Effects of a multifaceted treatment program for executive dysfunction after acquired brain injury on indications of executive functioning in daily life

Brain training improves recovery after stroke but waiting list improves equally: A multicenter randomized controlled trial of a computer-based cognitive flexibility training

BACKGROUND

Brain training is currently widely used in an attempt to improve cognitive functioning. Computer-based training can be performed at home and could therefore be an effective add-on to available rehabilitation programs aimed at improving cognitive functioning. Several studies have reported cognitive improvements after computer training, but most lacked proper active and passive control conditions.

OBJECTIVE

Our aim was to investigate whether computer-based cognitive flexibility training improves executive functioning after stroke. We also conducted within-group analyses similar to those used in previous studies, to assess inferences about transfer effects when comparisons to proper control groups are missing.

METHODS

We conducted a randomized controlled, double blind trial. Adults (30-80 years old) who had suffered a stroke within the last 5 years were assigned to either an intervention group (n = 38), active control group (i.e., mock training; n = 35), or waiting list control group (n = 24). The intervention and mock training consisted of 58 half-hour sessions within a 12-week period. Cognitive functioning was assessed using several paper-and-pencil and computerized neuropsychological tasks before the training, immediately after training, and 4 weeks after training completion.

RESULTS AND CONCLUSIONS

Both training groups improved on training tasks, and all groups improved on several transfer tasks (three executive functioning tasks, attention, reasoning, and psychomotor speed). Improvements remained 4 weeks after training completion. However, the amount of improvement in executive and general cognitive functioning in the intervention group was similar to that of both control groups (active control and waiting list). Therefore, this improvement was likely due to training-unspecific effects. Our results stress the importance to include both active and passive control conditions in the study design and analyses. Results from studies without proper control conditions should be interpreted with care.

Long-Term Use and Perceived Benefits of Goal-Oriented Attentional Self-Regulation Training in Chronic Brain Injury

Primary Objective. To investigate the long-term use and perceived benefit(s) of strategies included in Goal-Oriented Attentional Self-Regulation (GOALS) training (Novakovic-Agopian et al., 2011) by individuals with acquired brain injury (ABI) and chronic executive dysfunction. Research Design. Longitudinal follow-up of training. Methods and Procedures. Sixteen participants with chronic ABI participated in structured telephone interviews 20 months (range 11 to 31 months) following completion of GOALS training. Participants responded to questions regarding the range of strategies they continued to utilize, perceived benefit(s) of strategy use, situations in which strategy use was found helpful, and functional changes attributed to training. Results. Nearly all participants (94%) reported continued use of at least one trained strategy in their daily lives, with 75% of participants also reporting improved functioning resulting from training. However, there was considerable variability with respect to the specific strategies individuals found helpful as well as the perceived impact of training on overall functioning. Conclusions. GOALS training shows promising long-term benefits for individuals in the chronic phase of brain injury. Identifying individual- and injury-level factors that account for variability in continued strategy use and the perceived long-term benefits of training will help with ongoing intervention development.

Brain training: hype or hope?

Brain training is topical yet controversial. Effects are often limited to trained tasks; and near and far effects to untrained tasks or everyday life measures are often small or lacking altogether. More recent approaches use evidence from cognitive neuroscience on neuroplasticity, resulting in novel cognitive interventions. This special issue encompasses the state of the art of these interventions. Two systematic reviews and nine experimental studies in a variety of patient groups or healthy participants are included, the results of which mostly confirm earlier findings: effects on trained tasks are consistently reported, but generalisation in terms of functional outcome is limited and little evidence is found of long-term effects. In general, the studies show promising, yet challenging training effects on cognition in healthy persons and patients with cognitive deficits. As such, they may be seen as positive "proof of principle" studies, highlighting that cognitive enhancement is possible. The field of brain training, however, is in urgent need of larger and more thoroughly designed studies. These future studies should also include outcome measures on daily functioning, self-efficacy and quality of life in addition to neuropsychological tests or tasks related to cognitive functioning.

Cerebral white matter lesions, subjective cognitive failures, and objective neurocognitive functioning: A follow-up study in women after hypertensive disorders of pregnancy

OBJECTIVE

Hypertensive disorders of pregnancy, like preeclampsia, are a leading cause of maternal and fetal morbidity/mortality worldwide. Preeclampsia can be complicated by the occurrence of convulsions (eclampsia). Women who experienced (pre)eclampsia more frequently report daily cognitive failures and showed increased emotional dysfunction several years later, but are not impaired on objective neurocognitive testing. In addition, women with preterm preeclampsia more often have cerebral white matter lesions (WML) on follow-up. We aimed to determine whether WML presence is related to cognitive dysfunction, anxiety, and depressive symptoms in (pre)eclamptic women.

METHOD

Forty-one eclamptic, 49 preeclamptic, and 47 control women who had a normotensive pregnancy completed the Cognitive Failures Questionnaire (CFQ), the Hospital Anxiety and Depression Scale (HADS), and a broad neurocognitive test battery (visual perception and speed of information processing, motor functions, working memory, long-term memory, attention, and executive functioning). All underwent cerebral magnetic resonance imaging (MRI), and WML presence was recorded. Median elapsed time since index pregnancy was 6 years. Average age was 40 years.

RESULTS

WML were more prevalent in women who had experienced preterm (pre)eclampsia (<37 weeks; 40%) than in controls (21%, p = .03). In (pre)eclamptic women, CFQ and HADS scores were higher than those in controls (44 ± 16.1 vs. 36 ± 11.0, p < .001, and 11 ± 6.3 vs. 8 ± 5.5, p < .001). There was no difference in objective cognitive performance as measured by neurocognitive tests. Subjective and objective cognitive functioning, anxiety, and depressive symptoms were not related to WML presence.

CONCLUSION

Formerly (pre)eclamptic women report cognitive dysfunction, but do not exhibit overt cognitive impairment when objectively tested on average 6 years following their pregnancy. The presence of WML is not related to objective nor to subjective cognitive impairment, anxiety, and depressive symptoms. Longitudinal studies are needed to study whether the presence of WML is a risk factor for developing objective cognitive impairment in the long term.

