5

State of Practice and Providers
of Cognitive Rehabilitation Therapy

The multi-faceted nature of cognitive rehabilitation therapy (CRT) means there is no standardized nomenclature for clinical practice. Providers in various disciplines aim to improve their patients’ cognitive functions to strengthen performance in daily activities, communication, or more complex activities at work or school. CRT is often described according to the intended outcome of treatment (e.g., improved memory or attention to tasks) or by the method or provider delivering the therapy. For practical purposes, CRT does not differ from occupational therapy, speech-language-pathology, and physical therapy when these treatments intend to reduce or compensate for an underlying cognitive disorder. Therefore, the committee concluded that these types of therapy sessions, when conducted to ameliorate deficits for patients with cognitive impairment, meet the definition of CRT.

STATE OF PRACTICE

Rehabilitation practice in the United States is affected by health care and related policies. Rehabilitation professionals regard therapy as a means to improve the lives of individuals with disabilities, and thus aid their return to active participation within family and social lives, communities, and work. Increased awareness of traumatic brain injury (TBI) and related cognitive deficits has promoted the rehabilitation needs of cognitively impaired individuals. At the same time, rising health care costs mean long-term rehabilitation programs are reduced, leading to shorter in-patient stays and condensed outpatient programs (Sohlberg and Mateer 2001). Providers adjust and modify programs to target outcomes as effectively and efficiently



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5 State of Practice and Providers of Cognitive Rehabilitation Therapy The multi-faceted nature of cognitive rehabilitation therapy (CRT) means there is no standardized nomenclature for clinical practice. Providers in various disciplines aim to improve their patients’ cognitive functions to strengthen performance in daily activities, communication, or more complex activities at work or school. CRT is often described according to the in- tended outcome of treatment (e.g., improved memory or attention to tasks) or by the method or provider delivering the therapy. For practical purposes, CRT does not differ from occupational therapy, speech-language-pathology, and physical therapy when these treatments intend to reduce or compensate for an underlying cognitive disorder. Therefore, the committee concluded that these types of therapy sessions, when conducted to ameliorate deficits for patients with cognitive impairment, meet the definition of CRT. STATE OF PRACTICE Rehabilitation practice in the United States is affected by health care and related policies. Rehabilitation professionals regard therapy as a means to improve the lives of individuals with disabilities, and thus aid their re- turn to active participation within family and social lives, communities, and work. Increased awareness of traumatic brain injury (TBI) and related cognitive deficits has promoted the rehabilitation needs of cognitively im- paired individuals. At the same time, rising health care costs mean long- term rehabilitation programs are reduced, leading to shorter in-patient stays and condensed outpatient programs (Sohlberg and Mateer 2001). Providers adjust and modify programs to target outcomes as effectively and efficiently 89

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90 COGNITIVE REHABILITATION THERAPY FOR TBI as possible, while constrained by reduced health care funds and time with the patient. The Role of Families Family members, dedicated caretakers, or paraprofessionals provide an important support system to individuals with cognitive or behavioral defi- cits due to TBI, as discussed in Chapter 3. This support system also plays an important role in the rehabilitation process (Sohlberg and Mateer 2001). The changed cognitive or behavioral functioning caused by brain injury not only affects the injured individual, but also places enormous demands on families. Emotional stress, perceived burdens of caretaking, and disrupted family functioning as well as unmet needs of other members of the family may contribute to unhealthy family communication or functioning. Because rising health care costs and the costly nature of neurorehabili- tation have led to shorter inpatient stays, outpatient rehabilitation is an important component of therapy, one that relies on a support person for the injured individual (Harrison-Felix et al. 1996; Kreutzer et al. 2009; Sander et al. 2002). Successful rehabilitation requires cooperation, participation, and encouragement from the patient’s support network for success; ongoing activities may include providing transportation, monitoring or maintaining finances, implementing leisure activities, providing emotional support, and reinforcing newly learned behaviors to compensate for brain injury-related deficits (Jacobs 1988). Long-term treatment efforts require collaboration among the providers, their clients, and the clients’ families (Levack et al. 2009). Garnering family support throughout the treatment process captures a unique resource to maintain treatment effects, provide generalization from clinical applications to real-life situations, and facilitate ongoing recovery (Kreutzer et al. 2003; Malec et al. 1993). These partnerships can help ensure realistic treatment goals considering the expertise, needs, and concerns of client and family (Sohlberg and Mateer 2001). Family stress and unhealthy family communication and roles can hin- der the rehabilitation process; potential barriers arise to successful rehabili- tation outcome when a family member does not align with treatment goals or objectives of the entire team (i.e., patient, clinician, and family) (Levack et al. 2009; Sander et al. 2002). Constructive family functioning has been associated with greater improvement in persons with TBI, lessening overall disability and increasing employability. Ideally, family members or caretak- ers act as facilitators to the brain-injured individual’s care and recovery. Evaluations of CRT interventions sometimes include or require a family member or caregiver to participate in the study, because of the unique capability of caregivers to help translate clinical practices to real-world applications. For example, a provider may demonstrate use of a journal or

