Who, what, when, where, why, and how: a systematic review of the quality of post-stroke cognitive rehabilitation protocols

BACKGROUND

. Rehabilitation research findings are not routinely incorporated into clinical practice. A key barrier is the quality of reporting in the original study, including who provided the intervention, what it entailed, when and where it occurred, how patient outcomes were monitored, and why the intervention was efficacious.

OBJECTIVES

. To facilitate clinical implementation of post-stroke cognitive rehabilitation research, we undertook a review to examine the quality of intervention reporting in this literature.

METHODS

. Four databases were systematically searched, identifying 27 randomised controlled trials of post-stroke cognitive rehabilitation. The quality of intervention protocol descriptions in each study was independently rated by 2 of the authors using the 12-item Template for Intervention Description and Replication (TIDieR) checklist.

RESULTS

.Why, when, and where items were reported in more than 70% of interventions, what materials and procedures used was described in 50% to 70%, how items were described in approximately half of the interventions, and who provided interventions was reported in 22% of studies. No study addressed all 12 TIDieR items. "Active ingredients" that may further characterise an intervention and the potential mechanisms of action included restorative training, massed practice, feedback, and tailoring demands (present in approximately 50% of studies).

CONCLUSIONS

. Descriptions of intervention protocols are variable and frequently insufficient, thereby restricting the ability to understand, replicate, and implement evidence-based cognitive rehabilitation. Use of reporting checklists to address this barrier to research translation is a readily achievable and effective means to advance post-stroke care.

Memory rehabilitation for people with multiple sclerosis

BACKGROUND

Problems with cognition, particularly memory, are common in people with multiple sclerosis (MS) and can affect their ability to complete daily activities and can negatively affect quality of life. Over the last few years, there has been considerable growth in the number of randomised controlled trials (RCTs) of memory rehabilitation in MS. To guide clinicians and researchers, this review provides an overview of the effectiveness of memory rehabilitation for people with MS.

OBJECTIVES

To determine whether people with MS who received memory rehabilitation compared to those who received no treatment, or an active control showed better immediate, intermediate, or longer-term outcomes in their: 1. memory functions, 2. other cognitive abilities, and 3. functional abilities, in terms of activities of daily living, mood, and quality of life.

SEARCH METHODS

We searched CENTRAL which includes Clinicaltrials.gov, World Health Organization (The Whoqol) International Clinical Trials Registry Portal, Embase and PubMed (MEDLINE), and the following electronic databases (6 September 2020): CINAHL, LILACS, the NIHR Clinical Research Network Portfolio database, The Allied and Complementary Medicine Database, PsycINFO, and CAB Abstracts.

SELECTION CRITERIA

We selected RCTs or quasi-RCTs of memory rehabilitation or cognitive rehabilitation for people with MS in which a memory rehabilitation treatment group was compared with a control group. Selection was conducted independently first and then confirmed through group discussion. We excluded studies that included participants whose memory deficits were the result of conditions other than MS, unless we could identify a subgroup of participants with MS with separate results.

DATA COLLECTION AND ANALYSIS

Eight review authors were involved in this update in terms of study selection, quality assessment, data extraction and manuscript review. We contacted investigators of primary studies for further information where required. We conducted data analysis and synthesis in accordance with Cochrane methods. We performed a 'best evidence' synthesis based on the methodological quality of the primary studies included. Outcomes were considered separately for 'immediate' (within the first month after completion of intervention), 'intermediate' (one to six months), and 'longer-term' (more than six months) time points.

