494156

2013
SAP43310.1177/0081246313494156South African Journal of PsychologyWilson

South African Journal of Psychology 43(3) 267­–277 © The Author(s) 2013

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DOI: 10.1177/0081246313494156 sap.sagepub.com

State of the Science Editorial

Neuropsychological rehabilitation:
State of the science

Barbara A Wilson

Abstract
Neuropsychological rehabilitation is concerned with the amelioration of cognitive, emotional,
psychosocial, and behavioural deficits caused by an insult to the brain. Major changes in the field
have occurred over the past decade or so. In 2011, Wilson published an article titled ‘Cutting
edge developments in neuropsychological rehabilitation and possible future directions’, in which
10 of the most important changes in neuropsychological rehabilitation over the previous 5 years
were described. This article is an update of those changes: some of the topics in the 2011 article
have been omitted, others added, and the order of importance has been changed. For the most
part, the developments described relate to the rehabilitation of adults with non-progressive
brain injury, the exceptions being a development for people with dementia and another relates
to children. Topics considered are new assessment procedures, new treatment strategies for
cognitive and emotional problems, recognition of the need to find new ways to evaluate the efficacy
of rehabilitation, and evidence for the effectiveness of comprehensive-holistic rehabilitation.

Keywords
rehabilitation, neuropsychology, traumatic brain injury, assessment, treatment

Introduction
The 21st century is an exciting time to be involved in neuropsychological rehabilitation (NR). This is
because research is progressing in a number of different areas, not all of which can be included here.
One area that attracts a considerable amount of funding but which was not considered for inclusion
in the earlier article (or in this one) was brain imaging. Although some might have felt that imaging
had much to offer rehabilitation, it was not included because it was, and continues to be, argued that
imaging tells us little about a person’s ability to function in the real world. Imaging does not meet the
essential criterion of NR, which deals with problems that arise in daily living. The purpose of NR is

Oliver Zangwill Centre for Neuropsychological Rehabilitation, UK

Corresponding author:
Barbara A Wilson, Oliver Zangwill Centre for Neuropsychological Rehabilitation, The Princess of Wales Hospital, Lynn
Road, Ely, Cambridgeshire CB6 1DN, UK.
Email: barbara.wilson00@gmail.com
268 South African Journal of Psychology 43(3)

to enable people with disabilities to achieve their optimum level of well-being, to reduce the impact
of their problems on everyday life, and to help them return to their own most appropriate environ-
ments. There are many things brain imaging studies can do: They can identify specific lesions and
areas of impaired functioning, tell us what connections are disrupted, determine the severity of brain
damage, monitor change in brain functioning over time, help with making decisions (such as surgi-
cal), and predict which people are likely to remain with persistent problems after a traumatic brain
injury (TBI). At present, however, imaging studies do not tell us what the patient and family think is
important, they are of little help in setting goals or providing information on the best compensatory
systems, or how to teach the use of these systems. Brain scans do not tell us how to deal with emo-
tional difficulties or which jobs are suitable for specific types of functional difficulties. Costly imag-
ing procedures are of limited assistance in helping us design strategies to alleviate cognitive,
emotional, psychosocial, and behavioural deficits caused by an insult to the brain.
Topics considered for inclusion in this second article but rejected because of time and space
constraints were fatigue after brain injury, awareness issues, brain–computer interaction, pharma-
cological studies, developments in cognitive behaviour therapy (CBT), and computational model-
ling. In themselves of course, these are extremely noteworthy areas for discussion. However, when
restricted to 10 areas, the author has had to limit her horizons. Not all readers will agree with the
10 areas selected, and most will probably disagree with the final order of importance. The chosen
list is personal and may be regarded by some as idiosyncratic but, for better or worse, these are the
10 areas, in reverse order of importance, that have been chosen.

Number 10: compassion focussed therapy

Compassion focussed therapy (CFT; Gilbert, 2009) emphasises the emotional experience associated
with psychological problems. It draws on social, evolutionary (especially attachment) theory, and
neurophysiological approaches to the regulation of distress. The model argues that attachment and
affiliative behaviours have evolved over many millions of years to regulate threat-based emotions
and action tendencies. It has been adapted for use with survivors of brain injury (Ashworth, Gracey,
& Gilbert, 2011). Although CFT utilises many of the techniques in CBT, the focus is on developing
emotions of kindness, care, support, encouragement, and validation as part of the experience of
these interventions. For example, if a patient identifies negative thoughts and then can generate
more evidence-based alternatives, they are trained to bring into being feelings of warmth, kindness,
understanding, and support for these alternatives. Also integral to the CFT approach is the view that
we can be kind, compassionate, and understanding towards ourselves or we can be critical and even
self-loathing. People high in self-criticism can experience a range of mental health difficulties,
whereas those who are self-compassionate are far more resilient to these problems (Gilbert, 2010).
One simple CFT approach is to identify self-criticism and help people refocus on self-compassion
and develop self-validation and acceptance through producing feelings of kindness and warmth. In
a case study (Ashworth et al., 2011), a woman with a TBI was noted to have increased ratings of
self-esteem as a result of CFT. Other reports can be found in the study by Ashworth (in press). In
conclusion, CFT may help to refocus emotional responses from self-critical to more positive ones.
It remains to be seen whether this is true when larger studies are carried out.