Self-Awareness After Brain Injury: Relation with Emotion Recognition and Effects of Treatment

Self-awareness is often impaired after acquired brain injury (ABI) and this hampers rehabilitation, in general: unrealistic reports by patients about their functioning and poor motivation and compliance with treatment. We evaluated a self-awareness treatment that was part of a treatment protocol on executive dysfunction (Spikman, Boelen, Lamberts, Brouwer, & Fasotti, 2010). A total of 63 patients were included, aged 17–70, suffering non-progressive ABI, and minimum time post-onset of 3 months. Self-awareness was measured by comparing the patient's Dysexecutive Questionnaire (Wilson, Alderman, Burgess, Emslie, & Evans, 1996) score with that of an independent other. As emotion recognition is associated with self-awareness and influences the effect of rehabilitation treatment, we assessed this function using the Facial Expressions of Emotion-Stimuli and Tests (Young, Perrett, Calder, Sprengelmeyer, & Ekman, 2002). Results showed that patients in the experimental treatment group (n= 29) had better self-awareness after training than control patients (n= 34). Moreover, our results confirmed that the level of self-awareness before treatment was related to emotion recognition. Hence, self-awareness can improve after neuropsychological treatment fostering self-monitoring. Since neuropsychological treatment involves social learning, impairments in social cognition should be taken into account before starting and during treatment.

Goal Management Training Combined With External Cuing as a Means to Improve Emotional Regulation, Psychological Functioning, and Quality of Life in Patients With Acquired Brain Injury: A Randomized Controlled Trial

OBJECTIVE

To investigate whether goal management training (GMT) expanded to include external cuing and an emotional regulation module is associated with improved emotional regulation, psychological functioning, and quality of life (QOL) after chronic acquired brain injury (ABI).

DESIGN

Randomized controlled trial with blinded outcome assessment at baseline, posttraining, and 6-month follow-up.

SETTING

Outpatient.

PARTICIPANTS

Persons with ABI and executive dysfunction (N=70; 64% traumatic brain injury; 52% men; mean age ± SD, 43±13y; mean time since injury ± SD, 8.1±9.4y).

INTERVENTION

Eight sessions of GMT in groups, including a new module addressing emotional regulation, and external cuing. A psychoeducative control condition (Brain Health Workshop) was matched on amount of training, therapist contact, and homework.

MAIN OUTCOME MEASURES

Emotional regulation was assessed with the Brain Injury Rehabilitation Trust Regulation of Emotions Questionnaire, the Emotional Control subscale and the Emotion Regulation factor (Behavior Rating Inventory of Executive Function-Adult Version), and the Positive and Negative Affect subscales from the Dysexecutive Questionnaire. Secondary outcome measures included psychological distress (Hopkins Symptom Checklist-25) and QOL (Quality of Life After Brain Injury Scale).

RESULTS

Findings indicated beneficial effects of GMT on emotional regulation skills in everyday life and in QOL 6 months posttreatment. No intervention effects on measures of psychological distress were registered.

CONCLUSIONS

GMT is a promising intervention for improving emotional regulation after ABI, even in the chronic phase. More research using objective measures of emotional regulation is needed to investigate the efficacy of this type of training.

Dysexecutive symptoms and carer strain following acquired brain injury: Changes measured before and after holistic neuropsychological rehabilitation

BACKGROUND

Following acquired brain injury (ABI), deficits in executive functioning (EF) are common. As a result many brain-injured patients encounter problems in every-day functioning, and their families experience significant strain. Previous research has documented the benefits of cognitive rehabilitation for executive dysfunction, and rehabilitation programmes designed to ameliorate functional problems associated with ABI.

OBJECTIVES

This study primarily aims to evaluate whether a neuropsychological rehabilitation programme reduces reported symptoms of everyday dysexecutive behaviour and carer strain.

METHODS

In this study 66 ABI outpatients attended comprehensive holistic neuropsychological rehabilitation programme. A repeated-measures design was employed to determine the effect of rehabilitation on EF and carer strain, as part of a service evaluation. Outcome measures comprised the dysexecutive questionnaire (DEX/DEX-I) and carer strain index (CSI), applied pre- and post-rehabilitation.

RESULTS

Results indicate rehabilitation benefited clients and carers in 5 of 6 DEX/DEX-I subscales, and 2 of 3 CSI subscales, (p < 0.05). An effect of aetiology on rehabilitation was found on the metacognitive scale of the DEX-I.

CONCLUSIONS

Therefore, this study supports a comprehensive holistic neuropsychological rehabilitation programme as effective in reducing reported symptoms of dysexecutive behaviour and carer strain following ABI.

Training Endogenous Task Shifting Using Music Therapy: A Feasibility Study

BACKGROUND

People with acquired brain injury (ABI) are highly susceptible to disturbances in executive functioning (EF), and these effects are pervasive. Research studies using music therapy for cognitive improvement in this population are limited.

OBJECTIVE

The purpose of this study was to determine the feasibility of a Musical Executive Function Training (MEFT) intervention to address task-shifting skills in adults with ABI and to obtain preliminary evidence of intervention effect on task shifting.

METHODS

Fourteen participants were randomly assigned to one of three groups: a music therapy intervention group (MTG), a singing group (SG), or the no-intervention control group (CG). The SG and MTG met for one hour a day for five days. Feasibility measures included participant completion rates and intervention fidelity. Potential benefits were measured using the Trail Making Test and the Paced Auditory Serial Addition Task as a pre- and posttest measure.

RESULTS

Participant completion rates and interventionist fidelity to the protocol supported feasibility. One-way ANOVA of the pre- and posttest group differences revealed a trend toward improvement in the MTG over the SG.

CONCLUSIONS

Feasibility and effect size data support a larger trial of the MEFT protocol.

Associations between the Brief Memory and Executive Test (BMET), Activities of Daily Living, and Quality of Life in Patients with Cerebral Small Vessel Disease

OBJECTIVES

In addition to neuropsychological difficulties, patients with cerebral small vessel disease (SVD) can have reduced activities of daily living and a poorer quality of life compared to healthy adults. The Brief Memory and Executive Test (BMET), is a cognitive screening tool designed to be sensitive to the neuropsychological profile of patients with SVD. While the BMET is sensitive to the cognitive consequences of SVD, it is unclear how well scores on this measure relate to functional outcomes. The aims of this study are to investigate the relationship between scores on the BMET and functional outcomes (activities of daily living and quality of life) in SVD, and to compare this with other commonly used cognitive screening tools.

METHODS

This study included 184 participants with SVD (mean age=63.2; SD=9.9) and 299 healthy controls (mean age=62.4; SD=13.8) who were tested using the BMET, Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination (MMSE), Stroke Specific - Quality of Life Scale (SS-QoL), Geriatric Depression Scale (GDS), and measures of both instrumental activities of daily living (IADL) and basic activities of daily living (BADL).

RESULTS

After controlling for covariates the scores on the BMET, but not the MoCA or MMSE, were significantly related to poorer IADL and quality of life in the SVD group. In addition to the BMET scores, symptoms of depression were found to be significant associated with functional outcome.

