An RCT to Treat Learning Impairment in Traumatic Brain Injury

Efficacy of Interventions to Improve Cognitive Function in Adults with Spinal Cord Injury: A Systematic Review

Cognitive impairment is a common complication following spinal cord injury (SCI) and imposes a significant negative impact on adjustment, functional independence, physical and mental health, and quality of life. It is unclear whether interventions for cognitive impairment following SCI are effective. A systematic review of controlled trials was performed to evaluate the effect of interventions on cognitive functions in adults with SCI using search engines: Embase, The Cochrane Library, MEDLINE, Scopus, CINAHL, and Web of Science up to December 2023. Two reviewers independently screened the articles, and study findings were synthesized and summarized. The risk of bias was evaluated using the Cochrane Risk of Bias 2.0 tool. Eight moderate-quality studies were found that investigated the effects of physical exercise/activity-based therapy plus cognitive training or intermittent hypoxia, diet modification and dietary supplements, tibial nerve or cortical stimulation, and drug therapy on cognitive function in SCI. Physical exercise/activity-based therapy plus cognitive training showed most promise for improving cognitive functions, while drug therapy, diet modification, and dietary supplements showed potential for improving cognitive function. However, about half of the participants experienced heightened instability in blood pressure following the administration of midodrine, and one participant reported gastrointestinal side effects after taking omega-3 fatty acids. There was no evidence of improvement in cognitive function for stimulation techniques. The current review highlights the scarcity of research investigating the effectiveness of interventions that target cognitive function after SCI. Further, the effects of these eight studies are uncertain due to concerns about the quality of designs and small sample sizes utilized in the trials, as well as the employment of insensitive neurocognitive tests when applied to adults with SCI. This review highlights a significant gap in knowledge related to SCI cognitive rehabilitation.

The effects of cognitive rehabilitation combined with aerobic exercise or stretching-and-toning on new learning and memory in persons with moderate-to-severe TBI: Protocol for a randomized controlled trial

This paper describes the protocol for a Phase I/II, parallel-group, blinded randomized controlled trial that compares the effects of 12-weeks of combined learning and memory rehabilitation with either aerobic cycling exercise or stretching on cognitive, neuroimaging, and everyday life outcomes in 60 persons with moderate-to-severe traumatic brain injury (TBI) who demonstrate impairments in new learning. Briefly, participants will undergo baseline testing consisting of neuropsychological testing, neuroimaging, daily life measures, and cardiorespiratory fitness. Following baseline testing, participants will be randomized to one of 2 conditions (30 participants per condition) using concealed allocation. Participants will be masked as to the intent of the conditions. The conditions will both involve supervised administration of an enhanced, 8-week version of the Kessler Foundation modified Story Memory Technique, embedded within either 12-weeks of supervised and progressive aerobic cycling exercise training (experimental condition) or 12-weeks of supervised stretching-and-toning (active control condition). Following the 12-week intervention period, participants will complete the same measures as at baseline that will be administered by treatment-blinded assessors. The primary study outcome is new learning and memory impairment based on California Verbal Learning Test (CVLT)-III slope, the secondary outcomes include neuroimaging measures of hippocampal volume, activation, and connectivity, and the tertiary outcomes involve measures of daily living along with other cognitive outcomes. We further will collect baseline sociodemographic data for examining predictors of response heterogeneity. If successful, this trial will provide the first Class I evidence supporting combined memory rehabilitation and aerobic cycling exercise training for treating TBI-related new learning and memory impairment.

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

OBJECTIVES

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Episodic Memory Impairment in Parkinson's Disease: Disentangling the Role of Encoding and Retrieval

OBJECTIVE

The source of episodic memory (EM) impairment in Parkinson's disease (PD) is still unclear. In the present study, we sought to quantify specifically encoding, consolidation, and retrieval process deficits in a list-learning paradigm by a novel method, the item-specific deficit approach (ISDA).

METHODS

We applied the ISDA method to the Free and Cued Selective Reminding Test (FCSRT) in a sample of 15 PD patients and 15 healthy participants.

