Computerized Cognitive Rehabilitation of Attention and Executive Function in Acquired Brain Injury: A Systematic Review

Computer-assisted training of executive functions in adult patients with non-progressive acquired brain damage - a pilot study on efficacy of a new therapeutic application

Executive dysfunction is most often caused by post-traumatic or post-stroke damage to the prefrontal regions of the brain. The aim of this study was to compare the efficacy of two computer-assisted therapy programs for executive dysfunctions in patients with acquired brain injury. Patients were trained using either a newly developed application ExeSystem (designed to help improve the ability to manage and control one's own behavior by performing tasks imitating natural, everyday situations) or a combination of two commercial applications RehaCom and CogniPlus. Data collected after a three-week period of therapy conducted in two 15-person groups of participants indicated comparable efficacy of both therapy programs in improving quality of daily functioning, executive attention, as well as planning and problem-solving but not memory. The improvement in social competence (p = .028) was the only advantage of therapy with the ExeSystem. Therapeutic interactions using computer programs were shown to be positively evaluated by patients (p < .01). This study confirmed at least equal efficacy of computer-based executive function therapy using ExeSystem compared to RehaCom and CogniPlus. However, despite the implementation of a more ecological and comprehensive approach to the content of a new application, the benefits of this approach were limited.

Systematic review and meta-analysis of standalone digital interventions for cognitive symptoms in people without dementia

Cognitive symptoms are prevalent across neuropsychiatric disorders, increase distress and impair quality of life. Self-guided digital interventions offer accessibility, scalability, and may overcome the research-to-practice treatment gap. Seventy-six trials with 5214 participants were identified. A random-effects meta-analysis investigated the effects of all digital self-guided interventions, compared to controls, at post-treatment. We found a small-to-moderate positive pooled effect on cognition (k = 71; g = -0.51, 95%CI -0.64 to -0.37; p < 0.00001) and mental health (k = 30; g = -0.41, 95%CI -0.60 to -0.22; p < 0.0001). Positive treatment effects on fatigue (k = 8; g = -0.27, 95%CI -0.53 to -0.02; p = 0.03) and quality of life (k = 22; g = -0.17, 95%CI -0.34 to -0.00; p = 0.04) were only marginally significant. No significant benefit was found for performance on activities of daily living. Results were independent of control groups, treatment duration, risk of bias and delivery format. Self-guided digital transdiagnostic interventions may benefit at least a subset of patients in the short run, yet their impact on non-cognitive outcomes remains uncertain.

Aerobic exercise and cognitive function in chronic severe traumatic brain injury survivors: a within-subject A-B-A intervention study

BACKGROUND

Following acute and sub-acute rehabilitation from severe traumatic brain injury (TBI), minimal to no efficacious interventions to treat ongoing cognitive deficits are available. Aerobic exercise is a non-invasive behavioral intervention with promise to treat cognitive deficits in TBI populations.

METHODS

Six individuals, aged 24-62 years, with chronic (> 8 months since injury) severe (Glasgow Coma Scale of 3-8) TBI were recruited from two outpatient rehabilitation centers. In an A-B-A study design, 20-weeks of supervised aerobic exercise interventions were delivered three times per week (phase B) in addition to participants typical rehabilitation schedules (phases A). The effect of phase B was tested on a trail making test part B (primary outcome measure of executive function) as well as objective daily physical activity (PA), using both group level (linear mixed effect models) and single subject statistics.

RESULTS

Five of six participants increased trail-making test part B by more than 10% pre-to-post phase B, with three of six making a clinically meaningful improvement (+ 1SD in normative scores). A significant main effect of time was seen with significant improvement in trail-making test part B pre-to-post exercise (phase B). No significant effects in other planned comparisons were found. Statistically significant increases in daily moderate-to-vigorous PA were also seen during phase B compared to phase A with three of six individuals making a significant behaviour change.

CONCLUSIONS

The addition of supervised aerobic exercise to typical rehabilitation strategies in chronic survivors of severe TBI can improve executive set shifting abilities and increase voluntary daily PA levels.

TRIAL REGISTRATION

Retrospective trial registration on July 11 2024 with trial number: ISRCTN17487462.

At-distance neurocognitive rehabilitation during COVID-19 pandemic: A first glance of patients' perspectives about the process and an online platform

Despite the use of digital communication technologies in neurocognitive rehabilitation has been widely used in face-to-face interventions, the difficulties of using ICT-based tools to provide rehabilitation services and the unfamiliarity of the neuropsychologists with internet interventions limited the use of these kinds of interventions in their clinical practices. The lockdown and mitigating measures associated with the COVID-19 pandemic, on the other hand, forced the use of at-distance and online interventions as a means to mitigate the impact of those measures on the mental health and rehabilitation processes of people with neurological disorders. Overall, little is known about the perspectives of patients with acquired neurological conditions about rehabilitation services delivered at distance. Therefore, the main goal of this study was to explore the perceptions that patients with neurological disorders have on at-distance online neurocognitive rehabilitation, namely during the COVID-19 pandemic. Sixteen patients with acquired neurological conditions attending an online neurocognitive rehabilitation program in a Portuguese rehabilitation center filled in an online questionnaire during the mandatory lockdown. The results of this study highlight the potential of delivering rehabilitation services at distance, presenting its advantages and limitations from patients' perspectives, as well as suggestions for improving both neurorehabilitation processes and the online rehabilitation platform used.

Efficacy of Computerized vs. Traditional Cognitive Interventions for the Treatment of Chronic mTBI Symptoms Among Service Members

INTRODUCTION

Military service members (SMs) with mild traumatic brain injury (mTBI or concussion) frequently report cognitive and behavioral difficulties. Currently, military clinical guidelines recommend clinician-run, manualized cognitive rehabilitation (CR) to treat these symptoms; however, it is unclear whether this approach adequately addresses the unique needs of warfighters. Computerized cognitive training (CCT) programs represent an innovative, promising approach to treating cognitive difficulties; however, whether these programs can effectively remediate cognitive impairment in individuals with mTBI remains unclear.

MATERIALS AND METHODS

A total of 65 SMs with a history of at least 1 diagnosed mTBI were recruited from a military hospital. Participants received 1 of 2 interventions: Clinician-run, manualized CR (Study of Cognitive Rehabilitation Effectiveness [SCORE]; n = 37), consisting of 60 total intervention hours over 6 weeks, or CCT (n = 28), in which participants trained with either a commercial CCT (n = 14) or noncommercial CCT (n = 14), for a total of 12 hours over 4 weeks. Participants were assessed pre- and postintervention, using a combination of self-report and objective outcome measures: Key Behaviors Change Inventory (KBCI), a self-report measure of functional difficulties; Paced Auditory Serial Addition Test (PASAT), an objective cognitive assessment that measures both information processing speed and sustained and divided attention; and Symbol Digit Modalities Test (SDMT), an objective cognitive assessment that measures information processing speed.

RESULTS

Mixed ANOVA revealed no interaction effect between intervention type and time (pre- and postassessment) on the PASAT (P = .643, ηp2 = 0.003), SDMT (P = .423, ηp2 = 0.010), or KBCI (P = .434, ηp2 = 0.010); however, there was a significant within-group main effect (time) on all 3 outcome measures (PASAT P < .001, ηp2 = 0.54; SDMT P < .001, ηp2 = 0.25; and KBCI P = .001, ηp2 = 0.15). On average, participants showed improvement over baseline on the PASAT (SCORE delta = 6.98, SD = 7.25, P < .001; CCT delta = 7.79, SD = 6.45, P < .001), SDMT (SCORE delta = 4.62, SD = 8.82, P = .003; CCT delta = 6.58, SD = 10.81, P = .003), and KBCI (SCORE delta = -3.22, SD = 7.09, P = .009; CCT delta = -2.00, SD = 4.72, P = .033). Additional analysis comparing the relative effectiveness of the 2 different CCTs revealed that while training with either program resulted in improved performance on the PASAT (P < .001, ηp2 = 0.627), SDMT (P = .003, ηp2 = 0.286), and KBCI (P = .036, ηp2 = 0.158), there was no interaction effect of CCT program type and change over time for any measure (PASAT P = .102, ηp2 = 1.00; SDMT P = .317, ηp2 = 0.038; and KBCI P = .719, ηp2 = 0.005).

CONCLUSIONS

We showed that CCT programs do not differ in efficacy compared to clinician-run, manualized CR for treating symptoms associated with mTBI; however, exploratory analyses suggest that each approach may have distinct advantages for treating specific symptoms. Additionally, we showed that the improvement in the CCT intervention did not differ between those who trained using the commercial program vs. those who trained with the noncommercial program.

Attention Training After Moderate-to-Severe Traumatic Brain Injury in Adults: A Systematic Review

OBJECTIVE

To determine the extent and efficacy of attentional training as a form of neuropsychological rehabilitation to ameliorate attention deficits in adults with moderate-to-severe traumatic brain injury.

DATA SOURCES

Articles published in Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, PubMed, PsycINFO, Scopus, and Web of Science were searched between January 17, and February 27, 2021.

STUDY SELECTION

Two reviewers blindly assessed studies for eligibility according to the following criteria: any article evaluating the efficacy of any type of behavioral intervention that targeted attention (by means of cognitive rehabilitative, psychoeducational, or neuropsychological strategies, at either an individual or group level) in adults who had sustained a formally documented moderate-to-severe traumatic brain injury.