CONCLUSION

These results support the clinical utility of using of the BMET, in combination with a standardized depression questionnaire, during the early assessment of patients with SVD.

Computer-Based Cognitive Training for Executive Functions after Stroke: A Systematic Review

Background: Stroke commonly results in cognitive impairments in working memory, attention, and executive function, which may be restored with appropriate training programs. Our aim was to systematically review the evidence for computer-based cognitive training of executive dysfunctions.

Methods: Studies were included if they concerned adults who had suffered stroke or other types of acquired brain injury, if the intervention was computer training of executive functions, and if the outcome was related to executive functioning. We searched in MEDLINE, PsycINFO, Web of Science, and The Cochrane Library. Study quality was evaluated based on the CONSORT Statement. Treatment effect was evaluated based on differences compared to pre-treatment and/or to a control group.

Results: Twenty studies were included. Two were randomized controlled trials that used an active control group. The other studies included multiple baselines, a passive control group, or were uncontrolled. Improvements were observed in tasks similar to the training (near transfer) and in tasks dissimilar to the training (far transfer). However, these effects were not larger in trained than in active control groups. Two studies evaluated neural effects and found changes in both functional and structural connectivity. Most studies suffered from methodological limitations (e.g., lack of an active control group and no adjustment for multiple testing) hampering differentiation of training effects from spontaneous recovery, retest effects, and placebo effects.

Conclusions: The positive findings of most studies, including neural changes, warrant continuation of research in this field, but only if its methodological limitations are addressed.

Rehabilitation of Executive Functions in Patients with Chronic Acquired Brain Injury with Goal Management Training, External Cuing, and Emotional Regulation: A Randomized Controlled Trial

Executive dysfunction is a common consequence of acquired brain injury (ABI), causing significant disability in daily life. This randomized controlled trial investigated the efficacy of Goal Management Training (GMT) in improving executive functioning in patients with chronic ABI. Seventy patients with a verified ABI and executive dysfunction were randomly allocated to GMT (n=33) or a psycho-educative active control condition, Brain Health Workshop (BHW) (n=37). In addition, all participants received external cueing by text messages. Neuropsychological tests and self-reported questionnaires of executive functioning were administered pre-intervention, immediately after intervention, and at 6 months follow-up. Assessors were blinded to group allocation. Questionnaire measures indicated significant improvement of everyday executive functioning in the GMT group, with effects lasting at least 6 months post-treatment. Both groups improved on the majority of the applied neuropsychological tests. However, improved performance on tests demanding executive attention was most prominent in the GMT group. The results indicate that GMT combined with external cueing is an effective metacognitive strategy training method, ameliorating executive dysfunction in daily life for patients with chronic ABI. The strongest effects were seen on self-report measures of executive functions 6 months post-treatment, suggesting that strategies learned in GMT were applied and consolidated in everyday life after the end of training. Furthermore, these findings show that executive dysfunction can be improved years after the ABI.

An economic evaluation of an augmented cognitive behavioural intervention vs. computerized cognitive training for post-stroke depressive symptoms

Background

Stroke survivors encounter emotional problems in the chronic phase after stroke. Post-stroke depressive symptoms have major impact on health-related quality of life (HRQol) and lead to increased hospitalization and therefore substantial healthcare costs. We present a cost-effectiveness and cost-utility evaluation of a cognitive behavioural therapy augmented with occupational and movement therapy to support patients with a stroke with depressive symptoms in goal-setting and goal attainment (augmented CBT) in comparison with a computerized cognitive training program (CogniPlus) as a control intervention.

Methods

A trial-based economic evaluation was conducted from a societal perspective with a time horizon of 12 months. Stroke patients (aged 18+ years) with signs of depression (Hospital Anxiety and Depression Scale (HADS) – subscale depression > 7) were eligible to participate. Primary outcomes were the HADS and Quality Adjusted Life Years (QALYs) based on the three-level five-dimensional EuroQol (EQ-5D-3 L). Missing data were handled through mean imputation (costs) and multiple imputation (HADS and EuroQol), and costs were bootstrapped. Sensitivity analyses were performed to test robustness of baseline assumptions.

Results

Sixty-one patients were included. The average total societal costs were not significantly different between the control group (€9,998.3) and the augmented CBT group (€8,063.7), with a 95 % confidence interval (−5,284, 1,796). The augmented CBT intervention was less costly and less effective from a societal perspective on the HADS, and less costly and slightly more effective in QALYs, in comparison with the control treatment. The cost-effectiveness and cost-utility analyses provided greater effects and fewer costs for the augmented CBT group, and fewer effects and costs for the HADS. Based on a willingness to pay (WTP) level of €40,000 per QALY, the augmented CBT intervention had a 76 % chance of being cost-effective. Sensitivity analyses showed robustness of results.

Conclusion

The stroke-specific augmented CBT intervention did not show convincing cost-effectiveness results. In addition to other literature, this study provided new insights into the potential cost-effectiveness of an adjusted cognitive behavioural therapy intervention. However, as our study showed a 76 % chance of being cost-effective for one outcome measure (QALY) and did not provide convincing cost-effectiveness results on the HADS we recommend further research in a larger population.

Response to goal management training in veterans with blast-related mild traumatic brain injury

Veterans with blast-related mild traumatic brain injury (TBI) experience cognitive deficits that interfere with functional activities. Goal Management Training (GMT), which is a metacognitive intervention, offers an executive function rehabilitation approach that draws upon theories concerning goal processing and sustained attention. GMT has received empirical support in studies of patients with TBI but has not been tested in Veterans with blast-related mild TBI. GMT was modified from 7 weekly to 10 biweekly sessions. Participants included six combat Veterans that reported multiple blast exposures resulting in symptoms consistent with mild TBI. Group analysis showed a significant improvement in measures of executive function derived from performance on the computerized Tower of London. There were no significant changes on self/informant questionnaires of executive function, indicating a lack of generalization of improvement from the clinic to everyday activities. Overall, while the data indicate efficacy of GMT in the rehabilitation of combat Veterans with executive function deficits because of blast-related mild TBI, enhancement of generalization is needed.