RESULTS

The results revealed differences in free recall performance between PD patients and controls. These patients, however, benefited from cues as much as controls did, and total recall did not differ between groups. When analyzing the ISDA indices for encoding, consolidation, and retrieval deficits, the results showed a general memory deficit, but with a clear focus on encoding and retrieval, as revealed by the sensitivity values. Moreover, controlling for initial learning did not eliminate group effects in retrieval.

CONCLUSIONS

Our findings reveal a mixed pattern in PD patients, with deficits in both encoding and retrieval processes in memory. Also, despite the fact that an encoding dysfunction may explain some of the deficits observed at retrieval, it cannot fully account for the differences, highlighting that both encoding and retrieval factors are necessary to understand memory deficits in PD.

Delaying memory decline: different options and emerging solutions

Memory decline can be a devastating disease and increases in aging Western populations. Memory enhancement technologies hold promise for this and other conditions. Approaches include stem cell transplantation, which improved memory in several animal studies as well as vaccination against Alzheimer´s disease (AD) by β-amyloid antibodies. For a positive clinical effect, the vaccine should probably be administered over a long period of time and before amyloid pathologies manifest in the brain. Different drugs, such as erythropoietin or antiplatelet therapy, improve memory in neuropsychiatric diseases or AD or at least in animal studies. Omega-3 polyunsaturated fatty acid-rich diets improve memory through the gut-brain axis by altering the gut flora through probiotics. Sports, dancing, and memory techniques (e.g., Method of Loci) utilize behavioral approaches for memory enhancement, and were effective in several studies. Augmented reality (AR) is an auspicious way for enhancing memory in real time. Future approaches may include memory prosthesis for head-injured patients and light therapy for restoring memory in AD. Memory enhancement in humans in health and disease holds big promises for the future. Memory training helps only in mild or no impairment. Clinical application requires further investigation.

The application of Strategy-based Training to Enhance Memory (STEM) in multiple sclerosis: A pilot RCT

New learning and memory (NLM) impairments are common in multiple sclerosis (MS), negatively impacting daily life. Few studies seek to remediate these deficits to improve everyday functioning. Self-generation, spaced learning and retrieval practice have been shown to improve NLM in healthy persons and have been incorporated into an 8-session treatment protocol, Strategy-based Training to Enhance Memory (STEM). STEM teaches participants about each of the techniques, how to apply them in daily life and provides practice. Participants are taught to restructure a memory-demanding situation to optimize self-generation, spaced learning and retrieval practice. This pilot double-blind, placebo-controlled, randomized clinical trial (RCT) tested the efficacy of STEM in 20 learning-impaired participants with clinically definite MS (9 treatment, 11 control). Significant treatment effects were noted on self-report measures of daily functioning (primary outcome). Objective neuropsychological testing approached significance, showing a medium-large effect on verbal NLM. Results suggest that STEM may improve everyday functioning in individuals with MS. A full-scale RCT is warranted to validate findings in a larger sample so that findings may be generalized to the broader MS community.

Comparing learning performance on the open trial selective reminding test with the California verbal learning test II in traumatic brain injury

Introduction: Learning and memory deficits are prevalent following moderate to severe traumatic brain injury (TBI), affecting between 54% and 84% of impacted individuals.Objective: The current study examined learning performance on two tests of verbal memory: the OT-SRT and the CVLT-II.Methods: Sixty-eight participants with TBI performed the OT-SRT and the CVLT-II on two different days. Additionally, all participants completed cognitive tests assessing processing speed, working memory and executive functions. By definition, all participants with TBI were identified as having impaired learning on the OT-SRT, however only 38 were also identified as impaired on the CVLT-II. The sample was thus divided into two groups, those who failed both tests (Fail-2) and those who failed only the OT-SRT (Fail-1).Results: The Failed-1 group showed significantly better performance in processing speed, working memory and executive functions compared to the Fail-2 group. On the CVLT-II, the Fail-1 group performed significantly better on the number of words recalled on trials 1 and 5 compared to the Fail-2 group. Both groups performed similarly the OT-SRT.Discussion: The CVLT-II and the OT-SRT are not equivalent tests and should not be used interchangeably.

