Cognitive Rehabilitation: Restorative and Compensatory Approaches

 Cognitive rehabilitation is a systematic, goal-oriented treatment program designed to improve cognitive functions and functional abilities, and increase levels of self-management and independence following neurological damage to the central nervous system. Although the specific tasks are individualized to patients' needs, treatment generally emphasizes restoring lost functions; teaching compensatory strategies to circumvent impaired cognitive functions; and improving competence in performing instrumental activities of daily living (IADLs) such as managing medications, using the telephone and handling finances. Cognitive rehabilitation has been postulated to lead to maintenance or improvement in language, memory and other cognitive abilities in neurologically impaired individuals.

 There are two treatment approaches to cognitive rehabilitation. The restorative approach is based on the theory that repetitive exercise can restore lost functions. Restorative cognitive rehabilitation (RCR) targets internal cognitive processes with a goal of generalizing improvements in real-world environments. Techniques include auditory, visual and verbal stimulation and practice, number manipulation, computer assisted stimulation and practice, performance feedback, reinforcement, video feedback and metacognitive procedures such as behavior modification (Agency for Healthcare Research and Quality [AHRQ], 1999).

 The second rehabilitation model, the compensatory approach, strives to develop external prosthetic assistance for dysfunctions. Compensatory cognitive rehabilitation (CCR) does not rely on the ability to generalize learning or restore lost abilities. CCR employs visual cues, written instructions, memory notebooks, watches, beepers, computers and other electronic devices to trigger behavior. Therapists simplify complex tasks, capture the patient’s attention, minimize distractions and teach self-monitoring procedures. This approach encourages and reinforces an individual’s remaining strengths with the goal of achieving or maintaining independence. The compensatory approach to cognitive rehabilitation has been more widely accepted than the restorative approach, but these techniques are not mutually exclusive. Many therapeutic programs employ both techniques. Prior to initiation of a cognitive rehabilitation program, patients often undergo comprehensive neuropsychological testing to evaluate and identify specific baseline deficits and impairments as well as to direct a treatment plan and develop measurable goals.