Executive Dysfunction 25 Years after Treatment with Cranial Radiotherapy for Pediatric Lymphoid Malignancies

The first cohorts to survive childhood lymphoid malignancies treated with cranial irradiation are now aging into adulthood, and concerns are growing about the development of radiotherapy-induced cognitive deficits in the aging brain. These deficits are hypothesized to increase over time. Their impact on daily functioning of older survivors, and the accompanying need for interventions, should be anticipated. By describing a detailed profile of executive function deficits and their associations with age, specific targets for neuropsychological intervention can be identified. Fifty survivors of childhood lymphoid malignancies and 58 related controls were assessed with the Amsterdam Neuropsychological Tasks program. The survivors were on average 31.1 (4.9) years old, treated with 22.5 (6.8) Gy cranial irradiation, and examined on average 25.5 (3.1) years after diagnosis. The survivors showed significantly decreased response speed, irrespective of the task at hand. Furthermore, we found deficits in working memory capacity, inhibition, cognitive flexibility, executive visuomotor control, attentional fluctuations, and sustained attention. Older age was associated with poorer performance on executive visuomotor control and inhibition. On executive visuomotor control, 50% of female survivors performed more than 1.5 SD below average, versus 15.4% of male survivors. The combination of visuospatial working memory problems and decreasing executive visuomotor control could result in difficulty with learning new motor skills at older ages, like walking with a cane. Deterioration of executive control and inhibition may result in decreased behavioral and emotional regulation in aging survivors. Especially the deficiency in executive visuomotor control in female survivors should be considered for (prophylactic) intervention.

"Keep your brain fit!" Effectiveness of a psychoeducational intervention on cognitive functioning in healthy adults: A randomised controlled trial

A psychoeducational intervention (Keep your brain fit!) was designed for the middle-aged and older working population. The intervention focuses on increasing knowledge and awareness about cognitive ageing and teaching strategies to cope with cognitive changes. The primary aim of this study was to investigate the effectiveness of the e-health intervention in terms of subjective cognitive functioning. As secondary aims, objective cognitive functioning and psychological well-being were also measured. A randomised controlled trial that included people aged 40 to 65 years was conducted. A maximum of 4 weeks was allowed to complete the intervention. The outcome measures were obtained from an online test battery that was administered at baseline, post-test and at 4-week follow-up. A total of 376 participants completed the whole study. After the intervention, the experimental group reported more feelings of stability concerning memory functioning and perceived greater locus of control over memory compared to the control group. These effects were maintained at the 4-week follow-up. Taking into account the relatively low costs and easy accessibility of this e-health intervention, we consider the programme to be a valuable contribution to public healthcare interventions for middle-aged and older adults.

Do Old Errors Always Lead to New Truths? A Randomized Controlled Trial of Errorless Goal Management Training in Brain-Injured Patients

Both errorless learning (EL) and Goal Management Training (GMT) have been shown effective cognitive rehabilitation methods aimed at optimizing the performance on everyday skills after brain injury. We examine whether a combination of EL and GMT is superior to traditional GMT for training complex daily tasks in brain-injured patients with executive dysfunction. This was an assessor-blinded randomized controlled trial conducted in 67 patients with executive impairments due to brain injury of non-progressive nature (minimal post-onset time: 3 months), referred for outpatient rehabilitation. Individually selected everyday tasks were trained using 8 sessions of an experimental combination of EL and GMT or via conventional GMT, which follows a trial-and-error approach. Primary outcome measure was everyday task performance assessed after treatment compared to baseline. Goal attainment scaling, rated by both trainers and patients, was used as secondary outcome measure. EL-GMT improved everyday task performance significantly more than conventional GMT (adjusted difference 15.43, 95% confidence interval [CI] [4.52, 26.35]; Cohen's d=0.74). Goal attainment, as scored by the trainers, was significantly higher after EL-GMT compared to conventional GMT (mean difference 7.34, 95% CI [2.99, 11.68]; Cohen's d=0.87). The patients' goal attainment scores did not differ between the two treatment arms (mean difference 3.51, 95% CI [-1.41, 8.44]). Our study is the first to show that preventing the occurrence of errors during executive strategy training enhances the acquisition of everyday activities. A combined EL-GMT intervention is a valuable contribution to cognitive rehabilitation in clinical practice.

Goal setting and strategies to enhance goal pursuit for adults with acquired disability participating in rehabilitation

BACKGROUND

Goal setting is considered a key component of rehabilitation for adults with acquired disability, yet there is little consensus regarding the best strategies for undertaking goal setting and in which clinical contexts. It has also been unclear what effect, if any, goal setting has on health outcomes after rehabilitation.

OBJECTIVES

To assess the effects of goal setting and strategies to enhance the pursuit of goals (i.e. how goals and progress towards goals are communicated, used, or shared) on improving health outcomes in adults with acquired disability participating in rehabilitation.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, four other databases and three trials registers to December 2013, together with reference checking, citation searching and contact with study authors to identify additional studies. We did not impose any language or date restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs and quasi-RCTs evaluating the effects of goal setting or strategies to enhance goal pursuit in the context of adult rehabilitation for acquired disability.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed search results for inclusion. Grey literature searches were conducted and reviewed by a single author. Two authors independently extracted data and assessed risk of bias for included studies. We contacted study authors for additional information.

MAIN RESULTS

We included 39 studies (27 RCTs, 6 cluster-RCTs, and 6 quasi-RCTs) involving 2846 participants in total. Studies ranged widely regarding clinical context and participants' primary health conditions. The most common health conditions included musculoskeletal disorders, brain injury, chronic pain, mental health conditions, and cardiovascular disease.Eighteen studies compared goal setting, with or without strategies to enhance goal pursuit, to no goal setting. These studies provide very low quality evidence that including any type of goal setting in the practice of adult rehabilitation is better than no goal setting for health-related quality of life or self-reported emotional status (8 studies; 446 participants; standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.17 to 0.88, indicative of a moderate effect size) and self-efficacy (3 studies; 108 participants; SMD 1.07, 95% CI 0.64 to 1.49, indicative of a moderate to large effect size). The evidence is inconclusive regarding whether goal setting results in improvements in social participation or activity levels, body structure or function, or levels of patient engagement in the rehabilitation process. Insufficient data are available to determine whether or not goal setting is associated with more or fewer adverse events compared to no goal setting.Fourteen studies compared structured goal setting approaches, with or without strategies to enhance goal pursuit, to 'usual care' that may have involved some goal setting but where no structured approach was followed. These studies provide very low quality evidence that more structured goal setting results in higher patient self-efficacy (2 studies; 134 participants; SMD 0.37, 95% CI 0.02 to 0.71, indicative of a small effect size) and low quality evidence for greater satisfaction with service delivery (5 studies; 309 participants; SMD 0.33, 95% CI 0.10 to 0.56, indicative of a small effect size). The evidence was inconclusive regarding whether more structured goal setting approaches result in higher health-related quality of life or self-reported emotional status, social participation, activity levels, or improvements in body structure or function. Three studies in this group reported on adverse events (death, re-hospitalisation, or worsening symptoms), but insufficient data are available to determine whether structured goal setting is associated with more or fewer adverse events than usual care.A moderate degree of heterogeneity was observed in outcomes across all studies, but an insufficient number of studies was available to permit subgroup analysis to explore the reasons for this heterogeneity. The review also considers studies which investigate the effects of different approaches to enhancing goal pursuit, and studies which investigate different structured goal setting approaches. It also reports on secondary outcomes including goal attainment and healthcare utilisation.