MAIN RESULTS

We added 29 studies during this update, bringing the total to 44 studies, involving 2714 participants. The interventions involved various memory retraining techniques, such as computerised programmes and training on using internal and external memory aids. Control groups varied in format from assessment-only groups, discussion and games, non-specific cognitive retraining, and attention or visuospatial training. The risk of bias amongst the included studies was generally low, but we found eight studies to have high risk of bias related to certain aspects of their methodology. In this abstract, we are only reporting outcomes at the intermediate timepoint (i.e., between one and six months). We found a slight difference between groups for subjective memory (SMD 0.23, 95% CI 0.11 to 0.35; 11 studies; 1045 participants; high-quality evidence) and quality of life (SMD 0.30, 95% CI 0.02 to 0.58; 6 studies; 683 participants; high-quality evidence) favoring the memory rehabilitation group. There was a small difference between groups for verbal memory (SMD 0.25, 95% CI 0.11 to 0.40; 6 studies; 753 participants; low-quality evidence) and information processing (SMD 0.27, 95% CI 0.00 to 0.54; 8 studies; 933 participants; low-quality evidence), favoring the memory rehabilitation group.  We found little to no difference between groups for visual memory (SMD 0.20, 95% CI -0.11 to 0.50; 6 studies; 751 participants; moderate-quality evidence), working memory (SMD 0.16, 95% CI -0.09 to 0.40; 8 studies; 821 participants; moderate-quality evidence), or activities of daily living (SMD 0.06, 95% CI -0.36 to 0.24; 4 studies; 400 participants; high-quality evidence).  AUTHORS' CONCLUSIONS: There is evidence to support the effectiveness of memory rehabilitation on some outcomes assessed in this review at intermediate follow-up. The evidence suggests that memory rehabilitation results in between-group differences favoring the memory rehabilitation group at the intermediate time point for subjective memory, verbal memory, information processing, and quality of life outcomes, suggesting that memory rehabilitation is beneficial and meaningful to people with MS. There are differential effects of memory rehabilitation based on the quality of the trials, with studies of high risk of bias inflating (positive) outcomes. Further robust, large-scale, multi-centre RCTs, with better quality reporting, using ecologically valid outcome assessments (including health economic outcomes) assessed at longer-term time points are still needed to be certain about the effectiveness of memory rehabilitation in people with MS.

Group cognitive rehabilitation to reduce the psychological impact of multiple sclerosis on quality of life: the CRAMMS RCT

BACKGROUND

People with multiple sclerosis have problems with memory and attention. The effectiveness of cognitive rehabilitation has not been established.

OBJECTIVES

The objectives were to assess the clinical effectiveness and cost-effectiveness of a cognitive rehabilitation programme for people with multiple sclerosis.

DESIGN

This was a multicentre, randomised controlled trial in which participants were randomised in a ratio of 6 : 5 to receive cognitive rehabilitation plus usual care or usual care alone. Participants were assessed at 6 and 12 months after randomisation.

SETTING

The trial was set in hospital neurology clinics and community services.

PARTICIPANTS

Participants were people with multiple sclerosis who had cognitive problems, were aged 18-69 years, could travel to attend group sessions and gave informed consent.

INTERVENTION

The intervention was a group cognitive rehabilitation programme delivered weekly by an assistant psychologist to between four and six participants for 10 weeks.

MAIN OUTCOME MEASURES

The primary outcome was the Multiple Sclerosis Impact Scale - Psychological subscale at 12 months. Secondary outcomes included results from the Everyday Memory Questionnaire, the 30-Item General Health Questionnaire, the EuroQol-5 Dimensions, five-level version and a service use questionnaire from participants, and the Everyday Memory Questionnaire - relative version and the Modified Carer Strain Index from a relative or friend of the participant.

RESULTS

Of the 449 participants randomised, 245 were allocated to cognitive rehabilitation (intervention group) and 204 were allocated to usual care (control group). Of these, 214 in the intervention group and 173 in the control group were included in the primary analysis. There was no clinically important difference in the Multiple Sclerosis Impact Scale - Psychological subscale score between the two groups at the 12-month follow-up (adjusted difference in means -0.6, 95% confidence interval -1.5 to 0.3; p = 0.20). There were no important differences between the groups in relation to cognitive abilities, fatigue, employment, or carer strain at follow-up. However, there were differences, although small, between the groups in the Multiple Sclerosis Impact Scale - Psychological subscale score at 6 months (adjusted difference in means -0.9, 95% confidence interval -1.7 to -0.1; p = 0.03) and in everyday memory on the Everyday Memory Questionnaire as reported by participants at 6 (adjusted difference in means -5.3, 95% confidence interval -8.7 to -1.9) and 12 months (adjusted difference in means -4.4, 95% confidence interval -7.8 to -0.9) and by relatives at 6 (adjusted difference in means -5.4, 95% confidence interval -9.1 to -1.7) and 12 months (adjusted difference in means -5.5, 95% confidence interval -9.6 to -1.5) in favour of the cognitive rehabilitation group. There were also differences in mood on the 30-Item General Health Questionnaire at 6 (adjusted difference in means -3.4, 95% confidence interval -5.9 to -0.8) and 12 months (adjusted difference in means -3.4, 95% confidence interval -6.2 to -0.6) in favour of the cognitive rehabilitation group. A qualitative analysis indicated perceived benefits of the intervention. There was no evidence of a difference in costs (adjusted difference in means -£574.93, 95% confidence interval -£1878.93 to £729.07) or quality-adjusted life-year gain (adjusted difference in means 0.00, 95% confidence interval -0.02 to 0.02). No safety concerns were raised and no deaths were reported.