DATA EXTRACTION

Methodological quality of each article was blindly assessed by 2 reviewers. Data were extracted from each study, including study type, sample size, sample characteristics, summary of intervention, measures used to assess attention, statistical outcomes and results, effect size, conclusion, and limitations.

DATA SYNTHESIS

7314 articles were retrieved from databases, 4325 articles remained after duplicate removal, and finally 21 articles met eligibility criteria and were included in this review. Articles represented varied methodological quality in group or single subject design. Irrespective of the heterogeneity regarding intervention types and attentional outcome measures used across the studies, overall findings suggest that attentional gains can be made in this sample, irrespective of time since injury, age, and injury severity. Further, a growing interest in technology-based interventions is frequently used and holds promise to bettering rehabilitation efforts. However, there is still limited evidence supporting the ecological validity of attentional training interventions (eg, the transfer of treatment effects to daily activities).

CONCLUSIONS

This article plays a crucial role in informing ongoing rehabilitation practices, guiding clinicians with evidence-based strategies and shaping future research directions for more effective attentional training guidelines.

Nonpharmacological Therapies for the Management of the Cognitive Dysfunctions in Poststroke Patients: A Systematic Review and Network Meta-analysis

OBJECTIVE

The aim of the study is to investigate the comparative effects of nonpharmacological therapies for managing global, attention, memory, and execution cognitive functions in stroke patients.

DESIGN

We searched PubMed, Embase, CINAHL, Cochrane Library, Web of Science, PEDro, and Google Scholar for randomized controlled trials that evaluated the effects of nonpharmacological therapies for treating stroke cognitive dysfunctions. We performed a network meta-analysis to estimate the mean treatment effect of 95% credible interval.

RESULTS

Seventy-three randomized controlled trials were included in the network meta-analysis for evidence syntheses. All therapies had significant effects than control on global cognition in stroke patients. Combined therapy was superior to other therapies for global cognition of all patients (vs. cognitive task therapy: 0.71, 95% credible interval = 0.14 to 1.29; vs. exercise: 0.88, 95% credible interval = 0.31 to 1.45, vs. physical modality therapy: 0.77, 95% credible interval = 0.16 to 1.40). Different therapies have effects on specific cognitive domains in stroke patients.

CONCLUSIONS

Our findings suggest that nonpharmacological therapies are effective in improving global cognitive function in stroke patients, with cognitive task therapy, exercise therapy, physical modality therapy, and combined therapy being viable options (most optimal approach: combined therapy). Precise selection of therapies based on the time since stroke onset and specific cognitive domains can further enhance treatment outcomes.

Training to deal with distractions and conflicting situations in activities of daily living after traumatic brain injury (TBI): Preliminary evidence from a single-case experimental design study

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03958487.

Computerized social cognitive training in the subacute phase after traumatic brain injury: A quasi-randomized controlled trial

OBJECTIVES

To assess the usefulness of a computerized tasks module designed for the rehabilitation of social cognition (SC) in acquired brain injury.

METHODS

Quasi-randomized controlled trial (ClinicalTrials.gov:NCT03479970) involving 45 patients with moderate-severe traumatic brain injury (TBI) in a subacute inpatient rehabilitation hospital. The experimental group (n = 28) received treatment with a computerized SC module in combination with a non-SC module. The control group (n = 26) only received a treatment with non-SC module.

RESULTS

Intragroup comparisons showed that the experimental group had better results for all SC measures, except for International Affective Picture System (IAPS). The control group improved for Facial Expressions of cEmotion-Stimuli and Tests (FEEST) and Moving Shapes Paradigm (MSP), showing no changes with respect to pretreatment in IAPS, MSP and Reading the Mind in the Eyes Test (RMET). Intergroup comparisons did not present differences between the two groups for pretreatment measures. Post-treatment comparison showed that the experimental group obtained better results for RMET than the control group.

CONCLUSION

The computerized SC module was useful for the rehabilitation of SC in patients with moderate-severe TBI in the subacute phase. The group that received combined rehabilitative treatment (SC + non-SC) obtained better results for SC than the group that received treatment intended only for non-SC.

Cognitive impairment in people living with HIV: mechanisms, controversies, and future perspectives

Despite the dramatic decrease in HIV-associated neurocognitive impairment (NCI) in the combined antiretroviral treatment (cART) era, subtler neuropsychological complications remain prevalent. In this review, we discuss the changing pathophysiology of HIV-associated NCI, considering recent evidence of HIV neuropathogenesis, and the pivotal role of cART. Furthermore, we address the multifactorial nature of NCI in people living with HIV, including legacy and ongoing insults to the brain, as well as host-specific factors. We also summarize the ongoing debate about the refinement of diagnostic criteria, exploring the strengths and limitations of these recent approaches. Finally, we present current research in NCI management in people living with HIV and highlight the need for using both pharmacological and nonpharmacological pathways toward a holistic approach.

A Comparison between the Effectiveness of computerized Cognitive Rehabilitation Training and transcranial Direct Current Stimulation on Dialysis Patients' Executive Functions

Purpose

Executive function impairments are among the most common dialysis side effects. The present study aims to compare the efficiency of transcranial Direct Current Stimulation (tDCS) with computerized Cognitive Rehabilitation Training (cCRT) on dialysis patients' executive functions.

Research method

The present study, a quasi-experimental effort, adopted a pre-test/post-test method that included a control (sham) group.

Design

The study sample consisted of 30 participants, selected through the convenience sampling method, and categorized into three groups of cCRT, tDCS, and sham participants. The cCRT participants were asked to complete 8 tasks in Captain's Log MindPower Builder software. The tDCS participants were treated with a 0.06 mA/cm2 current with the anodal electrode on F3 and the cathodal electrode on Fp2. For the sham participants, the electrodes were put on the same regions but there was no current stimulation. The treatment lasted for 10 sessions carried out every other day.

Results

The results of MANCOVA showed no significant difference between the sham group and the cCRT group in any of the executive function items. . However, between the sham group and the tDCS group was detected a significant difference in spatial working memory (p \< 0.05) and a marginally significant in cognitive flexibility (p = 0.091). No significant difference was reported between cCRT and tDCS groups in any item.

Conclusion

According to the findings of the study, given the efficacy of tDCS on spatial working memory and cognitive flexibility for dialysis patients, it can be used to improve these skills.

Implementing neuropsychological rehabilitation following severe traumatic brain injury in a low-to-middle income country: a case report

Introduction

TBI incidence and distribution are largely overrepresented in low- to middle-income countries (LMICs), such as South Africa (SA), with substantial associated human and financial costs. However, access to rehabilitation for the public is severely limited and not standard practice in SA. Given this background, studies demonstrating the successful implementation of neuropsychological rehabilitation in a LMIC setting are important. Published studies of this nature are generally lacking in this context. Further, there is a need to evaluate interventions that can be implemented at a low cost. To this end, we report on a neuropsychological rehabilitation program for an individual with severe TBI in a LMIC context, aimed at improving his capacity for activities of daily living.

Method

A 33-year-old, South African male who sustained a severe traumatic brain injury (TBI) partook in a neuropsychological intervention aimed at remediating functional deficits and enhancing independent functioning. The intervention utilised principles of Goal Management Training and external memory aids, with reliance on procedural memory and errorless learning, to target the participant's impairments in executive functioning and memory through the use of assistive technology-namely smart device applications.

Results

Data collected pre- and post-intervention on formal neuropsychological measures demonstrated no significant change in cognition. However, observational data and qualitative feedback from the participant's family indicated notable improvement in performance on everyday tasks with reduced number of errors and reduced need for external prompting whilst completing intervention tasks across sessions.

Discussion

In the context of severe TBI, neuropsychological rehabilitation can facilitate gains in independent functioning. This study provides support for the value of neurorehabilitation especially for interventions that can be rolled out at low cost and should serve as impetus for further such research in South Africa, where neuropsychological rehabilitation infrastructure and services are lacking.

Virtual reality as a method of cognitive training of processing speed, working memory, and sustained attention in persons with acquired brain injury: a protocol for a randomized controlled trial

BACKGROUND

Acquired brain injury (ABI) often leads to persisting somatic, cognitive, and social impairments. Cognitive impairments of processing speed, sustained attention, and working memory are frequently reported and may negatively affect activities of daily living and quality of life. Rehabilitation efforts aiming to retrain these cognitive functions have often consisted of computerized training programs. However, few studies have demonstrated effects that transfer beyond the trained tasks. There is a growing optimism regarding the potential usefulness of virtual reality (VR) in cognitive rehabilitation. The research literature is sparse, and existing studies are characterized by considerable methodological weaknesses. There is also a lack of knowledge about the acceptance and tolerability of VR as an intervention method for people with ABI. The present study aims to investigate whether playing a commercially available VR game is effective in training cognitive functions after ABI and to explore if the possible effects transfer into everyday functioning.

METHODS

One hundred participants (18-65 years), with a verified ABI, impairments of processing speed/attention, and/or working memory, and a minimum of 12 months post injury will be recruited. Participants with severe aphasia, apraxia, visual neglect, epilepsy, and severe mental illness will be excluded. Participants will be randomized into two parallel groups: (1) an intervention group playing a commercial VR game taxing processing speed, working memory, and sustained attention; (2) an active control group receiving psychoeducation regarding compensatory strategies, and general cognitive training tasks such as crossword puzzles or sudoku. The intervention period is 5 weeks. The VR group will be asked to train at home for 30 min 5 days per week. Each participant will be assessed at baseline with neuropsychological tests and questionnaires, after the end of the intervention (5 weeks), and 16 weeks after baseline. After the end of the intervention period, focus group interviews will be conducted with 10 of the participants in the intervention group, in order to investigate acceptance and tolerability of VR as a training method.