AUTHORS' CONCLUSIONS

There is some very low quality evidence that goal setting may improve some outcomes for adults receiving rehabilitation for acquired disability. The best of this evidence appears to favour positive effects for psychosocial outcomes (i.e. health-related quality of life, emotional status, and self-efficacy) rather than physical ones. Due to study limitations, there is considerable uncertainty regarding these effects however, and further research is highly likely to change reported estimates of effect.

Cognitive and psychological flexibility after a traumatic brain injury and the implications for treatment in acceptance-based therapies: A conceptual review

This paper provides a selective review of cognitive and psychological flexibility in the context of treatment for psychological distress after traumatic brain injury, with a focus on acceptance-based therapies. Cognitive flexibility is a component of executive function that is referred to mostly in the context of neuropsychological research and practice. Psychological flexibility, from a clinical psychology perspective, is linked to health and well-being and is an identified treatment outcome for therapies such as acceptance and commitment therapy (ACT). There are a number of overlaps between the constructs. They both manifest in the ability to change behaviour (either a thought or an action) in response to environmental change, with similarities in neural substrate and mental processes. Impairments in both show a strong association with psychopathology. People with a traumatic brain injury (TBI) often suffer impairments in their cognitive flexibility as a result of damage to areas controlling executive processes but have a positive response to therapies that promote psychological flexibility. Overall, psychological flexibility appears a more overarching construct and cognitive flexibility may be a subcomponent of it but not necessarily a pre-requisite. Further research into therapies which claim to improve psychological flexibility, such as ACT, needs to be undertaken in TBI populations in order to clarify its utility in this group.

Maintenance of treatment effects of an occupation-based intervention with video feedback for adults with TBI

BACKGROUND

Video feedback interventions have been found to improve self-awareness and occupational performance to a greater extent than other feedback interventions after traumatic brain injury (TBI). However, it is unclear whether the effects of video feedback are maintained over time.

OBJECTIVE

To evaluate the maintenance of gains in self-awareness achieved with a video feedback intervention in people with TBI.

METHODS

There were 32 participants with TBI and impaired self-awareness who had completed a randomized controlled trial with three feedback conditions (video plus verbal, verbal and experiential). Eight to ten weeks after the final feedback intervention session, a follow-up assessment was conducted. The primary outcome was maintenance of gains in online awareness measured by the number of errors made during a meal preparation task. Group outcomes were compared using an unstructured linear mixed regression model.

RESULTS

The video plus verbal feedback group continued to demonstrate significantly greater gains in online awareness compared to the verbal feedback group (mean difference 20.6, 95% CI 8.8 to 32.3) and the experiential feedback group (mean difference 14.4, 95% CI 3.1 to 25.6). There was no significant impact of the interventions on participants' emotional status at the 8 to 10 week follow-up.

CONCLUSIONS

A combination of video plus verbal feedback is an effective technique for achieving maintained gains in self-awareness in people with TBI.

The Effect of Occupation-based Cognitive Rehabilitation for Traumatic Brain Injury: A Meta-analysis of Randomized Controlled Trials

Traumatic brain injury (TBI) is the leading cause of death and disability among people younger than 35 years in the United States. Cognitive difficulty is a common consequence of TBI. To address cognitive deficits of patients with TBI, various cognitive rehabilitation approaches have been used for the clinical setting. The purpose of this study was to investigate the overall effect of occupation-based cognitive rehabilitation on patients' improvement in cognitive performance components, activity of daily living (ADL) performance, and values, beliefs and spirituality functions of patients with TBI. The papers used in this study were retrieved from the Cochrane Database, EBSCO (CINAHL), PsycINFO, PubMed and Web of Science published between 1997 and 2014. The keywords for searching were cognitive, rehabilitation, occupation, memory, attention, problem-solving, executive function, ADL, values, beliefs, spirituality, randomized controlled trials and TBI. For the meta-analysis, we examined 60 effect sizes from nine studies that are related to the occupation-based cognitive rehabilitation on persons with TBI. In persons with TBI, overall mental functions, ADL, and values, beliefs and spirituality were significantly improved in the groups that received occupation-based cognitive rehabilitation compared with comparison groups (mean d = 0.19, p < .05). Evidence from the present meta-analytic study suggests that occupation-based cognitive rehabilitation would be beneficial for individuals with TBI for improving daily functioning and positively be able to affect their psychosocial functions. Collecting many outcome measures in studies with relatively few participants and the final data are less reliable than the whole instrument itself. Future research should evaluate the effectiveness of specific occupation-based cognitive rehabilitations programmes in order to improve consistency among rehabilitation providers.

Parkinson's patients' executive profile and goals they set for improvement: Why is cognitive rehabilitation not common practice?

Impairments in executive functions (EF) are the core cognitive impairment in patients with Parkinson's disease (PD). Surprisingly, cognitive rehabilitation is not routinely offered to patients with PD. However, in patients with acquired brain injury (ABI), cognitive rehabilitation, in particular strategic executive training, is common practice and has been shown to be effective. In this study, we determined whether PD patients have different needs and aims with regard to strategic executive training than ABI patients, and whether possible differences might be a reason for not offering this kind of cognitive rehabilitation programme to patients with PD. Patients' needs and aims were operationalised by individually set goals, which were classified into domains of EF and daily life. In addition, patients with PD and ABI were compared on their cognitive, in particular EF, profile. Overall, PD patients' goals and cognitive profile were similar to those of patients with ABI. Therefore, based on the findings of this study, there is no reason to assume that strategic executive training cannot be part of standard therapy in PD. However, when strategic executive training is applied in clinical practice, disease-specific characteristics need to be taken into account.

Activity interventions for cognitive problems

Cancer and its life-saving treatments often result in long-term impairments in neurocognitive functions. These neurocognitive impairments are not only problematic, but they also limit the ability to perform meaningful everyday activities critical to independence in the home, school, and community. The "bottom-up" and "top-down" models inherent in many neurological rehabilitation interventions provide a gross framework for describing interventions designed to address neurocognitive functions. Activity interventions show promise for improving performance of everyday activities, as well as improving underlying neurocognitive functions. However, additional empirical examination is warranted. Future studies examining activity interventions should clearly specify the active ingredient of the intervention, and evaluate the impact of the intervention on neurocognitive as well as activity-based outcomes.

