At first, Joanne Schrimpf thought her life was returning to normal. She was recovering physically from the car accident that nearly killed her in February 2002. Then her behavior began to take an odd turn.

She was convinced it was 1998, not 2002. She mistook her daughter for a stranger and forgot the family had a cat. On a trip to the grocery store, she couldn't decide whether to get cereal with or without sugar, and began to sob. 

To tackle the problem, Ms. Schrimpf was offered cognitive rehabilitation, a medical treatment that tries to reteach injured parts of the brain how to perform basic functions, like organizing the day or tuning out distractions. The therapy sent Ms. Schrimpf on a long road toward recovery that entailed twists she never could have predicted.

Ms. Schrimpf, now 51 years old, is one of about nine million people in the U.S. disabled from the effects of strokes, traumatic brain injury and brain hemorrhages. Of that number, according to estimates from doctors and support groups, over half suffer damage to their memory, mental processing or behavior.

Many specialists are convinced that cognitive rehabilitation can help this largely overlooked group, even allowing some patients to resume work. Unlike Ms. Schrimpf, however, most don't receive treatment. Medical studies, while compelling, aren't comprehensive enough for some, and unlike with a physical injury, it's often hard to assess a patient's progress. Many insurance companies, citing these factors, don't pay for this therapy, or limit its scope. In addition, acute-care doctors often simply consign patients to nursing homes.

'Walking Wounded'
This silent club -- doctors sometimes refer to its members as the "walking wounded" -- is only getting bigger. Thanks to improving medical procedures, more people survive accidents and strokes that would have killed them just two decades ago. Many look perfectly normal, have mild or no physical symptoms and yet are badly out of sync with the world.

"If you can't feel it, see it or touch it, the person won't get rehab," says Patricia J. Hantsch, medical director for brain-injury rehabilitation at Schwab Rehabilitation Hospital in Chicago, a well-regarded institution in its field.
Cognitive treatment has evolved rapidly over roughly the past three decades. Many of its techniques were borrowed from those used to teach children with learning disabilities. Others arose out of vocational rehabilitation programs that helped the disabled return to work.

INVISIBLE INJURIES

• The Issue: Millions of brain-injury patients get minimal, if any, therapy to treat memory and other problems.

• The Background: Most insurers don't pay for such care, and doctors often consign patients to nursing homes.

• What It Means: Patients with physical disabilities are more likely to get treatment than those with mental impairments.

The treatment takes many forms, including reading and computer exercises, as well as relearning everyday activities such as planning for shopping. Therapists at some centers use card games and computer programs in which patients are asked to identify pictures and colors. Patients are also taught how to sidestep their impaired memories through the use of stickers, timers, notebooks and handheld computers. Others are videotaped, so they can observe their altered behavior, which often involves speaking too loudly and swearing inappropriately.

The treatment is based on recent discoveries about how the brain functions. Research suggests that a damaged brain can adapt by creating new pathways between cells. MRIs, for example, show unusual areas of the brain lighting up when an impaired person is asked to perform a task during rehab, suggesting that new neurons are taking over for destroyed ones.

"The results suggest that alterations in the allocation of brain resources can occur even in a subject many years post-severe traumatic brain injury," says Linda K. Laatsch, a University of Illinois at Chicago psychologist who conducted the MRI studies. Scientists find the reverse is true, too. Disuse can lead to deterioration of brain pathways and loss of function, researchers say.

Standing in the way of establishing cognitive rehab as routine treatment is a big problem: "It's hard to demonstrate cognitive progress to the insurance company," says Thomas K. Watanabe, the physical medicine and rehabilitation professor who treated Ms. Schrimpf, who now works at Philadelphia's Moss Rehab. By contrast, he says, "If a patient starts out in a wheelchair and then starts walking with a cane, you can measure that progress."

Denial of Claims
Outright denial of claims is common. After blood vessels burst in her brain in February 1998, Frances Carmen, a nurse who inspected nursing homes in Syracuse, N.Y., was left disoriented. Her neurosurgeon strongly recommended cognitive rehabilitation. She says her insurer, Prepaid Health Plan of Syracuse, refused. PHP was later bought by Excellus Blue Cross Blue Shield of Central New York, which says it has no knowledge of the case.

Ms. Carmen went back to work for New York state within nine months of her brain bleed. She struggled to deal with colleagues and sometimes showed up hours late for work. Initially, her boss was understanding. But later, another boss wrote her up for tardiness and put her performance under close scrutiny, say Ms. Carmen and a co-worker. Ms. Carmen quit her job two years ago. The supervisor didn't return phone calls seeking comment.

"I found it so exhausting to try to appear normal to everyone," Ms. Carmen says. She recently began a new job as a nurse at a rehabilitation hospital. She still hasn't gone through rehab herself.

"She was a very high-functioning lady and we were able to save her life," says Ms. Carmen's neurosurgeon, Gary Rodziewicz. "But without further therapy, such people are left at low-functioning capacity." Dr. Rodziewicz says such rehab "is not only the right thing to do, but the smart thing to do because some of these people can become high-functioning again."