LIMITATIONS

The trial included a sample of participants who had relatively severe cognitive problems in daily life. The trial was not powered to perform subgroup analyses. Participants could not be blinded to treatment allocation.

CONCLUSIONS

This cognitive rehabilitation programme had no long-term benefits on quality of life for people with multiple sclerosis.

FUTURE WORK

Future research should evaluate the selection of those who may benefit from cognitive rehabilitation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN09697576.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 4. See the National Institute for Health Research Journals Library website for further project information.

Therapist competence and clinical outcome in the rehabilitation of memory following traumatic brain injury trial

Objectives: Therapist competencies when delivering an intervention can impact clinical outcomes. However, the relationship between competence and outcome in the context of memory rehabilitation has not previously been investigated. We aimed to evaluate whether therapist competencies in delivering a group-based memory rehabilitation intervention, as part of a randomized-controlled trial, was associated with changes in clinical outcome in the participants with traumatic brain injury.Method: Outcome data on the Everyday Memory Questionnaire (EMQ) and Goal Attainment Scaling (GAS) were obtained for 24 participants of the memory rehabilitation trial. Video recordings of intervention sessions delivered by six therapists were coded using a checklist designed to evaluate therapist competence in group facilitation.Results: Therapists demonstrated consistently high levels of competency in facilitating the memory group. Correlational analyses showed that there was a non-significant weak association between EMQ and therapist competence (r = .28, p = .18), and between GAS and therapist competence for short- and long-term goals (r = -.33, p = .12 and r = -.24, p = .25, respectively).Conclusions: We found no significant association between competence and outcome in this memory rehabilitation trial. This may reflect insufficient variability in therapist competence and/or the nature of the clinical outcome measures used. Further research is needed to understand competence-outcome relationships in cognitive rehabilitation.

Description and Effectiveness of Communication Partner Training in TBI: A Systematic Review

OBJECTIVES

To evaluate the current evidence on communication partner training and its effectiveness on outcomes for people with traumatic brain injury (TBI) and/or their communication partners.

METHODS

Information sources: Systematic searches of 9 databases (AMED, CINAHL, EMBASE, Medline/EBSCOHOST, PsycINFO, PsycBITE, PsycARTICLES, PubMed, and Scopus) from database inception to February 2019. Eligibility criteria: Empirical studies on interventions for adult communication partners where the primary focus of the program (>50%) was on improving communication skills of people with TBI and/or communication partners. Data: Participants, characteristics of the training, outcome measures, and findings. Risk of bias: Standard checklists were used for methodological quality (PEDro, ROBiN-T) and intervention description (TIDieR). Synthesis: Narrative synthesis and effect sizes (Cohen's d) for group-level studies.

OUTCOMES

Ten articles (describing 8 studies) met eligibility criteria: 3 randomized controlled trials, 2 nonrandomized controlled trials, and 3 single-case experimental designs. Studies included a total of 258 people with TBI and 328 communication partners; however, all but one study had fewer than 65 participants. Methodological quality varied and intervention description was poor. Three studies in the final synthesis (n = 41 communication partners, n = 36 people with TBI) reported positive intervention effects. Effect sizes in group studies were d = 0.80 to 1.13 for TBI and d = 1.16 to 2.09 for communication partners.

CONCLUSIONS

The articles provided encouraging, though limited, evidence for training communication partners. Greater methodological rigor, more clearly described interventions, and consistent use of outcome measures and follow-up after treatment are needed. Further research on this topic is warranted.

A group memory rehabilitation programme for people with traumatic brain injuries: the ReMemBrIn RCT

BACKGROUND

People with traumatic brain injuries (TBIs) commonly report memory impairments. These are persistent, debilitating and reduce quality of life, but patients do not routinely receive memory rehabilitation after discharge from hospital.

OBJECTIVE

To assess the clinical effectiveness and cost-effectiveness of a group memory rehabilitation programme for people with TBI.

