CRAs: Making the case for a new model of community-based cognitive rehabilitation 

Rehabilitation Assistants are often regarded as the unsung heroes of brain injury rehabilitation. But what makes cognitive rehabilitation assistants (CRAs) so effective in supporting their clients to attain their goals of greater independence? 

Our research project at The BIS Services presents a novel conceptual framework for understanding how CRAs facilitate goal attainment and functional independence for individuals with traumatic brain injury (TBI) in community-based settings.

This work moves beyond traditional models of cognitive rehabilitation by emphasising the interactive, person-centred nature of CRA support and the application of cognitive strategies in real-world contexts.

Our study highlights the importance of ecological validity in cognitive rehabilitation, stressing the need for evidence-based strategy use that is embedded within the routines, environments, and lived experiences of individuals with TBI.  

Cognitive Strategies as a Conceptual Framework for Rehabilitation 

At the heart of our work at BIS Services, is the idea that cognitive strategies are not just compensatory techniques but integral to targeting cognitive processes, strengthening self-efficacy, and fostering sustained behavioural change.

Cognitive strategies involve verbal, visual, auditory, or gestural cues which support individuals with TBI to re-engage with everyday tasks and regain a sense of control and autonomy. This aligns with contemporary views on supported thinking (Gagnon-Roy et al., 2024), which emphasise the role of external supports in structuring and guiding cognitive processes.

Rather than treating cognition as an isolated, internal function, this approach considers how cognitive strategies interact with environmental, social, and contextual factors to promote goal attainment. The application of goal-oriented cognitive strategies in rehabilitation allows individuals to navigate real-world challenges with increasing levels of independence, rather than relying solely on structured clinical interventions that may not generalise beyond the therapeutic setting.

For instance, repeating instructions enhances memory and comprehension through verbal repetition, written and visual aids, and multimodal feedback. Similarly, stimulating planning involves guided questioning, “if-then” planning, visual tools, and role-playing scenarios, all of which promote active cognitive engagement rather than passive reception of information.

These strategies reflect a fundamental shift toward self-regulated learning in rehabilitation, where individuals are empowered to engage with their own cognitive processes rather than being passive recipients of support. 

Contextualised Cognitive Rehabilitation 

Our conceptual framework underscores the importance of contextualised rehabilitation, where CRAs do not simply apply cognitive strategies in isolation but instead work within the individual’s unique barriers and facilitators.

The dynamic interplay between cognition and context means that rehabilitation is not a one-size-fits-all process; rather, it is a highly individualised, adaptive approach. Our CRAs are trained to identify, implement, and adapt cognitive strategies in real-world situations, ensuring that individuals receive personalised support that aligns with their daily routines and personal goals.

This approach allows for support to be provided in the moment, within the real-world environments where cognitive challenges arise. For example, individuals with attentional difficulties benefit from structured redirection techniques, such as verbal reminders, visual cues, and physical repositioning to sustain focus during complex or demanding tasks.

Similarly, action priming techniques, such as timers, visual reminders, and verbal prompts, help individuals initiate tasks that may otherwise seem overwhelming. By embedding these strategies within daily life, CRAs help clients transition from structured rehabilitation sessions to meaningful, independent engagement in their communities. 

Rethinking Cognitive Rehabilitation as an Adaptive Process 

Our research challenges the “deficit-based approach” by emphasising that cognitive rehabilitation is an inherently adaptive, interactive process—one that is continuously shaped by an individual’s routines, environment, and personal experiences.

The role of goal-setting and attainment in this framework is critical. By using Kompass, a patient rehabilitation goal-setting platform, we measure goal attainment through the Goal Attainment Scale (GAS). The GAS provides a dynamic, personalised measure of functional progress, capturing the extent to which rehabilitation strategies translate into real-world improvements.

Furthermore, using GAS scoring informed by factors such as importance, difficulty, and feasibility (Stolee et al., 2013), we are able to capture individualised rehabilitation trajectories, ensuring that each participant’s goals are aligned with their lived experience and long-term aspirations.

The International Classification of Functioning (ICF) assessment, completed in collaboration with CRAs, further supports a holistic understanding of individual functioning, recognising both facilitators and barriers to goal attainment in community settings. 

Integrating Cognitive Rehabilitation with Mental Health and Well-Being 

Our research also emphasises the interplay between cognition, mental health, and well-being. Individuals with TBI frequently experience emotional dysregulation, anxiety, and depression, which can negatively impact cognition and goal attainment.

Recognising this, we have integrated mental health assessments using CREYOS, an online battery that evaluates working memory, reasoning, verbal abilities, and attention, alongside self-reported measures of depression (PHQ-9) and anxiety (GAD-7). This approach allows us to examine the bidirectional relationship between cognitive and emotional functioning, providing insight into how cognitive strategies influence not just task performance, but overall psychological well-being.

For example, an individual struggling with executive dysfunction and anxiety may benefit from structured solution generation, where CRAs guide problem-solving through clear choices and alternative strategies, reinforcing confidence and self-efficacy. Similarly, pacing strategies—such as incorporating short breaks, structured work-rest cycles, and encouraging physical movement—ensure that cognitive demands remain manageable and sustainable.

By integrating these cognitive and emotional elements, our framework acknowledges that rehabilitation is about restoring a sense of self and emotional resilience. 

Case Study Insights 

While our study employs a longitudinal, multi-measure approach, we also emphasise the importance of qualitative, individualised insights through case studies.

The heterogeneous nature of brain injury means that rehabilitation outcomes vary significantly across individuals, making case study analysis essential for capturing the nuanced experiences of participants. By analysing how different cognitive strategies are applied in real-world scenarios, case studies provide a deeper understanding of rehabilitation beyond quantitative metrics.

They highlight how individuals navigate challenges, adapt strategies, and regain independence, reinforcing the need for personalised, flexible rehabilitation approaches. 

Conclusion: Toward a New Model of Community-Based Cognitive Rehabilitation 

Our research advances the conceptualisation of cognitive rehabilitation as a dynamic, context-driven process, where goal-directed cognitive strategies, real-world application, and individualised support shape the rehabilitation experience.

This work provides a transformative lens through which rehabilitation professionals can refine best practices, improve training approaches for CRAs, and ultimately enhance the quality of life for individuals with TBI. 

For further information please visit https://www.thebiss.co.uk/training-research