Cognitive and everyday functioning after bacterial brain abscess: a prospective study of functional recovery from 8 weeks to 1 year post-treatment

OBJECTIVE

A bacterial brain abscess may damage surrounding brain tissue by mass effect, inflammatory processes, and bacterial toxins. The aim of this study was to examine cognitive and functional outcomes at 8 weeks and 1 year following acute treatment.

METHODS

Prospective study of 20 patients with bacterial brain abscess (aged 17-73 years; 45% females) with neuropsychological assessment at 8 weeks and 1 year post-treatment. Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A) and Patient Competence Rating Scale (PCRS) were used to assess everyday functioning and administered to patients and informants.

RESULTS

Cognitive impairment was found in 30% of patients at 8 weeks and 22% at 1 year. Significant improvements were seen on tests of perceptual reasoning, attention, verbal fluency, and motor abilities (p < 0.05). At 1 year, 45% had returned to full-time employment. Nevertheless, patients and their informants obtained scores within the normal range on measures of everyday functioning (PCRS and BRIEF-A) at 8 weeks and 1 year. No significant improvements on these measures emerged over time.

CONCLUSION

Residual long-term cognitive impairment and diminished work ability affected 22% and 45% of patients one year after BA. Persistent cognitive impairment emphasizes the importance of prompt acute treatment and cognitive rehabilitation.

Delivery of Neuropsychological Interventions for Adult and Older Adult Clinical Populations: An Australian Expert Working Group Clinical Guidance Paper

Delivery of neuropsychological interventions addressing the cognitive, psychological, and behavioural consequences of brain conditions is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings. However, there are numerous approaches to neuropsychological intervention, requiring different sets of skills, and with varying levels of supporting evidence across different diagnostic groups. This clinical guidance paper provides an overview of considerations and recommendations to help guide selection, delivery, and implementation of neuropsychological interventions for adults and older adults. We aimed to provide a useful source of information and guidance for clinicians, health service managers, policy-makers, educators, and researchers regarding the value and impact of such interventions. Considerations and recommendations were developed by an expert working group of neuropsychologists in Australia, based on relevant evidence and consensus opinion in consultation with members of a national clinical neuropsychology body. While the considerations and recommendations sit within the Australian context, many have international relevance. We include (i) principles important for neuropsychological intervention delivery (e.g. being based on biopsychosocial case formulation and person-centred goals); (ii) a description of clinical competencies important for effective intervention delivery; (iii) a summary of relevant evidence in three key cohorts: acquired brain injury, psychiatric disorders, and older adults, focusing on interventions with sound evidence for improving activity and participation outcomes; (iv) an overview of considerations for sustainable implementation of neuropsychological interventions as 'core business'; and finally, (v) a call to action.

Combined Cognitive and Psychological Interventions Improve Meaningful Outcomes after Acquired Brain Injury: A Systematic Review and Meta-Analysis

Interventions addressing cognitive and emotional difficulties after acquired brain injury (ABI) often focus on specific impairments in cognition or mood. These interventions can be effective at addressing their specific target, but do not routinely translate to improved activity and participation outcomes. Approaches that combine cognitive and psychological rehabilitation are increasingly popular; however, to date, there have been no systematic evaluations of their efficacy. We conducted a systematic review of five databases, searching for randomised controlled trials of adults with diagnoses of non-progressive ABI at least 1-month post injury, in receipt of interventions that combined cognitive and psychological components compared to any control. Screening and data extraction were evaluated by two independent reviewers using a standardised protocol. Effect sizes were calculated using Hedge's g and estimated using a random-effects model. Risk of bias was assessed using the PEDro-P rating system, and quality of evidence evaluated using the grading of recommendation, assessment, development and evaluation (GRADE) approach. Thirteen studies were included in the meta-analysis (n = 684). There was an overall small-to-medium effect (g = 0.42) for combined interventions compared with controls, with gains maintained at 6-month follow-up. Improvements were observed at the level of impairment, activity, participation and quality of life. GRADE ratings and analyses investigating sensitivity, heterogeneity and publication bias indicated that these effects were robust. No a priori variables moderated these effects. Overall, this review provides strong evidence that combined cognitive and psychological interventions create meaningful change in the lives of people with ABI.

Implementation of an assistive technology for meal preparation within a supported residence for adults with acquired brain injury: a mixed-methods single case study

OBJECTIVES

This study aimed to investigate the feasibility of implementing an assistive technology for meal preparation called COOK within a supported community residence for a person with an acquired brain injury.

METHODS

Using a mixed-methods approach, a multiple baseline single-case experimental design and a descriptive qualitative study were conducted. The participant was a 47-year-old woman with cognitive impairments following a severe stroke. She received 21 sessions of training on using COOK within a shared kitchen space. During meal preparation, independence and safety were evaluated using three target behaviours: required assistance, task performance errors, and appropriate responses to safety issues, which were compared with an untrained control task, making a budget. Benefits, barriers, and facilitators were assessed via three individual interviews with the client and three focus groups with the care team.

RESULTS

Both quantitative and qualitative analyses showed that COOK significantly increased independence and safety during meal preparation but not in the control task. Stakeholders suggested that the availability of a training toolkit to a greater number of therapists at the residence and installation of COOK within the client's apartment would help with successful adoption of this technology.

CONCLUSION

COOK is a promising assistive technology for individuals with cognitive deficits who live in supported community residences.Implication For RehabilitationCOOK is a promising assistive technology for cognition to increase independence and safety in meal preparation for clients with ABI within their supported living contexts.Receiving training from an expert and the availability of technical support are imperative to the successful adoption of COOK.

Exploring Pragmatic Deficits in Relation to Theory of Mind and Executive Functions: Evidence from Individuals with Right Hemisphere Stroke

Research investigating pragmatic deficits in individuals with right hemisphere damage focuses on identifying the potential mechanisms responsible for the nature of these impairments. Nonetheless, the presumed shared cognitive mechanisms that could account for these deficits have not yet been established through data-based evidence from lesion studies. This study aimed to examine the co-occurrence of pragmatic language deficits, Theory of Mind impairments, and executive functions while also exploring their associations with brain lesion sites. Twenty-five patients suffering from unilateral right hemisphere stroke and thirty-seven healthy participants were recruited for this study. The two groups were tested in pragmatics, Theory of Mind, and executive function tasks. Structural imaging data were also obtained for the identification of the lesion sites. The findings of this study suggest a potential convergence among the three aforementioned cognitive mechanisms. Moreover, we postulate a hypothesis for a neural circuitry for communication impairments observed in individuals with right hemisphere damage.

