Bibliography of Research Articles Concerning Computer-Assisted Cognitive Rehabilitation Therapy

Most research on computerized cognitive rehabilitation (CCR) for individuals with traumatic brain injury has focused on the process of the intervention and its immediate impact on memory and cognitive functioning. Few studies have examined the long term impact on CCR on an individual’s functioning. Even in a study where longer term outcomes were evaluated, the follow-up periods were six to twelve months and focused primarily on memory functioning. This case study describes the long term outcome of a middle aged male who had a traumatic brain injury as a result of hypoxia secondary to a heart attack. The patient had received CCR daily during the period of inpatient hospitalization. The CCR consisted of the PSSCogRehab program, which incorporates rehearsal, compensation, and strategies in various activities of daily living including in vivo trips to the grocery store and route finding. After discharge from the inpatient unit, the patient self administered the CCR protocol twice daily with supervised administration weekly and individual and couples psychotherapy twice a week. ver a period of two years, this was tapered to one psychotherapy session per week during which a few minutes were allotted to go over his progress on the CCR program and make adjustments, as necessary. A qualitative methodology utilizing written questionnaires and follow-up interviews was used to collect information in the areas of executive, interpersonal, and social functioning. This outcome study documents the return of functioning in cognitive abilities of an individual seven years post-injury. Executive, interpersonal, and social skills were also discussed.

This study was designed in an attempt to determine whether computer-assisted cognitive retraining was anymore effective in remediating the cognitive sequelae of severe closed head injury than were comparable noncomputerized cognitive treatment techniques.  The experimental group was comprised of 17 severe closed head injuried patients and the noncomputerized control group had 17 patients.  Each group received 20 hours of cognitive therapy over a four to six week period.  The anaylsis revealed that on all measures there was a significant improvement in the level of performance on the experimental and the control subjects at the time of the posttreatment assessment compared to the pretreatment assessment.

No abstract.

This study examined sixty five patients with schizophrenia or schizoaffective disorder randomly assigned to neurocognitive enhancement therapy (NET) with work therapy (WT) or WT alone.  Neurocognitive enhancement therapy included computer-based training on attention, memory, and executive function tasks; an information processing group; and feedback on cognitive performance in the workplace.  Work therapy included paid work activity in job placements at the medical center (eg. mail room, gorunds, library) with accompanying supports.  Neuropsychological testing was performed at intake and 5 months later.  Prior to enrollment, both groups did poorly on neuropsychological testing.  The results showed patients receiving NET + WT showed greater improvements on pretest-posttest variables of executive function, working memory, and affect recognition.  As many as 60% in the NET + WT group improved on some measures and were 4 to 5 times more lilkely to show large effect size improvements.  The number of patients with normal working memory performance increased significantly with NET + WT, from 45% to 77%, compared with a decrease from 56% to 45% for those receiving WT. These results demonstrate that the benefits of computerized cognitive training for cognitive dysfunction in patients with schizophrenia can generalize to independent outcome measures.

No abstract.

Both computer-assisted classroom education and computer-assisted cognitive rehabilitation are established in learning and rehabilitation methods.  The use of rehabilitation techniques for the development of foundational cognitive skills in the general populations of school children has gone untested.  This experiment demonstrates the utility of computer-assisted cognitive skills training for improving the intellectual functioning of 12 to 14 year-old children.  Eighty middle school students participated in a 9-week study.  The students enrolled in either a computer-assisted cognitive skills training group (which utilized computerized exercises modified from brain injury rehabilitation applications) or a study hall control group.  A significant increase in intellectual functioning (p<.01) was found only in the experimental group for Full Scale and Performance IQ scores as measured by Jackson's Multidimensional Aptitude Battery.  This is an indication of the possible benefits of a computerized cognitive skills training program focused on training attentional, executive, visuospatial, and problem solving skills.

The Brain Injury Association of America (BIAA) adopted this position paper in November 2006 to call attention to the need for treatment of cognitive dysfunction. The paper provides definitions and principles for the application of cognitive rehabilitation, discusses research evidence for the efficacy of treatment and highlights the burden on individuals and their caregivers resulting from limitations and denials of service coverage. BIAA acknowledges the need for additional research, further development of clinical guidelines and modification to public systems of care and private sector insurance policies. The fact that research questions remain about cognitive rehabilitation and that techniques are constantly being improved should not be an excuse to withhold payer support for treatment. Individuals with brain injury must have access to cognitive rehabilitation that is of sufficient scope, duration and intensity and is available as cognitive skills and related problems change over time. Availability, accessibility and ease of movement among services in systems of care for persons with brain injury must be improved.