Number 9: neurological music therapy

In recent years, there has been a paradigm shift in neurological music therapy from a social science
approach whereby music therapy was used to enhance well-being to a neuroscience model in
Wilson 269

which music engages brain and behaviour functions. This has been driven by advances in the neu-
roscience of music (Thaut, 2012). Music shares neural networks with memory, language, attention,
perception, and motor control. It has been used to improve gait, attention, memory and executive
functions, and speech (through melodic intonation therapy [MIT]). It has also been used to reduce
unilateral neglect, anxiety, depression, and hostility. One of the best articles is that by a Finnish
group (Särkämö et al., 2008), whose study focussed on 60 patients with a right or left hemisphere
stroke who were randomly allocated to a music group, a language group, or a control group. Of
those who completed the study (N = 54), people in the music group scored better on verbal memory
and focussed attention measures. They also showed less depression and confusion. Another study
by Soto et al. (2009) found that patients with unilateral neglect showed more awareness of left side
when they listened to preferred music (compared to non-preferred music). This happened both
while the music was being played and if the music was heard before they were tested for neglect.
MIT which was popular some 30 years ago (Sparks & Holland, 1976) and then fell out of fashion
is now very much on the agenda again (Conklyn, Novak, Boissy, Bethoux, & Chemalib, 2012).
Positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) (Belin
et al., 1996; Schlaug, Marchina, & Norton, 2009) have shown increased activity in Broca’s area
during MIT training compared to speech repetition. This activity correlates with better verbal out-
put and suggests it might be possible to recruit right hemisphere structures for speech and language
processing (Conklyn et al., 2012). These are just a few of the recent developments in neurological
music therapy which promises to have an exciting future.

Number 8: virtual reality assessments

Virtual reality (VR) refers to the use of computer hardware and software to create interactive simu-
lations and environments to allow opportunities to engage in settings that resemble and feel similar
to real-world interactions (Kizony, 2011). Thus, VR simulates real-world environments and situa-
tions; these can then be easily adapted to the needs and characteristics of various patient groups in
order to train cognitive strategies in many contexts, facilitating their transfer to the real world. The
ultimate goal of VR-based intervention is to make it possible for clients to become more able to
participate in community life. Users are provided with different types of feedback modalities for
their performance. These include visual and audio feedback and, less often, haptic and vestibular
feedback (Weiss, Kizony, Feintuich, & Katz, 2006). VR technologies are now starting to be used
as assessment and treatment tools in rehabilitation, in general, and in cognitive rehabilitation (CR),
in particular (Jansari, 2010; Kizony, 2011).
Experiential and active learning in a relevant setting encourages and motivates the user. This
is particularly important for survivors of brain injury with cognitive deficits and, often, poor moti-
vation. Many different situations have been used in VR assessments including a virtual kitchen to
assess cognitive abilities during meal preparation in people with TBI (Christiansen, Huddleston,
& Ottenbacher, 2001) and a virtual mall (Rand, Weiss, & Katz, 2009) to look at executive func-
tions and a library-based task (Renison, Ponsford, Testa, Richardson, & Brownfield, 2012),
requiring participants to prioritise and complete multiple tasks while managing interruptions and
new information necessitating a shift in their approach. This study assessed seven types of execu-
tive functioning, namely, task analysis, strategy generation and regulation, prospective working
memory (WM), interference and dual task management, response inhibition, time-based prospec-
tive memory, and event-based prospective memory. It seems highly likely that VR assessments
and treatment approaches will become the norm in neuropsychology and rehabilitation within the
next decade.
270 South African Journal of Psychology 43(3)

Number 7: restitution of WM deficits

There is no evidence that we can restore episodic memory deficits (Wilson, 2009). Instead, we have
to help people to compensate for their problems and to help them learn more efficiently (Wilson,
2009). There is, however, evidence that some restoration of WM is possible with healthy adults
(Dahlin, Stigsdotter-Neeley, Larrson, Bäckman, & Nyberg, 2008; Jaeggi, Buschkuehl, Jonides, &
Perrig, 2008), with patients with stroke (Westerberg et al., 2007) and with TBI (Lundqvist, Grundstron,
Samuelson, & Rönnberg, 2010; Serino et al., 2007), as well as with children with poor WM (Holmes,
Gathercole, & Dunning, 2009) and with attention deficit hyperactivity disorder (ADHD; Beck,
Hanson, Puffenberger, Benninger, & Benninger, 2010; Klingberg et al., 2005).
In addition to showing benefits to WM capacity, there is evidence of generalisation too. For
example, the studies by Jaeggi et al. (2008) and Thorell et al. (2009) found benefits to fluid IQ,
while the study by Klingberg et al. (2005) reported reductions in parent ratings of ADHD symp-
toms following WM training. Holmes et al. (2009) found that children with poor WM performance
improved on an ecologically valid, classroom-based WM task with training compared to the con-
trol group. They also found that at a 6-month follow-up, the training group had disproportionately
improved scores on a Wechsler Objective Number Dimensions task suggesting that their improved
WM enabled children to engage more in lessons or to benefit more from their lessons. In conclu-
sion to the WM training studies, there is good quality evidence in support of computerised WM
training from several different studies, from different centres, and from different populations.
There is also evidence of generalisation to other tasks or everyday behaviours. The main character-
istics of beneficial training procedures include the following: first, adaptation to participant perfor-
mance whereby task demands increase as the participant improves, and second, the tasks are varied
in terms of modality and cognitive demands.