Language-Specific Dual-Task Effects After Stroke: A Systematic Review

PURPOSE

The dual-task paradigm has been frequently used to examine stroke-related deficits because it samples behavioral performance under conditions of distraction similar to functioning in real-life environments. This original systematic review synthesizes studies that examined dual-task effects involving spoken language production in adults affected by stroke, including transient ischemic attack (TIA) and poststroke aphasia.

METHOD

Five databases were searched (inception to March 2022) for eligible peer-reviewed articles. The 21 included studies reported a total of 561 stroke participants. Thirteen studies focused on single word production, for example, word fluency, and eight on discourse production, for example, storytelling. Most studies included participants who had suffered a major stroke. Six studies focused on aphasia, whereas no study focused on TIA. A meta-analysis was not appropriate because of the heterogeneity of outcome measures.

RESULTS

Some single word production studies found dual-task language effects whereas others did not. This finding was compounded by the lack of appropriate control participants. Most single word and discourse studies utilized motoric tasks in the dual-task condition. Our certainty (or confidence) assessment was based on a methodological appraisal of each study and information about reliability/fidelity. As 10 of the 21 studies included appropriate control groups and limited reliability/fidelity information, the certainty of the findings may be described as weak.

CONCLUSIONS

Language-specific dual-task costs were identified in single word studies, especially those that focused on aphasia as well as half of the nonaphasia studies. Unlike single word studies, nearly all studies of discourse showed dual-task decrements on at least some variables.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23605311.

Criterion-Related Validation of a Music-Based Attention Assessment for Individuals with Traumatic Brain Injury

The music-based attention assessment (MAA) is a melody contour identification task that evaluates different types of attention. Previous studies have examined the psychometric and physiological validity of the MAA across various age groups in clinical and typical populations. The purpose of this study was to confirm the MAA's criterion validity in individuals with traumatic brain injury (TBI) and to correlate this with standardized neuropsychological measurements. The MAA and various neurocognitive tests (i.e., the Wechsler adult intelligence scale DST, Delis-Kaplan executive functioning scale color-word interference test, and Conner's continuous performance test) were administered to 38 patients within two weeks prior to or post to the MAA administration. Significant correlations between MAA and neurocognitive batteries were found, indicating the potential of MAA as a valid measure of different types of attention deficits. An additional multiple regression analysis revealed that MAA was a significant factor in predicting attention ability.

Occupational therapy for cognitive impairment in stroke patients

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

AUTHORS' CONCLUSIONS

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

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.

Effects of activities of daily living-based dual-task training on upper extremity function, cognitive function, and quality of life in stroke patients

Objectives

The aim of this study was to investigate the effect of daily living dual-task training focused on improving attention and executive function of the upper extremities, cognitive function, and quality of life in stroke patients.

Methods

We included 30 stroke patients who were hospitalized between July 2020 and October 2020. They were divided into experimental and control groups through randomization. The experimental group performed 20 minutes of dual-task training and received 10 minutes of conventional occupational therapy, while the control group performed 20 minutes of single-task training and received 10 minutes of conventional occupational therapy. Both groups underwent their respective rehabilitation for 30 minutes per session, 5 times per week for 5 weeks.

Results

Both groups showed significant improvements in upper extremity function, cognitive function, and quality of life; the experimental group showed higher results for all items. A significant between-group difference was observed in the magnitude of the changes.

Conclusion

In stroke patients, dual-task training that combined attention and executive function with daily living activities was found to be meaningful, as it encouraged active participation and motivation. This study is expected to be used as a foundation for future interventions for stroke patients.

Measuring age differences in executive control using rapid motor decisions in a robotic object hit and avoid task

Age-related declines in executive control are commonly assessed with neuropsychological tests that also rely on sensory and motor processes that are not typically measured in those tasks. It is therefore difficult to isolate the cognitive contributions from sensorimotor contributions to performance impairments. Rapid motor decision-making tasks may also be sensitive to age differences in executive control but allow for the measurement of sensorimotor contributors to task performance. Recently developed object hit (OH) and object hit and avoid (OHA) tasks using a robotic manipulandum are sensitive to motor and cognitive aspects of performance in stroke and Parkinson's disease. However, the impact of healthy aging, and the specific cognitive mechanisms involved in these tasks has not been assessed. We administered the OH and OHA tasks to 77 younger and 59 healthy older adults to evaluate the relative age differences in the perceptual-motor/sensory, movement coordination, and cognitive measures of performance. The Trail Making Test (TMT) Parts A and B were administered to assess the extent to which the cognitive contributors to OHA task performance are associated with executive functioning. After controlling for hand movement speed, age differences were largest for cognitive measures, with smaller differences in perceptual-motor speed and sensory measures, and little differences in bimanual and spatial coordination measures of performance. The cognitive measures were associated with executive functioning measures from the TMT task. These findings provide evidence that rapid motor decision-making tasks are sensitive to age differences in executive control and can isolate the cognitive from the sensorimotor contributions to task performance. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Efficacy of a Training on Executive Functions in Potentiating Rehabilitation Effects in Stroke Patients

Cognitive impairment after a stroke has a direct impact on patients' disability. In particular, impairment of Executive Functions (EFs) interferes with re-adaptation to daily life. The aim of this study was to explore whether adding a computer-based training on EFs to an ordinary rehabilitation program, regardless of the specific brain damage and clinical impairment (motor, language, or cognitive), could improve rehabilitation outcomes in patients with stroke. An EF training was designed to have minimal motor and expressive language demands and to be applied to a wide range of clinical conditions. A total of 37 stroke patients were randomly assigned to two groups: a training group, which performed the EF training in addition to the ordinary rehabilitation program (treatment as usual), and a control group, which performed the ordinary rehabilitation exclusively. Both groups were assessed before and after the rehabilitation program on neuropsychological tests covering multiple cognitive domains, and on functional scales (Barthel index, Functional Independence Measure). The results showed that only patients who received the training improved their scores on the Attentional Matrices and Phonemic Fluency tests after the rehabilitation program. Moreover, they showed a greater functional improvement in the Barthel scale as well. These results suggest that combining an EF training with an ordinary rehabilitation program potentiates beneficial effects of the latter, especially in promoting independence in activities of daily living.

Effects of therapeutic instrumental music performance and motor imagery on chronic post-stroke cognition and affect: A randomized controlled trial

BACKGROUND

The burden of post-stroke cognitive impairment, as well as affective disorders, remains persistently high. With improved stroke survival rates and increasing life expectancy, there is a need for effective interventions to facilitate remediation of neurocognitive impairments and post-stroke mood disorders.

OBJECTIVE

To investigate the effects of Therapeutic Instrumental Music Performance (TIMP) training with and without Motor Imagery on cognitive functioning and affective responding in chronic post-stroke individuals.