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91 STATE OF PRACTICE AND PROVIDERS OF CRT notebook to help an individual with a memory deficit stay on schedule; the provider also instructs the family member to provide prompts for use of the reminder notebook at home. Clinicians provide educational, skill-building, and psychological support components to the family as well as the patient. Results of a few studies have reported benefits to families such as • A greater number of met needs and perception of fewer obstacles to receiving services post-treatment (Kreutzer et al. 2009), • I mprovement in psychological distress (Brown et al. 1999; Sinnakaruppan et al. 2005), and • R educed burden, improved satisfaction with caregiving and in- creased perception of caregiving competency (Albert et al. 2002). Delivery of CRT When, where, and how long CRT is provided are interrelated factors that vary depending on the patient’s needs and means for participating in rehabilitation (e.g., willingness, affordability, family support). Currently, depending on the severity of injury and the patient’s acute recovery, CRT typically includes a wide range of therapeutic ingredients and is practiced by professionals with specific expertise in different settings or environ- ments. The current state of health care provision in the United States, with myriad payers for care, affects how patients receive care. Patients who would benefit from treatment, according to their physicians or ongo- ing research, may not receive prescribed treatments due to limitations in payer plans. Furthermore, when treatment is available, policies unique to individual payer plans may impact treatment type, timing and duration of delivery, the setting in which the treatment is provided, and the professional who provides it. As such, payment policy may affect how treatment is la- beled. When delivered by a member of one of the disciplines described in this chapter, a treatment may be identified as “speech therapy,” even though activities meet the definition of CRT. This may occur when health benefits provide coverage for speech therapy but not CRT. Treatment approaches may include comprehensive inpatient or outpa- tient CRT programs, outpatient CRT delivered by a sole practitioner, or comprehensive CRT programs with multiple providers working together on a team. The individual treatment ingredients of comprehensive, inter- disciplinary rehabilitation programs are not typically recorded. Therefore, ingredients delivered through these programs are harder to quantify for comparison purposes than modular CRT, which is more singularly focused, as described in the prior chapter. There is debate about when and where to deliver CRT. Some advocate for early intervention, while others call for intervention at more chronic recovery stages (Ben-Yishay and Diller 1993).

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92 COGNITIVE REHABILITATION THERAPY FOR TBI Most patients who receive CRT do so as inpatients when their medical status has stabilized. Few patients receive CRT more than 1 year after injury, even though spontaneous neurological recovery will have slowed by this time, and patients are more likely to have better awareness of their limitations and abilities. The timing of CRT is generally dictated by health payer policies, not by when the patient would benefit most from such re- habilitation. Unfortunately, unlike the injury itself, which may be a single discrete event, the effects of TBI may occur across time. Deficits associated with brain injury may require treatment throughout the patient’s lifespan, which is in keeping with the World Health Organization’s International Classification of Functioning and Disability (WHO-ICF) label of “chronic condition.” As patients’ conditions change (improve or decline) due to life transitions (e.g., new job, new home, new city), new cognitive rehabilita- tion treatments may be required. This type of care is similar to the ongoing care provided to patients with other chronic conditions, such as paralysis. Inpatient Care During acute, inpatient rehabilitation, professionals evaluate and treat patients’ cognitive and communication abilities, functional daily activities, physical and mobility skills, and early psychosocial well-being. It is com- mon for this early phase of CRT to aim to increase attention, learning, and basic communication skills, while at the same time reduce disorientation, confusion, and even agitation. Also during this phase, physiatry and reha- bilitation nursing provide important medical care to patients, while social workers and psychologists provide support as families and friends plan for discharge to the patient’s home or another facility. Comprehensive, interdisciplinary inpatient CRT is provided to pa- tients who have recovered from moderate or severe injuries sufficiently to participate (e.g., 3 hours of therapy a day). Based on their needs, patients receive a combination of restorative and compensatory CRT approaches from various professionals on the rehabilitation team. For example, pa- tients who are highly confused and remain in posttraumatic amnesia (PTA) may receive reinforcement for using a simple calendar that logs their daily routine (compensating for poor memory) and work on decontextualized paper- and pencil-tasks aimed at improving their attention skills (restoring sustained attention). Some comprehensive inpatient programs are specifically designed for patients who have severe cognitive impairments that cause serious psycho- logical or behavioral problems, including aggressive and inappropriate be- haviors, which are chronically disabling. These behaviors may cause family crises and render caregivers unable to supervise the patient without the risk of injury. While some patients may be transferred to these programs directly