Number 6: errorless learning for people with language deficits

Errorless learning (EL) is a teaching technique whereby people are prevented, as far as possible,
from making mistakes while they are learning a new skill or acquiring new information. This can
be carried out in a number of ways, for example, through the provision of spoken or written instruc-
tions or physically guiding the trainee through a task. The principle is to avoid mistakes being
made during learning and to minimise the possibility of erroneous responses. Baddeley and Wilson
(1994) posed the question ‘Do people with amnesia learn more if prevented from making mistakes
while learning?’ The answer was a resounding ‘YES’. Since then, EL has been an important prin-
ciple in memory rehabilitation. Several studies have used EL to teach several everyday tasks to
people from different diagnostic groups and of different ages and at different times post insult.
There is convincing evidence that EL is superior to trial–error learning for people with severe
memory problems (Wilson, 2011). The reason it is effective for these patients is, probably, because
in order to benefit from our mistakes, we need to be able to remember them. EL depends on
implicit memory (Page, Wilson, Shiel, Carter, & Norris, 2006), and this system is not good at error
elimination: Episodic memory does that. Therefore, those people whose episodic memory is
severely impaired and who are dependent on implicit memory functioning cannot correct their
incorrect responses, and once errors are introduced, they may, indeed, be strengthened.
Consequently, we should try to prevent any incorrect responses.
What about EL for people with language impairments? Recently, there has been a surge of inter-
est in EL, especially in speech and language therapy (SALT). In 2010, in just one issue of the
journal, Neuropsychological Rehabilitation, there were three articles comparing EL with other
approaches. Two of these studies were with language-impaired patients: Raymer, Strobel, Prokup,
Wilson 271

Thomason, and Reff (2010) compared EL with errorful learning (EF) to train spelling for people
with acquired dysgraphia. There was a tendency for the EF to be better, but the patients preferred
the EL strategy. Jokel, Rochon, and Anderson (2010) used EL and a computer-based treatment for
a patient with semantic dementia. The man was able to relearn words using this approach. More
recently, Conroy and Lambon-Ralph (2012) edited a special issue of Neuropsychological
Rehabilitation ‘Errorless learning and rehabilitation of language and memory impairments’. It is
probably true to say that the jury is out for the value of EL in SALT and the results are mixed. This
may be because language-impaired people do not necessarily have severe episodic memory defi-
cits so, unlike people with severe amnesia, they can benefit from their mistakes. Lambon-Ralph
(personal communication, 2010) says that the general consensus from his studies, and those of
many others, is that EL and EF are equally effective for name relearning but that patients (espe-
cially the more severe) tend to strongly prefer the EL.

Number 5: problem-solving therapy for people with executive

deficits
Evans (2009) says that problem-solving difficulties are one of the major characteristics of the dys-
executive syndrome (DES), and much of the rehabilitation efforts for people with executive defi-
cits focus on problem-solving therapy (PST). There is evidence for the efficacy of PST from earlier
studies. Von Cramon, Matthes-von Cramon, and Mai (1991), for example, compared a PST group
(N = 20) with a control ‘memory therapy’ (MT) group (N = 17). They found the PST group showed
a significant improvement on ratings of problem-solving ability and some test performance (e.g.,
Tower of Hanoi). A later study by Rath, Simon, Langenbahn, Sherr, and Diller (2003) included 60
outpatients who had sustained a brain injury, all of whom were at least 1-year post injury. The
participants were divided into two groups: one received conventional group NR and the other PST.
The PST group showed greater improvement on an executive test, self-appraisal, and role play.
More recently, Spikman, Boelen, Lamberts, Brouwer, and Fasotti (2010) carried out a ran-
domised control trial (RCT) of a multifaceted treatment programme for executive dysfunction.
They included 75 patients who were randomised into a control group and a PST group in which
treatment focussed on self-awareness, goal-setting, planning, self-initiation, self-monitoring, self-
inhibition, flexibility, and strategic behaviour. The PST group showed greater improvements on a
number of measures including role resumption, goal attainment, and performance on a specially
designed executive secretarial task.
Miotto, Evans, and Souza Da Lucia (2009) carried out a carefully designed study comparing
three groups of people with executive deficits: the participants comprised 15 males and 15 females
with lesions in frontal lobes of whom 23 patients had undergone surgery for a tumour and 7 had
sustained a TBI; 9 had lesions in the orbitofrontal cortex (OFC), 8 had lesions in the dorsolateral
prefontal cortex (DLPFC), and 13 had combined lesions in the OFC and DLPFC. The average time
since injury was 2.4 years with a standard deviation of 1.04 years. Patients were randomly allo-
cated to the attention and problem-solving group (APSG), an information and education group, and
a treatment-as-usual group. The APSG showed greater improvement on tests, a functional multi-
element task, and the Dysexecutive Questionnaire (Wilson, Alderman, Burgess, Emslie, & Evans,
1996). The APSG was then given to the other participants.
K. D. Cicerone et al. (2011) in a meta-analysis of the treatment of executive deficits say that
only the problem-solving treatment resulted in significant beneficial effects on measures of execu-
tive functioning, self-appraisal of clear thinking, self-appraisal of emotional self-regulation, and
objective observer-ratings of interpersonal problem-solving behaviours in naturalistic
simulations.
272 South African Journal of Psychology 43(3)