Brain activation patterns associated with paragraph learning in persons with multiple sclerosis: The MEMREHAB trial

The modified Story Memory Technique (mSMT) is a memory rehabilitation program that combines training in visualization and context formation to improve learning and memory. Previous studies have shown improvement in learning and memory in individuals with multiple sclerosis (MS) after undergoing the mSMT, including changes in brain activity related to working memory and word encoding. The current study examined changes in brain activity in 16 individuals diagnosed with MS (n _treatment = 6; n _{placebo control} = 10) when they were presented with to-be-remembered information within a meaningful context (i.e. a paragraph) from before to after mSMT treatment. We expected treatment-related changes in brain activation in the language network (LAN), default mode network (DMN), and executive control network (ECN). Consistent with this prediction, fMRI results revealed reduced brain activation in the LAN, DMN and ECN after completing the mSMT treatment in the context of paragraph learning. While no significant behavioral changes were observed, a marginally significant improvement with a large effect size was noted between baseline and follow-up performance on the Rivermead Behavioral Memory Test in persons who completed treatment. Results are discussed in terms of the impact of imagery training on patterns of cerebral activation when learning words presented within a context.

Clinical and cost effectiveness of memory rehabilitation following traumatic brain injury: a pragmatic cluster randomized controlled trial

OBJECTIVE

To evaluate the clinical and cost effectiveness of a group-based memory rehabilitation programme for people with traumatic brain injury.

DESIGN

Multicentre, pragmatic, observer-blinded, randomized controlled trial in England.

SETTING

Community.

PARTICIPANTS

People with memory problems following traumatic brain injury, aged 18-69 years, able to travel to group sessions, communicate in English, and give consent.

INTERVENTIONS

A total of 10 weekly group sessions of manualized memory rehabilitation plus usual care (intervention) vs. usual care alone (control).

MAIN MEASURES

The primary outcome was the patient-reported Everyday Memory Questionnaire (EMQ-p) at six months post randomization. Secondary outcomes were assessed at 6 and 12 months post randomization.

RESULTS

We randomized 328 participants. There were no clinically important differences in the primary outcome between arms at six-month follow-up (mean EMQ-p score: 38.8 (SD 26.1) in intervention and 44.1 (SD 24.6) in control arms, adjusted difference in means: -2.1, 95% confidence interval (CI): -6.7 to 2.5, p = 0.37) or 12-month follow-up. Objectively assessed memory ability favoured the memory rehabilitation arm at the 6-month, but not at the 12-month outcome. There were no between-arm differences in mood, experience of brain injury, or relative/friend assessment of patient's everyday memory outcomes, but goal attainment scores favoured the memory rehabilitation arm at both outcome time points. Health economic analyses suggested that the intervention was unlikely to be cost effective. No safety concerns were raised.

CONCLUSION

This memory rehabilitation programme did not lead to reduced forgetting in daily life for a heterogeneous sample of people with traumatic brain injury. Further research will need to examine who benefits most from such interventions.

The efficacy of the modified Story Memory Technique in progressive MS

Background:

Impairments in new learning and memory are common in individuals with multiple sclerosis (MS), negatively impacting everyday life, including occupational and social functioning.

Objective:

This study examined the efficacy of the modified Story Memory Technique (mSMT) in a progressive multiple sclerosis (PMS) sample through a double-blind, placebo-controlled, randomized clinical trial (RCT).

Methods:

Thirty (30) individuals with PMS, naïve to the mSMT, were randomized to the treatment or placebo control group. The Treatment Group completed mSMT training twice per week for 5 weeks while the Placebo Group met with the therapist at the same frequency, engaging in non-training-oriented tasks to control for professional contact and disease alterations.

Results:

The treatment group showed significant improvements in learning compared with the placebo control group, evident on both objective evaluation of new learning and self-report of functioning in daily life. Increased awareness of cognitive deficits was also noted post-treatment.

Conclusion:

These data provide Class I evidence supporting the efficacy of the mSMT in PMS. A behavioral intervention, targeted to specifically strengthen new learning, can significantly improve memory performance in PMS, and this improvement in memory performance is maintained 3 months later.