METHODS

Thirty chronic post-stroke, community-dwelling participants were randomized to one of three experimental arms: (1) 45 minutes of active TIMP, (2) 30 minutes of active TIMP followed by 15 minutes of metronome-cued motor imagery (TIMP+cMI), (3) 30 minutes of active TIMP followed by 15 minutes of motor imagery without cues (TIMP+MI). Training took place three times a week for three weeks, using a selection of acoustic and electronic instruments. Assessments, administered at two baselines and post-training, included the Trail Making Test (TMT) - Part B to assess mental flexibility, the Digit Span Test (DST) to determine short-term memory capacity, the Multiple Affect Adjective Checklist - Revised (MAACL-R) to ascertain current affective state, and the General Self-Efficacy Scale (GSE) to assess perceived self-efficacy. The Self-Assessment Maniqin (SAM) was also administered prior to and following each training session.

RESULTS

Thirty participants completed the protocol, ten per arm [14 women; mean age = 55.9; mean time post-stroke = 66.9 months]. There were no statistically significant differences between pooled group baseline measures. The TIMP+MI group showed a statistically significant decrease in time from pre-test 2 to post-test on the TMT. The TIMP group showed a significant increase on MAACL sensation seeking scores, as well as on the Valence and Dominance portions of the SAM; TIMP+cMI showed respective increases and decreases in positive and negative affect on the MAACL, and increases on the Valence, Dominance, and Arousal portions of the SAM. No statistically significant association between cognitive and affective measures was obtained.

CONCLUSIONS

The mental flexibility aspect of executive functioning appears to be enhanced by therapeutic instrumental music training in conjunction with motor imagery, possibly due to multisensory integration and consolidation of representations through motor imagery rehearsal following active practice. Active training using musical instruments appears to have a positive impact on affective responding; however, these changes occurred independently of improvements to cognition.

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.

Cognitive strategy training for adults with neurological conditions: a systematic review and meta-analysis exploring effect on occupational performance

Introduction

The objective of this systematic review was to synthesise the evidence for cognitive strategy training to determine its effectiveness to improve performance of activities of daily living in an adult neurological population.

Method

Medline, CINAHL, EMBASE, PSYCInfo, PsycBITE and Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were searched until August 2019. Studies examining the effect of cognitive strategy training on functional performance were included. Population criteria included adults with non-progressive neurological conditions. External and internal validity of included studies was systematically evaluated using an appropriate methodological quality assessment for each study design. A content analysis was conducted of the methodologies used.

Findings

Forty-one studies met the inclusion criteria and were appraised for content, 16 randomised or quasi-randomised trials were meta-analysed. Trial quality was generally ‘good’, Physiotherapy Evidence Database scale scores ranged from 3 to 8 (out of 10). For activity performance outcomes post-intervention, there was a significant benefit of cognitive strategy training over usual care (standardised mean difference 0.79, 95% confidence interval 0.49–1.09; P < 0.00001).

Conclusion

More high-quality research is needed to strengthen the evidence base for cognitive strategy interventions to improve activity performance outcomes for adults with non-progressive neurological conditions.

Systematic review registration

PROSPERO CRD42016033728

Microstructural degeneration and cerebrovascular risk burden underlying executive dysfunction after stroke

Executive dysfunction affects 40% of stroke patients, but is poorly predicted by characteristics of the stroke itself. Stroke typically occurs on a background of cerebrovascular burden, which impacts cognition and brain network structural integrity. We used structural equation modelling to investigate whether measures of white matter microstructural integrity (fractional anisotropy and mean diffusivity) and cerebrovascular risk factors better explain executive dysfunction than markers of stroke severity. 126 stroke patients (mean age 68.4 years) were scanned three months post-stroke and compared to 40 age- and sex-matched control participants on neuropsychological measures of executive function. Executive function was below what would be expected for age and education level in stroke patients as measured by the organizational components of the Rey Complex Figure Test, F(3,155) = 17, R2 = 0.25, p < 0.001 (group significant predictor at p < 0.001) and the Trail-Making Test (B), F(3,157) = 3.70, R2 = 0.07, p < 0.01 (group significant predictor at p < 0.001). A multivariate structural equation model illustrated the complex relationship between executive function, white matter integrity, stroke characteristics and cerebrovascular risk (root mean square error of approximation = 0.02). Pearson's correlations confirmed a stronger relationship between executive dysfunction and white matter integrity (r = - 0.74, p < 0.001), than executive dysfunction and stroke severity (r = 0.22, p < 0.01). The relationship between executive function and white matter integrity is mediated by cerebrovascular burden. White matter microstructural degeneration of the superior longitudinal fasciculus in the executive control network better explains executive dysfunction than markers of stroke severity. Executive dysfunction and incident stroke can be both considered manifestations of cerebrovascular risk factors.

Heart Rate Variability Mainly Relates to Cognitive Executive Functions and Improves Through Exergame Training in Older Adults: A Secondary Analysis of a 6-Month Randomized Controlled Trial

Heart rate variability (HRV) mirrors autonomic nervous system activities and might serve as a parameter to monitor health status in older adults. However, it is currently unknown which functional health measures, including cognitive, physical, and gait performance parameters, are most strongly related to HRV indices. This knowledge would enable implementing HRV assessments into health monitoring routines and training planning for older adults. Simultaneous cognitive-motor and exergame training may be effective to improve HRV indices but has not been investigated yet. Eighty-nine healthy older adults (≥70 years of age) were randomized into three groups: (1) virtual reality video game dancing, i.e., exergaming (DANCE); (2) treadmill walking with simultaneous verbal memory training (MEMORY); or (3) treadmill walking only (PHYS). Strength and balance exercises complemented each program. Over 6 months, two weekly 1-h training sessions were performed. HRV indices (standard deviation of N-N intervals, SDNN; root mean square of successive R-R interval differences, RMSSD; and absolute power of high-frequency band (0.15-0.4 Hz), HF power) and various measures of cognitive, physical, and gait performance were assessed at baseline and after 3 months and 6 months. Multiple linear regression analyses with planned comparisons were calculated. At baseline, 8-12% of HRV variance was significantly explained by cognitive executive functions and leg strength (inversely related). Verbal long-term memory, aerobic and functional fitness, and gait performance did not contribute to the model (SDNN: R² = 0.082, p = 0.016; RMSSD: R² = 0.121, p = 0.013; HF power: R² = 0.119, p = 0.015). After 6 months, DANCE improved HRV indices, while MEMORY and PHYS did not (time × intervention interactions: first-contrast DANCE/MEMORY vs. PHYS: SDNN p = 0.014 one-tailed, ΔR ² = 0.020 and RMSSD p = 0.052 one-tailed (trend), ΔR ² = 0.007; second-contrast DANCE vs. MEMORY: SDNN p = 0.002 one-tailed, ΔR ² = 0.035, RMSSD p = 0.017 one-tailed, ΔR ² = 0.012, and HF power p = 0.011 one-tailed, ΔR ² = 0.013). We conclude that mainly cognitive executive functions are associated with HRV indices and that exergame training improves global and parasympathetic autonomic nervous system activities in older adults. Periodic assessments of HRV in older citizens could be particularly beneficial to monitor cognitive health and provide indications for preventative exercise measures.