Developing complex interventions: lessons learned from a pilot study examining strategy training in acute stroke rehabilitation

OBJECTIVE

To examine the feasibility of a strategy training clinical trial in a small group of adults with stroke-related cognitive impairments in inpatient rehabilitation, and to explore the impact of strategy training on disability.

DESIGN

Non-randomized two-group intervention pilot study.

SETTING

Two inpatient rehabilitation units within an academic health centre.

PARTICIPANTS

Individuals with a primary diagnosis of acute stroke, who were admitted to inpatient rehabilitation and demonstrated cognitive impairments were included. Individuals with severe aphasia; dementia; major depressive disorder, bipolar, or psychotic disorder; recent drug or alcohol abuse; and anticipated length of stay less than five days were excluded.

INTERVENTION

Participants received strategy training or an attention control session in addition to usual rehabilitation care. Sessions in both groups were 30-40 minutes daily, five days per week, for the duration of inpatient rehabilitation.

MAIN OUTCOME MEASURES

We assessed feasibility through participants' recruitment and retention; research intervention session number and duration; participants' comprehension and engagement; intervention fidelity; and participants' satisfaction. We assessed disability at study admission, inpatient rehabilitation discharge, 3 and 6 months using the Functional Independence Measure.

RESULTS

Participants in both groups (5 per group) received the assigned intervention (>92% planned sessions; >94% fidelity) and completed follow-up testing. Strategy training participants in this small sample demonstrated significantly less disability at six months (M (SE) = 117 (3)) than attention control participants (M(SE) = 96 (14); t 8 = 7.87, P = 0.02).

CONCLUSIONS

It is feasible and acceptable to administer both intervention protocols as an adjunct to acute inpatient rehabilitation, and strategy training shows promise for reducing disability.

Self-Generated Strategic Behavior in an Ecological Shopping Task

OBJECTIVES. The use of cognitive strategies optimizes performance in complex everyday tasks such as shopping. This exploratory study examined the cognitive strategies people with traumatic brain injury (TBI) effectively use in an unstructured, real-world situation.

METHOD. A behavioral analysis of the self-generated strategic behaviors of 5 people with severe TBI using videotaped sessions of an ecological shopping task (Instrumental Activities of Daily Living Profile) was performed.

RESULTS. All participants used some form of cognitive strategy in an unstructured real-world shopping task, although the number, type, and degree of effectiveness of the strategies in leading to goal attainment varied. The most independent person used the largest number and a broader repertoire of self-generated strategies.

CONCLUSION. These results provide initial evidence that occupational therapists should examine the use of self-generated cognitive strategies in real-world contexts as a potential means of guiding therapy aimed at improving independence in everyday activities for people with TBI.

Goal Management Training improves everyday executive functioning for persons with spina bifida: self-and informant reports six months post-training

Executive dysfunction accounts for significant disability for many patients with spina bifida (SB), thus indicating the need for effective interventions aimed at improving executive functioning in this population. Goal Management Training™ (GMT) is a cognitive rehabilitation approach that targets disorganised behaviour resulting from executive dysfunction, and has received empirical support in studies of other patient groups. The purpose of this study was to determine if GMT would lead to perceived improved executive functioning in the daily lives of patients with SB, as evidenced by reduced report of dysexecutive problems in daily life on self- and informant questionnaires. Thirty-eight adults with SB were included in this randomised controlled trial (RCT). Inclusion was based upon the presence of executive functioning complaints. Experimental subjects (n = 24) received 21 hours of GMT, with efficacy of GMT being compared to results of subjects in a wait-list condition (n = 14). All subjects were assessed at baseline, post-intervention, and at six-month follow-up. Self-report measures indicated that the GMT group's everyday executive functioning improved significantly after training, lasting at least 6 months post-treatment. There were no significant effects on informant-report questionnaires. Overall, these findings indicate that executive difficulties in everyday life can be ameliorated for individuals with congenital brain dysfunction.

Managing executive dysfunction following acquired brain injury and stroke using an ecologically valid rehabilitation approach: a study protocol for a randomized, controlled trial

Background

We have been investigating an ecologically valid strategy-training approach to enable adults with executive dysfunction to attain everyday life goals. Here, we report the protocol of a randomized controlled trial of the effects of this training compared to conventional therapy in a sample of community-dwelling adults with acquired brain injury and/or stroke.

Methods/design

We will recruit 100 community-dwelling survivors at least six months post-acquired brain injury or stroke who report executive dysfunction during a telephone interview, confirmed in pre-training testing. Following pre-training testing, participants will be randomized to the ecologically valid strategy training or conventional therapy and receive two one-hour sessions for eight weeks (maximum of 15 hours of therapy). Post-testing will occur immediately following the training and three months later. The primary outcome is self-reported change in performance on everyday life activities measured using the Canadian Occupational Performance Measure, a standardized, semi-structured interview. Secondary outcomes are objective measurement of performance change from videotapes of treatment session, Performance Quality Rating Scale; executive dysfunction symptoms, Behavioural Rating Inventory of Executive Function – Adult; participation in everyday life, Mayo-Portland Adaptability Inventory Participation Index; and ability to solve novel problems, Instrumental Activities of Daily Living Profile.

Discussion

This study is of a novel approach to promoting improvements in attainment of everyday life goals through managing executive dysfunction using an ecologically valid strategy training approach, the Cognitive Orientation to daily Occupational Performance. This study compares the efficacy of this approach with that of conventional therapy. The approach has the potential to be a valuable treatment for people with chronic acquired brain injury and/or stroke.

Trial registration

clinicaltrials.gov, Trial Identification Number: NCT01414348

Neuropsychological rehabilitation: State of the science

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

Who benefits from treatment for executive dysfunction after brain injury? Negative effects of emotion recognition deficits

Deficits in emotion recognition, a crucial aspect of social cognition, are common after serious brain injury, as are executive deficits. Since social cognition and executive function are considered to be separate constructs, our first aim was to examine the presence of emotion recognition problems in brain injury patients with dysexecutive problems. We studied 65 brain injury patients of mixed aetiology participating in a randomised controlled trial evaluating the effects of a multifaceted treatment for executive dysfunction (Spikman, Boelen, Lamberts, Brouwer, & Fasotti, 2010 ) and 84 matched controls with a test for emotion recognition. Results showed that, in patients with acquired brain injury exhibiting executive deficits, emotion recognition deficits are also present. Male patients are more impaired than female patients, irrespective of aetiology. Our second aim was to investigate whether emotion recognition problems negatively predict the results of the treatment programme. Pre-treatment emotion recognition performance significantly predicted resumption of roles in daily life (Role Resumption List; RRL) and performance on an ecologically valid test for everyday executive functioning (Executive Secretarial Task; EST) post-treatment and, in addition, interfered negatively with treatment condition. Moreover, worse pre-treatment emotion recognition skills affect the learning of compensatory strategies for executive dysfunction negatively, whereas pre-treatment dysexecutive deficits do not.