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93 STATE OF PRACTICE AND PROVIDERS OF CRT from an inpatient multi-disciplinary CRT program, others are admitted after attempts by caregivers have failed at home. Outpatient Care Most individuals with TBI continue to need CRT long after inpatient rehabilitation ends because they have not yet learned the full impact of cognitive deficits on their ability to function at home, in the community, at work, or at school. While severity of injury predicts early and general recovery from TBI, the CRT services that patients receive later depend more on the amount of cognitive recovery, the projected goals and capacity of the patients to eventually reach those goals, and the nature of patients’ cogni- tive strengths and weaknesses. After acute inpatient rehabilitation, CRT approaches vary and be- come even more individualized as patient confusion subsides and attention and memory improve. Individuals who have a combination of cognitive, psychological, or behavioral issues after TBI may participate in a com- prehensive, interdisciplinary outpatient program that “includes individual and group cognitive rehabilitation, psychotherapy, psycho-education, and family therapy” (Tsaousides and Gordon 2009). These patients typically are unable to reintegrate back into the community, find or keep a job, or suc- ceed in college or other training programs. They also may engage in illegal activities and get in trouble with the law or cause family conflicts. Compre- hensive outpatient or day programs are typically for patients who are able to live in less restrictive environments or who have family to care for daily needs. In these programs, providers not only help patients understand and accept limitations and deficits, but also provide strategies to compensate for cognitive or physical deficits (Rath et al. 2003; Wilson et al. 2008). For example, patients may receive CRT through an occupational thera- pist (OT), speech-language pathologist (SLP), and vocational counselor, any one of whom may teach a patient how to manage a weekly schedule or de- velop organizational strategies needed to return to work. Other patients with severe cognitive impairments may have more limited goals that would allow them to be safe at home alone and perform daily activities without assistance. In this case, the OT and SLP may teach the patient to improve self-care activi- ties, to use a cell phone, and to follow explicit instructions in an emergency. Some patients may benefit from modular intervention aimed at strength- ening specific skills. For example, patients who have trouble paying atten- tion in noisy settings or have trouble switching their attention from one task to another may benefit from a combination of direct attention training, edu- cation about attention problems, and practical tools to manage attention problems at home, school, or work. And as patients return home or move to an alternative living environment, CRT can occur within the context in

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94 COGNITIVE REHABILITATION THERAPY FOR TBI which the skills will be used. For example, individuals who are returning to school may learn to use study strategies specifically tailored to their postin- jury learning style. Providing CRT in context allows both the patient and clinician to focus explicitly on techniques and strategies immediately tested and tried (American Speech-Language-Hearing Association 2003; Ylvisaker et al. 2008). Contextualized therapy may also occur in comprehensive treat- ment. When contextualized therapy becomes possible, individuals typically become more aware of how their cognitive impairments may impact return to work, school, and community. Delivery of CRT for Mild TBI The delivery of CRT to patients with mild TBI may differ from the CRT provided to those with moderate or severe TBI, based on when the diagnosis is made and the specificity of symptoms expressed. In civilians with mild TBI, diagnosis can occur immediately after an athletic activ- ity or other incident such as a motor vehicle accident. Not all mild TBIs are diagnosed immediately, however, due to the ubiquitous nature of the symptoms, which are not always recognized as being related to the inci- dent. Likewise, mild TBI in military populations is frequently missed, and diagnosis occurs much later—sometimes not until the patient attempts to reintegrate into the home, community, work, and school. This fact is particularly true for those who have been injured by blasts, as discussed in Chapter 3 (Adamson et al. 2008). When this type of injury occurs, ide- ally the CRT provided would be individualized to the patient’s needs, as would other treatments to address coexisting symptoms such as fatigue, headaches, vertigo, and visual deficits. For example, a male patient with mild TBI may have difficulty paying attention, and thus difficulty keeping track of a daily schedule. An OT or SLP would first educate him about the injury and symptoms; instruct him to use the calendar on an electronic de- vice; have him log his activities and symptoms (e.g., fatigue or headaches) throughout the week so that an activity management plan could be put in place; and assist him in organizing the materials he needs to learn for work. Clinical Practice Guidelines for Mild TBI, from the U.S. Department of Veterans Affairs (VA)/U.S. Department of Defense (DoD), outlines man- agement of concussion or mild TBI, including CRT for those who need it (VA/DoD 2009). Unfortunately, it is unclear how many service members and veterans with TBI receive this care. PROVIDERS Describing the roles of the professionals from the various disciplines that deliver CRT may help provide context for its definition and attributes

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95 STATE OF PRACTICE AND PROVIDERS OF CRT (as described in Chapter 4). The following sections provide descriptions of rehabilitation professionals and their role on the rehabilitation team. In general, an interdisciplinary team of rehabilitation professionals delivers CRT interventions to patients and provides education, training, and sup- port to families or caregivers. These professions include medicine (phys- iatry, neurology), nursing, clinical or neuropsychology, speech-language pathology, occupational therapy, and physical therapy (Prigatano 2005). Other members of the rehabilitation team may include an audiologist, kinesiotherapist, neuro-ophthalmologist, or rehabilitation counselor. The shared intention among disciplines is to improve patients’ cognitive impair- ments that interfere with the ability to function, or help patients learn to function more fully with persistent cognitive impairments, irrespective of strategy. In other words, rehabilitation aims either to restore functioning of an impaired cognitive system or compensate for the adverse effects of an impaired cognitive system by providing strategies and supportive aids or techniques. Professional associations, such as the American Occupational Therapy Association, the American Physical Therapy Association, and the American Speech-Language-Hearing Association, determine the required education and training for providers to become credentialed. U.S. states regulate the licensing requirements for each profession, including education necessary to obtain a license. Requirements for licensing and credentialing of rehabilita- tion providers vary across states. Furthermore, general certification does not indicate all certified professionals are qualified to provide cognitive re- habilitation. Table 5-1 provides information for rehabilitation professionals services, education and training, licensing and credentialing, and the setting in which they work. Due to the diversity of requirements and certifications, the committee did not assess or compare U.S. state requirements for licens- ing and credentialing. However, the committee recognizes the authority of these licensing entities and the consideration of rigorous standards in establishing quality of care within respective disciplines. Overall, rehabilitation professional organizations do not provide or promote continuing education credits in brain injury rehabilitation. How- ever, a voluntary certification is available from the Academy of Certified Brain Injury Specialists (ACBIS). To become a Certified Brain Injury Spe- cialist (CBIS), a professional must demonstrate 500 hours of supervised clinical practice as well as pass the national certification exam provided by ACBIS. No education level is required beyond a high school diploma or the equivalent. The certification exam includes topics such as brain anatomy, brain-behavior relationships, functional impact of brain injury, effective treatment approaches and medical management, as well as the role of families, and legal or ethical issues (ACBIS 2010). In 2010, ACBIS reported 4,207 individuals in the United States were CBISs. As previously