Often medical professionals, tending toward pessimism, direct people to nursing homes and discount the possibilities of rehab. Frank Tishka Jr., a 42-year-old pipe fitter from Chicago, underwent emergency surgery for a brain hemorrhage after collapsing in his basement last March. Three days later, he couldn't speak or hold up his head.

His family says doctors at Advocate Christ Medical Center in Oak Lawn, Ill., advised them to look for a nursing home. "They gave us to understand he would be this way for the rest of his life," says his sister, Laura Tucker. A spokesman for Advocate Christ says it can't comment on Mr. Tishka's case, but that doctors generally try to strike a balance between giving hope and telling the truth about very ill patients, and that this "balancing act" can "be misinterpreted."

Mr. Tishka went to a nursing facility, but there an aide suggested he could be helped by Chicago's Schwab center. After weeks of intensive physical and cognitive rehab, Mr. Tishka began talking and walking. He kept a "memory book" to aid recalling daily and weekly activities. Therapists worked on his "left neglect," a condition in which patients aren't aware of anything to their left, even though they can see perfectly well.

Today, Mr. Tishka is living with his father. His speech has returned to a level that appears normal to most listeners. He can get around without a walker, although one hand is still weak and unsteady.

In recent decades, the survival rate for accident, stroke and brain hemorrhage victims has dramatically increased, helped by the advent of 911 emergency systems, high-tech trauma centers and advanced neurointensive care. The Brain Injury Association of America estimates that the fatality rate from serious auto accidents has fallen to about 20% today from about 50% two decades ago.
Studies into the use of cognitive rehab haven't kept pace with this new demand. 

In addition to the lack of funding from pharmaceutical companies for studies, brain injury is uniquely difficult to study. Brain injuries vary greatly, depending on the portion of the brain injured and the nature of the patient. What, for example, would constitute success for two patients with dramatically differing pre-accident levels of intelligence and job demands? Also, rehab doctors say it's unethical to withhold treatment from some so they can be a "control" group in a study.

Stephan A. Mayer, director of neurointensive care at New York-Presbyterian Hospital/Columbia University Medical Center, says brain rehabilitation "is simply not an area where clinical-research methodology has penetrated very much." He says, nonetheless, it's obvious that patients who get warehoused in nursing homes tend to deteriorate. "We know what happens to babies in custodial care," he says. "They regress. It's the same thing with human beings dealing with brain injuries."

In 1998, the government's National Institutes of Health set up a panel to evaluate cognitive rehabilitation. Several existing studies had defects such as small sample sizes but the panel still concluded that the "evidence supports the use of certain cognitive and behavioral rehabilitation strategies" if they're part of a structured plan.

A 2006 article in Archives of Physical Medicine and Rehabilitation evaluated 87 studies of cognitive rehabilitation and said "there is substantial evidence to support cognitive rehabilitation for people with traumatic brain injury." The authors recommended future research to isolate which factors make the therapy work best. Earlier, a European neurological-societies task force came to similar conclusions.

Insufficient Evidence
Some insurers contend this evidence is insufficient. Many insurers don't pay for cognitive rehabilitation, or they strictly limit its scope and duration, often to a matter of weeks.

The Blue Cross Blue Shield Association's Technology Evaluation Center, which advises 39 participating plans covering more than 98 million people, wrote in December 2002: "Available data are considered insufficient to make conclusions on whether cognitive rehabilitation results in beneficial health outcomes."

Naomi Aronson, executive director of the Blue Cross technology center, says the group would like to see a treatment for such patients, but "we don't have as rigorous a body of literature as we would hope to see." She says studies of cognitive rehabilitation tend to be small, have mixed results or measure matters not relevant to the real world.

One big insurer, WellPoint Inc. of Indianapolis, says it pays for cognitive rehab for accident victims but not for stroke patients. Cigna Corp. covers cognitive rehabilitation for brain injury, stroke and brain hemorrhage if doctors document the impairment and report weekly progress. For "patients with traumatic brain injury and acute brain insult, receiving cognitive rehabilitation has become the standard of care in the community," says John Poniatowski, Cigna's vice president of coverage policy.

Sometimes patients don't realize they're impaired. Anne Forrest, a 49-year-old Yale-educated economist who worked for an environmental group in Washington, was hit in what seemed like a fairly minor traffic accident in 1997. When she tried going back to work, she found she couldn't read, do math, use her computer or dial the phone. Her short-term memory vanished. Her husband joked that she could hide her own Easter eggs. She was plagued by weird food mishaps, such as putting the mayonnaise on the outside of a sandwich.

After nine months, a new primary-care doctor suggested rehabilitation. With no advocate guiding her way, it took Ms. Forrest almost two years to work out what rehab she needed and how to get insurance coverage.
She persisted and received two years of cognitive rehab. She relearned math, how to filter out noise and understand figures of speech that brain-injury patients tend to take literally. "My life has been turned around dramatically," she says.

Ms. Forrest now gives talks about brain injury to groups including neuropsychology students, speech and language therapists and survivors of brain injury. She hopes to resume her career as an economist, and she and her husband are adopting a baby, a task she couldn't have handled a few years ago.

