Cognitive rehabilitation aims to help recover mental functions impaired by brain injury through restoration, substitution, and restructuring approaches. Computerized cognitive rehabilitation (CACR) uses computer programs and exercises to retrain impaired cognitive skills. It provides personalized feedback and reinforcement through tasks of increasing difficulty. Research shows CACR improves attention, memory, and executive functions in patients with brain injuries, learning disabilities, schizophrenia, substance abuse disorders, depression, and multiple sclerosis compared to control groups. CACR appears as effective as traditional face-to-face rehabilitation with similar costs. Issues include variability in brain injury characteristics and rehabilitation programs across studies.

1. Oana Mircea
Concordia University, Montreal
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2. What is cognitive rehabilitation ?
Treatment designed to help people recover from mental functions that are
lost or impaired following a brain injury .
Different rehabilitation approaches:
 1. Restoration: Cognitive training and retraining strategies meant to
strengthen and restore one function
 2. Substitution: Compensatory devices that help to replace a lost function
 3. Restructuring:
 Environmental restructuring: Changing family demands placed on the
individual
 Using educational and vocational facilities
 Following the patients in their environment (Sohlberg & Mateer, 2001)
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3. What is not
• Cognitive rehabilitation concerns information processing
 Cognitive rehabilitation = cognitive retraining = cognitive remediation
• Psychotherapy influences patient’s image on self and surroundings
• Psychoactive drugs targets brain receptors
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4. What is computerised cognitive
rehabilitation (CACR) ?
 A computer is used as a high tech tool for retraining impaired cognitive skills of
neurologically- and psychiatrically-based problems (Bracy, 1999)
Requirements: clinically stable patients -able to concentrate 20 min
accurate cognition assessment
 The key elements include:
1. Intrinsic motivation –task performance is in itself rewarding
2. Guided practice in computer-based training exercises
3. Supportive, one-on-one ,training sessions
4. Task engagement through contextualization
5. Personalized feedback
6. Positive reinforcement (Medalia, J & Revheim, 1999; Castelnuovo, Prione, Liccione, &
Cioffi,2003)
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5. Historical Development
 Introduction of game-like programs in cognitive rehabilitation of brain-injured
individuals (Lynch,1983)
 First software program designed to train
Attention Reaction time Perceptual motor skills
Memory Problem solving Reasoning (Lynch, 1992).
• Program software designed to exercise visual perception, attention, and
memory capacity (Gianutsos, 1992)
• NeurXercise: Cognitive training videogame-like program for individuals
suffering from brain-injuries (Podd & Seeling, 1992)
 A battery of interrelated cognitive-training set of programs (Bracy, 1983)
developed into a Psychological Software Service (PSS)
o Neuroscience Center of Indianapolis (NSC): First evidence-based cognitive
rehabilitation clinic
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6. Building Block Theory
The training tasks unfold in a hierarchically fashion.
Level 1: Exercises address basic cognitive processes, such as:
- Receptors, nerve pathways and primary cortical areas function
properly
Level 15: Exercises grow in complexity and build on previous levels.
-integrate perceptions
Level 24:
-retrieve stored information (Bracy O.L., 1986)
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7. Computer assisted cognitive
rehabilitation clinic
 NeuroScience Center of Indianapolis (NSC) clinical services are based
on PSSCogRehab program developed by Dr. Bracy
 It contains 8 software modules; 64 computerized tasks.
 Applications: Assessment, diagnostics, report writing , and
rehabilitation therapy
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8. Empirical support for PSSCogRehab
 Brain injuries
o Patients with severe closed head injury received 20 hours over 4 to 6 weeks
o PSSCogRehab displayed significant improvements from pre- to post-
treatment and in comparaison to non-computerised control group
o (Batchelor, Shores, Marosszeky, Sandanam, & Lovarini, 1988).
o Patients with brain injury received CACR /Control matched group received
only speech and occupational therapies.
o Both higher on post neuropsychological measures on attention, memory, visuo-
spatial ability, and problem solving.
o No differences between groups (Chen, Thomas, Glueckauf, & Bracy, 1997)
 Learning
o 80 children
o Computer assisted programs for education and cognitive rehabilitation
targeting intellectual functioning (9 weeks)
o Significant advancement on problem solving skills, attention, and visuo-
spatial tests (Bracy, Oakes, Cooper, Watkins, Brown, & Jewell, 1999)
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9. Empirical support for PSSCogRehab
 Schizophrenia and schizoaffective disorder:
o N=65 ; randomly assigned
 Experimental group: Computer-based training on attention, memory,
and executive functions & work therapy (i.e. paid work with supportive
aids)
 control group: Only work therapy
 Measures: Cognitive abilities & feedback on work performance
 Experimental group improved on WM, affect recognition, and
executive function
 1 year follow-up
o Maintanance: WM, affect recognition and executive functioning
o Increased value on job market
(Bell, Bryson, Greig, Corcoran, & Wexler, 2001; Bell, Zito, Greig, & Wexler, 2008).