Goal management training of executive functions in patients with spina bifida: a randomized controlled trial

Executive dysfunction causes significant real-life disability for patients with spina bifida (SB). However, no previous research has been directed toward the amelioration of executive functioning deficits amongst persons with SB. Goal Management Training (GMT) is a compensatory cognitive rehabilitation approach, addressing underlying deficits in sustained attention to improve executive function. GMT has received empirical support in studies of other patient groups. The purpose of the present study was to determine the efficacy of GMT in treating subjects with SB, using inpatient intervention periods. We hypothesized post-intervention changes in scores on neuropsychological measures to reflect improved attentional control, including sustained attention and inhibitory control. Thirty-eight adult subjects with SB were included in this randomized controlled trial. Inclusion was based upon the presence of executive functioning complaints. Experimental subjects (n = 24) received 21 hr of GMT, with efficacy of GMT being compared to results of subjects in a wait-list condition (n = 14). All subjects were assessed at baseline, post-intervention, and at 6-month follow-up. Findings indicated superior effects of GMT on domain-specific neuropsychological measures and on a functional "real-life" measure, all lasting at least 6 months post-treatment. These results show that deficits in executive functioning can be ameliorated in patients with congenital brain dysfunction.

A randomized controlled trial on errorless learning in goal management training: study rationale and protocol

Background

Many brain-injured patients referred for outpatient rehabilitation have executive deficits, notably difficulties with planning, problem-solving and goal directed behaviour. Goal Management Training (GMT) has proven to be an efficacious cognitive treatment for these problems. GMT entails learning and applying an algorithm, in which daily tasks are subdivided into multiple steps. Main aim of the present study is to examine whether using an errorless learning approach (preventing the occurrence of errors during the acquisition phase of learning) contributes to the efficacy of Goal Management Training in the performance of complex daily tasks.

Methods/Design

The study is a double blind randomized controlled trial, in which the efficacy of Goal Management Training with an errorless learning approach will be compared with conventional Goal Management Training, based on trial and error learning. In both conditions 32 patients with acquired brain injury of mixed etiology will be examined. Main outcome measure will be the performance on two individually chosen everyday-tasks before and after treatment, using a standardized observation scale and goal attainment scaling.

Discussion

This is the first study that introduces errorless learning in Goal Management Training. It is expected that the GMT-errorless learning approach will improve the execution of complex daily tasks in brain-injured patients with executive deficits. The study can contribute to a better treatment of executive deficits in cognitive rehabilitation.

Trial registration

(Dutch Trial Register): http://NTR3567

A systematic review of assessments for identifying executive function impairment in adults with acquired brain injury

PURPOSE

To synthesize quantitative findings concerning measures of executive function (EF) in adults with acquired brain injury (ABI).

METHOD

Electronic databases were searched for studies of EF assessments in adults with ABI that reported any of 3 values: likelihood ratios (LRs), standardized group mean comparisons (ds), or correlations (rs) among EF tests. Forest plots were constructed for each value.

RESULTS

Searches yielded 1,417 unique citations. Full texts of 129 articles were reviewed; 34 reported at least 1 value of interest. Nineteen positive and negative LRs were calculated from 8 studies of 8 EF measures; some point estimates were in the clinically informative range, but all confidence intervals extended beyond it. From 24 studies of 14 measures, 114 d values were calculated; d values for only 11 measures had lower bounds > 0.80. From 8 studies involving 10 EF measures, 104 correlations were reported; in only 5 cases were r(2) values > .5.

CONCLUSIONS

Strong evidence concerning diagnostic accuracy and concurrent validity of EF measures for adults with ABI is lacking. Better specification of the construct of EF as well as research aimed at improving the quality of evidence concerning EF tests are needed.

Cognitive rehabilitation for attention deficits following stroke

BACKGROUND

Many survivors of stroke complain about attentional impairments, such as diminished concentration and mental slowness. However, the effectiveness of cognitive rehabilitation for improving these impairments is uncertain.

OBJECTIVES

To determine whether (1) people receiving attentional treatment show better outcomes in their attentional functions than those given no treatment or treatment as usual, and (2) people receiving attentional treatment techniques have a better functional recovery, in terms of independence in activities of daily living, mood and quality of life, than those given no treatment or treatment as usual.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (October 2012), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library October 2012), MEDLINE (1948 to October 2012), EMBASE (1947 to October 2012), CINAHL (1981 to October 2012), PsycINFO (1806 to October 2012), PsycBITE and REHABDATA (searched October 2012) and ongoing trials registers. We screened reference lists and tracked citations using Scopus.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of cognitive rehabilitation for impairments of attention for people with stroke. The primary outcome was measures of global attentional functions, and secondary outcomes were measures of attention domains, functional abilities, mood and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed trial quality.

MAIN RESULTS

We included six RCTs with 223 participants. All six RCTs compared cognitive rehabilitation with a usual care control. Meta-analyses demonstrated no statistically significant effect of cognitive rehabilitation for persisting effects on global measures of attention (two studies, 99 participants; standardised mean difference (SMD) 0.16, 95% confidence interval (CI) -0.23 to 0.56; P value = 0.41), standardised attention assessments (two studies, 99 participants; P value ≥ 0.08) or functional outcomes (two studies, 99 participants; P value ≥ 0.15). In contrast, a statistically significant effect was found in favour of cognitive rehabilitation when compared with control for immediate effects on measures of divided attention (four studies, 165 participants; SMD 0.67, 95% CI 0.35 to 0.98; P value < 0.0001) but no significant effects on global attention (two studies, 53 participants; P value = 0.06), other attentional domains (six studies, 223 participants; P value ≥ 0.16) or functional outcomes (three studies, 109 participants; P value ≥ 0.21).Thus there was limited evidence that cognitive rehabilitation may improve some aspects of attention in the short term, but there was insufficient evidence to support or refute the persisting effects of cognitive rehabilitation on attention, or on functional outcomes in either the short or long term.

AUTHORS' CONCLUSIONS

The effectiveness of cognitive rehabilitation remains unconfirmed. The results suggest there may be a short-term effect on attentional abilities, but future studies need to assess the persisting effects and measure attentional skills in daily life. Trials also need to have higher methodological quality and better reporting.

