injury, cognition, emotion, psychosocial, holistic programs
December 11, 2007
The Annual Review of Clinical Psychology is online Abstract

at http://clinpsy.annualreviews.org
Neuropsychological rehabilitation (NR) is concerned with the
This articles doi: amelioration of cognitive, emotional, psychosocial, and behavioral
10.1146/annurev.clinpsy.4.022007.141212
decits caused by an insult to the brain. Major changes in NR have
Copyright c 2008 by Annual Reviews. occurred over the past decade or so. NR is now mostly centered
All rights reserved
on a goal-planning approach in a partnership of survivors of brain
1548-5943/08/0427-0141$20.00 injury, their families, and professional staff who negotiate and select
goals to be achieved. There is widespread recognition that cogni-
tion, emotion, and psychosocial functioning are interlinked, and all
should be targeted in rehabilitation. This is the basis of the holistic
approach. Technology is increasingly used to compensate for cogni-
tive decits, and some technological aids are discussed. Evidence for
effective treatment of cognitive, emotional, and psychosocial dif-
culties is presented, models that have been most inuential in NR
are described, and the review concludes with guidelines for good
practice.
141
several cognitive problems such as poor at-

Contents tention, poor memory, and planning and or-
ganizational difculties, together with some
INTRODUCTION: WHAT IS
emotional problems such as anxiety, depres-
NEUROPSYCHOLOGICAL
sion, or in some cases, post-traumatic stress
REHABILITATION? . . . . . . . . . . . . 142
disorder. The patient may exhibit behavior
HOW HAS
problems such as poor self-control or anger
NEUROPSYCHOLOGICAL
outbursts and may experience some subtle
REHABILITATION CHANGED
motor difculties leading to reduced stamina
IN RECENT YEARS? . . . . . . . . . . . 144
and unsteady gait, as well as problems con-
Goal Setting to Plan
nected with social skills and relationships. In
Rehabilitation . . . . . . . . . . . . . . . . . 144
addition, the patients family members may be
Cognitive, Emotional, and

unable to comprehend what has happened to
Psychosocial Decits are
the person they once felt they knew and un-

Interlinked . . . . . . . . . . . . . . . . . . . . 145
derstood, and the patient will probably strug-
Increasing Use of Technology in
gle with issues connected with the continu-
Neuropsychological
ation of work or education. Tables 1 and 2
Rehabilitation . . . . . . . . . . . . . . . . . 146
show the main patient groups seen by neu-
Rehabilitation Needs a Broad
ropsychologists working in rehabilitation and
Theoretical Base . . . . . . . . . . . . . . 147
the main problems these patients face.
COGNITIVE ASPECTS OF
We can dene neuropsychology as the
NEUROPSYCHOLOGICAL
study of the relationship between brain
REHABILITATION . . . . . . . . . . . . . 147
and behavior. One of the major differences
EMOTIONAL ASPECTS OF
between academic neuropsychologists en-
NEUROPSYCHOLOGICAL
gaged in rehabilitation research and clini-
REHABILITATION . . . . . . . . . . . . . 149
cal neuropsychologists working in rehabili-
PSYCHOSOCIAL ASPECTS OF
tation centers is the manner in which the
NEUROPSYCHOLOGICAL
needs of brain-injured people are determined.
REHABILITATION . . . . . . . . . . . . . 151
Academic neuropsychologists believe that de-
MODELS AND THEORETICAL
tailed assessments informed by theoretical
APPROACHES
models can highlight areas that require re-
CONTRIBUTING TO
habilitation. Thus, testing of different com-
NEUROPSYCHOLOGICAL
ponents contained in a model of language
REHABILITATION . . . . . . . . . . . . . 153
can identify a particular decit as the area
GUIDELINES FOR GOOD
to work on in rehabilitation (Caramazza &
PRACTICE IN
NEUROPSYCHOLOGICAL
REHABILITATION . . . . . . . . . . . . . 154 Table 1 Main patient groups seen by
SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . 156 neuropsychologists working in rehabilitation
Main groups seen for rehabilitation
Traumatic brain injury
Stroke (cerebrovascular accident; CVA)
INTRODUCTION: WHAT IS
Infections of the brain (e.g., encephalitis)
NEUROPSYCHOLOGICAL
Hypoxic brain damage
REHABILITATION? Other groups sometimes seen
Most people receiving rehabilitation for the Progressive conditions
consequences of brain injury have both cog- (e.g., Alzheimers disease, multiple sclerosis)
nitive and noncognitive problems. A typ- Cerebral tumors
ical patient in a rehabilitation center has Epilepsy (idiopathic)
142 Wilson
Hillis 1993). Clinical neuropsychologists, on Table 2 Problems faced by survivors of brain injury
the other hand, are less likely to determine A. Problems faced by B. Typical cognitive problems
rehabilitation needs through theoretically in- survivors of brain injury
formed models and are more likely to target Motor Memory
real-life problems identied by patients and Sensory Attention
their families. As discussed below, both ap- Cognitive Communication
Behavioral Planning

proaches play a part in the rehabilitation of
Social Organization

individuals who have sustained an insult to the
Emotional Reasoning
brain.
Pain Perception
A good denition of rehabilitation is pro-
vided by McLellan (1991). He suggests that Fatigue, etc.
C. Typical emotional and
Spatial awareness
D. Typical behavior problems
rehabilitation is a two-way, interactive process
psycho-social problems
whereby people who are disabled by injury or
Anxiety Temper outbursts

disease work together with professional staff, Depression Shouting

relatives, and members of the wider commu- Anger Swearing
nity to achieve their optimum physical, psy- Fear Physical aggression
chological, social, and vocational well-being Social isolation Disinhibition
Grief Poor self control

(McLellan 1991). Using McLellans denition
Poor self-esteem Refusal to cooperate, etc.

as a guide, we can dene cognitive rehabilita-
Lack of condence
tion as a process whereby people with brain
injury work together with professional staff
and others to remediate or alleviate cognitive involved. The focus of treatment is on im-
decits arising from a neurological insult. Al- proving aspects of everyday life and, as
though cognitive rehabilitation is often a ma- Ylvisaker & Feeney (2000, p. 13) say, reha-
jor part of the work of clinical neuropsychol- bilitation needs to involve personally mean-
ogists, they are also increasingly involved in ingful themes, activities, settings and inter-
a wider range of issues. Thus, it could be ar- actions. An example of this is provided by
gued, neuropsychological rehabilitation (NR) Wilson et al. (2002), who describe the treat-
is broader than cognitive rehabilitation, as it ment of a man with both a stroke and a head
is concerned with the amelioration of cogni- injury. One of this mans goals was to y his
tive, emotional, psychosocial, and behavioral model helicopter againan important goal
decits caused by an insult to the brain. for him that would never have been consid-
McLellan (1991) believed that rehabilita- ered 30 years ago. Tate et al. (2003), in descrip-
tion, unlike surgery or drugs, is not something tions of their service for people with brain in-
that is done to or given to individuals. Instead, jury, also imply that partnership is important,
the disabled person is part of a two-way inter- and Clare (2007) describes how people with
active process. This view reected a growing dementia are encouraged to select their own
NR:
change in rehabilitation. For many years, per- targets for treatments. This is a much health- neuropsychological
sons with a disability were told what to ex- ier state of affairs than providing clients with rehabilitation
pect in and from rehabilitation; the rehabili- experimental or articial material on which Goal: the state (or
tation staff determined what areas to work on, to work. Motivation is likely to be increased change in state) that
what goals to set, and what was and was not because all those involved are working on an intervention or
achievable. Sometime in the 1980s, the phi- real-life problems, which also prevents gen- course of action
losophy began to change, at least in some cen- eralization difculties. Because the ultimate intends to achieve
ters, so that in many rehabilitation programs goal of rehabilitation is to enable people with Stroke: a brain
today, clients and families are asked about disabilities to function as adequately as pos- injury caused by a
sudden interruption
their expectations, and rehabilitation goals are sible in their own, most appropriate, envi- of blood ow
discussed and negotiated between all parties ronments (Ben-Yishay 1996), real-life issues
www.annualreviews.org Neuropsychological Rehabilitation 143