DISCUSSION

This study will contribute to improve understanding of how VR is tolerated and experienced by the ABI population. If proven effective, the study can contribute to new rehabilitation methods that persons with ABI can utilize in a home setting, after the post-acute rehabilitation has ended.

Inconclusive results of slow cortical potential neurofeedback for the treatment of chronic post-stroke attention deficits

Introduction

Individuals who have suffered a stroke may experience long-lasting cognitive impairments that can worsen if left untreated. We investigated whether voluntary control of slow cortical potentials (SCP) through neurofeedback would help alleviate chronic post-stroke symptoms of impaired attention.

Methods

The study initially enrolled twenty-eight participants, but due to a high drop-out rate, only sixteen participants completed eight SCP neurofeedback training sessions within three to four weeks. During these sessions, we gave feedback to the participants on their ability to regulate SCPs on a computer screen.

Results

Our findings showed a non-significant increase in SCP regulation towards cortical negativity. On the behavioral level, we found improved test values in the divided attention and attentional flexibility subtests of the test battery for attention performance. However, we cannot eliminate the possibility that nonspecific effects influenced or caused our results. We have not observed any improvement regarding the effects of attention deficits on participants' daily lives. We identified five individuals who could gain SCP control successfully and consistently towards negativity. In this group of responders, we observed an improvement in the test results related to divided attention but no other attention-related improvements.

Discussion

Based on our observations, results of SCP neurofeedback training for the treatment of attention deficits after a stroke are inconclusive. More research is necessary to determine the effectiveness of SCP neurofeedback in helping stroke survivors cope with attention-related challenges in their daily lives.

Effectiveness of teleneuropsychological rehabilitation: Systematic review of randomized controlled trials

OBJECTIVE

The effectiveness of neuropsychological rehabilitation is supported by the evidence found in previous reviews, but there is a lack of research regarding the effectiveness of remotely conducted neuropsychological rehabilitation. This review aimed to identify and evaluate the results of studies investigating the effectiveness of teleneuropsychological rehabilitation.

METHODS

Relevant articles were extracted from electronic databases and filtered to include studies published in 2016 or later to focus on recent practices. Data were synthesized narratively.

RESULTS

A total of 14 randomized controlled studies were included in the synthesis (9 for children/adolescents, 5 for adults). The most common type of intervention was computerized cognitive training with regular remote contact with the therapist (seven studies). Regarding children and adolescents, the evidence for the effectiveness was found only for these types of interventions with improvements in cognitive outcomes. The results regarding the family-centered interventions were mixed with improvements only found in psychosocial outcomes. No support was found for the effectiveness of interventions combining cognitive and motor training. Regarding adults, all included studies offered support for the effectiveness, at least to some extent. There were improvements particularly in trained cognitive functions. Long-term effects of the interventions with generalization to global functioning remained somewhat unclear.

CONCLUSION

Remote interventions focused on computerized cognitive training are promising methods within teleneuropsychological rehabilitation. However, their impact on long-term meaningful, everyday functioning remained unclear. More research is needed to reliably assess the effectiveness of teleneuropsychological interventions, especially with more comprehensive approaches.

Case report: Neural timing deficits prevalent in developmental disorders, aging, and concussions remediated rapidly by movement discrimination exercises

Background

The substantial evidence that neural timing deficits are prevalent in developmental disorders, aging, and concussions resulting from a Traumatic Brain Injury (TBI) is presented.

Objective

When these timing deficits are remediated using low-level movement-discrimination training, then high-level cognitive skills, including reading, attention, processing speed, problem solving, and working memory improve rapidly and effectively.

Methods

In addition to the substantial evidence published previously, new evidence based on a neural correlate, MagnetoEncephalography physiological recordings, on an adult dyslexic, and neuropsychological tests on this dyslexic subject and an older adult were measured before and after 8-weeks of contrast sensitivity-based left-right movement-discrimination exercises were completed.

Results

The neuropsychological tests found large improvements in reading, selective and sustained attention, processing speed, working memory, and problem-solving skills, never before found after such a short period of training. Moreover, these improvements were found 4 years later for older adult. Substantial MEG signal increases in visual Motion, Attention, and Memory/Executive Control Networks were observed following training on contrast sensitivity-based left-right movement-discrimination. Improving the function of magnocells using figure/ground movement-discrimination at both low and high levels in dorsal stream: (1) improved both feedforward and feedback pathways to modulate attention by enhancing coupled theta/gamma and alpha/gamma oscillations, (2) is adaptive, and (3) incorporated cycles of feedback and reward at multiple levels.

Conclusion

What emerges from multiple studies is the essential role of timing deficits in the dorsal stream that are prevalent in developmental disorders like dyslexia, in aging, and following a TBI. Training visual dorsal stream function at low levels significantly improved high-level cognitive functions, including processing speed, selective and sustained attention, both auditory and visual working memory, problem solving, and reading fluency. A paradigm shift for treating cognitive impairments in developmental disorders, aging, and concussions is crucial. Remediating the neural timing deficits of low-level dorsal pathways, thereby improving both feedforward and feedback pathways, before cognitive exercises to improve specific cognitive skills provides the most rapid and effective methods to improve cognitive skills. Moreover, this adaptive training with substantial feedback shows cognitive transfer to tasks not trained on, significantly improving a person's quality of life rapidly and effectively.

Game-supported cognitive strategy training for slowed information processing speed after acquired brain injury: study protocol for a randomised controlled trial

INTRODUCTION

Many individuals with acquired brain injury tend to experience problems with slowed information processing speed (IPS). A potentially beneficial and cost-effective supplement for cognitive rehabilitation of impaired IPS may be the implementation of serious gaming that focuses on compensatory learning as part of cognitive training. However, most digital platforms used during cognitive rehabilitation focus on restoring cognitive function and evidence for skill transfer from digital practice to everyday life is lacking. This study aims to investigate the efficacy of a game-supported cognitive strategy training. The training combines a well-validated time pressure management cognitive strategy training, targeting slowed IPS, with a novel game and a mobile application. The game-supported training focuses on the generalisation of strategy-use to untrained tasks in everyday life.

METHODS AND ANALYSIS

The study is designed as a randomised controlled trial in which the experimental group (Karman Line - Tempo module: an 8-week game-supported cognitive strategy training) will be compared with an active control group (CogniPlus training: an 8-week computerised cognitive function training). Data from 60 individuals with acquired brain injury (30 per group, ages between 16 and 75) will be collected at baseline (T0), post-treatment (T1) and at 3-month follow-up (T2). The primary outcome measure is an objective assessment of compensatory strategy use in an untrained experimental task. The secondary outcome is the attainment of trained and untrained treatment goals assessed by goal attainment scaling. Pre-training and post-training data will be analysed using a 2×2 repeated measure analysis of variance.

ETHICS AND DISSEMINATION

This study has been approved by the medical review ethics committee CMO Region Arnhem and Nijmegen (NL74818.091.20) and is registered in the Netherlands Trial Register. Research findings will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NL9437; The Netherlands Trial Register.

Innovations in Neuropsychology: Future Applications in Neurosurgical Patient Care

Over the last century, collaboration between clinical neuropsychologists and neurosurgeons has advanced the state of the science in both disciplines. These advances have provided the field of neuropsychology with many opportunities for innovation in the care of patients prior to, during, and following neurosurgical intervention. Beyond giving a general overview of how present-day advances in technology are being applied in the practice of neuropsychology within a neurological surgery department, this article outlines new developments that are currently unfolding. Improvements in remote platform, computer interface, "real-time" analytics, mobile devices, and immersive virtual reality have the capacity to increase the customization, precision, and accessibility of neuropsychological services. In doing so, such innovations have the potential to improve outcomes and ameliorate health care disparities.

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.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part II: Attention and Information Processing Speed

INTRODUCTION

Moderate to severe traumatic brain injury (MS-TBI) commonly causes disruption in aspects of attention due to its diffuse nature and injury to frontotemporal and midbrain reticular activating systems. Attentional impairments are a common focus of cognitive rehabilitation, and increased awareness of evidence is needed to facilitate informed clinical practice.

METHODS

An expert panel of clinicians/researchers (known as INCOG) reviewed evidence published from 2014 and developed updated guidelines for the management of attention in adults, as well as a decision-making algorithm, and an audit tool for review of clinical practice.

RESULTS

This update incorporated 27 studies and made 11 recommendations. Two new recommendations regarding transcranial stimulation and an herbal supplement were made. Five were updated from INCOG 2014 and 4 were unchanged. The team recommends screening for and addressing factors contributing to attentional problems, including hearing, vision, fatigue, sleep-wake disturbance, anxiety, depression, pain, substance use, and medication. Metacognitive strategy training focused on everyday activities is recommended for individuals with mild-moderate attentional impairments. Practice on de-contextualized computer-based attentional tasks is not recommended because of lack of evidence of generalization, but direct training on everyday tasks, including dual tasks or dealing with background noise, may lead to gains for performance of those tasks. Potential usefulness of environmental modifications is also discussed. There is insufficient evidence to support mindfulness-based meditation, periodic alerting, or noninvasive brain stimulation for alleviating attentional impairments. Of pharmacological interventions, methylphenidate is recommended to improve information processing speed. Amantadine may facilitate arousal in comatose or vegetative patients but does not enhance performance on attentional measures over the longer term. The antioxidant Chinese herbal supplement MLC901 (NeuroAiD IITM) may enhance selective attention in individuals with mild-moderate TBI.