Patients with chronic psychiatric disorders have been found to have significant cognitive deficits. This study examined the effectiveness of computer assisted cognitive rehabilitation on 69 inpatients diagnosed with psychotic disorders at a V.A. Medical Center. The treatment group (N = 40) showed significant improvement on most memory subtests of the Wechsler Memory Scale, as well as on the Trailmaking Test (Parts A and B), and reported significantly fewer cognitive complaints. Control subjects (N = 29) showed no changes on these variables. These results indicate that psychiatric patients can productively work with computers, and that computer-assisted cognitive rehabilitation can produce short-term improvements in psychiatric inpatients' cognitive performance.

This study examined the efficacy of computer-assisted cognitive rehabilitation (CACR) in persons with traumatic brain injury (TBI). Twenty persons with TBI who received hierarchically based CACR following inpatient neurorehabilitation were compared to a control group of twenty persons with TBI matched for age, education, days in coma and time between testing. The control group received traditional outpatient therapies including OT, PT and Speech Therapy. The difference between pre- and post- treatment neuropsychological test scores was used to measure improvements in the domains of attention, visual spatial ability, memory and problem solving.  The Computer Assisted Cognitive Rehabilitation Therapy group made statistically significant gains in cognitive/intellectual functioning on 16 neuropsychological test measures while the Traditional Therapy group make statistically significant gains on 7 measures.

This article establishes evidence-based recommendations for the clinical practice of cognitive rehabilitation, derived from a methodical review of the scientific literature concerning the effectiveness of cognitive rehabilitation for persons with traumatic brain injury (TBI) or stroke.  A literature review resulted in articles being assigned to 1 of 7 catergories according to their primary area of intervention: attention, visual perception and constructional abilities, language and communication, memory, problem solving and comprehensive-holistic cognitive rehabilitation.  All articles were independently reviewed by at least 2 committee members and abstracted according to specified criteria.  The 171 studies that passed initial interview were classified according to the strength of their methods.  Class I studies were defined as prospective, randomized controlled trials.  Class II studies were defined as prospective cohort studies, retrospective case control studies, or clinical series with well-designed controls.  Class III studies were defined as clincial series without concurrent controls, or studies with appropriate single-subject methodology.  The overall evidence within each predefined area of intervention was then synthesized and recommendations were derived based on consideration of the relative strengths of the evidence.  The resulting practice parameters were organized into three types of recommendations:  Practice Standards, Practice Guidelines, and Practice Options.  Overall, support exists for the effectiveness of several forms of cognitive rehabilitation for persons with stroke and TBI.  Specific recommendations can be made for remediation of language and perception after left and right hemisphere stroke, respectively, and for remediation of attention, memory, functional communication, and executive functioning after TBI.

Despite increasing awareness of the extent and severity of cognitive deficits in major depressive disorder (MDD), trials of cognitive remediation have not been conducted. We conducted a 10-week course of cognitive remediation in patients with long-term MDD to probe whether deficits in four targeted cognitive domains, (i) memory, (ii) attention, (iii) executive functioning and (iv) psychomotor speed, could be improved by this intervention. We administered a computerized cognitive retraining package (PSSCogRehab) with demonstrated efficacy to 12 stable patients with recurrent MDD. Twelve matched patients with MDD and a group of healthy control participants were included for comparison; neither comparator group received the intervention that involved stimulation of cognitive functions through targeted, repetitive exercises in each domain. Patients who received cognitive training improved on a range of neuropsychological tests targeted attention, verbal learning and memory, psychomotor speed and executive function. This improvement exceeded that observed over the same time period in a group of matched comparisons. There was no change in depressive symptoms scores over the course of the trial, thus improvement in cognitive performance occurred independent of other illness variables. These results provide preliminary evidence that improvement of cognitive functions through targeted, repetitive exercises is a viable method of cognitive remediation in patients with recurrent MDD.