should be at the forefront of rehabilitation worth reading today for the insights they of-
programs. fer. So too is Zangwills (1947) paper in which
he discusses, among other things, the princi-
Acquired brain
injury: a ples of re-education and refers to three main
HOW HAS approaches to rehabilitation: compensation,
nondegenerative
injury to the brain NEUROPSYCHOLOGICAL substitution, and direct retraining.
that has occurred REHABILITATION CHANGED Despite these similarities in concepts,
since birth IN RECENT YEARS? there have been major changes, four of which
In some ways, NR today is similar to that pro- are addressed in this section. The rst is
vided to soldiers in Germany in World War I goal setting to plan rehabilitation programs;
and in Russia and the United Kingdom in second is a growing recognition that cogni-
World War II. In their historical review of tive, emotional, and psychosocial difculties
NR in Germany, Poser et al. (1996) remind should all be addressed in rehabilitation; third
us, Many of the rehabilitation procedures de- is the increasing use of technology to compen-
veloped in special military hospitals during sate for cognitive difculties; and fourth is a
World War I are still in use today in mod- realization that NR requires a broad theoret-
ern rehabilitationat least to some extent ical base or indeed a number of theoretical
(p. 259). The vocational rehabilitation de- bases.
scribed by Poppelreuter in 1917 (translated
by Zihl & Weiskrantz 1991) is not unlike
that provided today. In addition, Poppelreuter Goal Setting to Plan Rehabilitation
(1917) argued for an interdisciplinary ap- The Concise Oxford Dictionary (1999) denes a
proach between psychology, neurology, and goal as an object of effort or a destination.
psychiatry, and in a paper published in 1918, In a discussion of rehabilitation goals, Wade
he emphasized the importance of the patients (1999) suggests, A goal is the state or change
own insight into the effects of disabilities in state that is hoped or intended for an inter-
and treatment. Goldstein (1942), also writing vention or course of action to achieve. When
about the First World War, stressed the im- we negotiate goals with our patients, their
portance of cognitive and personality decits families, and the rehabilitation team, we are
following brain injury and touched upon what looking for something that the client/patient
today would be called cognitive rehabilita- both will do and wants to do; this should
tion strategies (Prigatano 2005). In 1918, be something that reects the longer-term
Goldstein (quoted by Poser et al. 1996) was targets and indeed the steps toward them.
concerned with decisions as to whether to try Goals are important regulators and motiva-
to restore lost functioning or to compensate tors of human performance and action (Austin
for lost or impaired functions, and this debate & Vancouver 1996) and a desired outcome by
is still ongoing today. which progress can be measured.
During the Second World War, Luria in Goal setting has been used in rehabilita-
the (then) Soviet Union and Zangwill in the tion for a number of years with various diag-
United Kingdom were both working with nostic groups including people with cerebral
brain-injured soldiers. One important princi- palsy, spinal injuries, developmental learn-
ple, stressed by both Luria and Zangwill, was ing difculties, and acquired brain injury
that of functional adaptation, whereby an in- (McMillan & Sparkes 1999). Because goal
tact skill is used to compensate for a damaged planning is simple, focuses on practical every-
one. Goldstein was also committed to a sim- day problems, is tailored to individual needs,
ilar concept. Lurias publications of 1963 and and avoids the articial distinction between
1970 and his book with Naydin, Tsvetkova, many outcome measures and real-life func-
and Vinarskaya (Luria et al. 1969) are well tioning, it is used increasingly in rehabilitation
144 Wilson
programs. This approach provides direction sidered helpful, the client and the family
for rehabilitation, identies priorities for in- members involved are given a copy of the
tervention, evaluates progress, breaks rehabil- short-term goals to be achieved by the fol-
SMART: acronym
itation down into achievable steps, promotes lowing week or fortnight. Progress is reviewed applied to goals that
team working, and results in better outcomes every one or two weeks in a 30-minute meet- are specic,
(Nair & Wade 2003). ing with the rehabilitation team. Additional measurable,
McMillan & Sparkes (1999) proposed sev- short-term goals are set and, if necessary, addi- achievable, realistic,
and timely
eral principles involved in the goal-planning tional long-term goals are added. If any long-
approach. First, the patient should be en- or short-term goals are not achieved or are
gaged in setting his or her goals. Second, the only partially achieved, the reasons for this
goals set should be reasonable and client cen- are recorded. Failure to achieve a goal is at-
tered. Third, patients behavior when a goal tributed to reasons in one of four main cate-
is reached should be described. Fourth, the gories: (a) client/patient or carer (e.g., client
method to be used in achieving the goals unwell); (b) staff member (e.g., staff member
should be dened in such a manner that any- absent through illness); (c) internal admin-
one reading the plan would know what to istration (e.g., transport failed to arrive); or
do. In addition, goals should be specic and (d ) external administration (e.g., fund-
measurable and have a denite deadline. In ing withdrawn by rehabilitation purchaser)
most rehabilitation centers, long-term goals (McMillan & Sparkes 1999).
are those that the patient or client is expected Wilson et al. (2002) describe a success-
to achieve by the time of discharge from the ful goal-planning approach for a man who
program, whereas short-term goals are the sustained both a head injury and a stroke.
steps set each week or fortnight in order to Manly (2003) discusses the targeting of func-
achieve the long-term goals. An acronym that tional goals in treatment. Williams (2003) says
summarizes the main principles is SMART: goal-setting procedures are one of the main
Goals should be specic, measurable, achiev- components of programs dealing with cog-
able, realistic, and timely. nitive and emotional disorders. Most British
The process of goal planning typically in- rehabilitation centers follow a goal-planning
volves the allocation of a chairperson who approach (Sopena et al. 2007). Further sup-
conducts all meetings, limits meetings to the port comes from Kendall et al. (2006), whose
agreed upon time, claries for team members meta-analysis suggests, [D]irect patient in-
the aims of admission and the length of stay, volvement in neurorehabilitation goal setting
actively participates as a member of the re- results in signicant improvements in reach-
habilitation team, and ensures documentation ing and maintaining those goals (p. 465).
is complete. The chairperson should also en-
sure good communication between all rele-
vant parties, attend case conferences, coordi- Cognitive, Emotional, and
nate reports, encourage clients, relatives, and Psychosocial Deficits are Interlinked
staff members to be realistic, and make clear Although cognitive decits are, perhaps, the
arguments to the relevant people for changes major focus of NR, there is a growing aware-
to the discharge date. Following a detailed as- ness that the emotional and psychosocial
sessment period, the rst goal-planning meet- consequences of brain injury need to be
ing is held, a problem list is drawn up, and addressed in rehabilitation programs. Fur-
potential long-term goals are identied. The thermore, it is not always easy to separate cog-
goals are then discussed with the client and nitive, emotional, and psychosocial problems
the family, and the nal goals are negoti- from one another. Not only does emotion af-
ated and agreed upon. Both long-term and fect how we think and how we behave, but also
short-term goals are documented. If it is con- cognitive decits can be exacerbated by

emotional distress and can cause apparent be- Increasing Use of Technology in
havior problems. Psychosocial difculties can Neuropsychological Rehabilitation
also result in increased emotional and behav-
The increasing use of sophisticated technol-
ioral problems, and anxiety can reduce the ef-
ogy such as positron emission tomography
fectiveness of intervention programs. There
and functional magnetic resonance imaging is
is clearly an interaction between all these as-
enhancing our understanding of brain dam-
pects of human functioning, as recognized by
age (see, for example, Coleman et al. 2007).
those who argue for the holistic approach to
To what extent these methodologies can im-
brain injury rehabilitation. This approach, pi-
prove our rehabilitation programs remains to
oneered by Diller (1976), Ben-Yishay (1978),
be seen. What is clear is the value of technol-
and Prigatano (1986), is founded on the be-
ogy for reducing everyday problems of people
lief that the cognitive, psychiatric, and func-
with neurological damage. One of the major

tional aspects of brain injury should not be
themes in rehabilitation is the adaptation of
separated from emotions, feelings, and self-

technology for the benet of people with cog-
esteem. Holistic programs include group and
nitive impairments. Computers, for example,
individual therapy in which patients are (a) en-
may be used as cognitive prosthetics, as com-
couraged to be more aware of their strengths
pensatory devices, as assessment tools, or as a
and weaknesses, (b) helped to understand and
means for training. Given the current expan-
accept these, (c) given strategies to compen-
sion in information technology, this is likely
sate for cognitive difculties, and (d ) offered
to be an area of growth and increasing impor-
vocational guidance and support. Prigatano
tance in NR in the next decade. One of the
(1994) suggests that such programs appear to
earliest papers referring to the use an elec-
result in less emotional distress, increased self-
tronic aid with a person with brain damage
esteem, and greater productivity. Prigatano
was that by Kurlychek (1983). This was im-
(1999, 2005) and Sohlberg & Mateer (2001)
portant because the aid assisted in tackling a
describe the importance of dealing with the
real-life problem, which was to teach a man
cognitive, emotional, and psychosocial con-
to check his timetable. In 1986, Glisky and
sequences of brain injury. Wilson et al. (2000)
colleagues taught memory-impaired people
present a British holistic program, based
computer terminology; as a result, one of their
on the principles of Ben-Yishay (1978) and
participants was able to nd employment as
Prigatano (1986), that is followed at the Oliver
a computer operator. Kirsch and colleagues
Zangwill Center for Neuropsychological Re-
(1987) designed an interactive task guidance
habilitation in Ely, Cambridgeshire. Although
system to assist brain-injured people in per-
these programs appear to be expensive in the
forming functional tasks. Since then, reports
short term, they are probably cost-effective
of successful use of technology with brain-
in the long term (see Prigatano & Pliskin
injured people have appeared in many papers.
2002).
Boake (2003) includes discussion of some of
Williams (2003), who is concerned with
the early computer-based cognitive rehabili-
the rehabilitation of emotional disorders fol-
tation programs, and Wilson et al. (2001) de-
lowing brain injury, suggests that survivors are
scribe a randomized control crossover design
at particular risk of developing mood disor-
that demonstrates it is possible to reduce the
ders. He argues that this is one of the key
everyday problems of neurologically impaired
areas for development in neurological ser-
people with memory and/or planning difcul-
vices. Alderman (2003) targets behavior dis-
ties by using a paging system. The reminders
orders in work with some of the most severely
do not always have to be specic. Based on
disturbed brain-injured people in the United
work by Robertson et al. (1997) and Manly
Kingdom.
et al. (1999), Fish et al. (2007) found that
146 Wilson
sending general reminders to stop, think, certainly one of the most carefully worked
organize and plan led to improvement in a out and clinically useful models of emotion
prospective memory task. These content-free at this time. The neurobehavioral model of
Virtual reality
reminders work for people whose prospec- Wood (1987, 1990) is one that has inuenced (VR): a technology
tive memory problems result from execu- Aldermans work in the treatment of brain- that allows a user to
tive decits such as poor planning or divided injured people with severe behavior problems interact with a
attention difculties. For those with severe (Alderman 2003). In a survey of British clinical computer-simulated
environment
memory problems, however, a specic re- neuropsychologists working in brain injury
minder would be required. rehabilitation, 57 different models were re- CBT: cognitive
behavior therapy
Virtual reality (VR) represents another ported as inuencing clinical practice (Sopena
technology that will likely play an increasing et al. 2007). Ethical and effective NR requires Traumatic brain
injury (TBI): a
role in rehabilitation. VR can be used to sim- a synthesis and integration of several frame-
sudden trauma
ulate real-life situations and thus be bene- works, theories, and methodologies to achieve causing damage to
cial for both assessment and treatment. Rose its aims and ensure the best clinical practice. the brain (also called
et al. (2005) provide a review of the way VR head injury)
has been used in brain injury rehabilitation;
in addition, they discuss the use of VR for the COGNITIVE ASPECTS OF
assessment and treatment of memory prob- NEUROPSYCHOLOGICAL
lems, executive decits, visuo-spatial difcul- REHABILITATION
ties, and unilateral neglect. It is worth restating that it is not easy
to separate the cognitive, emotional, and
psychosocial consequences of brain injury.
Rehabilitation Needs a Broad However, because many of the studies in
Theoretical Base the literature report these three components
People with brain injury are likely to face separately, I examine them individually. Un-
multiple problems, including cognitive, so- less the brain damage is very mild, cognitive
cial, emotional, and behavioral, and no one decits are almost invariably found in sur-
model or group of models is sufcient to deal vivors of an insult to the brain. Problems with
with all these issues. In order to improve cog- memory, attention, executive functioning,
nitive, social, emotional, and behavioral func- and speed of information processing are the
tioning in the everyday life of these indi- most typical difculties faced by those who
viduals, we should not be constrained by a have sustained traumatic brain injury (TBI).
single theoretical framework. Of the many For survivors of stroke, language problems
theories that affect rehabilitation, four are are common after left hemisphere damage,
perhaps of particular importance, namely the- and unilateral neglect is seen frequently
ories of cognitive functioning, emotion, be- after right hemisphere damage. Numerous
havior, and learning. Consideration should studies have been published on the efcacy of
also be given to theories of assessment, recov- cognitive rehabilitation, ranging from single-
ery, and compensation. Wilson (2002) argues case experimental designs to randomized
for a broad-based model and provides a ten- controlled trials (RCTs).
tative comprehensive model of rehabilitation. Chesnut et al. (1999) traced 2536 abstracts
Boake (2003) describes the different method- from articles on rehabilitation to nd answers
ologies that inuenced some of the historical to ve questions, one of which was concerned
gures in the eld. Manly (2003) refers to nu- with cognitive rehabilitation. This particular
merous theories of attention that have guided report was based on 363 articles, of which
treatment approaches to this difcult area. 114 related to cognitive rehabilitation. The
Williams (2003) is particularly inuenced by authors asked specically, Does the applica-
cognitive behavior therapy (CBT), which is tion of compensatory rehabilitation enhance