DESIGN

Multicentre, pragmatic, cluster randomised controlled trial. Qualitative and health economic evaluations were also undertaken.

SETTING

Community settings in nine sites in England.

PARTICIPANTS

Participants were aged 18-69 years, had undergone a TBI > 3 months prior to recruitment, reported memory problems, were able to travel to a site to attend group sessions, could communicate in English and gave informed consent.

RANDOMISATION AND BLINDING

Clusters of four to six participants were randomised to the memory rehabilitation arm or the usual-care arm on a 1 : 1 ratio. Randomisation was based on a computer-generated pseudo-random code using random permuted blocks of randomly varying size, stratified by study site. Participants and therapists were aware of the treatment allocation whereas outcome assessors were blinded.

INTERVENTIONS

In the memory rehabilitation arm 10 weekly sessions of a manualised memory rehabilitation programme were provided in addition to usual care. Participants were taught restitution strategies to retrain impaired memory functions and compensation strategies to enable them to cope with memory problems. The usual-care arm received usual care only.

MAIN OUTCOME MEASURES

Outcomes were assessed at 6 and 12 months after randomisation. Primary outcome: patient-completed Everyday Memory Questionnaire - patient version (EMQ-p) at 6 months' follow-up. Secondary outcomes: Rivermead Behavioural Memory Test - third edition (RBMT-3), General Health Questionnaire 30-item version, European Brain Injury Questionnaire, Everyday Memory Questionnaire - relative version and individual goal attainment. Costs (based on a UK NHS and Personal Social Services perspective) were collected using a service use questionnaire, with the EuroQol-5 Dimensions, five-level version, used to derive quality-adjusted life-years (QALYs). A Markov model was developed to explore cost-effectiveness at 5 and 10 years, with a 3.5% discount applied.

RESULTS

We randomised 328 participants (memory rehabilitation, n = 171; usual care, n = 157), with 129 in the memory rehabilitation arm and 122 in the usual-care arm included in the primary analysis. We found no clinically important difference on the EMQ-p between the two arms at 6 months' follow-up (adjusted difference in mean scores -2.1, 95% confidence interval -6.7 to 2.5; p = 0.37). For secondary outcomes, differences favouring the memory rehabilitation arm were observed at 6 months' follow-up for the RBMT-3 and goal attainment, but remained only for goal attainment at 12 months' follow-up. There were no differences between arms in mood or quality of life. The qualitative results suggested positive experiences of participating in the trial and of attending the groups. Participants reported that memory rehabilitation was not routinely accessible in usual care. The primary health economics outcome at 12 months found memory rehabilitation to be £26.89 cheaper than usual care but less effective, with an incremental QALY loss of 0.007. Differences in costs and effects were not statistically significant and non-parametric bootstrapping demonstrated considerable uncertainty in these findings. No safety concerns were raised and no deaths were reported.

LIMITATIONS

As a pragmatic trial, we had broad inclusion criteria and, therefore, there was considerable heterogeneity within the sample. The study was not powered to perform further subgroup analyses. Participants and therapists could not be blinded to treatment allocation.

CONCLUSIONS

The group memory rehabilitation delivered in this trial is very unlikely to lead to clinical benefits or to be a cost-effective treatment for people with TBI in the community. Future studies should examine the selection of participants who may benefit most from memory rehabilitation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN65792154.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 16. See the NIHR Journals Library website for further project information.

Reporting on novel complex intervention development for adults with social communication impairments after acquired brain injury

PURPOSE

Interventions are often poorly described in published controlled trials, with relatively little information regarding intervention development, content and fidelity. This makes it difficult to conduct replication studies, interpret and compare findings across studies and for therapists to deliver the intervention in clinical practice. Complete reporting of interventions (including fidelity) is now recommended for treatment studies, and this standardized approach is achieved using the Template for Intervention Description and Replication (TIDieR). The aim of this article is to describe the multi-phase process of developing a novel intervention for adults with acquired brain injury (ABI) and report on the findings from involving practicing therapists in this process.

METHODS

Phase 1 involved a review of relevant literature and specifying the intervention as a prototype intervention manual. Phase 2 comprised a focus group with eight practicing therapists exploring their experiences and perceptions of the intervention, potential active components, and essential elements; it also included a review of the prototype manual. Data from the focus group discussion was transcribed and analyzed thematically. Phase 3 investigated actual fidelity of the intervention undertaken, achieved by observers viewing videoed sessions and appraising against the fidelity checklist, which was then analyzed using Cohen's kappa.