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TABLE 5-1 CRT Providers: Services, Practice Requirements, and Professional Setting 96 Provider Services Education and Training Licensing and Certification Professional Settings Clinical • Assesses, diagnoses, treats, • Doctor of Philosophy The American Psychological • Community mental Psychologist, and prevents mental (Ph.D.) or Doctor of Association (APA) accredits health centers Neuro- disorders Psychology (Psy.D.) doctoral training programs • Crisis counseling or psychologist • Uses a variety of • Courses in quantitative in clinical psychology. drug rehabilitation approaches aimed at experimental methods and centers 170,200 helping individuals through research design, which U.S. states’ licensing boards • Physical psychologists individual, family, or group include the use of computer- determine requirements rehabilitation therapy based analysis, are an for clinical psychologists. settings • Designs and implements integral part of graduate Requirements vary by state, • Private offices behavior modification study and are necessary to and generally include passing • Hospitals programs complete the dissertation. a standardized test and may • Universities and • An approved internship include continuing education medical schools Neuropsychology is a • 1 to 2 years of post- for license renewal. specialization within clinical doctoral, supervised psychology. professional experience Neurologist • Examines patients with • Doctor of medicine (M.D.) The American Board of • Hospitals neurologic disorders (e.g., • 4 years of residency, Psychiatry and Neurology • Outpatient clinics brain injury) or impaired specializing in neurology oversees the competency function of the brain, spinal • Internship examination to certify cord, peripheral nerves, neurologists. Board muscles, autonomic nervous certification ensures system, and related blood specialized skills and vessels knowledge to diagnose • Generally sees patients and treat specific problems referred by other and to provide medical physicians, but can serve management for a range of as the primary physician problems. for ongoing neurological disorders

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• Investigates, diagnoses, U.S. states regulate the and treats neurological licensing of physiatrists, and disorders. Diagnostic tests requirements vary by state. include: Licensing requires physicians ▪ Computed axial pass the U.S. Medical tomography (CAT) Licensing Examination ▪ Magnetic resonance (USMLE). imaging (MRI) ▪ Ultrasound ▪ Electroencephalography (EEG) ▪ Electromyography (EMG) Registered Nurse • Assesses, plans, implements, • Education levels vary Rehabilitation nurses • Acute care and evaluates the care of a among registered nurses are credentialed as a • Assisted living > 10,000 hospitalized patient (RNs) Certified Rehabilitation facilities rehabilitation • Promotes optimal • Education includes courses Registered Nurse (CRRN). • Community re- nurses functioning in anatomy, physiology, The Association for integration programs • Works with physicians microbiology, chemistry, Rehabilitation Nurses • Hospitals ~ 3,000 (e.g., physiatrist or nutrition, psychology, other oversees the certification of • Outpatient clinics neuroscience neurologist) to obtain behavioral sciences, and CRRNs. Requirements for • Rehabilitation units nurses detailed patient history and nursing. CRRN certification include or programs a comprehensive evaluation • Supervised clinical 2 years of recent practice in • Residential • Provides patient and experience required rehabilitation nursing, or communities family education, behavior a combination of one year • Universities and management, and of current practice as an medical schools management of the patient RN and 1 year of graduate environment study. . 97 continued

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TABLE 5-1 Continued 98 Provider Services Education and Training Licensing and Certification Professional Settings Neuroscience nurses are credentialed as a Certified Neuroscience Registered Nurse (CNRN). The American Association of Neuroscience Nurses oversees the certification of CNRNs. Requirements include 4,160 hours of recent experience in neuroscience nursing practice and passing a certification examination. U.S. states regulate the licensing for registered nurses (RNs), generally requiring graduation from an approved nursing program and passing the National Council Licensure Examination (NCLEX-RN).