outcomes for people who sustain TBI? Of is self-employed and completely independent
the 114 potential articles, only 32 reached the thanks largely to excellent use of compen-
nal selection to evaluate effectiveness; the re- satory strategies. By most standards of those
maining 82 articles were excluded for various involved in rehabilitation, these outcomes are
reasons, such as because they were review ar- very good indeed, yet if standardized tests had
ticles that were purely descriptive, reports on been used as measures of success, JC would
studies in which there were fewer than ve have failed dismally.
subjects, and so on. Of the 32 selected for eval- Some studies address real-life functional
uation, 11 were RCTs, with 5 measuring rele- issues. For example, Wilson et al. (2001) re-
vant health outcomes and 6 measuring inter- ported a randomized control study to evaluate
mediate outcomes. The authors of the report a paging system in which memory-impaired
concluded, along with the small size of the patients were randomly allocated to the pager
studies and the narrow range of interventions or to a waiting list. Patients and their families
studied, the lack of information about the rep- identied real-life problems involving tasks
resentativeness of the included patients makes such as taking medication, feeding the dog,
it difcult to apply the ndings of these studies and collecting children from school. In the
to cognitive rehabilitation practice generally baseline period, these behaviors were mon-
(p. 55). In other words, the RCTs did not re- itored and there was no difference between
veal much about the effectiveness of cognitive the two groups. Those allocated to the pag-
rehabilitation in any general sense. ing condition then received their pagers and
The cognitive rehabilitation section of the the same behaviors were monitored as be-
report was published separately (Carney et al. fore. The achievement of the target behav-
1999). The authors state that although the iors signicantly improved, whereas those on
desired outcome of cognitive rehabilitation the waiting list experienced no change. The
is improvement in daily function, many of pagers were then returned and given to the
the outcome measures are intermediate mea- people who had been on the waiting list. This
sures rather than health outcomes. By in- group then improved signicantly. Those who
termediate measures, the authors mean test had returned their pagers dropped back a lit-
scores (123 tests of cognition were described tle but were still better than they had been at
in the studies). The question was posed as to baseline. This suggested that some learning
whether improvements on test scores predict of the target behaviors had taken place during
improvement in real-life function. The au- the pager phase.
thors concluded that although there appeared Tackling real-life targets and individualiz-
to be some relationship between intermedi- ing programs within a specied framework
ate measures and employment, the associa- isor should bethe way forward in cog-
tion was not strong. One could argue that the nitive rehabilitation. Clare and colleagues
use of test scores irrespective of whether they (Clare et al. 1999, 2000, 2001) applied this
are intermediate or direct is not a good way principle to people with Alzheimers disease.
to evaluate rehabilitation. The ultimate goal Patients and families selected the target be-
of rehabilitation is to enable people with dis- haviors they wanted to achieve and a way was
abilities to function as adequately as possible found to teach new information. The main
in their most appropriate environment, so in- strategies used in this series of studies were
formation on changes in scores on the Wech- errorless learning and spaced retrieval.
sler scales or any other standardized test will Cicerone and colleagues (2000, 2005) have
not yield the required information. For ex- carried out major investigations into the ef-
ample, JC, a densely amnesic patient (Wilson cacy of cognitive rehabilitation. In their 2005
1999), has shown no improvement on stan- paper, they used search engines to locate cog-
dardized tests over a 10-year period, yet he nitive rehabilitation studies and identied 47
148 Wilson
studies that fullled certain inclusion crite- community-living survivors of TBI experi-
ria. They looked at several cognitive domains enced PTSD.
including attention difculties, visuo-spatial Gainotti (1993) distinguishes three main
decits, apraxia, language and communication factors causing emotional and psychosocial
problems, memory decits, executive func- problems after brain injury: those result-
tioning, problem solving, and awareness. On ing from neurological factors, those due to
the issue of retraining versus compensation, psychological or psychodynamic factors, and
they found that retraining was effective for those due to psychosocial factors. An exam-
some cognitive functions (for example, lan- ple of a neurological factor is an individual
guage), whereas compensation was necessary with brain stem damage leading to the so-
for others (such as memory decits). Their called catastrophic reaction, in which swings
overall conclusion was, There is now a sub- from tears to laughter may follow in rapid suc-
stantial body of evidence demonstrating that cession. Anosognosia, or lack of awareness of

patients with TBI or stroke benet from cog- ones decits, is also frequently due to organic
nitive rehabilitation (Cicerone et al. 2005, impairment. An important book on the topic
p. 1689). These authors also state, Future re- of unawareness (Prigatano & Schacter 1991)
search should move beyond the simple ques- posits several rationales for the existence of
tion of whether cognitive rehabilitation is anosognosia. Gainotti (1993) also addresses
effective, and examine the therapy factors unawareness in detail, and Clare & Halligan
and patient characteristics that optimize the (2006) characterize some of the key clini-
clinical outcomes of cognitive rehabilitation cal issues concerned with assessing and man-
(p. 1681). Halligan & Wade (2005) provide a aging pathologies of subjective or conscious
summary of much of the work on the effec- awareness.
tiveness of rehabilitation for cognitive decits. The second factor identied in Gainottis
(1993) three-part classication, that is, emo-
tional problems that are due to psychological
EMOTIONAL ASPECTS OF or psychodynamic causes, includes personal
NEUROPSYCHOLOGICAL attitudes toward the disability. An example is
REHABILITATION someone with an acquired dyslexia and con-
The management and remediation of emo- sequent loss of self-esteem together with de-
tional consequences of brain injury have be- pression because of an inability to read. De-
come increasingly important in recent years. nial is also thought to be relevant to some
Prigatano (1999) suggests that rehabilitation cases of this second type of emotional disor-
is likely to fail if clinicians do not deal with der. At some level, patients are aware of their
the emotional issues. Consequently, an under- disabilities but are unable to accept them. Be-
standing of theories and models of emotion cause denial can occur in conditions without
is crucial to successful rehabilitation. Social any damage to the brain, there must be (at
isolation, anxiety, and depression are com- least in some cases) nonorganic reasons for it
mon in survivors of brain injury. Kopelman & (Gainotti 1993). PTSD also ts into this clas-
Crawford (1996) found that 40% of 200 con- sication. Fear of what might happen in the
secutive referrals to a memory clinic were suf- future, panic because one cannot remember
fering from clinical depression. Bowen et al. what has happened in the past few minutes,
(1998) found that 38% of survivors of TBI grief at loss of functioning, and reduced self-
experienced mood disorders. Williams et al. esteem because of changes in physical appear-
(2002) found that estimates of the prevalence ance may all contribute to emotional changes.
of post-traumatic stress disorder (PTSD) fol- The third category put forward by
lowing TBI range from 3% to 27%. In Gainotti (1993) includes problems that arise
their own study, they found that 18% of 66 for psychosocial reasons. An example is an