CONCLUSION

Evidence for interventions to improve attention after TBI is slowly growing. However, more controlled trials are needed, especially evaluating behavioral or nonpharmacological interventions for attention.

Functional improvement in chronic stroke patients when following a supervised home-based computerized cognitive training

BACKGROUND

Computerized Cognitive Training (CCT) is an effective treatment for cognitive impairment in the post-acute stage of stroke. However, it is still not clear if it is suitable for chronic stage.

OBJECTIVES

To explore if patients with cognitive deficit following stroke may benefit from CCT.

METHODS

Thirty patients post-stroke between 24 and 62 years old were randomized into two groups (A and B) to receive two different types of CCT. All patients were tested with a neuropsychological battery and functional questionnaires, before and after each CCT and also 6 months after the end of the study. In phase I, Group A received a customized CCT and Group B received a non-customized CCT, over 6 weeks. Three months after, each group received the other intervention (phase II).

RESULTS

After phase I, between-group analyses revealed that Group A showed a relative decrease in subjective complaints. In contrast, Group B showed improvement in performance-based measures. After phase II, the decrease in subjective complaints continued in Group A, and both groups showed improvement in performance-based measures.

CONCLUSIONS

Patients with chronic stroke improved cognitive functioning after performing supervised home-based multi-domain computerized cognitive training.

Effects of Immersive Virtual Therapy as a Method Supporting Recovery of Depressive Symptoms in Post-Stroke Rehabilitation: Randomized Controlled Trial

PURPOSE

Depressive symptoms constitute an important group of mental problems that alter the course of post-stroke rehabilitation by reducing quality of life, physical activity, social functioning, and interpersonal relationships. Although several studies have shown the efficacy of virtual reality (VR) in the motor treatment of poststroke patients, there is a lack of studies that would also evaluate the impact of VR on psychological aspects. Thus, we investigated the effectiveness of immersive VR therapy on both functional activity and depressive symptoms in stroke survivors.

PATIENTS AND METHODS

We conducted a single blind, randomized controlled trial comparing VR therapy with Schultz's Autogenic Training (SAT). Patients randomized to the VR group received treatment in an immersive VR therapeutic garden with elements of psychotherapy and physical activity of the upper extremities, whereas patients in the control group received SAT. Additionally, patients in both groups received standard neurological rehabilitation. The full research cycle lasted six weeks. We used Geriatric Depression Scale, Generalized Self-Efficacy Scale, Acceptance of Illness Scale, Visual Analogue Scale of pain, Hospital Anxiety and Depression Scale, Barthel Index, Lawton Instrumental Activities of Daily Living Scale and Rivermead Motor Assessment for outcome assessment. This trial was registered with ClinicalTrials.gov (NCT03830372).

RESULTS

We assessed 60 patients and randomly assigned to the VR or control group. The VR group showed a significant reduction in depressive symptoms (ηp² = 0.13, p < 0.01) compared to SAT. The applied VR therapy significantly increased the sense of self-efficacy and the level of acceptance of the illness; however, this effect was similar to that obtained with the standard intervention. We did not observe statistically significant changes in the functional parameters of post-stroke patients.

CONCLUSION

The use of VR therapy combined with neurological rehabilitation had a positive effect on improving mood and reducing depressive symptoms in post-stroke patients.

Reversing the Ruin: Rehabilitation, Recovery, and Restoration After Stroke

PURPOSE OF REVIEW

Stroke is a common cause of disability in aging adults. A given individual's needs after stroke vary as a function of the stroke extent and location. The purpose of this review was to discuss recent clinical investigations addressing rehabilitation of an array of overlapping functional domains.

RECENT FINDINGS

Research is ongoing in the domains of movement, cognition, attention, speech, language, swallowing, and mental health. To best assist patients' recovery, innovative research has sought to develop and evaluate behavioral approaches, identify and refine synergistic approaches that augment the response to behavioral therapy, and integrate technology where appropriate, particularly to introduce and titrate real-world complexity and improve the overall experience of therapy. Recent and ongoing trials have increasingly adopted a multidisciplinary nature - augmenting refined behavioral therapy approaches with methods for increasing their potency, such as pharmaceutical or electrical interventions. The integration of virtual reality, robotics, and other technological advancements has generated immense excitement, but has not resulted in consistent improvements over more universally accessible, lower technology therapy.

Artificial Cognitive Systems Applied in Executive Function Stimulation and Rehabilitation Programs: A Systematic Review

This article presents a systematic review of studies on cognitive training programs based on artificial cognitive systems and digital technologies and their effect on executive functions. The aim has been to identify which populations have been studied, the characteristics of the implemented programs, the types of implemented cognitive systems and digital technologies, the evaluated executive functions, and the key findings of these studies. The review has been carried out following the PRISMA protocol; five databases have been selected from which 1889 records were extracted. The articles were filtered following established criteria, to give a final selection of 264 articles that have been used for the purposes of this study in the analysis phase. The findings showed that the most studied populations were school-age children and the elderly. The most studied executive functions were working memory and attentional processes, followed by inhibitory control and processing speed. Many programs were commercial, customizable, gamified, and based on classic tasks. Some more recent initiatives have begun to incorporate user-machine interfaces, robotics, and virtual reality, although studies on their effects remain scarce. The studies recognize multiple benefits of computerized neuropsychological stimulation and rehabilitation programs for executive functions in different age groups, but there is a lack of studies in specific population sectors and with more rigorous research designs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13369-022-07292-5.

Effects of computerized cognitive training on cognitive function, activity, and participation in individuals with stroke: A randomized controlled trial

BACKGROUND: Computerized cognitive training (CCT) is an emerging alternative intervention for stroke survivors. OBJECTIVE: This study investigated the effects of CCT on the cognition, activity, and participation of stroke survivors and compared the findings with those of match-dosed conventional cognitive training. METHODS: This randomized controlled trial included 39 patients with stroke who were divided into the intervention group (n = 19; receiving CCT with Lumosity software) and the control group (n = 20; receiving conventional cognitive training). Both the groups were trained for 20 min, twice a week, for 12 weeks. Participants were evaluated at pretest, posttest, and 4-week follow-up. Outcome measures included various cognitive function tests and the Stroke Impact Scale scores. RESULTS: The CCT group exhibited significant improvement in global cognitive function (evaluated using the Mini-Mental State Examination and Montreal Cognitive Assessment) and specific cognitive domains: verbal working memory (backward digit span test), processing speed (Symbol Digit Modalities Test), and three MoCA subtests (attention, naming, and delayed recall). CCT exerted no significant effect on activities and participation. No significant between-group differences in changes in cognitive function were noted. However, CCT significantly improved cognitive function domains immediately after training, and these effects were sustained at the 4-week follow-up. CONCLUSIONS: Cognitive function of individuals with chronic stroke could improve after administration of CCT. However, future studies with a more rigorous design and higher training dose are warranted to validate our findings.

Changes in the components of visual attention following traumatic brain injury: A systematic review and meta-analysis

Purpose

We conducted a systematic review and meta-analysis to understand the impact of traumatic brain injury (TBI) on visual attention and whether different components and processes of visual attention (such as selective, sustained, divided, and covert orientation of visual attention) are affected following brain injury.

Methods

A literature search between January 1980 to May 2021 was conducted using Medline, Scopus, PubMed, and Google Scholar databases was undertaken for studies that assessed visual attention using different tasks that target specific or multiple components of visual attention. Three hundred twenty-nine potentially relevant articles were identified, and 20 studies met our inclusion criteria.

Results

A total of 123 effect sizes (ES) were estimated from 20 studies that included 519 patients with TBI and 530 normal participants. The overall combined ES was statistically significant and large (ES = 0.92), but with high heterogeneity (Q = 614.83, p < 0.0001, I² = 80.32%). Subgroup analysis showed that the impact of TBI severity, with the ES for moderate-severe TBI significantly higher than mild TBI (t (112) = 3.11, p = 0.002). Additionally, the component of visual attention was differentially affected by TBI (F (2, 120) = 10.25, p<0.0001); the ES for selective attention (ES = 1.13) and covert orientation of visual attention (ES = 1.14) were large, whilst for sustained attention, the ES was medium at 0.43. A subgroup analysis comparing outcome measures showed that reaction time (ES = 1.12) was significantly more affected compared to performance accuracy (ES = 0.43), F (1, 96) = 25.98, p<0.0001).

Conclusion

Large and significant deficits in visual attention was found following TBI which can last for years after the initial injury. However, different components of visual attention were not affected to the same extent, with selective visual attention and orientation of visual attention most affected following TBI.

Evaluation of Computerized Cognitive Training and Cognitive and Daily Function in Patients Living With HIV: A Meta-analysis

IMPORTANCE

In the era of antiretroviral therapy (ART), the incidence of HIV-associated neurocognitive disorder (HAND) has not yet been controlled. With the exception of ART, there is no beneficial pharmacologic treatment. However, some studies have reported that computerized cognitive training (CCT) programs may improve cognitive function among people living with HIV.

OBJECTIVE

To examine the association between CCT programs and 8 domains measuring cognitive function (7 domains) and daily function (1 domain) among people living with HIV.