Number 4: support in the early stages of dementia

There is increasing recognition of the value and importance of psychosocial (‘non-pharmacologi-
cal’) interventions to help maintain or support functioning in early stage dementia. Interest in this
area has been encouraged by the recognition that the efficacy of currently available medications is
very limited. The first RCT of individual, goal-oriented CR aimed at supporting functioning in
everyday activities has been completed (Clare et al., 2010). This was a single-blind RCT compar-
ing CR with relaxation therapy (RT) and with no treatment (NT). It took place in an outpatient,
community-based setting, enrolling 69 individuals with a diagnosis of Alzheimer’s disease (AD)
or mixed AD and vascular dementia and a Mini Mental State Examination score of 18 or above.
Participants were receiving a stable dose of acetylcholinesterase-inhibiting medication. A total of
44 family carers also contributed.
Treatment took place over 8 weeks, consisting of individual sessions of CR with personalised
interventions to address individually relevant goals. This was supported by the provision of infor-
mation, practical aids and strategies, techniques for learning new information, practice in maintain-
ing attention and concentration, and techniques for stress management. The primary outcomes
were goal performance and satisfaction. Questionnaires assessing mood, quality of life and carer
strain, and a brief neuropsychological test battery were also administered. A subset of participants
underwent fMRI.
The CR produced significant improvement in ratings of goal performance and satisfaction,
while scores in the other two groups did not change. Behavioural changes in the CR group were
supported by fMRI data for a subset of participants. The results suggest that CR in the early stages
of dementia is clinically effective and helps people with dementia and their families to manage the
effects of the condition.

Number 3: recognition of the need to evaluate rehabilitation in

more appropriate ways
NR is a partnership between patients, families, and health-care staff (Wilson, Evans, Gracey, &
Bateman, 2009). It involves many complex processes aimed at enabling people who are disabled
by injury or disease to achieve their optimum level of physical, psychological, social, and voca-
tional well-being (McLellan, 1991). Because of the great heterogeneity of patients receiving such
rehabilitation and because of the variety of aims and methods required to achieve ultimate goals,
the measurement of treatment effectiveness and final outcomes resulting from rehabilitation are
difficult to evaluate (Hart, Fann, & Novack, 2008).
RCTs in rehabilitation are possible, but they are not easy to implement and they need to be thought
out carefully. Double-blind RCTs, where neither the person giving nor the person receiving the treat-
ment knows whether the ‘real’ treatment or a placebo control is being administered, are impossible in
rehabilitation. Single-blind RCTs, where the assessor is blind to whether ‘real’ or placebo treatments
are being given, are possible. RCTs, however, are not the only way to evaluate rehabilitation, and
there is increasing recognition that RCTs are of limited value in determining their efficacy. As
Andrews (1991) says, (the RCT) ‘is a tool to be used not a god to be worshipped’. He goes on to say
that the RCT is excellent where (1) the design is simple, (2) marked changes are expected, (3) the
factors involved are relatively specific, and (4) the number of additional variables likely to affect the
outcome are few and can be balanced out. This is quite unlike the situation in rehabilitation.
If we are asking a question such as ‘How many subjects improved?’ then we are asking about
groups: Results apply to groups and we need a group design to answer the question. In contrast, if
our question is ‘Is this patient improving’ followed by its associated question ‘If so, is the change
Wilson 273

