Effects of group versus individual therapy for patients with memory disorder after an acquired brain injury: A randomized, controlled study

Update on the Efficacy of Cognitive Rehabilitation After Moderate to Severe Traumatic Brain Injury: A Scoping Review

OBJECTIVES

To identify, categorize, and analyze the methodological issues of cognitive rehabilitation of patients with moderate to severe traumatic brain injury and its efficacy.

DATA SOURCES

Pubmed and PsycINFO were searched for studies published between 2015 and 2021 using keywords for cognitive intervention and traumatic brain injury.

STUDY SELECTION

Two independent reviewers selected articles concerning cognitive rehabilitation for adults with traumatic brain injury. Of 458 studies, 97 full-text articles were assessed and 46 met the inclusion criteria.

DATA EXTRACTION

Data were analyzed by 1 reviewer according to criteria concerning the methodological quality of studies.

DATA SYNTHESIS

Results showed a large scope of 7 cognitive domains targeted by interventions, delivered mostly in individual sessions (83%) with an integrative cognitive approach (48%). Neuroimaging tools as a measure of outcome remained scarce, featuring in only 20% of studies. Forty-three studies reported significant effects of cognitive rehabilitation, among which 7 fulfilled a high methodological level of evidence.

CONCLUSIONS

Advances and shortcomings in cognitive rehabilitation have both been highlighted and led us to develop methodological key points for future studies. The choice of outcome measures, the selection of control interventions, and the use of combined rehabilitation should be investigated in further studies.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part V: Memory

INTRODUCTION

Memory impairments affecting encoding, acquisition, and retrieval of information after moderate-to-severe traumatic brain injury (TBI) have debilitating and enduring functional consequences. The interventional research reviewed primarily focused on mild to severe memory impairments in episodic and prospective memory. As memory is a common focus of cognitive rehabilitation, clinicians should understand and use the latest evidence. Therefore, the INCOG ("International Cognitive") 2014 clinical practice guidelines were updated.

METHODS

An expert panel of clinicians/researchers reviewed evidence published since 2014 and developed updated recommendations for intervention for memory impairments post-TBI, a decision-making algorithm, and an audit tool for review of clinical practice.

RESULTS

The interventional research approaches for episodic and prospective memory from 2014 are synthesized into 8 recommendations (6 updated and 2 new). Six recommendations are based on level A evidence and 2 on level B. In summary, they include the efficacy of choosing individual or multiple internal compensatory strategies, which can be delivered in a structured or individualized program. Of the external compensatory strategies, which should be the primary strategy for severe memory impairment, electronic reminder systems such as smartphone technology are preferred, with technological advances increasing their viability over traditional systems. Furthermore, microprompting personal digital assistant technology is recommended to cue completion of complex tasks. Memory strategies should be taught using instruction that considers the individual's functional and contextual needs while constraining errors. Memory rehabilitation programs can be delivered in an individualized or mixed format using group instruction. Computer cognitive training should be conducted with therapist guidance. Limited evidence exists to suggest that acetylcholinesterase inhibitors improve memory, so trials should include measures to assess impact. The use of transcranial direct current stimulation (tDCS) is not recommended for memory rehabilitation.

CONCLUSION

These recommendations for memory rehabilitation post-TBI reflect the current evidence and highlight the limitations of group instruction with heterogeneous populations of TBI. Further research is needed on the role of medications and tDCS to enhance memory.

American Speech-Language-Hearing Association Clinical Practice Guideline: Cognitive Rehabilitation for the Management of Cognitive Dysfunction Associated With Acquired Brain Injury

BACKGROUND

Cognitive-communication impairments following acquired brain injury (ABI) can have devastating effects on a person's ability to participate in community, social, vocational, and academic preinjury roles and responsibilities. Guidelines for evidence-based practices are needed to assist speech-language pathologists (SLPs) and other rehabilitation specialists in the delivery of cognitive rehabilitation for the adult population.

PURPOSE

The American Speech-Language-Hearing Association, in conjunction with a multidisciplinary panel of subject matter experts, developed this guideline to identify best practice recommendations for the delivery of cognitive rehabilitation to adults with cognitive dysfunction associated with ABI.