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Physiatrist • Trained in the physical • Doctor of medicine (M.D.) The American Board of • Hospitals medicine and rehabilitation • 4 years of residency, Physical Medicine and • Outpatient clinics ~ 8,300 board (PM&R) specialty specializing in physical Rehabilitation (ABPMR) • Private offices certified • Aims to restore maximum medicine and rehabilitation oversees the competency • Rehabilitation physiatrists function lost through • Internship examination to certify centers injury, illness, or disabling physiatrists. Board conditions, affecting any certification ensures skills organ system and knowledge to diagnose • Provides assessment, and treat specific problems diagnosis, and nonsurgical and to provide medical interventions management for a range of • Develops treatment plans conditions. and leads a team of medical professionals U.S. states regulate the • Facilitates education to licensing of physiatrists, and patients and families about requirements vary by state. impairments Licensing requires physicians pass the U.S. Medical Licensing Examination (USMLE). 99 continued

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102 COGNITIVE REHABILITATION THERAPY FOR TBI mentioned, providers are not required to obtain certification, and many more professionals may be qualified via completed supervisory hours to provide cognitive rehabilitation services. Physiatrist Physiatrists are physical medicine and rehabilitation physicians with expertise in treating the impairments and disabilities resulting from a variety of conditions. Board-certified physiatrists in the United States are trained to diagnose, treat, and direct a rehabilitation plan to achieve op- timal patient outcomes. The physiatrist provides leadership for an inter- disciplinary rehabilitation team that may include occupational therapists, physical therapists, recreational therapists, rehabilitation nurses, psycholo- gists, social workers, and speech-language pathologists. Based on a medi- cal evaluation, the physiatrist designs and coordinates a treatment plan to address the whole person, considering physical, cognitive, emotional, and social needs. Treatment plans aim to maximize functional capacity and restore quality of life as much as possible. Physiatrists include the family or primary caregiver in an overall rehabilitation program and arrange family conferences as necessary (AAP 1999). Physiatrists earn a medical degree and complete a residency in physical medicine and rehabilitation; they receive certification from the American Board of Physical Medicine and Rehabilitation. Physiatrists can prescribe pharmacological and behavioral interven- tions for the treatment of related disturbances occurring as a result of brain injury. The range of psychiatric disturbances that may follow brain injury is extensive (see Chapter 3). Preinjury conditions such as personal- ity disorders, psychiatric disturbance, and genetic predisposition may also complicate recovery from brain injury. Physiatrists are trained to address these conditions or provide the most appropriate referral to another spe- cialist on the team. Neurologist and Neurosurgeon A neurologist is a medical doctor specializing in diagnosing, treating, and managing disorders of the brain and nervous system. A neurologist assesses and treats neurological deficits resulting from TBI, with emphasis on physical impairments, such as movement disorders, seizures, and pain. Neurologists may also address neurobehavioral conditions, such as mood problems, or cognitive conditions, such as memory deficits. A neurologist can help distinguish between varied disorders (for example, mild TBI shares symptoms of other neurogenic disorders), and then design the most appro- priate treatment plan for the patient, as treatment plans may not be identi-

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103 STATE OF PRACTICE AND PROVIDERS OF CRT cal for these different conditions. Neurologists earn a medical degree and complete a residency in neurology, which includes training in rehabilitation aspects of neurology as well as behavioral and cognitive neurology; they receive certification from the American Board on Psychiatry and Neurology. Neurologists can recommend surgical treatment, but they do not perform surgery. When treatment includes surgery, neurologists may monitor the patients and supervise their continuing treatment. Neurosurgeons are medi- cal doctors who specialize in performing surgical treatments of the brain or nervous system; neurosurgeons are typically involved primarily in the acute phase. Neurosurgical evaluations diagnose or rule out the presence of con- ditions requiring neurosurgical attention (e.g., hematomas, skull fractures, elevated intracranial pressure), or deliver differential diagnoses that may require other, focused treatments. Registered Nurse The registered nurse (RN) is responsible for the assessment, planning, implementation, and evaluation of the care of a hospitalized patient with a brain injury. The RN’s activities serve to promote optimal functioning. For example, the RN’s role in cognitive rehabilitation includes working with physicians (e.g., physiatrist or neurologist) to obtain detailed patient history and a comprehensive neurological evaluation. In addition, nursing care includes patient and family education, behavior management, and management of the patient environment (U.S. Department of Labor 2011a). Registered nurses must graduate from an accredited school of nursing and pass a state RN licensing examination called the National Council Licensure Examination for Registered Nurses (NCLEX-RN). A nurse pro- viding rehabilitative care to patients with TBI may be either a Certified Rehabilitation Registered Nurse (CRRN) or a Certified Neuroscience Regis- tered Nurse (CNRN). The Association for Rehabilitation Nurses comprises autonomous programs to oversee the certification of CRRNs. The Ameri- can Board of Neuroscience Nurses oversees the certification of CNRNs. The American Board of Nursing Specialties accredits these speciality orga- nizations. In 2011, the Association of Rehabilitation Nurses (ARN) and the American Association of Neuroscience Nurses (AANN) jointly published a clinical practice guideline for care of patients with mild TBI. Occupational Therapist An OT is the function expert who works with patients across the lifespan of the treatment to improve everyday function in daily routines. Common OT interventions include helping people who are recovering from brain injury to regain skills as they experience physical and cognitive