RESULTS

Project-based intervention was defined as having six essential elements: a project or tangible end product focus; group-based intervention; individualized communication-based goals; communication partner involvement; acknowledgement and support of participants' cognitive ability; and consideration and plan to address impaired awareness. Analysis of focus group data revealed four themes of essential elements; group context; therapeutic skills; and manual core components and informed the development of a fidelity checklist with 13 essential and 6 desirable criteria. Fidelity assessed using percent agreement was acceptable for almost all rater pairs; where significant, Kappa coefficients had values ranging from poor to excellent (k = 0.34-1.0) depending on rater pair and session.

DISCUSSION

The TIDieR framework provided a clear systematic approach for the complete description and reporting of a complex communication intervention for people with ABI. This article comprehensively described the development and manualisation of intervention in collaboration with practicing therapists which can be used for future testing. In addition, the process undertaken has the potential to inform rehabilitation researchers in other fields on the development of complex interventions.Implications for rehabilitationThe results of this study detail the steps needed to describe an intervention, from the identification of the essential elements through to the creation of a manual and checklist to show fidelity. The process provides a starting point for other rehabilitation researchers developing complex interventions.This article provides a clear and comprehensive description of a novel intervention containing six essential elements for people with acquired brain injury presenting with communication impairments.Project-based intervention is one intervention, which intends to help improve communication skills and quality of life in people with acquired brain injury.This study highlights the important role practicing therapists can play in the creation of an intervention manual and fidelity checklist and in ensuring that sufficient detail is provided to help therapists implement the intervention into clinical practice.

Reporting interventions in trials evaluating cognitive rehabilitation in people with multiple sclerosis: a systematic review

OBJECTIVE

To determine the quantity and quality of description of cognitive rehabilitation for cognitive deficits in people with multiple sclerosis, using a variety of published checklists, and suggest ways of improving the reporting of these interventions.

DATA SOURCES

A total of 10 electronic databases were searched, including MEDLINE, EMBASE, CINAHL and PsycINFO, from inception to May 2017. Grey literature databases, trial registers, reference lists and author citations were also searched.

REVIEW METHODS

Papers were included if participants were people with multiple sclerosis aged 18 years and over and if the effectiveness of cognitive rehabilitation in improving functional ability for memory, attention or executive dysfunction, with or without a control group, was being evaluated.

RESULTS

A total of 54 studies were included in this review. The reporting of a number of key aspects of cognitive rehabilitation was poor. This was particularly in relation to content of interventions (reported completely in 26 of the 54 studies), intervention procedures (reported completely in 16 of the 54 studies), delivery mode (reported completely in 24 of the 54 studies) and intervention mechanism of action (reported completely in 21 of the 54 studies).

CONCLUSION

The quality of reporting of cognitive rehabilitation for memory, attention and executive function for multiple sclerosis, across a range of study designs, is poor. Existing reporting checklists do not adequately cover aspects relevant to cognitive rehabilitation, such as the approaches used to address cognitive deficits. Future checklists could consider these aspects we have identified in this review.

Having an impact, making a difference: the Editor's review of the first 30 years

OBJECTIVES

To review publications in Clinical Rehabilitation over the last 30 years, discerning the original goals and whether they were met, and describing major trends over the 30 years.

METHODS

Personal review, backed up by data from 'most read' articles and 'most cited' articles, from yearly lists of all controlled trials published in the journal and other sources.

RESULTS

The original goals included making rehabilitation better understood both within and outside the speciality, and more scientific. The first goal is probably not achieved, but the scientific standard of publication is much higher and it routinely recommends the use of guidelines appropriate to the publication. The journal has established a pre-eminent position in publishing randomized controlled trials, systematic reviews and articles on goal-setting. It has developed a series describing rehabilitation interventions. It aims to increase consideration of the theoretical basis of rehabilitation practices. We would like to think its impact has increased - but we cannot prove that!

CONCLUSION

The journal has established some credentials as being a source of clinically relevant evidence and guidance across the whole field of rehabilitation and across most disabling conditions.