individual who loses all his or her friends and vivid intrusive cognitions and avoidance be-
colleagues following a brain injury and thus is haviors (Sbordone & Liter 1995). However,
very socially isolated. Social isolation is seen given that PTSD seems to occur even when
Psychosocial
functioning: in up to 60% of survivors of TBI (Hooen there is a loss of consciousness for the event,
encompasses work, et al. 2001). One aspect not covered by there could be two main mediating mecha-
leisure, and social Gainotti is the inuence of premorbid person- nisms to suggest how trauma-related material
relationships; ality. This is discussed by Moore & Stambrook may be processed to lead to PTSD symptoms.
overlaps with
(1995), Williams et al. (1999), and Tate (1998). First, survivors may evoke islands of mem-
emotional well-being
Tate, however, found that premorbid person- ory for their trauma, such as being trapped
ality had less effect on psychosocial function- in a crashed car, or other secondary experi-
ing than did severity of injury. In understand- ences that could fuel intrusive ruminations
ing emotion after brain injury, we need to (McMillan 1996). Second, survivors may be
consider neurological, physical, and bio- reminded of elements of their trauma event
chemical models such as those described by when exposed to similar situations that serve
Robinson & Starkstein (1989). Although such to produce intrusive thoughts and fuel avoid-
models address the issue of why emotional ance behaviors (Brewin et al. 1996). McNeil
problems arise following an insult to the brain, & Greenwood (1996) described a survivor of
they do not offer much help in understanding TBI who was hyperaroused in, and avoidant
the psychodynamic and psychosocial causes of of, situations that were similar to the trauma
emotional and mood disorders. Perhaps the event, a road trafc accident, even though
most helpful models come from CBT. he had no declarative memory of the event.
Ever since Becks highly inuential book, If an event is unexpected but has biological
Cognitive Therapy and Emotional Disorders, ap- signicance and, hence, emotional salience,
peared in 1976, CBT has been one of the most McNeil & Greenwood (1996) suggested, it
important and best-validated psychothera- may lead to the event being stored (or burned
peutic procedures (Salkovskis 1996). A main to memory) despite disruption to areas
jor strength of Becks updated model (Beck of the brain that store declarative memories
1996) has been the development of clinically (see Markowitsch 1998). Such a view would
relevant theories. Beck presents several theo- be compatible with the concept that PTSD is
ries not only for depression and anxiety but caused by a conditioning of fear. The mecha-
also for panic, obsessive-compulsive disor- nism responsible is one in which traumatic ex-
ders, and phobias. Mateer & Sira (2006) sug- periences can be processed independently of
gest that CBT is well suited for improving higher cortical functions (see Bryant 2001).
coping skills, helping clients to manage cog- Analytic psychotherapy is also used in reha-
nitive difculties, and addressing more gen- bilitation, particularly in the United States.
eralized anxiety and depression in the context Prigatano is perhaps the best-known propo-
of a brain injury. Williams et al. (2003) de- nent of psychotherapy treatment of individu-
scribe the use of CBT with two survivors of als surviving TBI. He describes his approach
TBI. One was a young man whose girlfriend (based on the milieu therapy approach of Ben-
was killed in a car crash while he was driv- Yishay) in Principles of Neuropsychological Reha-
ing. The other was a young woman, known bilitation (Prigatano 1999).
as CM, who had been severely assaulted while Dealing with the emotional consequences
traveling on a train (described in more detail of brain injury may make the difference be-
below). Williams et al. (2003) discuss the pos- tween a successful and an unsuccessful out-
sible mechanisms for PTSD after TBI. These come. CM, mentioned above, was stabbed
conditions were once thought to be mutually through the head in the right tempero-
exclusive because the survivor would lack a parietal area with a hunting knife while trav-
memory for the event from which to develop eling on a train. She was 19 at the time and
150 Wilson
did not lose consciousness, probably because PSYCHOSOCIAL ASPECTS OF

the knife did not enter her brain stem. She de- NEUROPSYCHOLOGICAL
scribed feeling a pain in her head and a weight REHABILITATION WHO: World
as if the carriage had fallen on top of her. She Health Organization
Considerable overlap exists between psy-
stood up and realized that something terrible
chosocial and emotional difculties. In-
had happened. She went into the next carriage
deed, one denition of a psychosocial
where a man told her to sit down and stay still
disorder is a mental illness caused or in-
and he would get help. She felt the knife with
uenced by life experiences, as well as mal-
her hand and asked if she was going to die. The
adjusted cognitive and behavioral processes
man said No and that he would get help. At
(www.healthatoz.com). In brain injury re-
the next stop, an ambulance arrived and took
habilitation, however, the term is more often
her to the hospital.
used to refer to psychosocial outcomes such as

A few months later, she came to our reha-
work, friendships, and community activities.
bilitation center. She had a number of cogni-

In other words, psychosocial functioning is
tive problems, including visuo-spatial issues
close to participation as dened by the Inter-
and memory decits, but the emotional dif-
national Classication of Functioning, Disability
culties took priority in treatment. She was
and Health (World Health Org. 2001). Wade
anxious and avoided many social situations;
(2005) says that the World Health Organi-
she would not look at people, feared for her
zation (WHO) framework was developed as
family, and had classic symptoms of PTSD
a means of describing the totality that is the
including ashbacks and nightmares; and she
experience of illness (p. 32). The framework
refused to use public transport. Like all other
consists of four levels: pathology, impairment,
patients there, she had both group and in-
activity, and participation. Thus, in the case of
dividual therapy, including a considerable
a brain-injured person, the pathology might
amount of psychological support and treat-
be damage to the cerebral cortex and the re-
ment for the emotional problems identied
sulting impairment might be a poor memory.
(Williams et al. 2003). This involved CBT,
This, in turn, causes limitations to the persons
including stress inoculation, and graduated
everyday activities; so, for example, s/he is un-
exposure to situations she avoided. She was
able to remember appointments. This prob-
also treated for her cognitive difculties, but
lem might affect the extent of participation in
if these had been the only problems treated,
the persons social environment, causing dif-
it is doubtful that she would have been able
culties with work, the duties of parenthood, or
to make such a good recovery and return to a
the ability to engage in leisure activities. The
full and meaningful life.
WHO model also considers three major con-
A recent study (Tiersky et al. 2005) exam-
texts inuencing behavior: personal, physical,
ined the effects of a rehabilitation program
and social contexts. Wade (2005) says these
offering psychotherapy and cognitive rehabil-
contexts might be considered to affect the
itation and compared a treatment group with
interactions between pathology and impair-
a control group. The treatment group showed
ment, impairment and activities and activi-
signicantly improved emotional function-
ties and participation (p. 34). Personal con-
ing, including lessened anxiety and depres-
text includes the relevant characteristics of an
sion. The authors concluded, Cognitive
individual such as expectations, beliefs, and
behavioral psychotherapy and cognitive re-
attitudes. Physical context refers to the en-
mediation appear to diminish psychologic
vironment in which the individual nds him-
distress and improve cognitive functioning
self or herself, and social context refers to the
among community-living persons with mild
culture in which the individual functions. All
and moderate TBI (Tiersky et al. 2005,
these factors contribute to the quality of life
p. 1565).

as experienced by the person with a disabil- injury, in comparison with those who were
ity. For the purposes of this review, psychoso- unemployed, were more likely to work after
cial problems are seen as synonymous with the rehabilitation. The type of occupation also
WHO denition of participation. inuenced return to work: Those in profes-
Twenty-rst century rehabilitation pro- sional or managerial jobs were more likely to
grams are typically concerned with psychoso- return to work than were those in other posi-
cial adjustment to disability (Sopena et al. tions. In another meta-analysis, Kendall et al.
2007, Yates 2003). Included in this category (2006) said, [T]he use of a narrow deni-
are employment or other productive activ- tion of return-to-work (i.e., full-time compet-
ity, social relationships, and leisure. Some itive work only) produced more apparent un-
believe that the psychosocial problems associ- employment than an inclusive denition (i.e.,
ated with TBI may actually be the major chal- any competitive work or productive activity)
lenge of rehabilitation (Morton & Wehman (p. 149). Although this is not surprising, it
1995). Survivors of brain injury face prob- highlights the fact that a return to full-time
lems of social isolation and decreased leisure employment after severe brain injury is not
activities, thus creating a renewed depen- always achievable and, in rehabilitation, we
dence on their family members. Karlovits & need to consider a range of productive activ-
McColl (1999) interviewed 11 survivors of se- ities for our patients/clients. In the words of
vere brain injury to discover impediments to Kendall et al. (2006), The denition of em-
reintegration into the community. Nine stres- ployment and the nature of preinjury employ-
sors were identied: orientation, transporta- ment is crucial to any interpretation of return-
tion, living situation, loss of independence, re- to-work in TBI. The current study also
lationships, loneliness, routine, problems with highlights the importance of measuring em-
studying, and work. Much of the focus of post ployment outcomes using multiple points
acute rehabilitation is on helping people to over time, rather than single data points or
return to a productive lifestyle (Petrella et al. rst return-to-work (p. 149). In an examina-
2005). Indeed, the success of NR programs tion of the effects of rehabilitation on return
is often measured by such outcomes. Lack to work for military personnel, Cullen et al.
of productivity, particularly employment, de- (2007) found moderate evidence to support
creases the opportunity for individuals with the view that inpatient rehabilitation results in
brain injury to develop social contacts and successful return to work and return to duty
leisure activities, which in turn contributes to for the majority of military service members.
depression and low self-esteem. In contrast, They also suggested that increasing the in-
engagement in paid and nonpaid productive tensity of rehabilitation not only reduced the
activities, such as volunteering or homemak- length of stay but also improved short-term
ing, has a benecial impact on community in- functional outcomes. Turner-Stokes et al.
tegration (Petrella et al. 2005). (2005) also found strong evidence to sup-
Return to work is one of the major port the claim that intensive rehabilitation
goals that clients in brain-injury rehabilita- led to more functional gains than did less-
tion programs want to achieve. A number intensive rehabilitation. In summary, people
of studies have addressed the issue of re- who are given intensive rehabilitation have
turning to work after rehabilitation. Failure an improved likelihood of returning to work,
to succeed at work is associated with poor and the denition of return to work should
self-awareness, impaired executive function- be expanded to include part-time work and
ing, and poor metacognition (Ownsworth & other meaningful functional activities rather
Fleming 2005). In a multicenter study, Walker than simply full-time competitive work.
et al. (2006) found that that those who were Social isolation is common after TBI,
employed prior to the onset of their brain in part because of decits in social skills
152 Wilson
(McDonald 2003). An increase in social skills understanding the consequences of brain in-
and social relationships should be one of the jury, followed by goals connected with work
major goals for rehabilitation. Some studies or study skills (119).
NeuroPage: a
have shown that it is possible to achieve these It is clear that rehabilitation for psychoso- reminding system
goals ( Johnson & Davis 1998, Ownsworth cial difculties is an important part of the care using radio-paging
et al. 2000, Ylvisaker et al. 2005). In their of survivors of brain injury. Physical difcul- technology
work with stroke patients, Haslam et al. (2007) ties are less likely to affect the quality of life
found that the number of social groups peo- of a brain-injured person than are the cog-
ple belonged to before their stroke predicted nitive, emotional, and psychosocial sequelae,
their sense of well-being after the stroke so these should be the focus of rehabilitation
and that this was a result of them being programs. In the words of Khan et al. (2003),
more likely to retain membership of more Cognitive and behavioral changes, difcul-
groups. ties maintaining personal relationships and