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104 COGNITIVE REHABILITATION THERAPY FOR TBI changes (e.g., visual deficits, cognitive and perceptual abilities to perform tasks in complex and multi-stimuli environments). The OT completes an individualized and comprehensive assessment of patients’ skills and treatment goals, often with support from patients and their family or caregiver. The OT designs customized interventions to improve patients’ ability to perform daily activities and reach their goals. Treatment goals are designed to enable patients to best manage their daily tasks, including self-care (feeding and dressing) and tasks in the community (shopping, driving, school, and work activities). Throughout treatment, OTs evaluate patient outcomes to ensure goals are being met and change the interven- tion plan as appropriate (American Occupational Therapy Association 2002, 2011). To accomplish overall treatment goals, patients may need to use special techniques, modify their physical environment, or use equipment ranging from simple memory aids to more advanced computers and environmental controls. To help them with these tasks, OTs provide services such as a com- prehensive evaluation of the patient’s home and other environments (e.g., workplace, school), recommendations for adaptive equipment and training in its use, and guidance and education for family members and caregivers (American Occupational Therapy Association 2002, 2011). Together with SLPs, OTs are among typical providers of CRT (Ashley and Persel 2003). The minimum requirement for entry into occupational therapy is a master’s degree from an academic program accredited by the Accreditation Council for Occupational Therapy Education (ACOTE). For national accreditation and licensure, OTs must pass an exam provided by ACOTE. Those who pass the exam become an Occupational Therapist Registered (OTR). The American Occupational Therapy Association over- sees the certification program by which OTs confirm their competencies. An OT may receive certification by board (e.g., physical rehabilitation or mental health) or specialty (e.g., driving and community mobility, feeding or swallowing). These certifications are renewed every 5 years, and qualified OTs must have completed a specific number of practice hours in order to be eligible (Golisz 2009). Physical Therapist Physical therapists provide assessment and treatment for balance dis- orders, dizziness, functional mobility, physical problems, and pain, all of which may result from or be related to TBI. Physical therapists can evaluate and address peripheral nerve and musculoskeletal injuries as well as weakness and balance issues related to brain trauma. Treatment goals include improving mobility, increasing strength, decreasing joint stiffness, improving static and dynamic balance, decreasing vertigo and dizziness, and

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105 STATE OF PRACTICE AND PROVIDERS OF CRT managing pain and discomfort. Physical therapists also evaluate a patient’s need for equipment, such as canes or braces, to improve safety and endur- ance. Physical therapists practice in hospitals, outpatient clinics, and private offices that have specially equipped facilities (American Physical Therapy Association 2003). Typical requirements for physical therapists include a graduate degree from an accredited physical therapy education program; passing the Na- tional Physical Therapy Examination; and fulfilling state requirements such as jurisprudence exams. A number of states require continuing education as a condition of maintaining licensure. The American Physical Therapy As- sociation’s accrediting body, the Commission on Accreditation of Physical Therapy Education (CAPTE), accredits graduate degree academic programs in physical therapy. These programs include foundational science courses such as biology, anatomy, physiology, cellular histology, exercise physiology, neuroscience, biomechanics, pharmacology, pathology, and radiology/imag- ing, as well as behavioral science courses such as evidence-based practice and clinical reasoning. Some of the clinically based courses include medical screening, examination tests and measures, diagnostic process, therapeutic interventions, outcomes assessment, and practice management. In addition to classroom and laboratory instruction, students receive supervised clinical experience (U.S. Department of Labor 2011b). Speech-Language Pathologist SLPs assist patients who have speech, language, and cognitive prob- lems in gaining optimal communication skills. For patients with cognitive impairments from TBI, SLPs evaluate and provide intervention for the underlying cognitive deficits responsible for communication behavior in everyday life. Communication problems may include difficulty understand- ing complex and abstract written or verbal information, finding words and expressing coherent ideas, and using language in interpersonal relations. SLPs also address transitions to school and work. Underlying cognitive problems that may be caused by TBI, such as difficulty paying attention, learning and remembering information, organizing ideas, reasoning, and solving problems, all interfere with communication skills and the ability to broadly interact in the environment (school, work, home, or community). The American Speech-Language-Hearing Association (ASHA) endorses the use of the WHO-ICF to describe management of cognitive and communica- tion disorders after TBI. Together with OTs, SLPs are among the most typical providers of CRT (American Speech-Language-Hearing Association 2005; Ylvisaker et al. 2003). Typical licensing requirements are a master’s degree from an ac- credited college or university; a passing score on the Praxis Examinations