Patients engaged in drug abuse treatment who also had cognitive impairment (N=72), mandated by the criminal justice system to complete at least 6 months of treatment in a residential program, were randomly assigned to one of four groups.  One group of patients (n=18) received 2 hours of computer-assisted cognitive rehabilitation per week over a 6 month period; a second group (n=18) received 2 hours of progressive muscle relaxation per week over a 6 month period; a third group (n=18) was taught typing on a computer; and a fourth group (n=18) received no treatment beyond that provided by the program.  All patients were tested with a neuropsychological test battery upon admission and at monthly intervals thereafter for 6 months.  Results indicated that residents in the cognitive rehabilitation group demonstrated a faster rate of cognitive recovery during the first 2 months of treatment and had more efficient cognitive functioning over the first 4 months of residence.  These patients were also rated as more "appropriately participatory" in the treatment program by the clinical staff.  Clinical implications of these findings are discussed.

This case report illustrates a neuropsychological approach to the priniciples and practice of cognitive remediation, and the potential application of microcomputer-assisted procedures in remediating certain aspects of cognitive impairment.  Initial neuropsychological evaluation of this patient indicated acquired impairment in a number of aspects of cognitive functioning.  An individually designed and systematically implemented programme of microcomputer exercises then focused on remediation on these particular deficits.  A general improvement in performance on the microcomputer exercises was observed during the course of the retraining programme.  Follow-up neuropsychological evaluation further indicated significant gain in new learning and problem solving skills, mental flexibility, and psychomotor functioning.  These findings strongly suggested generalization of the gains made on the microcomputer to independent test performance.  The implications of this case demonstration are discussed in terms of further delineating both the methods and parameters of such an approach to cognitive remediation, as well as the need to view such treatment efforts within the context of the overall rehabilitation process.

The research documenting neuropsychological deficits has consistently shown impairments in abstract reasoning ability, visuospatial and visuomotor ability, and learning and memory skills.  Despite these findings, it appears that many alcohol treatment clinicians interpret patient behavior from a psychological perspective and treatment programs make unwarranted assumptions about patients' ability to profit from standard treatment approaches.  This report discusses these isssues, and presents an outline of an innovative cognitive rehabilitation program designed specifically to meet the needs of neuropsychologically impaired alcoholic patients.

It is now fairly well established that people with aphasia have impairments in some forms of attention. However, the interaction of attention and linguistic performance is not fully understood. Attention may play an important role in conversational success. Unlike the traumatic brain injured population, there are very few reports of attempts to improve attention in people with aphasia. This report will look at improved performance on attention training tasks, improved performance on the Comprehensive Trail Making Test and the Integrated Visual and Auditory Continuous Performance Test and improved performance on the Porch Index of Communicative Ability (PICA) test and the measure of conversational success. The participant was a 62 year old female with a unilateral left hemisphere CVA and was 9 years post injury. She demonstrated chronic borderline fluent aphasia but had good repetition and auditory comprehension. Baseline and post-treatment testing was completed over six consecutive days immediately preceding/proceeding treatment. The treatment was delivered in 1-hour sessions, 5-days per week, over the course of 12 weeks. The treatment consisted of selected computerized tasks designed to improve attention skills from the PSSCogRehab software program. Although results of a case study must always be interpreted with caution, this case strengthens the understanding of the emerging relationship between attention, linguistic processing and functional communication in people with aphasia. The results suggest that treatment of attention in aphasia – even in someone years post-onset – may produce measurable changes in their attention skills and in their conversational communication. The lack of change on linguistic measures supports the idea that attention/executive functions play a more integral role in functional communication that isolated linguistic performances.

Deficits in social cognition and neurocognition are believed to underlie schizophrenia disability. Attempts at rehabilitation have had circumscribed effects on cognition, without concurrent improvement in broad aspects of behavior and adjustment. The objective was to determine the differential effects of cognitive enhancement therapy (a recovery-phase intervention) on cognition and behavior compared with state-of-the-art enriched supportive therapy. A total of 121 symptomatically stable, non-substance abusing but cognitively disabled and chronically ill patients with schizophrenia and schizoaffective disorder were used in this study. They were chosen from an outpatient research clinic housed in a medical center’s comprehensive care service for patients with severe mental illness. A 2-year, randomized controlled study was conducted with neuropsychological and behavioral assessments completed at baseline and at 12 and 24 months. The intervention used was cognitive enhancement therapy a multidimensional, developmental approach that integrates computer-assisted training in neurocognition with social cognitive group exercises. Six highly reliable summary measures – Processing Speed, Neurocognition, Cognitive Style, Social Cognition, Social Adjustment and Symptoms – were tested using analysis of covariance and linear tread analysis. At 12 months, robust cognitive enhancement therapy effects were observed on the Neurocognition and Processing Speed composites (P<.003), with marginal effects observed on the behavioral composites. By 24 months, differential cognitive enhancement therapy effects were again observed for the two neuropsychological composites and for Cognitive Style (P=.001), Social Cognition (P=.001), and Social Adjustment (P=.01). As expected, no differences were observed on the residual Symptoms composite. Effects were unrelated to the type of antipsychotic medication received. Enriched supportive therapy also demonstrated statistically significant within-group effect sizes, suggesting that supportive psychotherapy can also have positive, although more modest, effects on cognitive deficits.