DATA SOURCES

Records from the Cochrane Library, PsycINFO, PubMed, and Web of Science were searched from database inception to December 15, 2020. Supplementary searches to identify missing studies were conducted in Google Scholar using updated search terms from database inception to November 18, 2021.

STUDY SELECTION

Studies that compared changes before and after a CCT intervention among people living with HIV were included. Search terms were a combination of words associated with HIV (eg, people living with HIV, HIV, and/or AIDS) and cognitive training (eg, cognitive intervention, nonpharmacology intervention, computer game, video game, computerized training, cognitive exercise, cognitive stimulation, and/or cognitive enhancement). Studies were included if they (1) used CCT as the primary intervention or combined CCT with other types of interventions; (2) used placebo, passive control conditions, traditional cognitive training, or single training tasks as control conditions; (3) reported changes between baseline and posttraining; (4) included participants 18 years or older; and (5) were randomized clinical trials (RCTs). Studies were excluded if they (1) were not associated with HIV, (2) were research protocols or feedback reports, (3) were case reports, or (4) did not report findings for domains of interest.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Random-effects models were used to quantitatively synthesize the existing data.

MAIN OUTCOMES AND MEASURES

Primary outcomes were the meta-synthesized changes in each domain after CCT.

RESULTS

Among 1245 records identified, 1043 were screened after removal of duplicates. Of those, 1019 records were excluded based on titles and abstracts, and 24 full-text articles were assessed for eligibility. After exclusions, 12 eligible RCTs were selected for inclusion in the meta-analysis. These RCTs involved 596 total participants, with 320 individuals in the CCT group (mean age, 47.5-59.7 years; 0%-94% female; 8.3-14.2 years of education) and 276 individuals in the control group (mean age, 44.2-60.0 years; 19%-90% female; 9.0-14.9 years of education). The average HIV inhibition ratio (the proportion of participants who achieved virological suppression) ranged from 30% to 100%, and the CD4+ T-cell count ranged from 471 to 833 cells/μL. The time since training ranged from 3 to 24 weeks. After receipt of CCT, function significantly improved in 6 of the 8 domains: abstraction and executive function (standardized mean difference [SMD], 0.58; 95% CI, 0.26-0.91; P < .001), attention and working memory (SMD, 0.62; 95% CI, 0.33-0.91; P < .001), memory (SMD, 0.59; 95% CI, 0.20-0.97; P = .003), motor skills (SMD, 0.50; 95% CI, 0.24-0.77; P < .001), speed of information processing (SMD, 0.65; 95% CI, 0.37-0.94; P < .001), and daily function (SMD, 0.44; 95% CI, 0.02-0.86; P = .04). Sensory and perceptual skills (SMD, 0.06; 95% CI, -0.36 to 0.48; P = .78) and verbal and language skills (SMD, 0.46; 95% CI, -0.07 to 0.99; P = .09) did not significantly improve after CCT.

CONCLUSIONS AND RELEVANCE

This meta-analysis of RCTs found that CCT programs were associated with improvements in cognitive and daily function among people living with HIV. Future studies are needed to design optimal specific training programs and use implementation science to enable the transformation of CCT from a scientific research tool to a real-world clinical intervention.

A Systematic Review on Serious Games in Attention Rehabilitation and Their Effects

Attention is a basic and main mental task and can play an important role in the functioning of other brain abilities such as intelligence, memory, learning, and perception, and its deficit occurs in 80% of patients with traumatic brain injury. The use of game-based tools for rehabilitation is rapidly expanding. Cognitive rehabilitation via video games is an emerging hot topic in cognitive science. Serious games serve a specific purpose in addition to entertainment. They can be more engaging than exercises since they replace reward and motivation systems with real-world motivations as a complement for rehabilitation activities. This study was aimed at identifying and categorizing serious computer games used for attention rehabilitation and evaluating their effects. Six electronic databases (Scopus, PubMed, ISI, Embase, IEEE, and Cochrane) were searched in August 2021. The search strategy consisted of three main concepts of “serious game”, “cognitive deficits”, and “cognitive rehabilitation”. The inclusion criteria were (1) journal articles, (2) English language, (3) being published in the last 10 years, (4) human participants, and (5) game-based intervention. In the 30 included studies, 22 unique games were utilized for attention rehabilitation. Lumosity (20%), Brain Age (Dr. Kawashima's Brain Training) (10%), and MoHRS (6.66%) were the most common games among the studies. There were (57%) casual, (23%) action, (10%) simulation, and (10%) multiple genres. Of the 47 tools used in the studies, 5 utilized cross-modal oddball attention tasks, 4 utilized game performance, 3 utilized the paced auditory serial additional test (PASAT), and the rest employed other tools. A total of 73 outcome measures were related to attention, 42 measures did not have significant results, 30 were significantly improved, 1 was significantly deteriorated, and 4 articles did not have any specific measures for attention evaluation. Thus, the results revealed the positive effect of serious games on attention. However, issues such as absence of scientific teams, the variety of the disorders that cause defects, the variety of criteria, differences in measurements, lack of long-term follow-up, insufficient RCT studies, and small sample sizes should be considered when designing, developing, and using game-based systems to prevent bias.

Effects of computer-based cognitive rehabilitation on working memory in patients with acquired brain injury in the chronic phase, a pilot-study

BACKGROUND

Working memory impairment is common in patients in the chronic phase after acquired brain injury (ABI), and there is a need to develop efficacious rehabilitation methods. This trial explored the effects of two different computer-based cognitive rehabilitation (CBCR) programmes on working memory in the chronic phase after ABI, as well as the role of continuous support versus no support from a health professional on the efficacy of CBCR.

METHODS

A total of 72 patients were randomized into four different groups for a 12-week intervention: Two groups trained with the CBCR-programmes 'Cogmed' and 'Brain+ Health,' respectively, and one group completed active-control training. All three groups received continuous support from a health professional. The last group trained with the CBCR programme 'Brain+ Health' but received no support. Before and after the intervention, patients were tested with a neuropsychological battery of working memory, attention and executive functions.

RESULTS

Both CBCR-programmes improved working memory when administered with support from a health professional. The programmes improved different sub-components of working memory, possibly because of their individual content and design. None of the CBCR-programmes were more efficacious than sham-training with support. CBCR without support did not improve working memory in patients.

Neuropsychiatric Treatment for Mild Traumatic Brain Injury: Nonpharmacological Approaches

Postconcussive symptoms following mild traumatic brain injury (mTBI)/concussion are common, disabling, and challenging to manage. Patients can experience a range of symptoms (e.g., mood disturbance, headaches, insomnia, vestibular symptoms, and cognitive dysfunction), and neuropsychiatric management relies heavily on nonpharmacological and multidisciplinary approaches. This article presents an overview of current nonpharmacological strategies for postconcussive symptoms including psychoeducation; psychotherapy; vestibular, visual, and physical therapies; cognitive rehabilitation; as well as more novel approaches, such as neuromodulation. Ultimately, treatment and management of mTBI should begin early with appropriate psychoeducation/counseling, and be tailored based on core symptoms and individual goals.

The Effectiveness of Computer-Assisted Cognitive Rehabilitation and the Degree of Recovery in Patients with Traumatic Brain Injury and Stroke

Objectives: To determine the effectiveness of computer-assisted cognitive rehabilitation and compare the patterns of cognitive function recovery occurring in both traumatic brain injury (TBI) and stroke. Methods: A total of 62 patients were finally enrolled, consisting of 30 with TBI and 32 with stroke. The patients received 30 sessions of computer-assisted cognitive rehabilitation (Comcog) five times per week. Each session lasted for 30 min. Before and immediately after cognitive rehabilitation, all patients were evaluated by computerized neuropsychological test (CNT), Mini-Mental State Examination (MMSE), and modified Barthel index (MBI). Results: We analyzed the differences between pre- and post-cognitive rehabilitation in each TBI and stroke group. Significant differences were observed in MMSE, MBI, and some CNT contents, including digit span forward, verbal learning, verbal learning delayed recall, visual span forward, visual span backward, visual learning, trail making test A and B, and intelligence quotient (IQ) in the TBI group (p < 0.05). In the stroke group, in addition to significant differences that appeared in the TBI group, additional significant differences in the digit span backward, visual learning delayed recall, auditory continuous performance test (CPT), visual CPT, and card sorting test. We compared the difference values at pre- and post-cognitive rehabilitation for cognitive recovery between the TBI and stroke groups. All contents, except the digital span forward, visual learning, word-color test, and MMSE, had greater mean values in the stroke group; and thus, statistically significant higher values were observed in the visual span forward and card sorting test (p < 0.05). Conclusion: Most evaluation results showed improvement and the evaluation between the TBI and stroke groups also showed significant differences in cognitive functions in addition to more CNT contents, which significantly change in the stroke group. The stroke group showed a high difference value in most CNT contents. Therefore, those with stroke in the focal brain region tend to have better cognitive function recovery after a computer-assisted cognitive rehabilitation than those with TBI, which could cause diffuse brain damage and post-injury inflammation.

The prevalence, characteristics, and psychiatric correlates of traumatic brain injury in incarcerated individuals: an examination in two independent samples

PRIMARY OBJECTIVE

Identify the prevalence, characteristics, and psychological correlates of traumatic brain injury (TBI) among incarcerated individuals.