Memory rehabilitation for people with multiple sclerosis

BACKGROUND

This is an update of the Cochrane review 'Memory rehabilitation for people with multiple sclerosis' (first published in the Cochrane Library 14 March 2012, Issue 3). Impairments in cognitive function, particularly memory, are common in people with multiple sclerosis (MS) and can potentially affect their ability to complete functional activities. There is evidence from single-case or small group studies that memory rehabilitation can be beneficial for people with MS, but findings from randomised controlled trials (RCTs) and systematic reviews have been inconclusive.

OBJECTIVES

To determine whether people with MS who received memory rehabilitation showed: 1. better outcomes in their memory functions compared to those given no treatment or receiving a placebo control; and 2. better functional abilities, in terms of activities of daily living, mood, and quality of life, than those who received no treatment or a placebo.

SEARCH METHODS

We searched the Trials Specialised Register of the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Group (2 June 2015) and the following electronic databases: The NIHR Clinical Research Network Portfolio database (NIHR CRN) (from 2010 to June 2015), The Allied and Complementary Medicine Database (AMED) (2010 to June 2015), British Nursing Index (BNI) (2010 to June 2015), PsycINFO (2011 to June 2015), and CAB Abstracts (2010 to June 2015). Start dates for the electronic databases coincided with the last search for the previous review. We handsearched relevant journals and reference lists.

SELECTION CRITERIA

We selected RCTs or quasi-randomised trials of memory rehabilitation or cognitive rehabilitation for people with MS in which a memory rehabilitation treatment group was compared to a control group. Selection was conducted independently first and then confirmed through group discussion. We excluded studies that included participants whose memory deficits were the result of conditions other than MS unless we could identify a subgroup of participants with MS with separate results.

DATA COLLECTION AND ANALYSIS

Three review authors were involved in this update in terms of study selection, quality assessment, and data extraction. We contacted investigators of primary studies for further information where required. We conducted data analysis and synthesis in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We performed a 'best evidence' synthesis based on the methodological quality of the primary studies included.

MAIN RESULTS

We added seven studies during this update, bringing the total to 15 studies, involving 989 participants. The interventions involved various memory retraining techniques, such as computerised programmes and training on internal and external memory aids. Control groups varied in format from assessment-only groups, discussion and games, non-specific cognitive retraining, and attention or visuospatial training. The risk of bias of the included studies was generally low, but we found eight studies to have high risk of bias related to certain aspects of their methodology.We found significant effect of intervention on objective assessments of memory in both the immediate and long-term follow-ups: standardised mean difference (SMD) 0.23 (95% confidence interval (CI) 0.05 to 0.41) and SMD 0.26 (95% CI 0.03 to 0.49), respectively. We also found significant effect of intervention for quality of life in the immediate follow-up (SMD 0.23 (95% CI 0.05 to 0.41)). These findings showed that the intervention group performed significantly better than the control group. We also found a significant difference for activities of daily living (ADL) in the long-term follow-up (SMD -0.33 (95% CI -0.63 to -0.03)), showing that the control groups had significantly less difficulty completing ADLs than the intervention groups. We found no significant effects, either immediate or long-term, on subjective reports of memory problems (SMD 0.04 (95% CI -0.19 to 0.27) and SMD 0.04 (95% CI -0.19 to 0.27)); on mood (SMD 0.02 (95% CI -0.16 to 0.20) and SMD -0.01 (95% CI -0.21 to 0.20)); and on immediate follow-up for ADL (SMD -0.13 (95% CI -0.60 to 0.33)) and in the long term for quality of life (SMD 0.16 (95% CI -0.03 to 0.36)). We could not complete a sensitivity analysis of intention-to-treat in comparison with per-protocol analysis, due to insufficient information from the included papers. However, a sensitivity analysis of high- versus low-risk studies suggested that while quality of the trials did not affect most outcomes, differences were seen in the objective memory outcomes (both at immediate and long term) and quality of life (immediate) outcome, with studies with higher risk of bias inflating the overall effect size estimates for these outcomes, and the test of overall effect changing from being statistically significant to not significant when studies at high risk of bias were excluded. This suggests that lower-quality studies may have positively influenced the outcomes.

AUTHORS' CONCLUSIONS

There is some evidence to support the effectiveness of memory rehabilitation on memory function, as well as on quality of life. However, the evidence is limited and does not extend to subjective reports of memory functioning or mood. Furthermore, the objective measures used are not ecologically valid measures, and thus potentially limit generalisability of these findings into daily life. Further robust RCTs of high methodological quality and better quality of reporting, using ecologically valid outcome assessments, are still needed.