The Role of Parent Self-Regulation in Youth Type 1 Diabetes Management

PURPOSE OF REVIEW

Youth with strong self-regulation (SR), or the ability to manage thoughts, emotions, and behaviors, engage in more effective type 1 diabetes (T1D) management. However, while parent support and engagement are critical to ensuring positive youth T1D outcomes, it is rarely considered that parents' SR may also influence youth T1D management. If this is the case, novel interventions to improve parents' SR or ensure adequate support for parents with SR challenges offer great potential to improve family functioning and youth T1D management.

RECENT FINDINGS

Theoretical and preliminary empirical evidence suggests that parental SR impacts family processes that support youth T1D treatment regimen adherence. Furthermore, parent and youth SR likely interact, with high parent SR enhancing the positive effects of high youth SR or compensating for low youth SR. Continued research is needed to better understand the ways in which parent SR matters to youth T1D management and identify how to support improvements in T1D management among families of parents with low SR.

Speech-Language Pathology Practices for Adults With Right Hemisphere Stroke: What Are We Missing?

Purpose Limited evidence exists to guide the assessment and treatment of cognitive-communication disorders associated with right hemisphere stroke. The purpose of this study was to obtain information about speech-language pathologists' (SLPs') clinical practices and decision making for this population to understand what practices are being used and identify gaps in clinical practice. Method A survey was distributed via online ASHA Communities for the Special Interest Groups and other social media platforms. Respondents included 143 SLPs from across the United States representing 3-50 years of experience and a wide range of practice settings. Survey questions probed assessment practices including how tests are selected, what tests are used to diagnose specific deficits, and how confident SLPs were in their diagnoses. Treatment decisions were queried for a small set of disorders. Results SLPs routinely assess cognitive disorders using standardized tests. Communication disorders are less likely to be formally assessed. Three core right cerebral hemisphere deficits-anosognosia, aprosodia, and pragmatic deficits-are either not assessed or assessed only through observation by 80% of SLPs. Evidence-based treatments are commonly used for disorders of attention, awareness, and aprosodia. Conclusion Communication disorders are less likely to be formally assessed than cognitive disorders, creating a critical gap in care that cannot be filled by other allied health professionals. Suggestions for free or low-cost resources for evaluating pragmatics, prosody, and awareness are provided to aid SLPs in filling this gap. Supplemental Material https://doi.org/10.23641/asha.12159597.

Developing an Executive Functioning Composite Score for Research and Clinical Trials

OBJECTIVE

Executive functioning encompasses interactive cognitive processes such as planning, organization, set-shifting, inhibition, self-monitoring, working memory, and initiating and sustaining motor and mental activity. Researchers therefore typically assess executive functioning with multiple tests, each yielding multiple scores. A single composite score of executive functioning, which summarizes deficits across a battery of tests, would be useful in research and clinical trials. This study examines multiple candidate composite scores of executive functioning using tests from the Delis-Kaplan Executive Function System (D-KEFS).

METHOD

Participants were 875 adults between the ages of 20 and 89 years from the D-KEFS standardization sample. Seven Total Achievement scores were used from three tests (i.e., Trail Making, Verbal Fluency, and Color-Word Interference) to form eight composite scores that were compared based on their psychometric properties and association with intelligence (IQ).

RESULTS

The distributions of most composite scores were mildly to severely skewed, and some had a pronounced ceiling effect. The composite scores all showed a medium positive correlation with IQ. The composite scores were highly intercorrelated in the total sample and in four IQ subgroups (i.e., IQ <89, 90-99, 100-109, 110+), with some being so highly correlated that they appear redundant.

CONCLUSIONS

This study is part of a larger research program developing a cognition endpoint for research and clinical trials with sound psychometric properties and utility across discrepant test batteries. Future research is needed to examine the reliability and ecological validity of these composite scores.

Using telerehabilitation to improve cognitive function in post-stroke survivors: is this the time for the continuity of care?

Post-stroke cognitive disorders can affect different domains, depending on typology of stroke and lesion localization, onset time, age and diagnostic tools used. In recent years, telerehabilitation using virtual reality has been used to reduce the healthcare costs encouraging continuity of care. The aim of our study is to evaluate the efficacy of a virtual reality rehabilitation system in improving cognitive function in stroke survivors. Forty patients affected by stroke were enrolled in this study and randomized into either the control or the experimental groups in order of recruitment. The study lasted 6 months, and included two phases: (1) during the first phase the experimental group underwent cognitive rehabilitation training using the Virtual Reality Rehabilitation System-Evo, whereas the control group was submitted to standard cognitive training; (2) in the second phase (after discharge), the experimental group was treated by means of virtual reality rehabilitation system Home Tablet (three sessions a week, each session lasting about 50 minutes), and the control group continued the traditional training, with the same amount of treatment. The patients underwent a neuropsychological evaluation before and at the end of the treatment. Linear mixed-effects analysis results showed that the scores of Montreal overall cognitive assessment, attentive matrices, Trail Making Test B, Phonemic Fluency, Semantic Fluency, Rey Auditory Verbal Learning Test I, Hamilton Rating Scale-Anxiety and Hamilton Rating Scale-Depression were affected by the type of the rehabilitative treatment. Our data show the effectiveness of telerehabilitation for the treatment of cognitive disorders following stroke.

Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue following Stroke, 6th edition update 2019

The 2019 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Mood, Cognition and Fatigue following Stroke is a comprehensive set of evidence-based guidelines addressing three important issues that can negatively impact the lives of people who have had a stroke. These include post-stroke depression and anxiety, vascular cognitive impairment, and post-stroke fatigue. Following stroke, approximately 20% to 50% of all persons may be affected by at least one of these conditions. There may also be overlap between conditions, particularly fatigue and depression. If not recognized and treated in a timely matter, these conditions can lead to worse long-term outcomes. The theme of this edition of the CSBPR is Partnerships and Collaborations, which stresses the importance of integration and coordination across the healthcare system to ensure timely and seamless care to optimize recovery and outcomes. Accordingly, these recommendations place strong emphasis on the importance of timely screening and assessments, and timely and adequate initiation of treatment across care settings. Ideally, when screening is suggestive of a mood or cognition issue, patients and families should be referred for in-depth assessment by healthcare providers with expertise in these areas. As the complexity of patients treated for stroke increases, continuity of care and strong communication among healthcare professionals, and between members of the healthcare team and the patient and their family is an even bigger imperative, as stressed throughout the recommendations, as they are critical elements to ensure smooth transitions from acute care to active rehabilitation and reintegration into their community.