RESEARCH DESIGN

Three aims: (1) Determine the prevalence and characteristics of TBI in 1469 adults incarcerated in Wisconsin state prisons (1064 men, 405 women); (2) Characterize the relationship between mild TBI and mental illness in a sub-sample of men and women; (3) Reproduce the findings from Aim 1 and Aim 2 in an independent sample of 1015 adults incarcerated in New Mexico state prisons (600 men, 415 women).

METHODS AND PROCEDURES

Standardized TBI assessment with structured clinical interviews and self-report questionnaires.

MAIN OUTCOMES AND RESULTS

Rates of TBI were approximately five times greater than the general population, with a substantially higher rate of TBI caused by assault. In the Wisconsin sample, mild TBI was associated with greater levels of post-traumatic stress disorder (PTSD) among women (but not among men). In the New Mexico sample, TBI of any severity was associated with greater levels of major depressive disorder (MDD) among women (but not among men).

CONCLUSIONS

This study thus provides novel data on TBI and its correlates among individuals incarcerated in state prisons, and highlights a specific treatment need within the prison population.

Virtual Reality-Based Early Neurocognitive Stimulation in Critically Ill Patients: A Pilot Randomized Clinical Trial

This study focuses on the application of a non-immersive virtual reality (VR)-based neurocognitive intervention in critically ill patients. Our aim was to assess the feasibility of direct outcome measures to detect the impact of this digital therapy on patients’ cognitive and emotional outcomes. Seventy-two mechanically ventilated adult patients were randomly assigned to the “treatment as usual” (TAU, n = 38) or the “early neurocognitive stimulation” (ENRIC, n = 34) groups. All patients received standard intensive care unit (ICU) care. Patients in the ENRIC group also received adjuvant neurocognitive stimulation during the ICU stay. Outcome measures were a full neuropsychological battery and two mental health questionnaires. A total of 42 patients (21 ENRIC) completed assessment one month after ICU discharge, and 24 (10 ENRIC) one year later. At one-month follow-up, ENRIC patients had better working memory scores (p = 0.009, d = 0.363) and showed up to 50% less non-specific anxiety (11.8% vs. 21.1%) and depression (5.9% vs. 10.5%) than TAU patients. A general linear model of repeated measures reported a main effect of group, but not of time or group–time interaction, on working memory, with ENRIC patients outperforming TAU patients (p = 0.008, η_p² = 0.282). Our results suggest that non-immersive VR-based neurocognitive stimulation may help improve short-term working memory outcomes in survivors of critical illness. Moreover, this advantage could be maintained in the long term. An efficacy trial in a larger sample of participants is feasible and must be conducted.

Social Robots for Evaluating Attention State in Older Adults

Sustained attention is essential for older adults to maintain an active lifestyle, and the deficiency of this function is often associated with health-related risks such as falling and frailty. The present study examined whether the well-established age-effect on reducing mind-wandering, the drift to internal thoughts that are seen to be detrimental to attentional control, could be replicated by using a robotic experimenter for older adults who are not as familiar with online technologies. A total of 28 younger and 22 older adults performed a Sustained Attention to Response Task (SART) by answering thought probes regarding their attention states and providing confidence ratings for their own task performances. The indices from the modified SART suggested a well-documented conservative response strategy endorsed by older adults, which were represented by slower responses and increased omission errors. Moreover, the slower responses and increased omissions were found to be associated with less self-reported mind-wandering, thus showing consistency with their higher subjective ratings of attentional control. Overall, this study demonstrates the potential of constructing age-related cognitive profiles with attention evaluation instruction based on a social companion robot for older adults at home.

A Comparison of Methods for Predicting Future Cognitive Status: Mixture Modeling, Latent Class Analysis, and Competitors

PURPOSE

The present work compares various methods for using baseline cognitive performance data to predict eventual cognitive status of longitudinal study participants at the University of Kentucky's Alzheimer's Disease Center.

METHODS

Cox proportional hazards models examined time to cognitive transition as predicted by risk strata derived from normal mixture modeling, latent class analysis, and a 1-SD thresholding approach. An additional comparator involved prediction directly from a numeric value for baseline cognitive performance.

RESULTS

A normal mixture model suggested 3 risk strata based on Consortium to Establish a Registry for Alzheimer's Disease (CERAD) T scores: high, intermediate, and low risk. Cox modeling of time to cognitive decline based on posterior probabilities for risk stratum membership yielded an estimated hazard ratio of 4.00 with 95% confidence interval 1.53-10.44 in comparing high risk membership to low risk; for intermediate risk membership versus low risk, the modeling yielded hazard ratio=2.29 and 95% confidence interval=0.98-5.33. Latent class analysis produced 3 groups, which did not have a clear ordering in terms of risk; however, one group exhibited appreciably greater hazard of cognitive decline. All methods for generating predictors of cognitive transition yielded statistically significant likelihood ratio statistics but modest concordance statistics.

CONCLUSION

Posterior probabilities from mixture modeling allow for risk stratification that is data-driven and, in the case of CERAD T scores, modestly predictive of later cognitive decline. Incorporating other covariates may enhance predictions.

Application of neuropsychology and imaging to brain injury and use of the integrative cognitive rehabilitation psychotherapy model

BACKGROUND

An early approach to cognitive rehabilitation therapy (CRT) was developed based on A. R. Luria's theory of brain function. Expanding upon this approach, the Integrative Cognitive Rehabilitation Psychotherapy model (ICRP) was advanced.

OBJECTIVE

To describe the ICRP approach to treatment of clients post brain injury and provide a comprehensive list of evaluation tools to determine the client's abilities and needs. Finally, to provide a link between CRT and functional imaging studies designed to improve rehabilitation efforts.

METHODS

History of cognitive rehabilitation and neuropsychological testing is reviewed and description of cognitive, academic, psychiatric, and substance abuse tools are provided. Cognitive and emotional treatment techniques are fully described. Additionally, a method of determining the client's stage of recovery and pertinent functional imaging studies is detailed.

RESULTS

Authors have been able to provide a set of tools and techniques to use in comprehensive treatment of clients with brain injury.

CONCLUSIONS

Inclusive treatment which is outlined in the ICRP model is optimal for the client's recovery and return to a full and satisfying life post brain injury. The model provides a framework for neuropsychologists to integrate issues that tend to co-occur in clients living with brain injury into a unified treatment plan.

The effects of neuroplasticity-based auditory information processing remediation in adults with chronic traumatic brain injury

BACKGROUND

Adults with chronic traumatic brain injury (TBI) may experience long-term deficits in multiple cognitive domains. Higher-order functions, such as verbal memory, are impacted by deficits in the ability to acquire verbal information.

OBJECTIVE

This study investigated the effects of a neuroplasticity-based computerized cognitive remediation program for auditory information processing in adults with a chronic TBI.

METHODS

Forty-eight adults with TBI were randomly assigned to an intervention or control group. Both groups underwent a neuropsychological assessment at baseline and post-training. The Intervention group received 40 one-hour cognitive training sessions with the Brain Fitness Program.

RESULTS

The intervention group improved in performance on measures of the Woodcock-Johnson-III Understanding Directions subtest and Trail Making Test Part-A. They also reported improvement on the cognitive domain of the Cognitive Self-Report Questionnaire.

CONCLUSIONS

The present study demonstrated that a neuroplasticity-based computerized cognitive remediation program may improve objective and subjective cognitive function in adults with TBI several years post-injury.

A randomized clinical trial of plasticity-based cognitive training in mild traumatic brain injury

Clinical practice guidelines support cognitive rehabilitation for people with a history of mild traumatic brain injury (mTBI) and cognitive impairment, but no class I randomized clinical trials have evaluated the efficacy of self-administered computerized cognitive training. The goal of this study was to evaluate the efficacy of a self-administered computerized plasticity-based cognitive training programmes in primarily military/veteran participants with a history of mTBI and cognitive impairment. A multisite randomized double-blind clinical trial of a behavioural intervention with an active control was conducted from September 2013 to February 2017 including assessments at baseline, post-training, and after a 3-month follow-up period. Participants self-administered cognitive training (experimental and active control) programmes at home, remotely supervised by a healthcare coach, with an intended training schedule of 5 days per week, 1 h per day, for 13 weeks. Participants (149 contacted, 83 intent-to-treat) were confirmed to have a history of mTBI (mean of 7.2 years post-injury) through medical history/clinician interview and persistent cognitive impairment through neuropsychological testing and/or quantitative participant reported measure. The experimental intervention was a brain plasticity-based computerized cognitive training programme targeting speed/accuracy of information processing, and the active control was composed of computer games. The primary cognitive function measure was a composite of nine standardized neuropsychological assessments, and the primary directly observed functional measure a timed instrumental activities of daily living assessment. Secondary outcome measures included participant-reported assessments of cognitive and mental health. The treatment group showed an improvement in the composite cognitive measure significantly larger than that of the active control group at both the post-training [+6.9 points, confidence interval (CI) +1.0 to +12.7, P = 0.025, d = 0.555] and the follow-up visit (+7.4 points, CI +0.6 to +14.3, P = 0.039, d = 0.591). Both large and small cognitive function improvements were seen twice as frequently in the treatment group than in the active control group. No significant between-group effects were seen on other measures, including the directly-observed functional and symptom measures. Statistically equivalent improvements in both groups were seen in depressive and cognitive symptoms.