because of our intervention or would it have happened anyway’?, then we are asking about an
individual and this question cannot be answered through a group study. One way to answer ques-
tions about an individual’s response to treatment is to employ a single-case experimental design
(SCED). SCEDs avoid many of the problems inherent in group studies; they are often the method
of choice when evaluating an individual’s response to intervention. They are perfectly respectable
scientific methods, and they provide complementary information to group studies. Neither SCEDs
nor group studies are ‘better’: design depends on the question being asked. Large group studies
need many people to share out individual differences, but small groups and SCEDs do not have to
concern themselves with this as each subject is his or her own control, and baselines are used
instead of control groups.
The introduction of the SCED scale (Perdices & Tate, 2009; Tate et al., 2008) has led to an
increasing acceptance of SCEDs in rehabilitation settings. The scale considers whether or not the
SCED being examined reports or provides information on the following: (1) the history, (2) the
target behaviour, (3) the design, (4) a baseline, (5) the behaviour during treatment, (6) the raw data,
(7) a measure of inter-rater reliability, (8) an independent assessor, (9) statistical analysis, (10)
replication, and (11) information on generalisation. Thus, each article can be rated on its methodo-
logical quality. Of course, studies can be highly rated for methodology but still report on trivial,
meaningless, or unimportant aspects and can be poor in other ways, so further information will
always be needed. The value of the work of Tate, Perdices, and their Australian colleagues is likely
to be of great benefit in improving research into the evaluation of the efficacy of NR.

Number 2: SenseCam/Vicon revue

SenseCam is a small camera usually worn around the neck that takes pictures automatically. It does
not have a viewfinder but is fitted with a wide-angle (fish-eye) lens that maximises its field of view.
This means that nearly everything in the wearer’s view is captured by the camera (Hodges, Berry, &
Wood, 2011). Originally designed by Microsoft, SenseCam is now marketed by Vicon revue (http://
www.viconrevue.com). It passively records experiences, without conscious thought, and it allows
full participation in the event being photographed and is plugged into a standard personal computer,
so that the images can be viewed individually or as a jerky ‘movie’. A number of studies have looked
at the value of SenseCam to improve autobiographical memory (Berry et al., 2007; Hodges, Berry,
& Wood, 2011; Loveday & Conway, 2011). Patients’ recall of events is typically far better when the
SenseCam images have been reviewed compared not only to a baseline condition but also to the
same amount of time spent reviewing events written down in a diary. The camera has been used
successfully for patients with dementia and encephalitis and other kinds of brain injury.
SenseCam provides security, confidence, and ownership of experiences. Browne et al. (2011)
obtained information from users of SenseCam, one of whom said,

I was able to go over situations in the privacy of my own home to review things which I was uncomfortable
with. The outside world can be very frightening and fast and I felt afraid and thought I would have difficulty
keeping up. I was able to review my visits into the outside world . . . and practise at home and memorise
different situations and how I would address this when I was in that situation outside. This built my
confidence . . . so I was able to succeed when that situation arose again. Thank you for helping me – it is
an amazing piece of equipment which I’m sure would be helpful in many areas.

Families and carers feel positively too, with comments such as ‘Seeing the images brings mem-
ories flooding back’, ‘She is more relaxed socially and less anxious’, and ‘Sharing experiences
again was a sheer pleasure’ (Browne et al., 2011).
274 South African Journal of Psychology 43(3)

In addition to memory, SenseCam has many other potential applications: It has been used (1) to
identify triggers that lead to anger outbursts, (2) with patients receiving CBT to help them remem-
ber positive events, (3) with people with autism and learning difficulties, (4) in exercise and weight
reduction regimes, and (5) in emergency and disaster situations, to mention a few (Loveday &
Conway, 2011).

Number 1: evidence for the effectiveness of holistic

rehabilitation
Holistic rehabilitation was pioneered by Yehuda Ben-Yishay and George Prigatano (Ben-Yishay,
2000; Ben-Yishay & Prigatano, 1990; Prigatano, 1999). Holistic rehabilitation regards it as futile
to separate the cognitive consequences of brain injury from the emotional, social, and functional
consequences because how we feel affects how we think, remember, communicate, solve prob-
lems, and behave. Consequently, these functions are interconnected, hard to separate, and all need
to be dealt with in rehabilitation. All holistic programmes offer both group and individual therapy:
to increase awareness, promote acceptance and understanding, provide cognitive remediation,
develop compensatory skills, and provide vocational counselling.
Several studies have looked at comprehensive-holistic rehabilitation, and the findings suggest
that these programmes can improve community integration, functional independence, and produc-
tivity. This is true even for patients who are many years post injury (K. D. Cicerone et al., 2011).
Cicerone et al. (2008) carried out a RCT comparing standard rehabilitation with holistic rehabilita-
tion. The standard rehabilitation consisted primarily of individual, discipline-specific therapies
(physical therapy, occupational therapy, and speech therapy) along with 1 hr of individual CR. The
holistic intervention included individual and group therapies that emphasised metacognitive and
emotional regulation for cognitive deficits, emotional difficulties, interpersonal behaviours, and
functional skills. Neuropsychological functioning improved in both conditions, but the holistic
rehabilitation produced greater improvements in community functioning and productivity, self-
efficacy, and life satisfaction. Most participants (88%) had sustained a moderate or severe TBI, and
over half were more than 1-year post injury. Those in the holistic group were more severely disa-
bled and longer post injury, yet were twice as likely to make clinically significant gains in com-
munity functioning compared to those receiving conventional rehabilitation. In the later article, K.
D. Cicerone et al. (2011) concluded that there is substantial evidence to support interventions for
attention, memory, social communication skills, executive function, and for comprehensive-holis-
tic NR after TBI. They recommended that ‘Comprehensive-holistic neuropsychologic rehabilita-
tion is recommended to improve post-acute participation and quality of life after moderate or
severe TBI’ (K. D. Cicerone et al., 2011, p. 526).
Even more recently, Van Heugten, Gregório, and Wade (2012) completed a meta-analysis of 95
RCTs published between January 1980 and August 2010. The studies included 4068 patients in
total. Their conclusions were that there is a large body of evidence to support the efficacy of CR.
Evidence is strongly in favour of comprehensive-holistic rehabilitation programmes.