Addressing cognitive impairment following stroke: systematic review and meta-analysis of non-randomised controlled studies of psychological interventions

OBJECTIVE

Cognitive impairment is a pervasive outcome of stroke, reported in over half of patients 6 months post-stroke and is associated with increased disability and a poorer quality of life. Despite the prevalence of post-stroke cognitive impairment, the efficacy of existing psychological interventions for the rehabilitation of cognitive impairment following stroke has yet to be established. The aim of this study is to identify psychological interventions from non-randomised studies that intended to improve post-stroke cognitive function and establish their efficacy.

DESIGN

Systematic review and meta-analysis of non-randomised studies of psychological interventions addressing post-stroke cognitive impairment.

DATA SOURCES

Electronic searches were performed in the Pubmed, EMBASE and PsycINFO databases, the search dating from inception to February 2017.

ELIGIBILITY CRITERIA

All non-randomised controlled studies and quasi-randomised controlled trials examining psychological interventions to improve cognitive function following stroke were included, such as feasibility studies, pilot studies, experimental studies, and quasi-experimental studies. The primary outcome was cognitive function. The prespecified secondary outcomes were functional abilities in daily life and quality of life.

METHODS

The current meta-analyses combined the findings of seven controlled studies, examining the efficacy of psychological interventions compared with treatment-as-usual controls or active controls, and 13 one-group pre-post studies.

RESULTS

Results indicated an overall small effect on cognition across the controlled studies (Hedges' g=0.38, 95% CI=0.06 to 0.7) and a moderate effect on cognition across the one-group pre-post studies (Hedges' g=0.51, 95% CI=0.3 to 0.73). Specific cognitive domains, such as memory and attention also demonstrated a benefit of psychological interventions.

CONCLUSIONS

This review provides support for the potential of psychological interventions to improve overall cognitive function post-stroke. Limitations of the study, in terms of risk of bias and quality of included studies, and future research directions are explored.

PROSPERO REGISTRATION NUMBER

CRD42017069714.

Executive Function Performance Test: transcultural adaptation, evaluation of psychometric properties in Brazil

OBJECTIVES

Executive dysfunction occurs in 18.5% to 39% of patients who present with cognitive impairment. Occupational therapy aims to facilitate independence and autonomy, hence improving quality of life. The Executive Function Performance Test - Brazilian version (EFPT-BR) has been developed to assess the need for assistance in performing four basic daily tasks. The aims of this research were: (1) to offer cross-cultural adaptation in patients with stroke; (2) to assess the psychometric properties of the Brazilian version of the EFPT-BR in patients with stroke; (3) to assess the relationship between scores on the EFPT-BR in patients with stroke, and demographic variables, stroke location, symptoms of anxiety and depression.

METHODS

The transcultural adaptation and validation were performed based on standard procedures, and psychometric properties were assessed in 86 Brazilian patients who suffered a stroke.

RESULTS

The test has shown a good internal consistency (Cronbach's alpha: 0.819). The ICC for intra-rater reliability was 0.435 and for the inter-rater was 0.732. Significant correlations between scores in the EFPT-BR and executive measures (verbal fluency test, clock drawing test, digit span - forwards and backwards, zoo map test and Six Elements Test) were observed.

CONCLUSION

The EFPT-BR is a valid and reliable tool for occupational therapists to assess executive dysfunction in daily routine tasks in patients with stroke in Brazil.

Cyclosporin A-Mediated Activation of Endogenous Neural Precursor Cells Promotes Cognitive Recovery in a Mouse Model of Stroke

Cognitive dysfunction following stroke significantly impacts quality of life and functional independance; yet, despite the prevalence and negative impact of cognitive deficits, post-stroke interventions almost exclusively target motor impairments. As a result, current treatment options are limited in their ability to promote post-stroke cognitive recovery. Cyclosporin A (CsA) has been previously shown to improve post-stroke functional recovery of sensorimotor deficits. Interestingly, CsA is a commonly used immunosuppressant and also acts directly on endogenous neural precursor cells (NPCs) in the neurogenic regions of the brain (the periventricular region and the dentate gyrus). The immunosuppressive and NPC activation effects are mediated by calcineurin-dependent and calcineurin-independent pathways, respectively. To develop a cognitive stroke model, focal bilateral lesions were induced in the medial prefrontal cortex (mPFC) of adult mice using endothelin-1. First, we characterized this stroke model in the acute and chronic phase, using problem-solving and memory-based cognitive tests. mPFC stroke resulted in early and persistent deficits in short-term memory, problem-solving and behavioral flexibility, without affecting anxiety. Second, we investigated the effects of acute and chronic CsA treatment on NPC activation, neuroprotection, and tissue damage. Acute CsA administration post-stroke increased the size of the NPC pool. There was no effect on neurodegeneration or lesion volume. Lastly, we looked at the effects of chronic CsA treatment on cognitive recovery. Long-term CsA administration promoted NPC migration toward the lesion site and rescued cognitive deficits to control levels. This study demonstrates that CsA treatment activates the NPC population, promotes migration of NPCs to the site of injury, and leads to improved cognitive recovery following long-term treatment.

A customized home-based computerized cognitive rehabilitation platform for patients with chronic-stage stroke: study protocol for a randomized controlled trial

BACKGROUND

Stroke patients usually suffer primary cognitive impairment related to attention, memory, and executive functions. This impairment causes a negative impact on the quality of life of patients and their families, and may be long term. Cognitive rehabilitation has been shown to be an effective way to treat cognitive impairment and should be continued after hospital discharge. Computerized cognitive rehabilitation can be performed at home using exercise programs that advance with predetermined course content, interval, and pace. We hypothesize that computerized rehabilitation might be improved if a program could customize course content and pace in response to patient-specific progress. The present pilot study is a randomized controlled double-blind crossover clinical trial aiming to study if chronic stroke patients with cognitive impairment could benefit from cognitive training through a customized tele-rehabilitation platform ("Guttmann, NeuroPersonalTrainer"®, GNPT®).