Another study looking at personal rela- coping with school and work are reported by
tionships is that of Wood & Rutterford (2005), survivors as more disabling than any residual
who found that ve factors predicted prob- physical decits (p. 290).
lems with social relationships. These were A collection of papers on biopsychosocial
(a) loss of self-control (e.g., aggression, so- approaches in neurorehabilitation edited by
cial and/or sexual disinhibition), (b) emotional Williams & Evans (2003) summarizes much
dysfunction (e.g., mood swings, quick tem- of the work tackled in this eld.
per), (c) adynamia (e.g., lack of motivation for
leisure activities, fatigue, loss of libido, loss of
social interests), (d ) personality change (e.g., MODELS AND THEORETICAL
obsessiveness), and (e) cognitive dysfunction APPROACHES CONTRIBUTING
(e.g., memory loss, attention/concentration TO NEUROPSYCHOLOGICAL
difculties, organization and planning prob- REHABILITATION
lems). These are all factors that are or should Most neuropsychologists working in rehabili-
be addressed in rehabilitation. tation believe that treatment should be driven
Another area of research is leisure. A by theory, although they may also believe
Danish study by Engberg & Teasdale (2004) that theories are not necessarily sufcient on
found that maintenance of leisure-time inter- their own. For example, NeuroPage, a paging
ests and general life satisfaction was poorer system for helping memory-impaired peo-
in survivors of a cerebral lesion compared ple remember everyday tasks, was developed
with patients with a cranial fracture. A French by an engineer with no knowledge of psy-
study (Quintard et al. 2002) looked at late out- chological theory who had a son with a se-
come and satisfaction of life of 79 patients vere TBI (Hersch & Treadgold 1994). Even
with severe TBI. Up to 85% were indepen- though it is not theoretically driven, Neu-
dent in activities of daily living, 55% were in- roPage has led to theoretically driven ques-
dependent in social life, but only 36% were tions such as the effect of executive function-
satised with leisure activities. In some reha- ing on successful use of the pager (Fish et al.
bilitation programs, leisure goals are among 2007). Perhaps the most inuential models
the most common goals set. For example, and theories in NR over the past two decades
Bateman et al. (2005) looked at 680 goals set are those of cognition, emotion, behavior,
for 95 clients at the Oliver Zangwill Center and learning. Models of cognitive function-
in the United Kingdom. The most common ing that have proved useful in rehabilita-
goals were connected with managing activi- tion include language, reading (Howard 2005,
ties of daily living (248); leisure goals (154) Mitchum & Berndt 1995), memory (Baddeley
came second jointly with goals pertaining to 1992, 2007), attention (Robertson 1999), and

perception (Bruce & Young 1986). Given the els from a number of different areas. Con-
increasing recognition of the importance of straint of rehabilitation workers to one model
addressing emotional and psychosocial dif- could lead to poor clinical practice because
culties, emotional models are essential in NR. important aspects of patients lives could be
One of the most important of these, CBT, neglected.
is discussed above. Models and theories from
behavioral psychology have been employed in
NR for more than 40 years. They have pro-
GUIDELINES FOR GOOD
vided some of the most useful and inuen-
PRACTICE IN
tial theoretical contributions to rehabilitation,
NEUROPSYCHOLOGICAL
not only for the understanding, management,
REHABILITATION
and remediation of disruptive behaviors, but Although there are no denitive trials to sup-
also for the remediation of cognitive decits port the holistic approach, it has probably
(Wilson et al. 2003). Behavioral theories are been subjected to more evaluation studies
valuable in NR because they inform assess- than have other approaches (e.g., Cicerone
ment, treatment, and the measurement of re- et al. 2004, Diller & Ben-Yishay 2002) and,
habilitation efcacy. at present, is probably the most effective clin-
Learning theory is one of the cornerstones ically (Cicerone et al. 2007). Most holistic pro-
of behavior therapy and behavior modica- grams are concerned with increasing a clients
tion, with the other main theoretical inu- awareness, alleviating cognitive decits, de-
ences coming from biological, cognitive, and veloping compensatory skills, and providing
social psychology (Martin 1991). There is lit- vocational counseling. All such programs pro-
tle doubt, though, that the original behav- vide a mixture of individual and group therapy.
ioral treatments grew out of learning theory. This approach possibly could be improved
Eysenck (1964), for example, dened behav- by incorporating ideas and practical applica-
ior therapy as the attempt to alter human tions from learning theory, such as task analy-
behavior and emotion in a benecial man- sis, baseline recording, monitoring, and the
ner according to the laws of modern learning implementation of single-case experimental
theory (p. 1). designs to individual treatment programs. An-
Believing that the purpose of rehabilitation other potential improvement would be refer-
is to help people achieve their optimum level ring to cognitive neuropsychological models
of physical, psychological, social, and voca- in order to identify cognitive strengths and
tional functioning, Wilson (2002) attempted weaknesses in more detail to explain observed
to synthesize a number of approaches and phenomena and make predictions about cog-
models used in rehabilitation to reect the nitive functioning.
complexity of the eld and the range of is- Prigatano (1999) lists 13 principles of NR
sues to be dealt with. Wilson published a derived from a holistic approach, and there is
provisional model of cognitive rehabilitation no doubt that his work has considerably inu-
in which she argued that one model, or one enced current rehabilitation practice. These
group of models such as those from cognitive principles are described in Table 3.
neuropsychology, is insufcient to (a) deter- The Oliver Zangwill Center, inuenced
mine what needs to be rehabilitated, (b) plan by Prigatanos approach, bases its NR on six
appropriate treatment for neuropsychologi- core components that are described here to
cal impairments, and (c) evaluate response to illustrate the principles of good clinical prac-
rehabilitation. Rehabilitation is one of many tice in NR. More detail on the components is
elds that need a broad theoretical base in- available from the Oliver Zangwill Web site,
corporating frameworks, theories, and mod- www.ozc.nhs.uk.
154 Wilson
Table 3 Summary of Prigatanos 13 principles of neuropsychological rehabilitation

Principle No. Principle
1 Begin with the patients subjective or phenomenological experience.
2 The symptoms presented are a mixture of premorbid cognitive and personality characteristics together
with the neuropsychological changes resulting from the brain pathology.
3 Neuropsychological rehabilitation focuses on both the remediation of higher cerebral disturbances and
their management in interpersonal situations.
4 Neuropsychological rehabilitation helps patients observe their behavior to teach them about the direct
and indirect effects of brain injury.
5 Failure to study the interaction of cognition and personality leads to an inadequate understanding of
many issues.
6 Little is known about how to retrain cognitive dysfunction, but general guidelines of cognitive
remediation can be specied.