METHOD

A multidisciplinary panel identified 19 critical questions to be addressed in the guideline. Literature published between 1980 and 2020 was identified based on a set of a priori inclusion/exclusion criteria, and main findings were pooled and organized into summary of findings tables. Following the principles of the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision Framework, the panel drafted recommendations, when appropriate, based on the findings, overall quality of the evidence, balance of benefits and harms, patient preferences, resource implications, and the feasibility and acceptability of cognitive rehabilitation.

RECOMMENDATIONS

This guideline includes one overarching evidence-based recommendation that addresses the management of cognitive dysfunction following ABI and 11 subsequent recommendations focusing on cognitive rehabilitation treatment approaches, methods, and manner of delivery. In addition, this guideline includes an overarching consensus-based recommendation and seven additional consensus recommendations highlighting the role of the SLP in the screening, assessment, and treatment of adults with cognitive dysfunction associated with ABI. Future research considerations are also discussed.

Memory rehabilitation: restorative, specific knowledge acquisition, compensatory, and holistic approaches

Memory impairment following an acquired brain injury can negatively impact daily living and quality of life—but can be reduced by memory rehabilitation. Here, we review the literature on four approaches for memory rehabilitation and their associated strategies: (1) the restorative approach, aimed at a return to pre-morbid functioning, (2) the knowledge acquisition approach, involving training on specific information relevant to daily life, (3) the compensatory approach, targeted at improving daily functioning, and (4) the holistic approach, in which social, emotional, and behavioral deficits are addressed alongside cognitive consequences of acquired brain injury. Each memory rehabilitation approach includes specific strategies such as drill and practice (restorative), spaced retrieval (knowledge acquisition), memory aids (compensatory), or a combination of psychotherapy and cognitive strategies (holistic). Past research has demonstrated mixed support for the use of restorative strategies to improve memory function, whereas knowledge acquisition strategies show promising results on trained tasks but little generalization to untrained tasks and activities of daily living. Compensatory strategies remain widely used but require intensive training to be effectively employed. Finally, the holistic approach is becoming more widespread due to improvements in psychosocial wellbeing, yet there are considerable resource and cost requirements. Several factors can influence rehabilitation outcomes including metacognition and emotional disturbances. Considerations for future research to improve the applicability of strategies for memory rehabilitation include assessing memory impairment severity, examining memory needs in daily life, and exploring the long-term effects of memory rehabilitation.

Occupational therapy for cognitive impairment in stroke patients

BACKGROUND

Cognitive impairment is a frequent consequence of stroke and can impact on a person's ability to perform everyday activities. Occupational therapists use a range of interventions when working with people who have cognitive impairment poststroke. This is an update of a Cochrane Review published in 2010.