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10. Website-based cognitive
rehabilitation
 Neuropsycholine (NPO)
o Internet-based application for assessment, diagnosis, and treatment of
injury
o Upgrades are automatic
o Subscribers have unlimited use of the software to assess, diagnose, write
clinical reports and treat an unlimited number of patients
Challenging Our Minds was developed for children
http://www.challenging-our-minds.com/tour/sample1/t03t01.php
 Currently used for rehabilitation treatment in over 300 facilities
o 4 US Military Bases and 5US Veteran's Administration Medical Centers
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11. CACR randomised controlled trials
 Alzheimer’s Disease (N= 14 mildly cognitive impaired)
o 10 X 30 minutes of interactive computerized training for memory of
objects and routes in a standard residence
o Results: superior performance than control group-chat with a
psychologist (Schreiber, Schweizer, Lutz ,Kalveram, & Jäncke, 1999)
• Attention (N = 77 first grade with ADD symptoms)
o Captain’s Log program: 36 exercises - auditory and visual sustained
attention and impulse control
o Results: significantly less attention problems than control (Rabiner, Desiree,
Skinner, & Malone, 2010).
• ADHD ( N = 4 severe ADHD)
o 64 training sessions with Captain’s Log
o Decreased hyperactive behaviour (Slate, Meyer, Burns, & Montgomery, 1998).
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12. CACR randomised controlled trials
 Substance-abuse disorders
o Residential care patients (N=160; randomly assigned)
o CACR plus standard treatment condition OR computer-based typing
tutorial plus standard treatment.
o Follow up at 3, 6, 9 and 12 months.
o Results: CACR group were more engaged in treatment
Adherence to treatment was superior and
Longer abstinence time (Fals Stewart &Lam, 2010)
 Opioid-dependent outpatients
o Interactive program therapy plus with voucher-based contingency OR
only therapy implemented by clinician
o Results: Improvement compared to only therapy implemented by clinician
(Bickel, Marsch, Buchhalter, & Badger, 2008)
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13. CACR randomised controlled trials
 Depression (N=12 with recurrent MDD)
o Computerized treatment (first-time used; Elgamal et al, 2007).
o Results: Improvement on attention, verbal learning, memory, psychomotor
speed and executive function compared to healthy control group
o However, depressive symptoms persisted over the trial
 Multiple sclerosis (mild disabilities)
o Results: Treatment group (CACR for attention, information processing, and
executive functions) performed better than control group (no
rehabilitation program) after 3 months (Mattioli, Chiara, Deborah ,Giovanni, &
Ruggero, 2010)
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14. CACR versus face-to-face
rehabilitation
 Study comparing CACR and face-to-face rehabilitation
 Target: attention, reaction time, learning, visuospatial skills, and problem
solving
 Control: age, gender, education, dominant hand, IQ, and time elapsed since
injury
Results: no differences on living without anybody ‘s help, driving, and
school/home return
 Study also examined the cost: cost was similar for both groups.
 Time was longer for CACR group and cost per hour was higher for FTF
group (Schoenberg, Ruwe, Dawson, McDonald, Houston, & Forducey, 2008)
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15. Issues
 Brain injured patients with cognitive deficits need clear instructions;
unfriendliness in software may reinforce the patient's maladaptive
behaviour and affect the rate of learning
 Engaging clients in learning tasks can be quite challenging:
schizophrenia impacts motivation (Schoenberg, Ruwe, Dawson, McDonald,
Houston, & Forducey, 2008)
 Methodological issues in brain injuries research : variability in
preinjury characteristics of the sample, severity and site of injury, time
between injury moment and beginning of treatment ;
 Variability in data collections: intervention variability in terms of
frequency, intensity, and duration.
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16. CACR and computer-assisted
psychotherapy
Commonalities:
 Assessment procedure
 Treatment based on learning theory, cognitive psychology, neuropsychology
 Addressing the emotional state that may interfere with
rehabilitation process
Differences:
-Rehab: treatment involve exercises from occupational domain designed to address fine
motor manipulation, manipulations of blocks into various pattern, visual-spatial
analysis
-Psychotherapy: face-to-face interventions, strategies focus on changing how you think
and behave.
