Hi-Tech Cognitive Retraining
We live in an age of technology and everywhere we look, we
see it in use: iPods, DVD players, camera phones, digital voice
recorders; the list goes on and on. We also see the technology
trend in remediation of cognitive-linguistic disorders. Computers
and assistive technologies are becoming commonplace in therapy
for individuals who have suffered an acquired brain injury (ABI).
More than 73% of rehabilitation centers report use Computer-
Assisted Cognitive-Retraining (CACR) programs. These programs
utilize principals of cognitive rehabilitation–a therapeutic process
of increasing or improving an individual’s capacity to process
and use incoming information. This includes methods to restore
cognitive function and to train compensatory techniques (Sohlberg
and Mateer, 1989).
Current computer programs have evolved from game machines
such as Atari to sophisticated instruments that deal with complex
strategy and abstract thinking. Initially in therapy, use of these
need for interaction between clinician and patient (Falconer).
systems was restricted to developing reflexes and visuomotor
To obtain advantageous outcomes with CACR, careful planning
coordination. Now they facilitate a myriad of cognitive and
and analysis of performance data must be observed. Selection
language tasks. Current programs target specific deficit areas such
of appropriate software programs is crucial. The clinician must
as: Attention/ concentration, impulsivity, distractibility, eye-hand
understand why a particular program is being used and how it fits
coordination, thinking/ performance speed, cognitive endurance,
into the patient’s current treatment model. This process involves
learning/memory, visual tracking/scanning, planning/organization,
clinical merit evaluation. If the program is sound, clinicians must
sequencing, inattention/neglect, reasoning/abstraction, problem
decide what type of cognitive process it addresses and determine
solving, quality control/self-monitoring and spatial analysis/
where it fits in the treatment hierarchy. To facilitate this process, a
synthesis. The development of diverse programs was required
series of clinical and administrative questions should be answered
because TBI cognitive-linguistic disorders vary from person to
to determine a CACR’s use. (Matthews et. al, 1991, Sohlbery &
person and no single program could remediate a multitude of
deficits. Though cognitive-linguistic problems vary, they are
The current CACR trend is moving away from a process
amongst the most debilitating a person can suffer, whether mild
specific approach (targeting a discreet deficit area) to targeting
or severe, and require specialized and highly organized CACR
commonly impaired activities of daily living (LoPresti et.al, 2004).
Targeted activities include driving, everyday math skills, name
The most successful programs have made inroads improving
& face recall, and remembering to carryout future assignments.
attention, visual processing and reasoning/problem solving. Most
Further, emphasis is on technology as a cognitive prosthesis
memory programs have tended to involve practice drills, which
that functions as reminding system, recording or storage system,
try to increase the amount of information a person can recall. The
electronic scheduling or planning system. The target becomes
problem with memory programs is that they have shown little to
multi-dimensional with outcome objectives increasing functional
no carry-over to functional capabilities. While the individual may
problem solving–generalized into a variety of everyday tasks.
have scored well on the computer task, it does not necessarily
Though great promise and much hope is seen for CACR, in
translate to improved functioning outside of the computer-training
general, the literature has not shown it to be superior to traditional
task. Further, certain aspects of language are not amenable to
(non computer) cognitive rehabilitation approaches. CACR is
computerized retraining such as pragmatics or speech, due to the
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Does the accompanying literature clearly define the objectives of
Does the program address what it claims to address?
Is the reinforcement and feedback immediate, friendly and
Advantages for Clinicians
(Sohlerg & Mateer)
Is the program interesting?
1. Consistent, often adjustable, rate of
Are the instructions easy to follow?
Are appropriate and useful data collected and analyzed?
2. Automatic collection and tabulation of
Where would the program fit within the treatment model?
How much supervision is needed?
3. Efficient administration of tedious
Is the program free of bugs and technological problems?
4. Objective feedback
Is extra equipment needed to run the programs?
5. Free clinician to observe and record
Can screen advance be controlled?
valuable qualitative data
Can the clinician add unique content to the program so that
additional stimuli will be available?
Advantages for the individual
Can software be returned after an initial review period?
Help prepare for employment
Provide leisure activity
Provide ways for injured
individuals to interact with peers
Hi-Tech Cognitive Retraining continued
Opportunity to work independently
Tend to attend for longer
periods of time
generally effective in improving measure of attention in specific skill
Report feeling the computer is
training rather than general training that is not focused on designated tasks
less critical of poor performance
or deficit types (Park & Ingles, 2001). However, some studies have failed to
demonstrate significant differences in post treatment gains when compared
to controls not using computers (Chen, 1997). Further, single subject design
or anecdotal small group studies with poor control groups defined much of
the research (Cicerone et. al, 2000). More robust and well-designed efficacy
studies are clearly needed.
Despite questions regarding large-scale clinical efficacy, researchers
generally agree that use of technology to augment traditional therapies
should continue to be explored and encouraged. As we begin to understand
more about brain functioning, and as the technological world continues to
blossom with new and imaginative ideas and devices, CARC programs as a
clinical assistive device are here to stay.
Hi-Tech Cognitive Retraining continued
Written by Angie McCalla, MS, CCC-SLP, CBIS
Speech & Language Pathologist at Rainbow Rehabilitation
Copyright September 2006 – Rainbow Rehabilitation Centers,
Inc. All rights reserved. Printed in the United States of America.
No part of this publication may be reproduced in any manner
whatsoever without written permission from Rainbow
Rehabilitation Centers, Inc. For information, contact the editor at:
Rainbow Rehabilitation Centers, Inc.
5570 Whittaker Road, Ypsilanti, MI 48197, USA
Chen S, Thomas J, Glueckauf R, Bracy O. The effectiveness
of computer-assisted cognitive rehabilitation for persons with
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Cicerone KD, Dahlberg C, Kalmar K, et al. Evidence-based
cognitive rehabilitation: recommendations for clinical practice.
Archives of Physical Medicine Rehabilitation. 2000; 81:1596-
Falconer J. Computers and brain injury: some guidelines for
LoPresti E, Mihailidis A, Kirsh N. Assistive technology for cognitive
rehabilitation: state of the art. Neuropsychological Rehabilitation.
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Lynch B. Historical review of computer-assisted cognitive
retraining. Journal of Head Trauma Rehabilitation. 2002; 17(5)
Matthews C, Harley JP, Malec J. Guidelines for computer-assisted
neuropsychological rehabilitation and cognitive remediation.
Clinical Neuropsychology. 1991; 5:3-19.
Park N, Ingles J. Effectiveness of attention rehabilitation after an
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