OBJECTIVES

To assess the impact of occupational therapy on activities of daily living (ADL), both basic and instrumental, global cognitive function, and specific cognitive abilities in people who have cognitive impairment following a stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, four other databases (all last searched September 2020), trial registries, and reference lists.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that evaluated an intervention for adults with clinically defined stroke and confirmed cognitive impairment. The intervention needed either to be provided by an occupational therapist or considered within the scope of occupational therapy practice as defined in the review. We excluded studies focusing on apraxia or perceptual impairments or virtual reality interventions as these are covered by other Cochrane Reviews. The primary outcome was basic activities of daily living (BADL) such as dressing, feeding, and bathing. Secondary outcomes were instrumental ADL (IADL) (e.g. shopping and meal preparation), community integration and participation, global cognitive function and specific cognitive abilities (including attention, memory, executive function, or a combination of these), and subdomains of these abilities. We included both observed and self-reported outcome measures.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies that met the inclusion criteria, extracted data, and assessed the certainty of the evidence. A third review author moderated disagreements if consensus was not reached. We contacted trial authors for additional information and data, where available. We assessed the certainty of key outcomes using GRADE.  MAIN RESULTS: We included 24 trials from 11 countries involving 1142 (analysed) participants (two weeks to eight years since stroke onset). This update includes 23 new trials in addition to the one study included in the previous version. Most were parallel randomised controlled trials except for one cross-over trial and one with a two-by-two factorial design. Most studies had sample sizes under 50 participants. Twenty studies involved a remediation approach to cognitive rehabilitation, particularly using computer-based interventions. The other four involved a compensatory and adaptive approach. The length of interventions ranged from 10 days to 18 weeks, with a mean total length of 19 hours. Control groups mostly received usual rehabilitation or occupational therapy care, with a few receiving an attention control that was comparable to usual care; two had no intervention (i.e. a waiting list). Apart from high risk of performance bias for all but one of the studies, the risk of bias for other aspects was mostly low or unclear.  For the primary outcome of BADL, meta-analysis found a small effect on completion of the intervention with a mean difference (MD) of 2.26 on the Functional Independence Measure (FIM) (95% confidence interval (CI) 0.17 to 4.22; P = 0.03, I2 = 0%; 6 studies, 336 participants; low-certainty evidence). Therefore, on average, BADL improved by 2.26 points on the FIM that ranges from 18 (total assist) to 126 (complete independence). On follow-up, there was insufficient evidence of an effect at three months (MD 10.00, 95% CI -0.54 to 20.55; P = 0.06, I2 = 53%; 2 studies, 73 participants; low-certainty evidence), but evidence of an effect at six months (MD 11.38, 95% CI 1.62 to 21.14, I2 = 12%; 2 studies, 73 participants; low-certainty evidence). These differences are below 22 points which is the established minimal clinically important difference (MCID) for the FIM for people with stroke. For IADL, the evidence is very uncertain about an effect (standardised mean difference (SMD) 0.94, 95% CI 0.41 to 1.47; P = 0.0005, I2 = 98%; 2 studies, 88 participants). For community integration, we found insufficient evidence of an effect (SMD 0.09, 95% CI -0.35 to 0.54; P = 0.68, I2 = 0%; 2 studies, 78 participants). There was an improvement of clinical importance in global cognitive functional performance after the intervention (SMD 0.35, 95% CI 0.16 to 0.54; P = 0.0004, I2 = 0%; 9 studies, 432 participants; low-certainty evidence), equating to 1.63 points on the Montreal Cognitive Assessment (MoCA) (95% CI 0.75 to 2.52), which exceeds the anchor-based MCID of the MoCA for stroke rehabilitation patients of 1.22. We found some effect for attention overall (SMD -0.31, 95% CI -0.47 to -0.15; P = 0.0002, I2 = 20%; 13 studies, 620 participants; low-certainty evidence), equating to a difference of 17.31 seconds (95% CI 8.38 to 26.24), and for executive functional performance overall (SMD 0.49, 95% CI 0.31 to 0.66; P < 0.00001, I2 = 74%; 11 studies, 550 participants; very low-certainty evidence), equating to 1.41 points on the Frontal Assessment Battery (range: 0-18). Of the cognitive subdomains, we found evidence of effect of possible clinical importance, immediately after intervention, for sustained visual attention (moderate certainty) equating to 15.63 seconds, for working memory (low certainty) equating to 59.9 seconds, and thinking flexibly (low certainty), compared to control.

AUTHORS' CONCLUSIONS

The effectiveness of occupational therapy for cognitive impairment poststroke remains unclear. Occupational therapy may result in little to no clinical difference in BADL immediately after intervention and at three and six months' follow-up. Occupational therapy may slightly improve global cognitive performance of a clinically important difference immediately after intervention, likely improves sustained visual attention slightly, and may slightly increase working memory and flexible thinking after intervention. There is evidence of low or very low certainty or insufficient evidence for effect on other cognitive domains, IADL, and community integration and participation.  Given the low certainty of much of the evidence in our review, more research is needed to support or refute the effectiveness of occupational therapy for cognitive impairment after stroke. Future trials need improved methodology to address issues including risk of bias and to better report the outcome measures and interventions used.