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17. References
 Batchelor, J., Shores, E. A., Marosszeky, J. E., & Sandanam, J. (1988). Cognitive rehabilitation of
severely closed-head-injured patients using computer-assisted and noncomputerized treatment
techniques. The Journal of Head Trauma Rehabilitation, 3(3), 78-84. doi:10.1097/00001199-198809000-
00012
 Bell, M. D., Zito, W., Greig, T., & Wexler, B. E. (2008). Neurocognitive enhancement therapy with
vocational services: Work outcomes at two-year follow-up. Schizophrenia Research, 105(1-3), 18-29.
doi:10.1016/j.schres.2008.06.026
 Bell, M., Bryson, G., Greig, T., Corcoran, C., & Wexler, B. E. (2001). Neurocognitive enhancement
therapy with work therapy: Effects on neurocognitive test performance. Archives of General
Psychiatry, 58(8), 763-768. doi:10.1001/archpsyc.58.8.763
 Bickel, W. K., Marsch, L. A., Buchhalter, A. R., & Badger, G. J. (2008). Computerized behavior therapy
for opioid-dependent outpatients: A randomized controlled trial. Experimental and Clinical
Psychopharmacology, 16(2), 132-143. doi:10.1037/1064-1297.16.2.132
 Bracy, O. L. (1983). Computer-based cognitive rehabilitation. Journal of Cognitive Rehabilitation, 1, 7-
8.
 Bracy, O. L., & O. (1999). The effects of cognitive rehabilitation therapy techniques for enhancing the
cognitive/intellectual functioning of seventh and eighth grade children. International Journal of
Cognitive Technology, 4, 19-26.
 Bracy, O. L. (1986). Cognitive rehabilitation: A process approach. Cognitive Rehabilitation, 4(2), 10-17.
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18. References
 Castelnuovo, G., Priore, C. L., Liccione, D., & Cioffi, G. (2003). Virtual reality based tools for the
rehabilitation of cognitive and executive functions: The V-STORE. PsychNology Journal, 1(3), 310-325.
 Chen, S. H. A., & T. (1997). The effectiveness of computer-based cognitive rehabilitation for persons
with traumatic brain injury. Brain Injury, 11, 197-209.
 Elgamal, S., McKinnon, M. C., Ramakrishnan, K., Joffe, R. T., & MacQueen, G. (2007). Successful
computer-assisted cognitive remediation therapy in patients with unipolar depression: A proof of
principle study. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences,
37(9), 1229-1238. doi:10.1017/S0033291707001110
 Fals-Stewart, W., & Lam, W. K. K. (2010). Computer-assisted cognitive rehabilitation for the
treatment of patients with substance use disorders: A randomized clinical trial. Experimental and
Clinical Psychopharmacology, 18(1), 87-98. doi:10.1037/a0018058
 Mattioli, F., Chiara, S., Deborah,Z., Giovanni, P., & Ruggero, C. (2010). Efficacy and specificity of
intensive cognitive rehabilitation of attention and executive functions in multiple sclerosis. Journal of
the Neurological Sciences, 288(1-2), 101-105. doi:10.1016/j.jns.2009.09.024
 Gianutsos, R. (1992). The computer in cognitive rehabilitation: It's not just a tool anymore. The
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 Lynch, W. J. (1983). Cognitive retraining using microcomputer games and commercially available
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19. References
 Medalia, A., & Revheim, N. (1999). Computer assisted learning in psychiatric rehabilitation.
Psychiatric Rehabilitation Skills, 3(1), 77-98.
 Podd, M. H., & Seelig, D. P. (1992). Computer-assisted cognitive remediation of attention disorders
following mild closed head injuries. In L. K. Ross (Ed.), Handbook of head trauma: Acute care to
recovery. (pp. 231-244). New York, NY US: Plenum Press.
 Rabiner, D. L., Murray, D. W., Skinner, A. T., & Malone, P. S. (2010). A randomized trial of two
promising computer-based interventions for students with attention difficulties. Journal of Abnormal
Child Psychology: An Official Publication of the International Society for Research in Child and
Adolescent Psychopathology, 38(1), 131-142. doi:10.1007/s10802-009-9353-x
 Schreiber, M., Schweizer, A., Lutz, K., Kalveram, K. T., & Jancke, L. (1999). Potential of an interactive
computer-based training in the rehabilitation of dementia: An initial study. Neuropsychological
Rehabilitation, 9(2), 155-167.
 Schoenberg, M. R., Ruwe, W. D., Dawson, K., McDonald, N. B., Houston, B., & Forducey, P. G. (2008).
Comparison of functional outcomes and treatment cost between a computer-based cognitive
rehabilitation teletherapy program and a face-to-face rehabilitation program. Professional
Psychology: Research and Practice, 39(2), 169-175. doi:10.1037/0735-7028.39.2.169
 Slate, S. E., Meyer, T. L., Burns, W. J., & Montgomery, D. D. (1998). Computerized cognitive training
for severely emotionally disturbed children with ADHD. Behavior Modification, 22(3), 415-437.
doi:10.1177/01454455980223012
 Sohlberg, M. M., & Mateer, C. A. (2001). Cognitive rehabilitation :An integrative neuropsychological
approach. New York: Guilford Press.
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