Traumatic brain injury and frontal lobe plasticity

Over 1.4 million people in the United States experience traumatic brain injury (TBI) each year and approximately 52,000 people die annually due to complications related to TBI. Traditionally, TBI has been viewed as a static injury with significant consequences for frontal lobe functioning that plateaus after some window of recovery, remaining relatively stable thereafter. However, over the past decade there has been growing consensus that the consequences of TBI are dynamic, with unique characteristics expressed at the individual level and over the life span. This chapter first discusses the pathophysiology of TBI in order to understand its dynamic process and then describes the behavioral changes that are the result of injury with focus on frontal lobe functions. It integrates a historical perspective on structural and functional brain-imaging approaches used to understand how TBI impacts the frontal lobes, as well as more recent approaches to examine large-scale network changes after TBI. The factors most useful for outcome prediction are surveyed, along with how the theoretical frameworks used to predict recovery have developed over time. In this chapter, the authors argue for the need to understand outcome after TBI as a dynamic process with individual trajectories, taking a network theory perspective to understand the consequences of disrupting frontal systems in TBI. Within this framework, understanding frontal lobe dysfunction within a larger coordinated neural network to study TBI may provide a novel perspective in outcome prediction and in developing individualized treatments.

Patterns of cognitive deficits in persons with spinal cord injury as compared with both age-matched and older individuals without spinal cord injury

Context/Objective: Cognitive deficits can impact as many as 60% of individuals with spinal cord injury (SCI). In an effort to identify the nature of cognitive deficits in SCI, we examined neuropsychological test performance in individuals with SCI, age matched healthy controls and older healthy controls.Design: Participants completed a motor-free neuropsychological test battery assessing attention, working memory, information processing speed, new learning /memory and executive control.Setting: Outpatient rehabilitation research facility.Participants: Participants included 60 individuals with chronic spinal cord injury [SCI; 32 with paraplegia (T2-T12) and 28 with tetraplegia (C3-T1)], 30 age-matched healthy controls (AMHC; 30-40 years old) and 20 older healthy controls (OHC; 50-60 years old).Outcome Measures: Wechsler Intelligence Scale - 3^rd edition (WAIS-III) Digit Span and Letter-Number Sequencing; Symbol Digit Modalities Test (SDMT) - oral version; California Verbal Learning Test-II; Paced Auditory Serial Addition Test (PASAT); Wechsler Abbreviated Scale of Intelligence (WASI); Delis-Kaplan Executive Function System; Verbal Fluency subtest.Results: Significant differences were noted between the SCI and AMHC groups on measures of information processing speed, new learning and memory, and verbal fluency. No significant differences were noted between the groups on tests of attention or working memory.Conclusion: The current study documented differences in specific realms of cognitive functioning between a chronic SCI sample and AMHC. Implications for cognitive rehabilitation and overall quality of life are discussed. Additional research is needed utilizing a more comprehensive battery of motor-free neuropsychological tests that avoid the confound of upper limb motor limitations on cognitive performance.

A review of prospective memory in individuals with acquired brain injury

OBJECTIVE

Prospective memory (PM) deficits have emerged as an important predictor of difficulty in daily life for individuals with acquired brain injury (BI). This review examines the variables that have been found to influence PM performance in this population. In addition, current methods of assessment are reviewed with a focus on clinical measures. Finally, cognitive rehabilitation therapies are reviewed, including compensatory, restorative and metacognitive approaches.

METHOD

Preferred reporting items for systematic reviews and meta-analyses guidelines were used to identify studies. Studies were added that were identified from the reference lists of these.

RESULTS

Research has begun to elucidate the contributing variables to PM deficits after BI, such as attention, executive function and retrospective memory components. Imaging studies have identified prefrontal deficits, especially in the region of BA10 as contributing to these deficits. There are now several clinical measures available with good psychometric properties. Rehabilitation techniques have mostly focused on compensatory strategies, but, in addition, some restorative and metacognitive approaches have shown preliminary promise.

CONCLUSIONS

PM deficits are a common and important deficit after BI. Clinical evaluation is recommended and further understanding of rehabilitation techniques is needed.