Cognitive Enhancement Therapy (CET) is a developmental approach to the rehabilitation of schizophrenia patients that attempts to facilitate an abstracting and "gistful" social cognition as a compensatory alternative to the more demanding and controlled cognitive strategies that often characterize schizophrenia as well as much of its treatment.  Selected cognitive processes that developmentally underlie the capacity to acquire adult social cognition have been operationalized in the form of relevant interactive software and social group exercises.  Treatment methods address the impairments, disabilities, and social handicaps associated with cognitive styles that appear to underlie the positive, negative, and disorganized symptom domains of schizophrenia.  Style-related failures in secondary rather than primary socialization, particularly social cognitive deficits in context appraisal and perspective taking, are targeted goals.  Illustrative examples of the techniques used to address social and nonsocial cognitive deficits are provided, together with encouraging preliminary observations regarding the efficiacy of CET.

A critical review of randomized, controlled trials of extended programs of neurocognitive rehabilitation for the cognitive deficits characteristic of schizophrenia conducted between the years 2000 to 2002 was completed.  Over the past several years, two models of cognitive rehabilitation have emerged.  In one model, labeled "cognitive remediation," cognitive deficits are treated directly through repeated practice and acquisition of compensatory strategies on cognitive exercises desgned to engage underfunctioning brain systems.  In a second model, labeled "cognitive adaptation," neurocognitive deficits are addressed through modifications of the patients' environment to allow patients to bypass their deficits.  Reuslts revealed that a range of cognitive remediation strategies varying widely along dimensions of duration, intensity, method, target of behavioral intervention, and clinical status of participants produced improvements on measures of working memory, emotion perception, and executive function distinct from those trained during remediation.  No effects were evident in secondary verbal or nonverbal memory.  Results of two pilot studies using functional magnetic resonance imaging to assess changes in task-evoked brain activation have revealed that these interventions may produce changes in several functionally relevant neural systems in a subset of patients.  Results from studies of standardized cognitive adaptation interventions have indicated that these treatments can produce improvements in symptoms, psychosocial status, and relapse rates.

A case study to illustrate the relationship between changes in neuropsychological testing and changes in functional magnetic resonance imaging (fMRI) before and after cognitive rehabilitation therapy (CRT).  A woman with history of severe traumatic brain injury (TBI) 16 years before the study participated in individualized CRT using a developmental megacognitive model.  Neuropsychological tests and fMRI imaging were performed during an eye movement task and a reading comprehension task. Improvements on some neuropsychological test scores (>1 SD) and changes in the magnitude and distribution of the blood oxygen level dependent (BOLD) response as a function of task performance on both fMRI tasks.  Individuals with severe TBI many years postinjury can demonstrate improvements in neuropsychological testing following CRT.  Behavioral improvements can be related to changes in brain activity using fMRI.

This article details the introduction and development of the use of microcomputers as adjuncts to traditional cognitive rehabilitation of person with acquired brain injury.  Rehabilitation clinicians have produced and marketed specially written cognitive retraining software which is detailed and reviewed, as was recently released software from commercial sources.  The latter discussion included the latest development in the rehabilitation applications of personal digital assistants and related organizing, reminding, and dictation devices.  A summary of research on the general and specific efficacy of computer-assisted cognitive retraining illustrated the lingering controversy and sketpicism that have been associated with this field since its inception.  Computer-assisted cognitive retraining (CACR) can be an effective adjunct to a comprehensive program of cognitive rehabilitation.  Training needs to be focused, structured, monitored, and as ecologically relevant as possible for optimum effect.  Transfer or training or generalizability of skills remains a key issue in the field and should be considered the key criterion in evaluating whether to initiate or continue CACR.