Rehabilitation of executive function and social cognition impairments after brain injury

PURPOSE OF REVIEW

Brain injury is a major cause of long-term disability. Executive and social cognition sequelae are associated with poor outcome. This review examines recent evidence on the efficacy of rehabilitation in these areas.

RECENT FINDINGS

Accumulating evidence shows that interventions that work with patients on developing insight and strategies to offset executive impairments can produce significant benefits. Training of specific capacities, such as working memory, holds some promise, but more needs to be known about effect generalization. Evidence on social cognition rehabilitation following brain injury is sparse. Although there are some encouraging early results, more information on the clinical significance of change for everyday function is required.

SUMMARY

Rehabilitation in these areas is inherently difficult but vital if outcomes are to improve. Significant gains have been reported, and further work applying appropriate methods is urgently required.

Cognitive rehabilitation for executive dysfunction in adults with stroke or other adult non-progressive acquired brain damage

BACKGROUND

Executive functions are the controlling mechanisms of the brain and include the processes of planning, initiation, organisation, inhibition, problem solving, self monitoring and error correction. They are essential for goal-oriented behaviour and responding to new and novel situations. A high number of people with acquired brain injury, including around 75% of stroke survivors, will experience executive dysfunction. Executive dysfunction reduces capacity to regain independence in activities of daily living (ADL), particularly when alternative movement strategies are necessary to compensate for limb weakness. Improving executive function may lead to increased independence with ADL. There are various cognitive rehabilitation strategies for training executive function used within clinical practice and it is necessary to determine the effectiveness of these interventions.

OBJECTIVES

To determine the effects of cognitive rehabilitation on executive dysfunction for adults with stroke or other non-progressive acquired brain injuries.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (August 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library, August 2012), MEDLINE (1950 to August 2012), EMBASE (1980 to August 2012), CINAHL (1982 to August 2012), PsycINFO (1806 to August 2012), AMED (1985 to August 2012) and 11 additional databases. We also searched reference lists and trials registers, handsearched journals and conference proceedings, and contacted experts.

SELECTION CRITERIA

We included randomised trials in adults after non-progressive acquired brain injury, where the intervention was specifically targeted at improving cognition including separable executive function data (restorative interventions), where the intervention was aimed at training participants in methods to compensate for lost executive function (compensative interventions) or where the intervention involved the training in the use of an adaptive technique for improving independence with ADL (adaptive interventions). The primary outcome was global executive function and the secondary outcomes were specific components of executive function, working memory, ADL, extended ADL, quality of life and participation in vocational activities. We included studies in which the comparison intervention was no treatment, a placebo intervention (i.e. a rehabilitation intervention that should not impact on executive function), standard care or another cognitive rehabilitation intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts, extracted data and appraised trials. We undertook an assessment of methodological quality for allocation concealment, blinding of outcome assessors, method of dealing with missing data and other potential sources of bias.

MAIN RESULTS

Nineteen studies (907 participants) met the inclusion criteria for this review. We included 13 studies (770 participants) in meta-analyses (417 traumatic brain injury, 304 stroke, 49 other acquired brain injury) reducing to 660 participants once non-included intervention groups were removed from three and four group studies. We were unable to obtain data from the remaining six studies. Three studies (134 participants) compared cognitive rehabilitation with sensorimotor therapy. None reported our primary outcome; data from one study was available relating to secondary outcomes including concept formation and ADL. Six studies (333 participants) compared cognitive rehabilitation with no treatment or placebo. None reported our primary outcome; data from four studies demonstrated no statistically significant effect of cognitive rehabilitation on secondary outcomes. Ten studies (448 participants) compared two different cognitive rehabilitation approaches. Two studies (82 participants) reported the primary outcome; no statistically significant effect was found. Data from eight studies demonstrated no statistically significant effect on the secondary outcomes. We explored the effect of restorative interventions (10 studies, 468 participants) and compensative interventions (four studies, 128 participants) and found no statistically significant effect compared with other interventions.

AUTHORS' CONCLUSIONS

We identified insufficient high-quality evidence to reach any generalised conclusions about the effect of cognitive rehabilitation on executive function, or other secondary outcome measures. Further high-quality research comparing cognitive rehabilitation with no intervention, placebo or sensorimotor interventions is recommended.

Goal Management Training for rehabilitation of executive functions: a systematic review of effectiveness in patients with acquired brain injury

PURPOSE

To determine if Goal Management Training (GMT) is effective for the rehabilitation of executive functions following brain injury when administered alone or in combination with other interventions.

METHOD

Systematic review, with quality appraisal specific to executive functions research and calculation of effect sizes.

RESULTS

Twelve studies were included. Four studies were "Proof-of-principle" studies, testing the potential effectiveness of GMT and eight were rehabilitation studies. Effectiveness was greater when GMT was combined with other interventions. The most effective interventions appeared to be those combing GMT with: Problem Solving Therapy; personal goal setting; external cueing or prompting apply GMT to the current task; personal homework to increase patients' commitment and training intensity; ecological and daily life training activities rather than paper-and-pencil, office-type tasks. Level of support for GMT was higher for studies measuring outcome in terms of increases in participation in everyday activities rather than on measures of executive impairment.

CONCLUSION

Comprehensive rehabilitation programs incorporating GMT, but integrating other approaches, are effective in executive function rehabilitation following brain injury in adults. There is insufficient evidence to support use of GMT as a stand-alone intervention.

Traumatic brain injury and post-acute decline: what role does environmental enrichment play? A scoping review

Objectives: While a growing number of studies provide evidence of neural and cognitive decline in traumatic brain injury (TBI) survivors during the post-acute stages of injury, there is limited research as of yet on environmental factors that may influence this decline. The purposes of this paper, therefore, are to (1) examine evidence that environmental enrichment (EE) can influence long-term outcome following TBI, and (2) examine the nature of post-acute environments, whether they vary in degree of EE, and what impact these variations have on outcomes.

Methods: We conducted a scoping review to identify studies on EE in animals and humans, and post-discharge experiences that relate to barriers to recovery.

Results: One hundred and twenty-three articles that met inclusion criteria demonstrated the benefits of EE on brain and behavior in healthy and brain-injured animals and humans. Nineteen papers on post-discharge experiences revealed that variables such as insurance coverage, financial, and social support, home therapy, and transition from hospital to home, can have an impact on clinical outcomes.

Conclusion: There is evidence to suggest that lack of EE, whether from lack of resources or limited ability to engage in such environments, may play a role in post-acute cognitive and neural decline. Maximizing EE in the post-acute stages of TBI may improve long-term outcomes for the individual, their family and society.