Engagement in rehabilitation therapy and functional outcomes among individuals with acquired brain injuries

Purpose : The purpose was to examine the role of therapy engagement as a potential mediator for the relationship between neuropsychological performance and functional outcomes. Materials and method : Participants were 94 adults with medically documented ABI recruited from three outpatient rehabilitation clinics at the start of occupational therapy. Participants (57% men) ranged from 18 to 82 in age, with the majority (81%) having completed 12 or more years of education. They completed a comprehensive neuropsychological assessment at baseline. Separately, occupational therapists (OTs) assessed functional independence and disability at baseline and follow up. The OTs also rated the participants' therapy engagement. Results : Therapy engagement predicted functional outcomes and mediated the relationship between neuropsychological performance and outcomes. Moreover, therapy engagement accounted for unique variance in functional outcome, even after accounting for education, comorbid health conditions, emotional distress, apathy, and baseline functional ability. Conclusions : Engagement in therapy is a crucial patient characteristic in successful rehabilitation outcome. Cognitive deficits associated with ABI undermine full engagement in rehabilitation therapy, which in turn diminishes potential gains made in therapy and functional recovery. Neuropsychological assessment can enhance rehabilitation outcomes by identifying characteristics that underlie therapy engagement, which can ultimately be used to maximize the effectiveness of individualized treatment plans. Implications for rehabilitation Neuropsychological assessment can identify cognitive abilities that are strongly related to functional outcomes during occupational therapy for acquired brain injury. Therapy engagement is an important pathway by which neuropsychological impairment predicts functional outcomes after acquired brain injuries.

"I'm just not a Sudoku person": analysis of stroke survivor, carer, and healthcare professional perspectives for the design of a cognitive rehabilitation intervention

Purpose: Exploring the views of those impacted by stroke is key to the design of an effective and appropriate cognitive rehabilitation intervention for post-stroke cognitive impairment. This qualitative study examined the perspectives and preferences of stroke survivors, carers, and healthcare professionals to inform the design of a cognitive rehabilitation intervention.Design and methods: The research employed a qualitative study design and thematic analysis of data. In-depth semi-structured interviews were conducted with stroke survivors (n = 14), carers (n = 11), and healthcare professionals involved in providing stroke care (n = 19). Interviews were audio-recorded and transcribed. Coding was conducted and themes were developed both inductively and deductively.Results: Themes address five broad areas relevant for the design and implementation of the intervention: (i) activities to include; (ii) when it takes place; (iii) location; (vi) format; (v) who the intervention should include.Conclusions: Qualitative work with stroke survivors, carers and healthcare professionals provided vital information for the intervention design. Issues identified by participants as being key to intervention development included: (i) implications of post-stroke cognitive impairment survivors' confidence; (ii) their individual capacity in terms of fatigue and metacognition; and (iii) practical issues such as intervention location. The inclusion of psychoeducation regarding consequences of stroke was recommended.Implications for rehabilitationStroke survivors, carers, and rehabilitation professionals who provide stroke care can provide valuable insights and ideas to inform the development of a cognitive rehabilitation intervention.A cognitive rehabilitation intervention should be tailored to patient-specified goals, incorporating both group and individualized activities.Information, education, and communication are required to help stroke survivors and carers understand the cognitive, emotional, and behavioral consequences of stroke.Intervention content should be considerate of stroke survivors' capacity in terms of cognitive impairment and fatigue levels.

Comprehensive cognitive training improves attention and memory in patients with severe or moderate traumatic brain injury

Traumatic brain injury (TBI) leads to cognitive disorders, the most frequently affected functions being attention and memory. The present study aimed to investigate the effects of a cognitive rehabilitation program, consisting of individual and group interventions, on attention and memory in patients with TBI. Fifteen patients-in the postacute phase of recovery from moderate-to-severe TBI and subsequent cognitive disorders-were enrolled on a three-week waiting list and then underwent a three-week cognitive rehabilitation program. The patients were assessed using a set of five neuropsychological attention and memory tests. The patients and their caregivers were questioned to assess subjective changes in the everyday functioning of the former. The introduction of cognitive training was associated with improvement in one memory test and in two measures of attention. Mean effect size across all tests was higher over the period with treatment compared to the period without (d = 0.36 vs. 0.03). Both patients and caregivers reported significant improvements in everyday functioning (p < .05). There were no further improvements at the four-month follow-up assessment. A comprehensive program of cognitive rehabilitation may improve attention and memory, as well as everyday cognitive functioning, in patients with severe or moderate TBI.