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106 COGNITIVE REHABILITATION THERAPY FOR TBI in Audiology and Speech-Language Pathology, the national examination for certification in speech-language pathology, offered through the Praxis Series of the Educational Testing Service; 300 to 375 hours of supervised clinical experience; and 9 months of postgraduate professional clinical ex- perience. Most states have continuing education requirements for licensure renewal. Medicaid, Medicare, and private health insurers generally require a practitioner to be licensed to qualify for reimbursement. The Council on Academic Accreditation, an entity of ASHA, accredits postsecondary academic programs in speech-language pathology. Furthermore, a gradu- ate degree is required for ASHA credentialing. Speech-language pathology courses cover anatomy, physiology, and the development of the areas of the body involved in speech, language, and swallowing; the nature of disorders; principles of acoustics; and psychological aspects of communication. SLP graduate students may also learn to evaluate and treat speech, language, and swallowing disorders as part of a curriculum in supervised clinical practice (U.S. Department of Labor 2011c). Neuropsychologist A neuropsychologist (psychologist) is the key player in diagnosing cognitive impairments and emotional and behavioral sequelae of TBI. A neuropsychological assessment evaluates the areas of intellectual function- ing: attention and concentration, problem solving and judgment, memory and learning, and flexibility of thought and speed of information process- ing. Evaluations in these areas help patients and families understand the nature and severity of deficits and assist other team members when plan- ning patient treatment programs. Treatment services provided by neuro- psychologists are designed to help patients achieve maximum benefit from the rehabilitation program and to help them manage adjustment problems. Counseling may be offered to patients and family members who wish to know more about brain injury and who may be having difficulty coping with family and/or work-related stress. Clinical neuropsychologists are a subset of psychologists “dedicated to the understanding of brain–behavior relationships and applying this knowl- edge to human problems, in particular to persons with brain disorders” (CRSPPP 1996). The recommended education and training for licensure and accreditation includes a graduate degree in professional psychology, and relevant brain–behavior knowledge and clinical neuropsychology prac- tice skills. Knowledge and skills are generally developed through a doctoral program and related internships (Boake 2008).

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107 STATE OF PRACTICE AND PROVIDERS OF CRT Recreational Therapist Recreational therapists assist people with brain injury in resuming community life by helping them participate in play and leisure activities. Through leisure counseling, leisure education, leisure skills development, aquatic education, adaptive sports, resocialization programs, and commu- nity readjustment outings, people with brain injury learn how to participate in community life. Recreational therapists assess individuals through obser- vations; medical records; standardized assessments; and consultations with medical members of the rehabilitation team, with patients themselves, and with their families. Recreational therapists use this information for devel- oping and implementing therapeutic interventions consistent with clients’ goals. For example, a recreational therapist may encourage a client who is isolated from others or who has limited social skills to play games with oth- ers. Therapists may teach right-handed people with right-side paralysis how to use their unaffected left side to throw a ball or swing a racket. Recre- ational therapists may teach patients relaxation techniques to reduce stress and tension, stretching and limbering exercises, proper body mechanics for participation in recreational activities, pacing and energy conservation techniques, and team activities (U.S. Department of Labor 2011d). In acute settings such as hospitals and rehabilitation centers, recre- ational therapists treat individuals with specific health conditions, usually in conjunction or collaboration with physicians, nurses, psychologists, social workers, and physical and occupational therapists. In long-term and residential care facilities, recreational therapists use leisure activities— specially structured group programs—to improve and maintain patients’ general health and quality of life. Community-based recreational therapists may work in park and recreation departments; special education programs within school districts; or assisted living, adult day care, and substance abuse rehabilitation centers. In these facilities, they work on specific skills with patients and provide opportunities for exercise, mental stimulation, creativity, and fun (U.S. Department of Labor 2011d). Most entry-level recreational therapists need a bachelor’s degree in therapeutic recreation. A few may qualify with some combination of educa- tion, training, and work experience that would be equivalent to competency in the field. Therapeutic recreation education programs include courses in assessment, treatment and program planning, intervention design, and evaluation. Education also includes the study of human anatomy, physiol- ogy, abnormal psychology, medical and psychiatric terminology, character- istics of illnesses and disabilities, professional ethics, and the use of assistive devices and technology. Work in clinical settings often requires certification by the National Council for Therapeutic Recreation Certification. The

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108 COGNITIVE REHABILITATION THERAPY FOR TBI Council offers the Certified Therapeutic Recreation Specialist credential to candidates who pass a written certification examination and complete a supervised internship of at least 480 hours. Therapists must meet additional requirements to maintain certification (U.S. Department of Labor 2011d). Social Worker Social workers help patients and their families respond to social, emo- tional, or financial problems resulting from physical disability or chronic illness. Treatment modalities include individual and group psychotherapy, crisis intervention, family counseling, and family support groups. Social workers explore community resources and entitlement programs available to the patient and family. They may arrange for at-home services, such as meals-on-wheels or home care. Some social workers help people who face a disability, life-threatening disease, substance abuse, or social problem, such as inadequate housing or unemployment. Social workers also assist families who have serious domestic conflicts, sometimes involving child or spousal abuse. Some work on interdisciplinary teams that evaluate and treat certain kinds of patients, such as geriatric or organ transplant patients. Many social workers specialize in serving a particular population or working in a spe- cific setting, such as a hospital, nursing and personal care facility, individual and family services agency, or local government (U.S. Department of Labor 2011d). In all settings, these professionals may be called Licensed Clinical Social Workers (LCSWs) if they hold the appropriate license. Additionally, social workers may conduct research, advocate for improved services, or become involved in planning or policy development. A bachelor’s degree in social work is the most common minimum re- quirement to become a social worker; however, majors in psychology, soci- ology, and related fields may qualify for some entry-level jobs, especially in small community agencies. Although a bachelor’s degree is sufficient for entry into the field, an advanced degree is required for some positions. A Master of Social Work (MSW) is required for clinical work and typically required for positions in other health or school settings. U.S. states maintain the licens- ing, certification, or registration requirements regarding social work practice. Most states require 2 years or 3,000 hours of supervised clinical experience for licensure of clinical social workers (U.S. Department of Labor 2011e). Other Members of the Rehabilitation Team Audiologist Audiologists evaluate hearing deficits and determine the type of hearing loss. Hearing changes after TBI may include tinnitus or loss of acuity, espe- cially in noisy environments. Hearing aids may or may not be prescribed,