Do People With Severe Traumatic Brain Injury Benefit From Making Errors? A Randomized Controlled Trial of Error-Based and Errorless Learning

Background. Errorless learning (ELL) and error-based learning (EBL) are commonly used approaches to rehabilitation for people with traumatic brain injury (TBI). However, it is unknown whether making errors is beneficial in the learning process to promote skills generalization after severe TBI. Objective. To compare the efficacy of ELL and EBL for improving skills generalization, self-awareness, behavioral competency, and psychosocial functioning after severe TBI. Method. A total of 54 adults (79% male; mean age = 38.0 years, SD = 13.4) with severe TBI were randomly allocated to ELL or EBL and received 8 × 1.5-hour therapy sessions that involved meal preparation and other goal-directed activities. The primary outcome was total errors on the Cooking Task (near-transfer). Secondary outcome measures included the Zoo Map Test (far-transfer), Awareness Questionnaire, Patient Competency Rating Scale, Sydney Psychosocial Reintegration Scale, and Care and Needs Scale. Results. Controlling for baseline performance and years of education, participants in the EBL group made significantly fewer errors at postintervention (mean = 36.25; 95% CI = 32.5-40.0) than ELL participants (mean = 42.57; 95% CI = 38.8-46.3). EBL participants also demonstrated greater self-awareness and behavioral competency at postintervention than ELL participants ( P < .05). There were no significant differences on other secondary outcomes ( P > .05), or at the 6-month follow-up assessment. Conclusion. EBL was found to be more effective than ELL for enhancing skills generalization on a task related to training and improving self-awareness and behavioral competency.

Developing a Cognition Endpoint for Traumatic Brain Injury Clinical Trials

Cognitive impairment is a core clinical feature of traumatic brain injury (TBI). After TBI, cognition is a key determinant of post-injury productivity, outcome, and quality of life. As a final common pathway of diverse molecular and microstructural TBI mechanisms, cognition is an ideal endpoint in clinical trials involving many candidate drugs and nonpharmacological interventions. Cognition can be reliably measured with performance-based neuropsychological tests that have greater granularity than crude rating scales, such as the Glasgow Outcome Scale-Extended, which remain the standard for clinical trials. Remarkably, however, there is no well-defined, widely accepted, and validated cognition endpoint for TBI clinical trials. A single cognition endpoint that has excellent measurement precision across a wide functional range and is sensitive to the detection of small improvements (and declines) in cognitive functioning would enhance the power and precision of TBI clinical trials and accelerate drug development research. We outline methodologies for deriving a cognition composite score and a research program for validation. Finally, we discuss regulatory issues and the limitations of a cognition endpoint.

Individual Differences in Working Memory Capacity Predicts Responsiveness to Memory Rehabilitation After Traumatic Brain Injury

OBJECTIVE

To explore how individual differences affect rehabilitation outcomes by specifically investigating whether working memory capacity (WMC) can be used as a cognitive marker to identify who will and will not improve from memory rehabilitation.

DESIGN

Post hoc analysis of a randomized controlled clinical trial designed to treat learning and memory impairment after traumatic brain injury (TBI): 2 × 2 between-subjects quasiexperimental design (2 [group: treatment vs control] × 2 [WMC: high vs low]).

SETTING

Nonprofit medical rehabilitation research center.

PARTICIPANTS

Participants (N=65) with moderate to severe TBI with pre- and posttreatment data.

INTERVENTIONS

The treatment group completed 10 cognitive rehabilitation sessions in which subjects were taught a memory strategy focusing on learning to use context and imagery to remember information. The placebo control group engaged in active therapy sessions that did not involve learning the memory strategy.

MAIN OUTCOME MEASURE

Long-term memory percent retention change scores for an unorganized list of words from the California Verbal Learning Test-II.

RESULTS

Group and WMC interacted (P=.008, ηp(2)=.12). High WMC participants showed a benefit from treatment compared with low WMC participants. Individual differences in WMC accounted for 45% of the variance in whether participants with TBI in the treatment group benefited from applying the compensatory treatment strategy to learn unorganized information.

CONCLUSIONS

Individuals with higher WMC showed a significantly greater rehabilitation benefit when applying the compensatory strategy to learn unorganized information. WMC is a useful cognitive marker for identifying participants with TBI who respond to memory rehabilitation with the modified Story Memory Technique.