Conclusion
This article has described some of the main advances in NR over the past few years. It has described
some recent developments in assessment and treatment strategies, as well as studies looking at the
effectiveness of rehabilitation. One of the most important findings from the recent past is evidence for
the effectiveness of holistic rehabilitation programmes. K. Cicerone (2009), a great friend to, and
Wilson 275

advocate for, survivors of brain injury said, ‘The goal of rehabilitation, to assist people to lead mean-
ingful, fulfilling lives, is a tremendous undertaking, one that cannot be accomplished without a true,
collaborative effort’ (pp. ix, x). This is undoubtedly true, but, unfortunately, many survivors of brain
injury do not receive appropriate rehabilitation despite the fact that there is strong evidence for its
benefits. One of the main goals of clinical neuropsychologists in the immediate future is to persuade
health-care purchasers that rehabilitation makes clinical and economic sense. If we can save the lives
of people with an insult to the brain, we owe it to them to make sure their saved life is worth living.

Acknowledgements
A version of this article was presented at The International Congress of Psychology, Cape Town, July 2012.

Declaration of conflicting interests

None declared.

Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit
sectors.

References
Andrews, K. (1991). The limitations of randomized control trials in rehabilitation research. Clinical
Rehabilitation, 5, 5–8.
Ashworth, F. (in press). Natalie’s story: The phoenix rising from the ashes. In B. A. Wilson, J.
Winegardner & F. Ashworth (Eds.), Life after brain injury: Survivors’ stories. Hove, UK:
Psychology Press.
Ashworth, F., Gracey, F., & Gilbert, P. (2011). Compassion focused therapy after traumatic brain injury:
Theoretical foundations and a case illustration. Brain Impairment, 12, 128–139.
Baddeley, A. D., & Wilson, B. A. (1994). When implicit learning fails: Amnesia and the problem of error
elimination. Neuropsychologia, 32, 53–68.
Beck, S. J., Hanson, C. A., Puffenberger, S. S., Benninger, K. L., & Benninger, W. B. (2010). A controlled
trial of working memory training for children and adolescents with ADHD. Journal of Clinical Child &
Adolescent Psychology, 39, 825–836.
Belin, P., Van Eeckhout, P., Zilbovicius, M., Remy, P., Francois, C., & Guillaume, S. (1996). Recovery from
nonfluent aphasia after melodic intonation therapy: A PET study. Neurology, 47, 1504–1511.
Ben-Yishay, Y. (2000). Post acute neuropsychological rehabilitation: A holistic perspective. In A. L. Christensen
& B. Uzzell (Eds.), International handbook of neuropsychological rehabilitation (pp. 127–136). New
York, NY: Kluwer Academic/Plenum.
Ben-Yishay, Y., & Prigatano, G. P. (1990). Cognitive remediation. In M. Rosenthal, E. R. Griffith, M. R. Bond
& J. D. Miller (Eds.), Rehabilitation of the adult and child with traumatic brain injury (2nd ed., pp.
393–409). Philadelphia, PA: F.A. Davis.
Berry, E., Kapur, N., Williams, L., Hodges, S., Watson, P., Smyth, G., & . . . Wood, K. (2007). The use of a
wearable camera, SenseCam, as a pictorial diary to improve autobiographical memory in a patient with
limbic encephalitis: A preliminary report. Neuropsychological Rehabilitation, 17, 582–601.
Browne, G., Berry, E., Kapur, N., Hodges, S., Smyth, G., Watson, P., & Wood, K. (2011). SenseCam
improves memory for recent events and quality of life in a patient with memory retrieval difficulties.
Memory, 19, 713–722.
Christiansen, C. H., Huddleston, N., & Ottenbacher, K. J. (2001). Virtual reality in the kitchen. American
Journal of Physical Medicine & Rehabilitation, 80, 597–604.
Cicerone, K. (2009). Foreword. In B. A. Wilson, J. J. Evans, F. Gracey & A. Bateman (Eds.), Neuropsychological
rehabilitation: Theory, models, therapy and outcomes (pp. ix–x). Cambridge, UK: Cambridge University Press.
276 South African Journal of Psychology 43(3)

Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J. F., Bergquist, T., Azulay, J., & . . . Ashman,
T. (2011). Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through
2008. Archives of Physical Medicine and Rehabilitation, 92, 519–530.
Cicerone, K. D., Mott, T., Azulay, J., Sharlow-Galella, M. A., Elmo, W. J., Paradise, S., & Friel, J. (2008). A
Randomized Controlled Trial of Holistic Neuropsychologic Rehabilitation After Traumatic Brain Injury.
Archives of Physical Medicine and Rehabilitation, 89, 2239–2249.
Clare, L., Linden, D. E., Woods, R. T., Whitaker, R., Evans, S. J., Parkinson, C. H., & . . .Rugg, M. D. (2010).
Goal-oriented cognitive rehabilitation for people with early-stage Alzheimer’s disease: A single-blind
randomized controlled trial of clinical efficacy. American Journal of Geriatric Psychiatry, 18, 928–939.
Conklyn, D., Novak, E., Boissy, A., Bethoux, F., & Chemalib, K. (2012). The effects of modified melodic
intonation therapy on nonfluent aphasia: A pilot study. Journal of Speech, Language, and Hearing
Research, 55, 1463–1471.
Conroy, P., & Lambon-Ralph, M. (2012). Errorless learning and rehabilitation of language and memory
impairments. Neuropsychological Rehabilitation, 22, 137–328.
Dahlin, E., Stigsdotter-Neeley, A., Larrson, A., Bäckman, L., & Nyberg, L. (2008). Transfer of learning after
updating training mediated by the striatum. Science, 320, 1510–1512.
Evans, J. J. (2009). Rehabilitation of executive functioning: An overview. In M. Oddy & A. Worthington
(Eds.), The rehabilitation of executive disorders: A guide to theory and practice (pp. 59–73). Oxford, UK:
Oxford University Press.
Gilbert, P. (2009). The compassionate mind. London, England: Constable & Robinson.
P. Gilbert (Ed.). (2010). Compassion focused therapy (special issue). International Journal of Cognitive
Therapy, 3, 95–210.
Hart, T., Fann, J. R., & Novack, T. A. (2008). The dilemma of the control condition in experience-based cog-
nitive and behavioural treatment research. Neuropsychological Rehabilitation, 18, 1–21.
Hodges, S., Berry, E., & Wood, K. (2011). SenseCam: A wearable camera that stimulates and rehabilitates
autobiographical memory. Memory, 19, 685–696.
Holmes, J., Gathercole, S., & Dunning, D. L. (2009). Adaptive training leads to sustained enhancement of
poor working memory in children. Developmental Science, 12, 9–15.
Jaeggi, S. M., Buschkuehl, M., Jonides, J., & Perrig, W. J. (2008). Improving fluid intelligence with training
on working memory. Proceedings of the National Academy of Sciences of the United States of America,
105(19), 6829–6833.
Jansari, A. (2010). In search of an ecologically valid measure of the dysexecutive syndrome: Can virtual real-
ity help rehabilitation? Journal of Rehabilitation Medicine, 42(4), 399.
Jokel, R., Rochon, E., & Anderson, N. D. (2010). Errorless learning of computer-generated words in a patient
with semantic dementia. Neuropsychological Rehabilitation, 20, 16–41.
Kizony, R. (2011). Virtual reality for cognitive rehabilitation in cognition, occupation, and participation
across the life span. In N. Katz (Ed.), Neuroscience, neurorehabilitation, and models of intervention in
occupational therapy (3rd ed., pp. 143–158). Bethesda, MD: AOTA Press.
Klingberg, T., Fernell, E., Olesen, P. J., Johnson, M., Gustafsson, P., Dahlstrom, K., & . . .Westerberg, H.
(2005). Computerized training of working memory in children with ADHD – A randomized, controlled
trial. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 177–186.
Loveday, C., & Conway, M. A. (2011). SenseCam: The future of everyday memory research? Memory, 19,
1–124.
Lundqvist, A., Grundstron, K., Samuelson, K., & Rönnberg, J. (2010). Computerized training of working
memory in a group of patients suffering from acquired brain injury. Brain Injury, 24, 1173–1183.
McLellan, D. L. (1991). Functional recovery and the principles of disability medicine. In M. Swash & J. Oxbury
(Eds.), Clinical Neurology (pp. 768–790). Edinburgh, UK: Churchill Livingstone.
Miotto, E., Evans, J., & Souza Da Lucia, M. (2009). Rehabilitation of executive dysfunction: A controlled trial
of an attention and problem solving treatment group. Neuropsychological Rehabilitation, 19, 517–540.
Page, M., Wilson, B. A., Shiel, A., Carter, G., & Norris, D. (2006). What is the locus of the errorless-learning
advantage? Neuropsychologia, 44, 90–100.
Perdices, M., & Tate, R. L. (2009). Single subject designs as a tool for evidence-based practice: Are they
unrecognised and undervalued? Neuropsychological Rehabilitation, 19, 904–927.
Wilson 277