METHODS/DESIGN

Individuals with chronic-stage stroke will be recruited. Participants will be randomized to receive experimental intervention (customized tele-rehabilitation platform, GNPT®) or sham intervention (ictus.online), both with the same frequency and duration (five sessions per week over 6 weeks). After a washout period of 3 months, crossover will occur and participants from the GNPT® condition will receive sham intervention, while participants originally from the sham intervention will receive GNPT®. Patients will be assessed before and after receiving each treatment regimen with an exhaustive neuropsychological battery. Primary outcomes will include rating measures that assess attention difficulties, memory failures, and executive dysfunction for daily activities, as well as performance-based measures of attention, memory, and executive functions.

DISCUSSION

Customized cognitive training could lead to better cognitive function in patients with chronic-stage stroke and improve their quality of life.

TRIAL REGISTRATION

NCT03326349 . Registered 31 October 2017.

Neuropsychological assessment of 86-year-old man with Broca's aphasia complaining of memory difficulties

We report the clinical assessment of J.P., an 86 year-old man with Broca's aphasia complaining of memory problems. Our aim was to objectively investigate his level of cognitive functioning using standardized neuropsychological tests in order to determine the nature of his memory impairment. J.P.'s medical history included left-middle cerebral artery (left-MCA) stroke, high frequency hearing loss, macular degeneration, and a recent hospitalization related to a fall. Results from his neuropsychological testing and from information gathered during the clinical interview with his wife suggested that a deficit in executive functioning might have been the source for some of his perceived memory problems. We were unable to detect any progressive cognitive decline that might have been suggestive of something more sinister. Despite his age J.P. was a fully functioning and highly contributing member of his society who was completing quite complex activities of daily living (ADLs). We provided J.P. with a compensatory set of strategies in order for him to circumvent his executive difficulties and impairment in expressive language. In the elderly population survivors of stroke are continuing to rise with improvements in drug treatment and primary care. This case study is important as it provides information on neuropsychological assessment in aphasia; and draws attention to valuable information in a client's clinical history that might help clarify the prognosis.

Home-based hand rehabilitation with a robotic glove in hemiplegic patients after stroke: a pilot feasibility study

OBJECTIVE

To evaluate the feasibility and safety of home rehabilitation of the hand using a robotic glove, and, in addition, its effectiveness, in hemiplegic patients after stroke.

METHODS

In this non-randomized pilot study, 21 hemiplegic stroke patients (Ashworth spasticity index ≤ 3) were prescribed, after in-hospital rehabilitation, a 2-month home-program of intensive hand training using the Gloreha Lite glove that provides computer-controlled passive mobilization of the fingers. Feasibility was measured by: number of patients who completed the home-program, minutes of exercise and number of sessions/patient performed. Safety was assessed by: hand pain with a visual analog scale (VAS), Ashworth spasticity index for finger flexors, opponents of the thumb and wrist flexors, and hand edema (circumference of forearm, wrist and fingers), measured at start (T0) and end (T1) of rehabilitation. Hand motor function (Motricity Index, MI), fine manual dexterity (Nine Hole Peg Test, NHPT) and strength (Grip test) were also measured at T0 and T1.

RESULTS

Patients performed, over a mean period 56 (49-63) days, a total of 1699 (1353-2045) min/patient of exercise with Gloreha Lite, 5.1 (4.3-5.8) days/week. Seventeen patients (81%) completed the full program. The mean VAS score of hand pain, Ashworth spasticity index and hand edema did not change significantly at T1 compared to T0. The MI, NHPT and Grip test improved significantly (p = 0.0020, 0.0156 and 0.0024, respectively) compared to baseline.

CONCLUSION

Gloreha Lite is feasible and safe for use in home rehabilitation. The efficacy data show a therapeutic effect which need to be confirmed by a randomized controlled study.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

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

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

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

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

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

Examining the relationship between fatigue and cognition after stroke: A systematic review

Many stroke survivors experience fatigue, which is associated with a variety of factors including cognitive impairment. A few studies have examined the relationship between fatigue and cognition and have obtained conflicting results. The aim of the current study was to review the literature on the relationship between fatigue and cognition post-stroke. The following databases were searched: EMBASE (1980-February, 2014), PsycInfo (1806-February, 2014), CINAHL (1937-February, 2014), MEDLINE (1946-February, 2014), Ethos (1600-February, 2014) and DART (1999-February, 2014). Reference lists of relevant papers were screened and the citation indices of the included papers were searched using Web of Science. Studies were considered if they were on adult stroke patients and assessed the following: fatigue with quantitative measurements (≥ 3 response categories), cognition using objective measurements, and the relationship between fatigue and cognition. Overall, 413 papers were identified, of which 11 were included. Four studies found significant correlations between fatigue and memory, attention, speed of information processing and reading speed (r = -.36 to .46) whereas seven studies did not. Most studies had limitations; quality scores ranged from 9 to 14 on the Critical Appraisal Skills Programme Checklists. There was insufficient evidence to support or refute a relationship between fatigue and cognition post-stroke. More robust studies are needed.

Comparison of two cognitive interventions for adults experiencing executive dysfunction post-stroke: a pilot study

Purpose This pilot partially randomised controlled trial compared the feasibility and preliminary efficacy of two promising interventions for persons with executive dysfunction post-stroke: (1) occupation-based strategy training using an adapted version of the Cognitive Orientation to daily Occupational Performance (CO-OP) approach; and (2) Computer-based EF training (COMPUTER training). Method Participants received 16 h of either CO-OP or COMPUTER training. We assessed feasibility and acceptability of each intervention, and change in intervention outcomes at baseline, post-intervention and one-month follow-up. Performance and satisfaction with performance in self-selected everyday life goals were measured by the participant and the significant other-rated Canadian Occupational Performance Measure (COPM). Other intervention outcomes included changes in EF impairment, participation in daily life and self-efficacy. Results Six participants received CO-OP and five received COMPUTER training: one in each group discontinued the intervention for medical reasons unrelated to the intervention. The remaining nine participants completed all 16 sessions. Participants expressed high levels of satisfaction with both interventions. Both treatment groups showed large improvements in self and significant other-rated performance and satisfaction with performance on their goals immediately post-intervention and at follow-up (CO-OP: effect sizes (ES) = 1.6-3.5; COMPUTER: ES = 0.9-4.0), with statistically significant within-group differences in CO-OP (p < 0.05). The COMPUTER group also showed large improvements in some areas of EF impairment targeted by the computerised tasks (ES = 0.9-1.6); the CO-OP group demonstrated large improvements in self-efficacy for performing everyday activities (ES = 1.5). Conclusions Our findings provide preliminary evidence supporting the feasibility of using both CO-OP and COMPUTER training with patients with executive dysfunction post-stroke. Implications for Rehabilitation Computerised executive function training and occupation-based strategy training are feasible to deliver and acceptable to persons with executive dysfunction post-stroke. Preliminary evidence suggests that both interventions have a positive impact on real-world outcomes; and, that CO-OP might have a greater impact on improving self-efficacy for performing everyday activities.