No abstract

"Cognitive exercises, including computer-assisted strategies, have been used to improve specific neuropsychological processes, predominantly attention, memory, and executive skills. Both randomized controlled studies and case reports have documented the success of these interventions using intermediate outcome measures. Certain studies using global outcome measures also support the use of computer-assisted exercises in cognitive rehabilitation." (For a copy of the full NIH Consensus Statement, call 1-888-NIH-CONSENSUS [888-644-2667])

This study compared the iconic memory skills of brain-injury survivors and control subjects who all reached criterion levels of visual scanning skills.  This involved previous training for the brain-injury survivors using popular visual scanning programs that allowed them to visually scan with response time and accuracy within normal limits.  Control subjects required only minimal training to reach normal limits criteria.  This comparison allows for the dissociation of visual scanning skills and iconic memory skills.  The results are discussed in terms of their implications for cognitive rehabilitation and the relationship between visual scanning training and iconic memory skills.

This article discusses some of the principles of cognitive rehabilitation and the literature on the rehabilitation of various cognitive impairments is reviewed.  The growing use of computers is recognized and the many advantages of using computers within this field are outlined.  Advice in the selection of equipment and software is offered.

This study was designed to investigate the contribution of cognitive rehabilitation therapy delivered by computer within an educationally based treatment program for brain-injured adults.  The effectiveness of two forms of computer-assisted neuropsychological treatment was examined.  36 head-injured adults received the treatment targeting either attention and memory skills or reasoning and logical thinking skills.  Both groups were assessed on three measures of attention and memory and three measures of reasoning before and after the 8 week treatment.  Analysis indicated significant improvement on five of six measures by both groups.  No differential effect was shown by treatment condition.

Lorazepam has been reported to atypically disrupt visual processing compared to other benzodiazepines (BZs), but it is not known to what extent this effect extends to impairment in other modalities. Our objective was to compare the effects of lorazepam with those of flunitrazepam, a BZ with standard effects, on visual and auditory event-related potentials (ERPs) using the same paradigm. The study followed a placebo-controlled, double-blind, parallel group-design and involved single oral doses of lorzepam (2.0 mg), flunitrazepam (1.2 mg) and placebo. Thirty six young, healthy subjects completed a test battery before and after treatment including classic behavioural tests, visual and auditory EPRs. Both drugs led to comparable alterations on behavioural tests and double-dissociations were found, indicating that the doses used were equipotent: lorazepam was more deleterious than fluitrazepam and placebo in fragmented shape identification, while simple reaction times were prolonged for flunitrazepam in comparison to lorazepam and placebo. Effects on P3 latencies were also distinct: alterations in both modalities for flunitrazepam were equivalent and greater than placebo’s. In contrast, lorazepam at the frontal and central electrode sites led to greater changes in visual than in auditory latency, and also to longer visual latencies than flunitrazepam and placebo, but lorazepam’s auditory latency effects were only different to placebo’s at the parietal electrode site. Peripheral visual changes were not responsible for these effects. Differences in the impairment profile between eqipotent doses of lorazepam and flunitrazepam suggests that lorazepam induces atypical visual processing changes.

Recent reports from a variety of labs have demonstrated that some patients with aphasia have concomitant non-linguistic cognitive compromises, especially in the area of attention/executive functions. Recent findings also suggest that attention/executive functions may play an important role in the conversational success of persons with aphasia. This paper provides a review of recent work being carried out in a number of centers having to do with treatment of attention/executive function problems with persons with aphasia. Although results of the studies reviewed herein must be interpreted with caution, there is growing support for the notion that attention/executive function skills in persons with aphasia are remediable, and that there is an important relationship between attention/executive function and functional communication in people with aphasia. The results suggest that treatment of attention/executive function in aphasia – even in people many years post onset – may result in measurable changes in attention/executive function skills and in the transactional success of conversational communication. Of course further research must be completed in order to provide clinicians with adequate evidence for clinical decision making. However, this line of research represents a promising new direction in aphasia rehabilitation.