7 Psychotherapeutic interventions help patients (and families) deal with their personal losses.
8 Working with patients who have dysfunctional brains produces affective reactions in the patients family
and the rehabilitation staff. Appropriate management of these reactions facilitates adaptation.
9 Each neuropsychological rehabilitation program is a dynamic entity. The team needs to maintain a
dynamic, creative effort.
10 Failure to identify those patients who can and cannot be helped creates a lack of credibility.
11 Disturbances in self-awareness after brain injury are often poorly understood and poorly managed.
12 Competent patient management and planning depend on understanding mechanisms of recovery and
deterioration.
13 The rehabilitation of patients with higher cerebral decits requires both scientic and
phenomenological approaches.
1. Provide a Therapeutic Milieu ing in their lives. Although it is probably not

Derived from Ben-Yishays concept of the thought about consciously in everyday life,
therapeutic milieu (Ben-Yishay 1996), the activity enables individuals to achieve certain
therapeutic milieu in holistic rehabilitation aims or ambitions that are personally signif-
refers to the organization of the complete en- icant and thereby contributes to the sense of
vironment (physical, organizational, and so- identity.
cial aspects) to maximize support for the
process of adjustment and to increase social 3. Ensure Shared Understanding
participation. The milieu embodies a strong The notion of shared understanding comes
sense of mutual cooperation and trust, which from the use of formulation in clinical prac-
underpins the working alliance between client tice (Butler 1998). A formulation is seen as
and clinicians. a map or guide to intervention that com-
bines a model derived from established the-
2. Establish Meaningful and Functionally Therapeutic
ories and best evidence with the clients and milieu: the
Relevant Goals for Rehabilitation familys personal views, experiences, and sto- organization of the
Meaningful functional activity refers to ries. This concept, which should be applied environment to
all day-to-day activities that form the basis to all individual clinical work, inuences the ensure maximum
for social participation. These can be cate- way the rehabilitation experience is organized support to the
process of
gorized into vocational, educational, recre- as a whole. The shared understanding con- adjustment and to
ational, social, and independent living realms. cept incorporates team philosophy, includ- increase social
It is through participation in these areas that ing shared team vision, explicit values, and participation
individuals gain a sense of purpose and mean- goals. Understanding of research and theory,

sharing knowledge and experience with other concentration, holding important con-
professionals and families, peer audit of the versations when less fatigued).
service, and the views and contributions of Retraining is undertaken to improve per-
past clients are additional aspects of the shared formance of a specic function of the brain or
understanding ideal. to improve performance on a particular task
or activity. Retraining also helps to address
4. Apply Psychological Interventions skills lost through lack of use, e.g., through
Psychological interventions are based not being at work since an injury.
upon certain ways of understanding feelings
and behavior. Specic psychological mod- 6. Work Closely with Families and Carers
els (particularly those described above) are Families and carers sometimes report feel-
used to guide work depending upon the spe- ing like an afterthought in rehabilitation. Re-
cic needs of the individual. Approaches from cent policy (National Service Framework for
these models provide ways team members can Long Term Conditions, Dep. Health, London,
engage patients/clients in positive change and 2004) highlights how families and carers ex-
the tackling of specic problems. perience a signicant burden following ac-
quired brain injury and recommends provi-
5. Manage Cognitive Impairments sion of support. Many kinds of support can be
Through Compensatory Strategies and offered, for example, providing information,
Retraining Skills furnishing opportunities for peer support, in-
Compensatory strategies are alternative volving family and carers in rehabilitation, and
ways to enable individuals to achieve a desired providing individual family consultation or
objective when an underlying function of the therapy.
brain is not operating effectively. Compen-
satory approaches to managing impairments
take a number of forms, including: SUMMARY
cognitive compensation (e.g., using vi- Following denitions of neuropsychology, re-
sual imagery to compensate for a defec- habilitation, and NR, this review discusses
tive verbal memory, using a mental rou- some of the ways the eld has changed
tine for managing impulsivity or anger, in recent years. The particular focus is on
and clarifying to ensure effective com- (a) goal setting as a way of structuring re-
munication); habilitation, (b) the realization that the emo-
tional and psychosocial consequences of brain
enhanced learningtechniques such as
injury are as important as the cognitive conse-
errorless learning or spaced retrieval
quences, (c) the increasing use of technology
that lead to more effective learning of
in rehabilitation, and (d ) a recognition that
new knowledge or skills;
a wide range of theoretical models and ap-
external aids (e.g., using a diary for man- proaches is needed to inform the assessment
aging memory problems, checklists to and treatment of people who have survived
remember exercise routines, alarms to a brain injury. The three main components
increase attention to tasks, cue cards for of NRcognitive, emotion, and psychoso-
keeping on track during conversation); cial functioningare looked at in more de-
and tail. Given that how we feel affects how we
environmental adaptationsmodifying think, how we behave, and how we interact
relevant environments in order to re- with others, all three functions need to be
duce cognitive demands (e.g., working addressed in any rehabilitation program. Ev-
in a quiet, nondistracting room to aid idence is provided to show that difculties in
156 Wilson
these areas can be reduced through NR. Be- theoretical approaches used to plan rehabilita-
cause the eld is broad and complex, clinicians tion are described, particularly those relevant
need to be informed by a number of models to cognitive functioning, emotion, behavior,
and theories to reduce the everyday problems and learning. The review concludes with rec-
faced by people who have survived brain in- ommendations for good practice in the reha-
jury. Some of the most inuential models and bilitation of people with brain injury.
SUMMARY POINTS
1. Neuropsychological rehabilitation (NR) is concerned with the amelioration of cogni-
tive, emotional, psychosocial, and behavioral decits caused by an insult to the brain.
2. The main purpose of NR is to enable people to return to their own most appropriate
environments; for this reason, meaningful goals should be set in the areas of vocation,
education, recreation, social relationships, and independent living.

3. Although cognitive decits are perhaps the major focus of NR, emotional and psy-
chosocial consequences of brain injury need to be addressed in rehabilitation pro-
grams. There is an interaction between these different functions, and it is not always
easy to separate them from one another.
4. Technology is increasingly used to help people compensate for cognitive difculties.
Some technological aids are described and evaluated.
5. NR requires a broad theoretical base and some of the most inuential models and
theories inuencing current practice are described.
6. Evidence is provided to show that NR can reduce difculties in the three main areas
of cognitive, emotional, and psychosocial functioning.
7. Suggested guidelines for good clinical practice are outlined.
DISCLOSURE STATEMENT
The author is not aware of any biases that might be perceived as affecting the objectivity of
this review.
LITERATURE CITED
Alderman N. 2003. Rehabilitation of behaviour disorders. See Wilson 2003, pp. 17196
Austin JT, Vancouver JB. 1996. Goal constructs in psychology: structure, process, and content.
Psychol. Bull. 120(3):33875
Baddeley AD. 1992. Memory theory and memory therapy. In Clinical Management of Memory
Problems, ed. BA Wilson, N Moffat, pp. 131. London: Chapman & Hall
Baddeley M. 2007. Analysing herding: insights from neuroeconomics and social psychology. Presented
to Queens Econ. Semin., Cambridge Univ., May
Bateman A, Brentnall S, Evans J, Gartland D, Gracey F, et al. 2005. Outcomes of intensive neu-
ropsychological rehabilitation: the relationship between the Dysexecutive Questionnaire
(DEX) and European Brain Injury Questionnaire (EBIQ) and SMART goals attainment.
Brain Impair. 6(2):13233
Beck AT. 1976. Cognitive Therapy and Emotional Disorders. New York: Int. Univ. Press

Beck AT. 1996. Beyond belief: a theory of modes, personality, and psychopathology. In Frontiers
of Cognitive Therapy, ed. PM Salkovskis, pp. 125. New York: Guilford
Ben-Yishay Y, ed. 1978. Working Approaches to Remediation of Cognitive Decits in Brain Damaged
Persons. Rehabil. Monogr. 59. New York: NY Univ. Med. Cent.
Ben-Yishay Y. 1996. Reections on the evolution of the therapeutic milieu concept. Neuropsy-
chol. Rehabil. 6:32743
Boake C. 2003. Stages in the history of neuropsychological rehabilitation. See Wilson 2003,
pp. 1121
Bowen A, Neumann V, Conner M, Tennant A, Chamberlain MA. 1998. Mood disorders fol-
lowing traumatic brain injury: identifying the extent of the problem and the people at risk.
Brain Injury 12(3):17790
Brewin CR, Dalgleish T, Joseph S. 1996. A dual-representation theory of post-traumatic stress
disorder. Psychol. Rev. 103:67086

Bruce V, Young AW. 1986. Understanding face recognition. Br. J. Psychol. 77:30527
Bryant RA. 2001. Posttraumatic stress disorder and traumatic brain injury: Can they coexist?
Clin. Psychol. Rev. 21:93148
Butler G. 1998. Clinical formulation. In Comprehensive Clinical Psychology, ed. A Bellack, M
Hersen, pp. 124. Oxford, UK: Pergamon
Caramazza A, Hillis AE. 1993. For a theory of remediation of cognitive decits. Neuropsychol.
Rehabil. 3:21734
Carney N, Chesnut RM, Maynard H, Mann NC, Patterson P, Helfand M. 1999. Effects of
cognitive rehabilitation on outcomes for persons with traumatic brain injury: a systematic
review. J. Head Trauma Rehabil. 14:277307
Chesnut RM, Carney N, Maynard H, Patterson P, Mann NC, Helfand M. 1999. Rehabili-
tation for Traumatic Brain Injury. Rockville, MD: Agency Health Care Policy Res. Evid.
Rep./Technol. Assess. 2
Cicerone KD, Dahlberg C, Kalmar K, Langenbahn DM, Malec JF, et al. 2000. Evidence-based
cognitive rehabilitation: recommendations for clinical practice. Arch. Phys. Med. Rehabil.
81:1596615
Cicerone KD, Dahlberg C, Malec J, Langenbahn D, Felicetti T, et al. 2005. Evidence-
Thoroughly
based cognitive rehabilitation: updated review of the literature from 19982002.
reviews cognitive
rehabilitation. Arch. Phys. Med. Rehabil. 86:168192
Cicerone KD, Mott T, Azulay J, Friel JC. 2004. Community integration and satisfaction with
functioning after intensive cognitive rehabilitation for traumatic brain injury. Arch. Phys.
Med. Rehabil. 85(6):94350
Cicerone KD, Mott T, Azulay J, Sharlow-Galella M, Ellmo W, Paradise S. 2007. A practical
clinical trial of holistic neuropsychological rehabilitation. Brain Impair. 8:169 (Abstr.)
Clare L. 2007. Neuropsychological Rehabilitation and People with Dementia. Hove, UK: Taylor &
Francis
Clare L, Halligan PW. 2006. Pathologies of awareness: bridging the gap between theory and
practice. Neuropsychol. Rehabil. (Spec. issue) 16:353500
Clare L, Wilson BA, Breen K, Hodges JR. 1999. Errorless learning of face-name associations
in early Alzheimers disease. Neurocase 5(1):3746
Clare L, Wilson BA, Carter G, Breen K, Gosses A, Hodges JR. 2000. Intervening with everyday
memory problems in dementia of Alzheimer type: an errorless learning approach. J. Clin.
Exp. Neuropsychol. 22(1):13246
Clare L, Wilson BA, Carter G, Hodges JR, Adams M. 2001. Long-term maintenance of treat-
ment gains following a cognitive rehabilitation intervention in early dementia of Alzheimer
type: a single case study. Neuropsychol. Rehabil. 11(34):47794
158 Wilson
Coleman MR. Impaired Consciousness Research Group. Accessed July 30, 2007.
www.vegetativestate.info
Concise Oxford Dictionary. 1999. Oxford, UK: Oxford Univ. Press. 10th ed.
Cullen N, Chundamala J, Bayley M, Jutai J. 2007. The efcacy of acquired brain injury reha-
bilitation. Brain Injury 21:11332
Diller L. 1976. A model for cognitive retraining in rehabilitation. Clin. Psychol. 29:1315
Diller L, Ben-Yishay Y. 2002. The clinical utility and cost effectiveness of holistic, milieu
oriented, rehabilitation programs. In Clinical Neuropsychological and Cost Outcome Research:
A Beginning, ed. G Prigatano, N Pliskin, pp. 293312. New York: Psychol. Press
Engberg AW, Teasdale TW. 2004. A population-based study of survival and discharge status
for survivors after head injury. Acta Neurol. Scand. 110:28190
Eysenck HJ. 1964. The nature of behaviour therapy. In Experiments in Behaviour Therapy, ed.
HJ Eysenck, pp. 115. London: Pergamon