Neuropsychological Assessments of Patients With Acquired Brain Injury: A Cluster Analysis Approach to Address Heterogeneity in Web-Based Cognitive Rehabilitation

We aimed to (1) apply cluster analysis techniques to mixed-type data (numerical and categorical) from baseline neuropsychological standard and widely used assessments of patients with acquired brain injury (ABI) (2) apply state-of-the-art cluster validity indexes (CVI) to assess their internal validity (3) study their external validity considering relevant aspects of ABI rehabilitation such as functional independence measure (FIM) in activities of daily life assessment (4) characterize the identified profiles by using demographic and clinically relevant variables and (5) extend the external validation of the obtained clusters to all cognitive rehabilitation tasks executed by the participants in a web-based cognitive rehabilitation platform (GNPT). We analyzed 1,107 patients with ABI, 58.1% traumatic brain injury (TBI), 21.8% stroke and 20.1% other ABIs (e.g., brain tumors, anoxia, infections) that have undergone inpatient GNPT cognitive rehabilitation from September 2008 to January 2021. We applied the k-prototypes algorithm from the clustMixType R package. We optimized seven CVIs and applied bootstrap resampling to assess clusters stability (fpc R package). Clusters' post hoc comparisons were performed using the Wilcoxon ranked test, paired t-test or Chi-square test when appropriate. We identified a three-clusters optimal solution, with strong stability (>0.85) and structure (e.g., Silhouette > 0.60, Gamma > 0.83), characterized by distinctive level of performance in all neuropsychological tests, demographics, FIM, response to GNPT tasks and tests normative data (e.g., the 3 min cut-off in Trail Making Test-B). Cluster 1 was characterized by severe cognitive impairment (N = 254, 22.9%) the mean age was 47 years, 68.5% patients with TBI and 22% with stroke. Cluster 2 was characterized by mild cognitive impairment (N = 376, 33.9%) mean age 54 years, 53.5% patients with stroke and 27% other ABI. Cluster 3, moderate cognitive impairment (N = 477, 43.2%) mean age 33 years, 83% patients with TBI and 14% other ABI. Post hoc analysis on cognitive FIM supported a significant higher performance of Cluster 2 vs. Cluster 3 (p < 0.001), Cluster 2 vs. Cluster 1 (p < 0.001) and Cluster 3 vs. Cluster 1 (p < 0.001). All patients executed 286,798 GNPT tasks, with performance significantly higher in Cluster 2 and 3 vs. Cluster 1 (p < 0.001).

Poorer Theory of Mind in Amnestic Mild Cognitive Impairment Is Associated with Decreased Functional Connectivity in the Default Mode Network

BACKGROUND

Older adults living with amnestic mild cognitive impairment (aMCI) not only demonstrate impairments in Theory of Mind (ToM), relative to adults with non-amnestic MCI (naMCI), but are also at a higher risk of developing dementia.

OBJECTIVE

Our primary objective was to ascertain whether default mode network (DMN) functional connectivity was differentially associated with ToM abilities between MCI subgroups.

METHODS

Using functional magnetic resonance imaging, we investigated alterations in resting-state functional connectivity within the brain's DMN in a sample of 43 older adults with aMCI (n = 19) and naMCI (n = 24), previously reported to demonstrate poorer ToM abilities.

RESULTS

Compared to naMCI, the aMCI subgroup revealed a significant association between poorer ToM performance and reduced functional connectivity between the bilateral temporal pole (TempP) and the left lateral temporal cortex (LTC) (LTC_L-TempP_L: b = -0.06, t(33) = -3.53, p = 0.02; LTC_L-TempP_R: b = -0.07,t(33) = -3.20, p = 0.03); between the right TempP and the dorsal medial prefrontal cortex (dMPFC) (b = -0.04, t(33) = -3.02, p = 0.03) and between the left and right TempP (b = -0.05, t(33) = -3.26, p = 0.03). In the naMCI subgroup, the opposite relationship was present between the bilateral TempP and the left LTC (Combined correlation: r = -0.47, p = 0.02), however, not between the right TempP and the dMPFC (r = -0.14, p = 0.51) or the left and right TempP (r = -0.31, p = 0.14).

CONCLUSION

Our findings suggest that alterations in functional connectivity within the DMN involving temporal and frontal lobe regions are associated with ToM deficits in aMCI.

Intranasally Administered L-Myc-Immortalized Human Neural Stem Cells Migrate to Primary and Distal Sites of Damage after Cortical Impact and Enhance Spatial Learning

As the success of stem cell-based therapies is contingent on efficient cell delivery to damaged areas, neural stem cells (NSCs) have promising therapeutic potential because they inherently migrate to sites of central nervous system (CNS) damage. To explore the possibility of NSC-based therapy after traumatic brain injury (TBI), isoflurane-anesthetized adult male rats received a controlled cortical impact (CCI) of moderate severity (2.8 mm deformation at 4 m/s) or sham injury (i.e., no cortical impact). Beginning 1-week post-injury, the rats were immunosuppressed and 1 × 106 human NSCs (LM-NS008.GFP.fLuc) or vehicle (VEH) (2% human serum albumen) were administered intranasally (IN) on post-operative days 7, 9, 11, 13, 15, and 17. To evaluate the spatial distributions of the LM-NSC008 cells, half of the rats were euthanized on day 25, one day after completion of the cognitive task, and the other half were euthanized on day 46. 1 mm thick brain sections were optically cleared (CLARITY), and volumes were imaged by confocal microscopy. In addition, LM-NSC008 cell migration to the TBI site by immunohistochemistry for human-specific Nestin was observed at day 39. Acquisition of spatial learning was assessed in a well-established Morris water maze task on six successive days beginning on post-injury day 18. IN administration of LM-NSC008 cells after TBI (TBI + NSC) significantly facilitated spatial learning relative to TBI + VEH rats (p < 0.05) and had no effect on sham + NSC rats. Overall, these data indicate that IN-administered LM-NSC008 cells migrate to sites of TBI damage and that their presence correlates with cognitive improvement. Future studies will expand on these preliminary findings by evaluating other LM-NSC008 cell dosing paradigms and evaluating mechanisms by which LM-NSC008 cells contribute to cognitive recovery.

Neuropsychological Performance 1 Year After Status Epilepticus in Adults

OBJECTIVES

Status epilepticus (SE) may lead to or worsen cognitive dysfunction. Few studies have evaluated magnitude and profile of cognitive dysfunction in patients after SE. Characterization of cognitive deficits may be important for rehabilitation and follow-up. We assessed cognitive function in a consecutive, non-selected group of relatively healthy survivors with a comprehensive neuropsychological test battery.

METHODS

A total of 33 patients (24 men, 9 women; mean age 54,9 years, mean education 11,8 years) were tested 1 year after SE with Wechsler Adult Intelligence Scale Fourth edition (WAIS-IV), Rey Auditory Verbal Learning Test, subtests from the Wechsler Memory Scale-Revised, Phonemic and Semantic word list generation, and the Halstead-Reitan Battery. Premorbid IQ was estimated with a Norwegian version of the National Adult Reading Test (NART). Results were compared to published norms. Regression analyses and independent groups t-tests were performed to assess the influence of background variables.

RESULTS

Mean performance generally was about one standard deviation below average. Full scale IQ (WAIS-IV) was significantly reduced compared to estimated premorbid IQ (NART). Negative influence on cognition of brain lesions visible on computed tomography or magnetic resonance imaging and duration of SE >30 min was shown by group comparisons.

CONCLUSIONS

SE represents a marker for possible cognitive dysfunction, and follow-up with neuropsychological assessment and cognitive rehabilitation seems warranted in most patients. Complex problem-solving abilities with high general sensitivity to brain impairment showed the most prominent reduction. Otherwise, no specific profile of domain affection was found. Structural brain lesions and duration of SE over 30 min represent risk factors for cognitive deficit.

Cognitive impact of lower-grade gliomas and strategies for rehabilitation

Outcomes for patients with lower-grade gliomas (LrGGs) continue to improve with advances in molecular characterization and treatment. However, cognitive sequela from the tumor and its treatment leave a significant impact on health-related quality of life for these patients. Several factors affect each patient's cognition, such as tumor location, treatment, medication, and comorbidities. However, impairments of processing speed, attention, concentration, working memory, and executive function are common across LrGG patients. Cognitive rehabilitation strategies, well established in traumatic brain injury and stroke populations, are based on neural plasticity and functional reorganization. Adapting these strategies for implementation in patients with brain tumors is an active area of research. This article provides an overview of cognitive domains commonly impaired in LrGG patients and evidence for the use of cognitive rehabilitation strategies to address these impairments with the goal of improving health-related quality of life in this patient population.

Working memory training: Taking a step back to retool and create a bridge between clinical and neuroimaging research methods

Improvements in patient outcomes and mortality after brain injury alongside increasing ageing population have resulted in an increasing need to develop cognitive interventions for individuals experiencing changes in their cognitive function. One topic of increasing research interest is whether cognitive functions such as attention, memory and executive functioning can be improved through the use of working memory training interventions. Both clinical and neuroimaging researchers are working to evidence this, but their efforts rarely come together. We discuss here several issues that may be hindering progress in this area, including the tools researchers utilize to measure cognition, the choice between employing active or passive control groups, the focus on transfer effects at the expense of well-characterized training effects, and the overall lack of neuroimaging studies in individuals with neurological disorders. We argue that the only way to advance the field is to build bridges between the disciplines of clinical neuropsychology and cognitive neuroscience. We suggest a multi-level framework to validate the efficacy of working memory interventions and other forms of cognitive training that combine both clinical and neuroimaging approaches. We conclude that in order to move forward we need to form multidisciplinary teams, employ interdisciplinary methods, brain imaging quality rating tools and build national and international collaborations based on open science principles.