At Schwab in Chicago one recent afternoon, a woman in her 20s with a recent brain hemorrhage was working on her logic skills. Before her on a computer screen were five colored rectangles in a horizontal row. The patient had to pick new colors for each rectangle to conform to an unknown, correct pattern. After each round, the computer would say how many were correct.

The task took a huge amount of concentration: A color could be used once, twice or even five times in the row. It took the patient 45 minutes of trial-and-error to uncover the correct arrangement. At each step, she described her thought process while a therapist prompted her on different strategies.
At the Drake Center, a rehabilitation hospital affiliated with the University of Cincinnati, Karen Noonan, 42, was recently working to improve her short-term memory, which had been damaged from burst blood vessels in her brain. She was asked to plan a complex week's schedule of activities and to set up a chart to help her manage the data.

"It was very overwhelming going home," she says, "and these exercises help me."

Missing Out
There are many patients, however, who miss out. Gene Hildebrand, 64, of San Antonio, a former computer-electronics instructor in the Texas A&M system, suffered a stroke in 1997. "I went to sleep, and I woke up, and I've never been the same since," he says.

Because private insurance for his rehabilitation ran out within months of his stroke, he is a walking contradiction. Each morning, Mr. Hildebrand reads in a clear voice from Psalm 91 to the residents of the adult day-care center where he spends his days. His audience, many of whom suffer from dementia and other severe problems, mostly stare into the distance. Mr. Hildebrand sings songs, accompanying himself on guitar. In his spare time, he can take apart a computer and rebuild it.

Yet recently, he got into a fight over some crayons. His wife, Renee, holds his hand to guide him across the street. She worries that if a fire broke out in the home, he would sit and watch instead of calling for help.

Mr. Hildebrand went to a basic life-skills class -- a type of elementary cognitive rehab -- at a local center in the first months after his stroke. Doctors there say they don't have a long-term program to help with cognitive skills. As a result, Mr. Hildebrand is stuck in an adult day-care program tailored for people with far greater disability.

There, he works on coloring books of superheroes and Bible characters, and proudly takes them home to his wife.

"He's here because I didn't have a choice and he's regressing," his wife says. "I want there to be a choice. I know Gene is trapped in there, and I don't know how to get him out."

Alex C. Willingham, medical director of Warm Springs Rehabilitation Hospital in San Antonio, the institution Mr. Hildebrand attended directly after his stroke, says he knows of no San Antonio-area program available that would have given Mr. Hildebrand the more-advanced help he needed.

"For Gene, there's not really a good niche," he says. "He's very bright, and physically he's fine. Insurers don't like to admit that there are long-term problems. To me, this is where society really fails." Dr. Willingham says such a program could help, although it's hard to know for sure.

How Therapy Can Work
Ms. Schrimpf's story shows how therapy can work, and also how tough the journey can be. She was driving on Interstate 74 in Cincinnati in 2002 when a car swerved into her lane. She was pinned for an hour and almost died from a broken neck and severed arteries.

In the hospital, Ms. Schrimpf insisted she had caused the accident, but it wasn't true. She and her family thought her self-described "loopiness" was due to pain medication. But she stayed loopy. Dr. Watanabe, the rehabilitation physician, urged her to get cognitive rehab.

At the city's Drake Center she did exercises to help compensate for what her brain had lost. She placed Post-It notes around the house. A timer told her when to check her notes. Therapists taught her how to color-code sections of calendars as organizational tricks. It was, she says, "like Stephen Covey on steroids," referring to the author of "The Seven Habits of Highly Effective People." All the while, Dr. Watanabe encouraged her to get more active and return to work.

First she went back to coaching a high-school swim team she had organized. She found it difficult to record swimmers' times. Then she decided to go to work in the office of her husband, a surgeon. She didn't take Dr. Watanabe's advice, which was to get a vocational coach to ease her adjustment. It was, she says, a "horrible and humiliating" experience.

Ms. Schrimpf was disorganized and slow. She annoyed co-workers by prompting herself with audible cues. She was too loud, and spoke too close to people's faces. One co-worker complained to Dr. Schrimpf that Ms. Schrimpf was driving her crazy. Ultimately, she left the job.

Now, she's working with a job coach -- paid for by the state of Indiana -- who has taught her to be more subtle with her verbal cues and to substitute a Palm Pilot for a blizzard of Post-It notes. She has organized book-signing events, works on her public speaking and served as chairwoman of her church's 150th-anniversary activities. "I'm encouraged by her doing those activities," says Dr. Watanabe. "Our goal from the start was to get her interacting with people in a meaningful way."

Ms. Schrimpf also measures her progress by a seemingly small event. Ever since 2002, she had virtually no short-term memory, nothing her brain could process at night as dreams. But one night last year, a day after her daughter wanted pancakes at breakfast and the family car had a flat, she had an improbable dream about pancakes and car tires. She sees this as a milestone in her recovery.

"It meant I was getting better," she says. "I was arriving at the new 'normal.' "

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