Fish J, Evans JJ, Nimmo M, Martin E, Kersel D, et al. 2007. Rehabilitation of executive
dysfunction following brain injury: content-free cueing improves everyday prospective

memory performance. Neuropsychologia 45(6):131830
Fish J, Manly T, Emslie H, Evans JJ, Wilson BA. 2007. Compensatory strategies for acquired
disorders of memory and planning: differential effects of a paging system for patients with
brain injury of traumatic versus cerebrovascular aetiology. J. Neurol. Neurosurg. Psychiatry.
Manuscr. submitted
Gainotti G. 1993. Emotional and psychosocial problems after brain injury. Neuropsychol. Rehabil.
3:25977
Glisky EL, Schacter DL, Tulving E. 1986. Computer learning by memory impaired patients:
acquisition and retention of complex knowledge. Neuropsychologia 24:31328
Goldstein K, ed. 1942. Aftereffects of Brain Injury in War. New York: Grune & Stratton
Halligan PW, Wade DT, eds. 2005. Effectiveness of Rehabilitation for Cognitive Deficits.
Provides a valuable
Oxford, UK: Oxford Univ. Press
resource for
Haslam C, Holme A, Haslam SA, Iyer A, Jetten J, Williams WH. 2007. Maintaining group clinicians and other
memberships: social identity continuity predicts well-being after stroke. Neuropsychol. Re- professionals
habil. In press involved in
Hersch N, Treadgold L. 1994. NeuroPage: the rehabilitation of memory dysfunction by pros- neuropsychological
thetic memory and cueing. NeuroRehabilitation 4:18797 rehabilitation.
Hooen D, Gilboa A, Vakil E, Donovick PJ. 2001. Traumatic brain injury (TBI) 1020 years
later: a comprehensive outcome study of psychiatric symptomatology, cognitive abilities
and psychosocial functioning. Brain Injury 15:189210
Howard D. 2005. Language: cognitive models and functional anatomy. See Halligan & Wade
2005, pp. 15568
Johnson K, Davis PK. 1998. A supported relationships intervention to increase the social
integration of persons with traumatic brain injuries. Behav. Modif. 22(4):50228
Karlovits T, McColl MA. 1999. Coping with community reintegration after severe brain injury:
a description of stresses and coping strategies. Brain Injury 13:84561
Kendall E, Muenchberger H, Gee T. 2006. Vocational rehabilitation following traumatic
Summarizes an
brain injury: a qualitative synthesis of outcome studies. J. Vocat. Rehabil. 25:14960
important
Khan F, Baguley IJ, Cameron ID. 2003. Rehabilitation after traumatic brain injury. Med. J. meta-analysis of
Aust. 178:29095 factors involved in
Kirsch NL, Levine SP, Fallon-Krueger M, Jaros LA. 1987. The microcomputer as an orthotic return to work.
device for patients with cognitive decits. J. Head Trauma Rehabil. 2:7786
Kopelman M, Crawford S. 1996. Not all memory clinics are dementia clinics. Neuropsychol.
Rehabil. 6:187202

Kurlychek RT. 1983. Use of a digital alarm chronograph as a memory aid in early dementia.
Clin. Gerontol. 1:9394
Luria AR, Naydin VL, Vinarskaya EN. 1969. Restoration of higher cortical functions following
local brain damage. In Handbook of Clinical Neurology, ed. PJ Vinken, GW Bruyn, 3:368
433. New York: Elsevier
Manly T. 2003. Rehabilitation for disorders of attention. See Wilson 2003, pp. 2352
Manly T, Robertson IH, Galloway M, Hawkins K. 1999. The absent mind: further investiga-
tions of sustained attention to response. Neuropsychologia 37:66170
Markowitsch HJ. 1998. Cognitive neuroscience of memory. Neurocase 4:42935
Martin PR. 1991. Handbook of Behavior Therapy and Psychological Science: An Integrative Approach.
New York: Pergamon
Mateer C, Sira CS. 2006. Cognitive and emotional consequences of TBI: intervention strategies
for vocational rehabilitation. NeuroRehabilitation 21:31526

McDonald S. 2003. Traumatic brain injury and social function: Lets get social. Brain Impair.
4:3647
McLellan DL. 1991. Functional recovery and the principles of disability medicine. In Clinical
Neurology, ed. M Swash, J Oxbury, pp. 76890. Edinburgh, UK: Churchill Livingstone
McMillan TM. 1996. Post-traumatic stress disorder following minor and severe closed head
injury: 10 single cases. Brain Injury 10(10):74958
McMillan TM, Sparkes C. 1999. Goal planning and neurorehabilitation: The Wolfson Neu-
rorehabilitation Centre approach. Neuropsychol. Rehabil. 9:24151
McNeil JE, Greenwood R. 1996. Can PTSD occur with amnesia for the precipitating event?
Cogn. Neuropsychiatry 1:23946
Mitchum CC, Berndt RS. 1995. The cognitive neuropsychological approach to treatment of
language disorders. Neuropsychol. Rehabil. 5:116
Moore AD, Stambrook M. 1995. Cognitive moderators of outcome following traumatic brain
injury: a conceptual model and implications for rehabilitation. Brain Injury 9:10930
Morton MV, Wehman P. 1995. Psychosocial and emotional sequelae of individuals with trau-
matic brain injury: a literature review and recommendations. Brain Injury 9:8192
Nair KT, Wade DT. 2003. Satisfaction of members of interdisciplinary rehabilitation teams
with goal planning meetings. Arch. Phys. Med. Rehabil. 84(11):171013
National Service Framework for Long-Term Conditions. 2004. Dep. Health, London
Ownsworth TL, Fleming J. 2005. The relative importance of metacognitive skills, emo-
Examines the
tional status, and executive function in psychosocial adjustment following acquired
relative importance
of different skills in brain injury. J. Head Trauma Rehabil. Disord. Self-Awareness 20:31532
returning to work. Ownsworth TL, McFarland K, Young RM. 2000. Self-awareness and psychosocial functioning
following acquired brain injury: an evaluation of a group support programme. Neuropsychol.
Rehabil. 10:46584
Petrella L, McColl MA, Krupa T, Johnston J. 2005. Returning to productive activities: per-
spectives of individuals with long-standing acquired brain injuries. Brain Injury 19:64355
Poppelreuter W. 1917. Disturbances of Lower and Higher Visual Capacities Caused by Occipital
Damage: With Special Reference to the Psychopathological, Pedagogical, Industrial Implications.
Transl. J Zihl, L Weiskrantz, 1991. Oxford, UK: Oxford Univ.
Poser U, Kohler JA, Schonle PW. 1996. Historical review of neuropsychological rehabilitation
in Germany. Neuropsychol. Rehabil. 6:25778
Prigatano GP. 1986. Personality and psychosocial consequences of brain injury. In Neuropsy-
chological Rehabilitation after Brain Injury, ed. GP Prigatano, DJ Fordyce, HK Zeiner, JR
Roueche, M Pepping, BC Wood, pp. 2950. Baltimore/London: The John Hopkins Univ.
Press
160 Wilson
Prigatano GP. 1994. Individuality, lesion location, and psychotherapy after brain injury.
In Brain Injury and Neuropsychological Rehabilitation, ed. A-L Christensen, BP Uzzell,
pp. 17386. Hillsdale, NJ: Erlbaum Describes 13
Prigatano GP, ed. 1999. Principles of Neuropsychological Rehabilitation. New York: Oxford principles of
Univ. Press rehabilitation for
Prigatano GP. 2005. A history of cognitive rehabilitation. See Halligan & Wade 2005, pp. 310 those following the
holistic approach.
Prigatano GP, Pliskin N, eds. 2002. Clinical Neuropsychology and Cost-Outcome Research:
An Introduction. Hove, UK: Psychol. Press
Prigatano GP, Schacter DL, eds. 1991. Awareness of Decit After Brain Injury. New York: Oxford Addresses the cost
Univ. Press implications of
Quintard B, Croze P, Mazaux JM, Rouxel L, Joseph PA, et al. 2002. Satisfaction of life and late neuropsychological
psychosocial outcome after severe brain injury: a nine-year follow-up study in Aquitaine. rehabilitation.
Ann. Readapt. Med. Phys. 45:45665