Home-based telesurveillance and rehabilitation after stroke: a real-life study

BACKGROUND

After discharge from in-hospital rehabilitation, post-stroke patients should have the opportunity to continue the rehabilitation through structured programs to maintain the benefits acquired during intensive rehabilitation treatment.

OBJECTIVE

The primary objective was to evaluate the feasibility of implementing an home-based telesurveillance and rehabilitation (HBTR) program to optimize the patient's recovery by reducing dependency degree.

METHOD

Post-stroke patients were consecutively screened. Data were expressed as mean ±  standard deviation (SD). 26 patients enrolled: 15 were sub-acute (time since stroke: 112 ± 39 days) and 11 were chronic (time since stroke: 470 ± 145 days). For 3 months patients were followed at home by a nurse-tutor, who provided structured phone support and vital signs telemonitoring, and by a physiotherapist (PT) who monitored rehabilitation sessions by videoconferencing.

RESULTS

23 patients completed the program; 16.7 ± 5.2 phone contacts/patient were initiated by the nurse and 0.9 ± 1.8 by the patients. Eight episodes of atrial fibrillation that required a change in therapy were recorded in two patients. Physiotherapists performed 1.2 ± 0.4 home visits, 1.6 ± 0.9 phone calls and 4.5 ± 2.8 videoconference-sessions per patient. At least three sessions/week of home exercises were performed by 31% of patients, two sessions by 54%. At the end of the program, global functional capacity improved significantly (P < 0.001), in particular, static (P < 0.001) and dynamic (P = 0.0004) postural balance, upper limb dexterity of the paretic side (P = 0.01), and physical performance (P = 0.002). Symptoms of depression and caregiver strain also improved.

CONCLUSION

The home-based program was feasible and effective in both sub-acute and chronic post-stroke patients, improving their recovery, and maintaining the benefits reached during inpatient rehabilitation.

A virtual shopping task for the assessment of executive functions: Validity for people with stroke

The importance of assessing executive functions (EF) using ecologically valid assessments has been discussed extensively. Due to the difficulty of carrying out such assessments in real-world settings on a regular basis, virtual reality has been proposed as a technique to provide complex functional tasks under a variety of differing conditions while measuring various aspects of performance and controlling for stimuli. The main goal of this study was to examine the discriminant, construct-convergent and ecological validity of the Adapted Four-Item Shopping Task, an assessment of the Instrumental Activity of Daily Living (IADL) of shopping. Nineteen people with stroke, aged 50-85 years, and 20 age- and gender-matched healthy participants performed the shopping task in both the SeeMe Virtual Interactive Shopping environment and a real shopping environment (the hospital cafeteria) in a counterbalanced order. The shopping task outcomes were compared to clinical measures of EF. The findings provided good initial support for the validity of the Adapted Four-Item Shopping Task as an IADL assessment that requires the use of EF for people with stroke. Further studies should examine this task with a larger sample of people with stroke as well as with other populations who have deficits in EF.

Self-Management Support Interventions for Stroke Survivors: A Systematic Meta-Review

BACKGROUND

There is considerable policy interest in promoting self-management in patients with long-term conditions, but it remains uncertain whether these interventions are effective in stroke patients.

DESIGN

Systematic meta-review of the evidence for self-management support interventions with stroke survivors to inform provision of healthcare services.

METHODS

We searched MEDLINE, EMBASE, CINAHL, PsychINFO, AMED, BNI, Database of Abstracts of Reviews for Effectiveness, and Cochrane Database of Systematic Reviews for systematic reviews of self-management support interventions for stroke survivors. Quality was assessed using the R-AMSTAR tool, and data extracted using a customised data extraction form. We undertook a narrative synthesis of the reviews' findings.

RESULTS

From 12,400 titles we selected 13 systematic reviews (published 2003-2012) representing 101 individual trials. Although the term 'self-management' was rarely used, key elements of self-management support such as goal setting, action planning, and problem solving were core components of therapy rehabilitation interventions. We found high quality evidence that supported self-management in the context of therapy rehabilitation delivered soon after the stroke event resulted in short-term (< 1 year) improvements in basic and extended activities of daily living, and a reduction in poor outcomes (dependence/death). There is some evidence that rehabilitation and problem solving interventions facilitated reintegration into the community.

CONCLUSIONS

Self-management terminology is rarely used in the context of stroke. However, therapy rehabilitation currently successfully delivers elements of self-management support to stroke survivors and their caregivers with improved outcomes. Future research should focus on managing the emotional, medical and social tasks of long-term survivorship.

Cognitive impairments and mood disruptions negatively impact instrumental activities of daily living performance in the first three months after a first stroke

BACKGROUND

Cognition and mood play crucial roles in post-stroke recovery; however, the stroke literature is unclear as to how impairments in both domains influence performance of instrumental activities of daily living (IADL).

OBJECTIVE

(1) Evaluate the extent to which mood and cognition at two weeks post-stroke predict performance three months post-stroke. (2) Assess performance differences in patients with impairments in both cognition and mood to patients with impairments in either cognition or mood.

METHODS

Inpatients with a first-ever ischemic or hemorrhagic stroke were assessed at 2 weeks (n = 52) and at 3 months (n = 41) post-stroke. Patients completed a battery of neuropsychological tests, self-report measures and performance-based tests. Cognitive impairments and mood disruptions were assessed at 2 weeks and three months and IADL performance, as assessed by the Executive Function Performance Test, was evaluated at three months.

RESULTS

Complete data from the 41 patients assessed at both time points were analyzed. Regression analysis showed that composite cognition and composite mood variables at two weeks post-stroke predicted 48% of the variance in IADL performance at three months (F3,37 = 12.04; adjusted R(2) = 0.48, P < 0.001). Statistically significant differences were found in performance scores for patients with a single impairment (M = 7.86, SD = 7.81) and for those with impairments in both mood and cognition (M = 19.2, SD = 13.2) (t(39) = - 3.41, P = 0.008).

CONCLUSION

The results of this study suggest that cognitive and mood impairments at two weeks post-stroke are important predictors of performance in complex activities required for full independence at home and should be routinely assessed in stroke rehabilitation.

Diversity of approaches in assessment of executive functions in stroke: limited evidence?