Prigatano, G. P. (1999). Principles of neuropsychological rehabilitation. New York, NY: Oxford University Press.
Rand, D., Weiss, P., & Katz, N. (2009). Training multitasking in a virtual supermarket: A novel intervention
after stroke. American Journal of Occupational Therapy, 63, 535–542.
Rath, J. F., Simon, D., Langenbahn, D. M., Sherr, L., & Diller, L. (2003). Group treatment of problem solv-
ing deficits in outpatients with traumatic brain injury: A randomized outcome study. Neuropsychological
Rehabilitation, 13, 461–488.
Raymer, A., Strobel, J., Prokup, T., Thomason, B., & Reff, K.-L. (2010). Errorless versus errorful training of
spelling in individuals with acquired dysgraphia. Neuropsychological Rehabilitation, 20, 1–15.
Renison, B., Ponsford, J., Testa, R., Richardson, B., & Brownfield, K. (2012). The ecological and construct
validity of a newly developed measure of executive function: The virtual library task. Journal of the
International Neuropsychological Society, 18, 440–450.
Särkämö, T., Tervaniemi, M., Laitinen, S., Forsblom, A., Soinila, S., & Hietanen, M. (2008). Music listening
enhances cognitive recovery and mood after middle cerebral artery stroke. Brain, 131, 866–876.
Schlaug, G., Marchina, S., & Norton, A. (2009). Evidence for plasticity in white matter tracts of patients with
chronic Broca’s aphasia undergoing intense intonation-based speech therapy. Annals of the New York
Academy of Sciences, 1169, 385–394.
Serino, A., Ciaramelli, E., Di Santantonio, A., Malagù, S., Servadei, F., & Làdavas, E. (2007). A pilot study
for rehabilitation of central executive deficits after traumatic brain injury. Brain Injury, 21, 11–19.
Soto, D., Funes, M. J., Guzman-Garcia, A., Warbrick, T., Rotshtein, P., & Humphreys, G. (2009). Pleasant
music overcomes the loss of awareness in patients with visual neglect in patients with visual neglect.
Proceedings of the National Academy of Sciences of the United States of America, 106, 6011–6016.
Sparks, R. W., & Holland, A. L. (1976). Method: Melodic intonation therapy for aphasia. Journal of Speech
and Hearing Disorders, 41, 287–297.
Spikman, J. M., Boelen, D. H., Lamberts, K. F., Brouwer, W. H., & Fasotti, L. (2010). Effects of a multifaceted
treatment program for executive dysfunction after acquired brain injury on indications of executive function-
ing in daily life. Journal of the International Neuropsychological Society, 16, 118–129.
Tate, R. L., McDonald, S., Perdices, M., Togher, L., Schultz, R., & Savage, S. (2008). Rating the methodolog-
ical quality of single subject designs and n-of-1 trials: Introducing the Single-Case Experimental Design
(SCED) Scale. Neuropsychological Rehabilitation, 18, 385–401.
Thaut, M. (2012). Workshop on Neurologic Music Therapy: World Congress of Neuro Rehabilitation,
Melbourne, VIC, Australia.
Thorell, L. B., Lindqvist, S., Bergman, S., Bohlin, G., & Klingberg, T. (2009). Training and transfer effects
of executive functions in preschool children. Developmental Science, 12(1): 106–113.
Van Heugten, C., Gregório, G. W., & Wade, D. (2012). Evidence-based cognitive rehabilitation after acquired
brain injury: A systematic review of content of treatment. Neuropsychological Rehabilitation, 22, 653–673.
Von Cramon, D. Y., Matthes-von Cramon, G., & Mai, N. (1991). Problem-solving deficits in brain-injured
patients: A therapeutic approach. Neuropsychological Rehabilitation, 1, 45–64.
Weiss, P. L., Kizony, R., Feintuich, U., & Katz, N. (2006). Virtual reality in neurorehabilitation. In M. E.
Selzer, L. Cohen, F. H. Gage, S. Clarke & P. W. Duncan (Eds.), Textbook of neural repair and rehabilita-
tion (pp. 182–197). Cambridge, UK: University of Cambridge.
Westerberg, H., Jacobaeus, H., Hirvikoski, T., Clevberger, P., Ostensson, M., Bartfai, A., & Klingberg, T.
(2007). Computerized working memory training after stroke – a pilot study. Brain Injury, 21, 21–29.
Wilson, B. A. (2009). Memory rehabilitation: Integrating theory and practice. New York, NY: Guilford
Press.
Wilson, B. A. (2011). Cutting edge developments in neuropsychological rehabilitation and possible future
directions. Brain Impairment, 12, 33–42.
Wilson, B. A., Alderman, N., Burgess, P., Emslie, H., & Evans, J. J. (1996). The behavioural assessment of
the dysexecutive syndrome. Bury St Edmunds, UK: Thames Valley Test.
Wilson, B. A., Evans, J. J., Gracey, F., & Bateman, A. (2009). Neuropsychological rehabilitation: Theory,
models, therapy and outcomes. Cambridge, UK: Cambridge University Press.