Robertson IH. 1999. Theory-driven neuropsychological rehabilitation: the role of attention

and competition in recovery of function after brain damage. In Attention and Performance
XVII: Cognitive Regulation of Performance: Interaction of Theory and Application, ed. D Gopher,
A Koriat, pp. 67796. Cambridge, MA: MIT Press
Robertson IH, Ridgeway V, Greeneld E, Parr A. 1997. Motor recovery after stroke depends
on intact sustained attention: a two-year follow-up study. Neuropsychology 11:29095
Robinson RG, Starkstein SE. 1989. Mood disorders following stroke: new ndings and future
directions. J. Geriatr. Psychiatry 22:115
Rose FD, Brooks BM, Rizzo AA. 2005. Virtual reality in brain damage rehabilitation: review.
CyberPsychol. Behav. 8(3):24351
Salkovskis PM, ed. 1996. Frontiers of Cognitive Therapy. New York: Guilford
Sbordone RJ, Liter JC. 1995. Mild traumatic brain injury does not produce post-traumatic
stress disorder. Brain Injury 9(4):40512
Sohlberg MM, Mateer CA. 2001. Cognitive Rehabilitation: An Integrative Neuropsychological Ap-
proach. New York: Guilford
Sopena S, Rous R, Wilson BA. 2007. Neuropsychological rehabilitation: What is it all about?
Brain Impair. 8:70 (Abstr.)
Tate RL. 1998. It is not only the kind of injury that matters, but the kind of head: the
contribution of premorbid psychosocial factors to rehabilitation outcomes after severe
traumatic brain injury. Neuropsychol. Rehabil. 8:118
Tate RL, Strettles B, Osoteo T. 2003. Enhancing outcomes after traumatic brain injury: a social
rehabilitation approach. See Wilson 2003, pp. 13769
Tiersky LA, Anselmi V, Johnston MV, Kurtyka J, Roosen E, et al. 2005. A trial of neuropsy-
chologic rehabilitation in mild-spectrum traumatic brain injury. Arch. Phys. Med. Rehabil.
86:156574
Turner-Stokes L, Disler PB, Nair A, Wade DT. 2005. Multi-disciplinary rehabilitation for
acquired brain injury in adults of working age. Cochrane Database Syst. Rev. 2005(3):Art.
No. CD004170
Wade DT. 1999. Goal planning in stroke rehabilitation: why? what? how? evidence. Top. Stroke
Rehabil. 6(22):142 Considers the
Wade DT. 2005. Applying the WHO ICF framework to the rehabilitation of cognitive decits relationship
rehabilitation. See Halligan & Wade 2005, pp. 3142 between preinjury
occupational
Walker WC, Marwitz JH, Kreutzer JS, Hart T, Novack TA. 2006. Occupational cate-
category and return
gories and return to work after traumatic brain injury: a multicenter study. Arch. to work.
Phys. Med. Rehabil. 87:157682

Williams WH. 2003. Neuro-rehabilitation and cognitive behaviour therapy for emotional
disorders in acquired brain injury. See Wilson 2003, pp. 11536
Provides a valuable Williams WH, Evans JJ, eds. 2003. Biopsychosocial Approaches in Neurorehabilitation:
resource on Assessment and Management of Neuropsychiatric, Mood and Behavioural Disorders. A
assessment and Special Issue of Neuropsychological Rehabilitation. Hove, UK: Psychol. Press
management of
Williams WH, Evans JJ, Needham P, Wilson BA. 2002. Neurological, cognitive and attribu-
emotional and
psychosocial tional predictors of post-traumatic stress symptoms after traumatic brain injury. J. Trauma
problems. Stress 15(5):397400
Williams WH, Evans JJ, Wilson BA. 1999. Outcome measures for survivors of acquired brain
injury in day and outpatient neurorehabilitation programmes. Neuropsychol. Rehabil. 9:421
Describes a series 36
of case studies with Williams WH, Evans JJ, Wilson BA. 2003. Neurorehabilitation for two cases of post-traumatic
long-term
follow-ups (winner
stress disorder following traumatic brain injury. Cogn. Neuropsychiatry 8:118
of the British Wilson BA. 1999. Case Studies in Neuropsychological Rehabilitation. New York: Oxford
Psychological Univ. Press
Societys 2003 book Wilson BA. 2002. Towards a comprehensive model of cognitive rehabilitation.
award). Neuropsychol. Rehabil. 12:97110
Wilson BA, ed. 2003. Neuropsychological Rehabilitation: Theory and Practice. Lisse, The
Provides a Netherlands: Swets & Zeitlinger
synthesized model Wilson BA, Emslie HC, Quirk K, Evans JJ. 2001. Reducing everyday memory and planning
of the many factors problems by means of a paging system: a randomised control crossover study. J. Neurol.
to be considered in Neurosurg. Psychiatry 70:47782
neuropsychological
Wilson BA, Evans JJ, Brentnall S, Bremner S, Keohane C, Williams H. 2000. The Oliver
rehabilitation.
Zangwill Centre for Neuropsychological Rehabilitation: a partnership between health care
and rehabilitation research. In International Handbook of Neuropsychological Rehabilitation,
ed. A-L Christensen, BP Uzzell, pp. 23146. New York: Kluwer Acad./Plenum
Wilson BA, Evans JJ, Keohane C. 2002. Cognitive rehabilitation: a goal-planning approach.
J. Head Trauma Rehabil. 17(6):54255
Wilson BA, Herbert CM, Shiel A, eds. 2003. Behavioural Approaches in Neuropsychological Reha-
bilitation: Optimising Rehabilitation Procedures. Hove, UK: Psychol. Press
Wood RL, ed. 1987. Brain Injury Rehabilitation: A Neurobehavioural Approach. London: Croom
Helm
Wood RL. 1990. Towards a model of cognitive rehabilitation. In Cognitive Rehabilitation in
Perspective, ed. RL Wood, I Fussey, pp. 325. London: Taylor & Francis
Wood RL, Rutterford NA. 2005. Psychosocial adjustment 17 years after severe brain injury.
J. Neurol. Neurosurg. Psychiatry 77(1):14
World Health Org. 2001. International Classication of Functioning, Disability and Health. Geneva,
Switz.: WHO
Yates PJ. 2003. Psychological adjustment, social enablement and community integration fol-
lowing acquired brain injury. Neuropsychol. Rehabil. 13:291306
Ylvisaker M, Feeney T. 2000. Reconstruction of identity after traumatic brain injury. Brain
Impair. 1:1228
Ylvisaker M, Turkstra L, Coelho C. 2005. Behavioral and social interventions for individuals
with traumatic brain injury: a summary of the research with clinical implications. Semin.
Speech Lang. 26:25667
Zangwill OL. 1947. Psychological aspects of rehabilitation in cases of brain injury. Br. J. Psychol.
37:6069
162 Wilson
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ANRV339-CP04-06 ARI 22 February 2008 16:40

Cognition and Brain Sciences Unit, Medical Research Council, Addenbrookes

Annu. Rev. Clin. Psychol. 2008. 4:14162 Key Words

The Annual Review of Clinical Psychology is online Abstract

several cognitive problems such as poor at-

Cognitive, Emotional, and

the person they once felt they knew and un-

disease work together with professional staff, Depression Shouting

www.annualreviews.org Neuropsychological Rehabilitation 143

www.annualreviews.org Neuropsychological Rehabilitation 145

with neurological damage. One of the major

separated from emotions, feelings, and self-

www.annualreviews.org Neuropsychological Rehabilitation 147

stantial body of evidence demonstrating that cession. Anosognosia, or lack of awareness of

www.annualreviews.org Neuropsychological Rehabilitation 149

did not lose consciousness, probably because PSYCHOSOCIAL ASPECTS OF

used to refer to psychosocial outcomes such as

bilitation center. She had a number of cogni-

www.annualreviews.org Neuropsychological Rehabilitation 151

groups. ties maintaining personal relationships and

www.annualreviews.org Neuropsychological Rehabilitation 153

Table 3 Summary of Prigatanos 13 principles of neuropsychological rehabilitation

remediation can be specied.

1. Provide a Therapeutic Milieu ing in their lives. Although it is probably not

www.annualreviews.org Neuropsychological Rehabilitation 155

education, recreation, social relationships, and independent living.

www.annualreviews.org Neuropsychological Rehabilitation 157

disorder. Psychol. Rev. 103:67086

HJ Eysenck, pp. 115. London: Pergamon

dysfunction following brain injury: content-free cueing improves everyday prospective

www.annualreviews.org Neuropsychological Rehabilitation 159

for vocational rehabilitation. NeuroRehabilitation 21:31526

Ann. Readapt. Med. Phys. 45:45665

Robertson IH. 1999. Theory-driven neuropsychological rehabilitation: the role of attention

www.annualreviews.org Neuropsychological Rehabilitation 161

Contents Volume 4, 2008

Ecological Momentary Assessment

Modern Approaches to Conceptualizing and Measuring Human

Should Binge Eating Disorder be Included in the DSM-V? A Critical

Cumulative Index of Contributing Authors, Volumes 14 p p p p p p p p p p p p p p p p p p p p p p p p p p p395

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