Stroke is a leading cause of disability worldwide. Cognitive functions and, in particular, executive function, are commonly affected after stroke, leading to impairments in performance of daily activities, decrease in social participation and in quality of life. Appropriate assessment and understanding of executive dysfunction are important, firstly to develop better rehabilitation strategies for executive functions per se and secondly to consider executive function abilities on rehabilitation strategies in general. The purpose of this review was to identify the most widely used assessment tools of executive dysfunction for patients with stroke, and their psychometric properties.

We systematically reviewed manuscripts published in English in databases from 1999 to 2015. We identified 35 publications. The most frequently used instruments were the Stroop, Digit Span and Trail making tests. Psychometric properties were described for the Executive Function Performance Test, Executive Clock Drawing Task, Chinese Frontal Assessment Battery and Virtual Action Planning — Supermarket, and two subtests of the Cambridge Cognitive Examination — Revised.

There is a paucity of tools to reliably measure executive dysfunction after stroke, despite the fact that executive dysfunction is frequent. Identification of the best tools for executive dysfunction assessment is necessary to address important gaps in research and in clinical practice.

Executive function as a strong predictor of recovery from disability in patients with acute stroke: a preliminary study

BACKGROUND

Cognitive impairment impedes stroke rehabilitation. However, it is unclear whether cognitive impairment of specific domains or the degree of severity is more critical to functional recovery in patients with poststroke disability.

METHODS

We identified 182 patients who were disabled at 3 months after acute stroke, as defined by a modified Rankin Scale score of 2-5. At a single time point between 3 months and 1 year after onset, the following 4 cognitive domains were assessed: executive function, visuospatial ability, language, and memory. With respect to the severity of cognitive impairment, the patients were classified as having vascular dementia (VD), vascular cognitive impairment no dementia (VCIND), or normal cognition. The primary outcome was functional recovery between 3 months and 1 year after onset. To examine the association between cognitive status and functional recovery, multiple logistic regression with backward stepwise analysis was performed.

RESULTS

A total of 74 (40.7% of 182) patients demonstrated functional improvement at 1 year compared with 3 months. Patients with executive impairment demonstrated significantly less improvement in functional outcomes, with an adjusted odds ratio (OR) of .472 (95% confidence interval [CI], .245-.910). Patients with VD also demonstrated less functional recovery, with an adjusted OR of .289 (95% CI, .120-.700). The remaining 3 cognitive domains and VCIND were not significantly associated with functional recovery.

CONCLUSIONS

Executive function is a strong predictor of recovery from disability in patients with acute stroke. In addition, functional recovery is significantly hampered by cognitive impairment due to VD, but not VCIND.

A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic RevIew of Self-Management Support for long-term conditions

Background

Despite robust evidence concerning self-management for some long-term conditions (LTCs), others lack research explicitly on self-management and, consequently, some patient groups may be overlooked.

Aim

To undertake a rapid, systematic overview of the evidence on self-management support for LTCs to inform health-care commissioners and providers about what works, for whom, and in what contexts.

Methods

Self-management is ‘the tasks . . . individuals must undertake to live with one or more chronic conditions . . . [including] . . . having the confidence to deal with medical management, role management and emotional management of their conditions’. We convened an expert workshop and identified characteristics of LTCs potentially of relevance to self-management and 14 diverse exemplar LTCs (stroke, asthma, type 2 diabetes mellitus, depression, chronic obstructive pulmonary disease, chronic kidney disease, dementia, epilepsy, hypertension, inflammatory arthropathies, irritable bowel syndrome, low back pain, progressive neurological disorders and type 1 diabetes mellitus). For each LTC we conducted systematic overviews of systematic reviews of randomised controlled trials (RCTs) of self-management support interventions (‘quantitative meta-reviews’); and systematic overviews of systematic reviews of qualitative studies of patients’ experiences relating to self-management (‘qualitative meta-reviews’). We also conducted an original systematic review of implementation studies of self-management support in the LTCs. We synthesised all our data considering the different characteristics of LTCs. In parallel, we developed a taxonomy of the potential components of self-management support.

Results

We included 30 qualitative systematic reviews (including 515 unique studies), 102 quantitative systematic reviews (including 969 RCTs), and 61 studies in the implementation systematic review. Effective self-management support interventions are multifaceted, should be tailored to the individual, their culture and beliefs, a specific LTC and position on the disease trajectory, and underpinned by a collaborative/communicative relationship between the patient and health-care professional (HCP) within the context of a health-care organisation that actively promotes self-management. Self-management support is a complex intervention and although many components were described and trialled in the studies no single component stood out as more important than any other. Core components include (1) provision of education about the LTC, recognising the importance of understanding patients’ pre-existing knowledge and beliefs about their LTC; (2) psychological strategies to support adjustment to life with a LTC; (3) strategies specifically to support adherence to treatments; (4) practical support tailored to the specific LTC, including support around activities of daily living for disabling conditions, action plans in conditions subject to marked exacerbations, intensive disease-specific training to enable self-management of specific clinical tasks; and (5) social support as appropriate. Implementation requires a whole-systems approach which intervenes at the level of the patient, the HCP and the organisation. The health-care organisation is responsible for providing the means (both training and time/material resources) to enable HCPs to implement, and patients to benefit from, self-management support, regularly evaluating self-management processes and clinical outcomes. More widely there is a societal need to address public understanding of LTCs. The lack of public story for many conditions impacted on patient help-seeking behaviour and public perceptions of need.

Conclusions

Supporting self-management is inseparable from the high-quality care for LTCs. Commissioners and health-care providers should promote a culture of actively supporting self-management as a normal, expected, monitored and rewarded aspect of care. Further research is needed to understand how health service managers and staff can achieve this culture change in their health-care organisations.

Study registration

This study is registered as PROSPERO CRD42012002898.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Outcomes of neuropsychological interventions of stroke

The reported prevalence of cognitive deficits within the first month of stroke ranges widely from 10% to 82%, depending primarily on the criteria used to define cognitive impairment and on the selected patient population. These cognitive defects progress toward impairment over a course of time if left untreated. Among the most common cognitive deficits are the attentional, the visuoperceptual, the memory and executive function deficits. As these impairments are being increasingly recognized in the scientific communities, more and more studies are being devoted to the outcomes of various therapies for these disorders. In this review, we focus on the outcomes of various therapies for these cognitive disorders over time. We reviewed all the possible medical databases using key words for individual cognitive deficit treatment outcomes. All the possible studies including randomized controlled trials, pre-post design studies, case series and single case reports were included in this study. On the basis of present literature review, we conclude that the evidence is definitively positive only for outcomes of attentional and visuoperceptive skill deficits. On the other hand, there have been very few studies to conclude for effectiveness of various therapies for memory and executive function outcomes.