The Cognitive Behavioral Driver's Inventory (CBDI) was analyzed for its ability to discriminate brain-damaged patients from intact subjects who feigned brain-damage.  In a sample of 251 neurologically impaired patients and 48 malingering volunteers, the computer-administered distinguished most malingerers from genuine patients.  A jackknifed count revealed that the CBDI had 90% sensitivity for detecting malingerers, and 98% specificity for detecting non-malingering brain damaged patients.  Success was due to the inability of malingerers to avoid quantitative errs: excessive response latencies, unusual error rates, inflated variability in response latencies, and excessive within-subject, between-item variability.  The computer-administered battery may be an effective tool for identifying patients who malinger brain-damage in neuropsychological testing.

A pilot study was conducted that was one of the first controlled experiments comparing the efficacy of neuropsychological treatment with a nonstructured treatment providing equivalent professional attention and psychosocial support.  The neuropsychological treatment included computer-assisted training modules in the areas of selective attention, spatial integration, memory, and problem solving.  Forty head-injured patients were randomly assigned to one of two treatment protocols, each protocol involving daily sessions over an eight week period, totalling 160 hours of treatment per patient.  Analyses of pretreatment and post-treatment data on neuropsychological functioning demonstrated significiant improvements for both groups.  Moreover, the experimental group achieved greater relative gains on measures of memory and an error reduction of visual selective attention.

This case study describes the beneficial results of the neuropsychological rehabilitation of a gunshot victim, even with late initialization of the therapy - over one year after head trauma.  DE was a victim of bilateral damage of the parietal-occipital regions of the brain due to a gunshot.  DE was diagnosed with complex cognitive deficits syndrome, including visual associative agnosia, apraxia,  visuospatial and constructive disorders and linguistic defects.  Neuropsychological rehabilitation, first preceded by an initial neuropsychological examination (standard psychological tests: WAIS-R, RAVLT, Rey's CFT, BVRT and clinical experiments tailored to DE's condition), was initiated 1 year after trauma.  The rehabilitation programme consisted of computer-based tasks, paper and pencil exercises, and occupational therapy.  The patient's progress was assessed as improvement in performance in standardized tests and computer-based tasks.  After one year of rehabilitation the patient's functioning significantly improved as measured by psychological tests and computer-based tasks (p<.05) as well as the evaluation of the patient's quality of life.  The case study demonstrates beneficial effects of neurorehabilitation even initialized at the so-called 'late stage' after a brain injury.

No abstract

Tele-rehabilitation, through using advancements in networking and tailor-made software, has been developed and applied to the cognitive rehabilitation of persons with brain injury in the present study.  Tele-cognitive rehabilitation uses customized online computer software as a treatment mode.  The online treatment software is operated on an interactive tele-communication platform for example, video conferencing with screen sharing.  Through implementing the tele-cognitive rehabilitation activities, therapists can help clients to practice and thus improve their cognitive skills through using the treatment software successfully.  Moreover, hypermedia programming techniques allow the therapist to adjust the software to meet the client's treatment needs, so that the treatment is appropriate to his/her functional levels and living environment.  Also the software can customize immediate visual, auditory and personalized feedback to motivate the client and training can be set at the right pace for the client's needs.  The present study aimed to evaluate the effectiveness and perceived efficacy of the newly developed customized tele-cognitive rehabilitation programme for three subjects with traumatic brain injury through single-case and qualitative research design.  The cognitive factors investigated in this pilot study were, respectively, Chinese word recognition, prospective memory and semantic memory.  The subjects had undergone a recruitment proces with stipulated screening criteria.  A single case experimental design (ABA reversal/withdrawal design) consisted of a no-intervention baseline phase (A), an intervention phase (B) and a no-intervention withdrawal phase (A).  There were six sessions in each phase, making a total of 18 sessions.  Tele-cognitive rehabilitation software was tailor-made according to each subject's cognitive functional needs.  To monitor the change in cognitive functions, variables were tapped by tailor-made assessment and qualitative qestionnaires through interviews, and they were then used to explore subjects' opinions of the programme and to test the treatment efficacy of the tele-cognitive rehabilitation programme.  Finally, the relationships among the three phases were analyzed through visual anaylsis and trend line analysis by means of the split-middle method.  The three persons with brain injury showed improving trends and levels of specific cognitive performance during the treatment phase.  Qualitative findings were analyzed and confirmed the efficacy of the treatment module.  The tele-cognitive rehabilitation approach was well received by subjects.