Age differences in sustained attention tasks: A meta-analysis

Many aspects of attention decline with aging. There is a current debate on how aging also affects sustained attention. In this study, we contribute to this debate by meta-analytically comparing performance on the go/no-go Sustained Attention to Response Task (SART) in younger and older adults. We included only studies in which the SART had a low proportion of no-go trials (5%–30%), there was a random or quasirandom stimulus presentation, and data on both healthy younger and older adults were available. A total of 12 studies were suitable with 832 younger adults and 690 older adults. Results showed that older adults were slower than younger adults on go trials (g = 1, 95% CI [.72, 1.27]) and more accurate than younger adults on no-go trials (g = .59, 95% CI [.32, .85]). Moreover, older adults were slower after a no-go error than younger adults (g = .79, 95% CI [.60, .99]). These results are compatible with an age-related processing speed deficit, mostly suggested by longer go RTs, but also with an increased preference for a prudent strategy, as demonstrated by fewer no-go errors and greater posterror slowing in older adults. An inhibitory deficit account could not explain these findings, as older adults actually outperformed younger adults by producing fewer false alarms to no-go stimuli. These findings point to a more prudent strategy when using attentional resources in aging that allows reducing the false-alarm rate in tasks producing a tendency for automatic responding.

Cognitive rehabilitation interventions after stroke: protocol for a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Stroke is the second leading cause of death worldwide, and 53.4% of stroke survivors suffer from post-stroke cognitive impairment. Post-stroke cognitive impairment can increase hospitalization rate and cost of care and decrease the quality of life of stroke patients. To date, multiple cognitive rehabilitation interventions have been tested in stroke populations with post-stroke cognitive impairment. However, the most efficacious intervention has not been established. This systematic review aims to compare the efficacy of cognitive rehabilitation interventions for patients with post-stroke cognitive impairment.

METHODS

We will search MEDLINE, EMBASE, CENTRAL, PsycINFO, CINAHL, PubMed, and clinical trial registries to identify eligible randomized clinical trials with no restrictions in the date of publication and language. Studies conducted with patients aged 18 or over, with the presence of cognitive impairment after being diagnosed with stroke will be included. Studies will be restricted to randomized controlled trials comparing a cognitive rehabilitation intervention with another intervention. The primary outcome is any clinical changes in the general or specific cognitive domain (e.g., executive function, attention, memory, or perception). The secondary outcomes that will be collected include adverse effects (e.g., stroke, disability, or mortality) and quality of life. Two independent reviewers will assess articles to identify trials eligible for inclusion. Data extraction and risk of bias assessment of the included studies will also be done independently. Any discrepancies will be solved by discussion, or a third reviewer will be consulted if necessary. A meta-analysis will be carried out if appropriate.

DISCUSSION

This systematic review for patients with post-stroke cognitive impairment will assess the efficacy of cognitive rehabilitation interventions. And our results will help clinical decision-making and support the development of clinical practice guidelines.

TRIAL REGISTRATION

Systematic review registration: PROSPERO CRD42020173988.

Quality measurement of out-patient neuropsychological therapy after stroke in Germany: definition of indicators and retrospective pilot study

BACKGROUND

In contrast to the hospital setting, today little work has been directed to the definition, measurement, and improvement of the quality of out-patient medical and therapeutic care. We developed a set of indicators to measure the quality of out-patient neuropsychological therapy after stroke.

METHODS

The indicators cover core and interdisciplinary aspects of out-patient neuropsychological work such as mediation of patients into social care in case of need. Selection of the quality-indicators was done together with a consensus group of out-patient therapists and supported by evidence, validity, reliability as well as estimated relevance and variability with the quality of care. The set of indicators was further tested in a retrospective cohort study. Anonymous data of 104 patients were collected from out-patient clinical records of five clinics between November 2017 and April 2018. Associations between process and outcome quality were estimated exploitatively.

RESULTS

Results allowed for the identification of areas with greater variability in the quality of process care and indicated that attention training as recommended by current guidelines had the lowest overall rate for meeting the quality-aim (met in 44% of the cases). This was followed by time < 1 month until the start of therapy (63% met) and mediation into social care in case of need (65% met). We further observed that overall quality and involving relatives in the therapy was associated with higher rates of professional reintegration (p-value = 0.03). However, the need for mediation into social care was associated with a reduced chance for successful professional reintegration (p-value = 0.009).

CONCLUSION

In conclusion, we describe a first set of quality indicators which cover different aspects of out-patient neuropsychological therapy and sufficient variability with care. First data further suggests that meeting the specified quality aims may indeed have relevant effects on outcomes.

A Virtual, Randomized, Control Trial of a Digital Therapeutic for Speech, Language, and Cognitive Intervention in Post-stroke Persons With Aphasia

Background: Post-stroke aphasia is a chronic condition that impacts people's daily functioning and communication for many years after a stroke. Even though these individuals require sustained rehabilitation, they face extra burdens to access care due to shortages in qualified clinicians, insurance limitations and geographic access. There is a need to research alternative means to access intervention remotely, such as in the case of this study using a digital therapeutic.

Objective: To assess the feasibility and clinical efficacy of a virtual speech, language, and cognitive digital therapeutic for individuals with post-stroke aphasia relative to standard of care.

Methods: Thirty two participants completed the study (experimental: average age 59.8 years, 7 female, 10 male, average education: 15.8 years, time post-stroke: 53 months, 15 right handed, 2 left handed; control: average age 64.2 years, 7 female, 8 male, average education: 15.3 years, time post-stroke: 36.1 months, 14 right handed, 1 left handed). Patients in the experimental group received 10 weeks of treatment using a digital therapeutic, Constant Therapy-Research (CT-R), for speech, language, and cognitive therapy, which provides evidence-based, targeted therapy with immediate feedback for users that adjusts therapy difficulty based on their performance. Patients in the control group completed standard of care (SOC) speech-language pathology workbook pages.

Results: This study provides Class II evidence that with the starting baseline WAB-AQ score, adjusted by −0.69 for every year of age, and by 0.122 for every month since stroke, participants in the CT-R group had WAB-AQ scores 6.43 higher than the workbook group at the end of treatment. Additionally, secondary outcome measures included the WAB-Language Quotient, WAB-Cognitive Quotient, Brief Test of Adult Cognition by Telephone (BTACT), and Stroke and Aphasia Quality of Life Scale 39 (SAQOL-39), with significant changes in BTACT verbal fluency subtest and the SAQOL-39 communication and energy scores for both groups.

Conclusions: Overall, this study demonstrates the feasibility of a fully virtual trial for patients with post-stroke aphasia, especially given the ongoing COVID19 pandemic, as well as a safe, tolerable, and efficacious digital therapeutic for language/cognitive rehabilitation.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT04488029.

The efficacy of computerized cognitive rehabilitation in improving attention and executive functions in acquired brain injury patients, in acute and postacute phase

BACKGROUND

Cognitive deficits, particularly executive dysfunction is common following acquired brain injury (ABI) and has detrimental effect on functional status and autonomy in daily life. Among various cognitive training methods, computerized cognitive rehabilitation (CCR) has been investigated as an alternative method to therapist-driven cognitive rehabilitation (TCR). However, previous studies have shown conflicting results on the superiority or inferiority of CCR and TCR.

AIM

To investigate the efficacy of TCR and CCR in improving executive function in patients with acute-to-subacute ABI.

DESIGN

A prospective, assessor-blinded randomized controlled trial.

SETTING

Hospitalized care setting in the department of rehabilitation in a university hospital.

POPULATION

Thirty-two acute-to-subacute (less than 3 months after onset) ABI patients with executive dysfunctions were included in this study. The mean time after injury was 25.1±18.1 days.

METHODS

Participants were assigned to the TCR group (N.=14) or the CCR group (N.=18). Each group performed TCR or CCR for 30 minutes each day for two weeks in addition to routine rehabilitation. Neurocognitive function tests to assess complex attention, executive function, general cognitive function (mini-mental status examination [MMSE] and Montreal Cognitive Assessment [MoCA]), and functional evaluations [modified Barthel Index, MBI]) were performed at baseline (T0) and at the end of treatment (T1).

RESULTS

The TCR and CCR groups showed significant improvements in the MMSE (P=0.004, 0.000), MoCA (P=0.003, 0.006), and MBI (P=0.000, 0.000) scores. TCR and CCR groups both showed significant improvements in some of the complex attention tests (trail-making test A, P=0.002, 0.005) and executive function tests (trail-making test B, P=0.016, 0.016). The TCR group showed significant improvements in the additional executive function tests (phonemic fluency test, P=0.004, semantic fluency test, P=0.001), while the CCR group showed significant improvements in the additional complex attention tests (symbol search, P=0.02, digit symbol coding, P=0.002). In the intergroup comparison of the changes from pre- to postintervention, only the TCR group showed a significant improvement in the phonemic fluency test (P=0.013).

CONCLUSIONS

TCR might be more effective than CCR in improving frontal lobe-related executive function in ABI patients. CCR might be beneficial for improving psychomotor speed and working memory.

CLINICAL REHABILITATION IMPACT

TCR or CCR should be chosen according to the targeted domain of cognitive dysfunction in acute-to-subacute ABI patients.