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109 STATE OF PRACTICE AND PROVIDERS OF CRT depending upon the nature and severity of the problem. Audiologists may also be involved in diagnosing vestibular deficits (i.e., vertigo) that may lead to balance problems. A doctoral degree from an accredited institution is required to practice as an audiologist. The Council on Academic Ac- creditation (CAA)—an entity of the ASHA—accredits education programs in audiology. U.S. states regulate licensing. Kinesiotherapist A kinesiotherapist can recommend a cardiovascular conditioning pro- gram that promotes wellness and reduces the risk of injury or further dis- ability, generally to improve extended periods of physical exertion. The American Kinesiotherapy Association defines kinesiotherapy as “the ap- plication of scientifically based exercise principles adapted to enhance the strength, endurance, and mobility of individuals with functional limitations or those requiring extended physical conditioning” (American Kinesio- therapy Association 2011). Because fitness can enhance a person’s mental and physical stamina, reduce pain, and elevate feelings of well being, the goals of kinesiotherapy align well with CRT. The physical conditioning program should be initiated in the health care facility and gradually trans- ferred to a community gym as the person becomes more independent. Ki- nesiotherapists work with physicians or nurses on the rehabilitation team who prescribe and direct services for patients, which then is delivered by kinesiotherapists. Kinesiotherapy is commonly provided to soldiers due to the extended physical exertion often required by military profession. Neuro-Ophthalmologist Neuro-ophthalmology is a subspecialty of both neurology and ophthal- mology. Neuro-opthalmologists may address double vision, blurry vision, or other visual deficits following brain injury. Deficits in the visual system are often overlooked in mild TBI. A common visual deficit after mild TBI is convergence insufficiency, which is often described by the person as “blurry” vision. The neuro-ophthalmology evaluation should rule out potential eye damage involving the cornea, retina, vitreous fluids, occipital lobe (visual cortex), and optic nerve functioning. Therapeutic intervention may involve prism glasses and/or eye exercises. Training and education follows the guidelines for physicians pursuing a subspecialty, with the ac- companying residencies and certifications. Rehabilitation Counselor Rehabilitation counselors deal with the key issues regarding work reentry. They consult, and may provide a vocational evaluation covering

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110 COGNITIVE REHABILITATION THERAPY FOR TBI vocational interest, work values, academic testing, etc., to complement the neuropsychological evaluation in setting work-relevant goals. Rehabilita- tion counselors may act as a treatment coordinator for patients who have difficulty returning to work after brain injury. Some rehabilitation counsel- ors set up community-based functional vocational evaluations or may do active job placement and retention. In addition, rehabilitation counselors may help develop collaborative relationships between clients and their em- ployer or coworkers. Licensed rehabilitation counselors often must have a master’s degree. U.S. states regulate licensing for counselors. Voluntary certification is available through the Commission on Rehabilitation Coun- selor Certification. CONCLUSION The overall goal of rehabilitation is to improve functioning and quality of life of the patient with chronic disease or disability. Factors such as who provides CRT and for how long is it provided are interrelated factors that vary depending on the patient’s needs and ability for participating in reha- bilitation. Providers work in multi-disciplinary teams to design and imple- ment treatments plans that meet the goals of patients and their families. Because U.S. states regulate the licensure requirements for each profession, and a variety of professional organizations determine accrediting standards, a unified brain injury rehabilitation specialty or related requirements do not exist for most professions. REFERENCES AAP (Association of Academic Physiatrists). 1999. About our field. http://www.physiatry.org/ Field_Section.cfm (accessed July 14, 2011). ACBIS (Academy of Certified Brain Injury Specialists). 2010. Home. http://www.acbis.pro/ index.html (accessed June 30, 2011). Adamson, D. M., M. A. Burnam, R. M. Burns, L. B. Caldarone, R. A. Cox, E. D’Amico, C. Diaz, C. Eibner, G. Fisher, T. C. Helmus, T. Tanielian, B. R. Karney, B. Kilmer, G. N. Marshall, L. T. Martin, L. S. Meredith, K. N. Metscher, K. C. Osilla, R. L. Pacula, R. Ramchand, J. S. Ringel, T. L. Schell, J. M. Sollinger, L. H. Jaycox, M. E. Vaiana, K. M. Williams, and M. R. Yochelson. 2008. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Edited by T. Tanielian and L. H. Jaycox. Santa Monica: RAND Corporation. http://www.rand.org/ pubs/monographs/MG720.html (accessed March 11, 2011). Albert, S. M., A. Im, L. Brenner, M. Smith, and R. Waxman. 2002. Effect of a social work liaison program on family caregivers to people with brain injury. Journal of Head Trauma Rehabilitation 17(2):175–189. American Kinesiotherapy Association. 2011. American kinesiotherapy association. http://akta. org/ (accessed July 12, 2011).

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