Computer-based cognitive interventions in acquired brain injury: A systematic review and meta-analysis of randomized controlled trials

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

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03958487.

Nursing management of cognitive dysfunction in adults with brain injury: Summary of best evidence-practiced strategies

OBJECTIVE

To summarize the best evidence-based strategies for the management of cognitive dysfunction in patients with brain injury and to provide a reference for clinical nursing practice.

DESIGN

Review.

METHODS

The review was presented using PRISMA guidelines. A systematic search of evidence on the management of cognitive dysfunction in patients with brain injury was conducted in computerized decision systems, guideline websites, professional association websites and comprehensive databases from the date of creation to 21 June 2023. The types of evidence included were clinical decision making, guidelines, evidence summaries, best practices, recommended practices, expert consensus, systematic reviews and meta-analyses. Two researchers trained in evidence-based methodological systems independently evaluated the quality of the literature and extracted, integrated and graded the evidence for inclusion.

RESULTS

A total of 20 articles were selected, including nine guidelines, three expert consensus articles, one clinical practice article and seven systematic reviews, and the overall quality of the literature was high. Thirty pieces of evidence were summarized in seven areas: assessment, multidisciplinary team, rehabilitation program, cognitive intervention, exercise intervention, music intervention and medication management.

CONCLUSIONS

This study summarizes the latest evidence on the management of cognitive dysfunction in the care of adults with brain injury and provides a reference for clinical nursing practice. The best evidence should be selected for localized and individualized application in clinical work, and the best evidence should be continuously updated to standardize nursing practice.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Patients with cognitive impairment after brain injury often suffer from memory loss, attention deficit and disorientation and are unable to have a normal life and experience much enjoyment, which seriously affects their physical and mental health and creates a great burden of care for their families and society. Best evidence-based strategies for the nursing management of cognitive impairment in brain injury are essential for standardizing clinical nursing practice and providing timely, professional, systematic and comprehensive nursing interventions for patients.

REPORTING METHOD

This review is reported following the PRISMA 2020 statement guidelines, as applicable, to enhance transparency in reporting the evidence synthesis.

TRIAL AND PROTOCOL REGISTRATION

This study has been registered with the Fudan University Centre for Evidence-based Nursing, a JBI Centre of Excellence under registration number ES20232566, http://ebn.nursing.fudan.edu.cn/myRegisterList.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

NL9437; The Netherlands Trial Register.

Electronic Assistive Technology to Support Memory Function After Traumatic Brain Injury: A Systematic Review of Efficacy and User Perspectives

Abstract Rapid technology advances have led to diverse assistive technology (AT) options for use in memory rehabilitation after traumatic brain injury (TBI). This systematic review aimed to evaluate the efficacy of electronic AT for supporting phases of memory in daily life after TBI. A secondary aim was to examine user perspectives on the utility of AT and factors influencing uptake or use. A systematic search of PsycINFO, MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Excerpta Medica database (Embase), Scopus, and Cochrane Library was conducted from database inception to June 13, 2022, to identify eligible studies. Methodological quality was assessed by two independent reviewers. Nineteen eligible articles involving a total of 311 participants included four randomized controlled trials (RCTs; Class I), five single-case experimental designs (Class II), and 10 pre-post group (n > 10) or single-case studies without experimental control (Class III). Three Class I studies, two Class II studies and eight Class III studies supported the efficacy of AT for supporting memory functioning. Treatment fidelity was not examined in any study. There was the most empirical support for the efficacy of AT for facilitating retrieval and execution phases of memory (i.e., supported by 6/9 studies) with external support to encode memory intentions or pre-programmed reminders. Further controlled studies are needed to determine whether outcomes vary according to individuals' level of independence with use (e.g., self-initiated vs. pre-programmed reminders) and to examine user characteristics and design features influencing uptake and effectiveness. Greater involvement of end-users with brain injury in the design and evaluation of AT features is also recommended to enhance usability and uptake in daily life.

Comparing resting-state connectivity of working memory networks in U.S. Service members with mild traumatic brain injury and posttraumatic stress disorder

Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) are prevalent among military populations, and both have been associated with working memory (WM) impairments. Previous resting-state functional connectivity (rsFC) research conducted separately in PTSD and mTBI populations suggests that there may be similar and distinct abnormalities in WM-related networks. However, no studies have compared rsFC of WM brain regions in participants with mTBI versus PTSD. We used resting-state fMRI to investigate rsFC of WM networks in U.S. Service Members (n = 127; ages 18-59) with mTBI only (n = 46), PTSD only (n = 24), and an orthopedically injured (OI) control group (n = 57). We conducted voxelwise rsFC analyses with WM brain regions to test for differences in WM network connectivity in mTBI versus PTSD. Results revealed reduced rsFC between ventrolateral prefrontal cortex (vlPFC), lateral premotor cortex, and dorsolateral prefrontal cortex (dlPFC) WM regions and brain regions in the dorsal attention and somatomotor networks in both mTBI and PTSD groups versus controls. When compared to those with mTBI, individuals with PTSD had lower rsFC between both the lateral premotor WM seed region and middle occipital gyrus as well as between the dlPFC WM seed region and paracentral lobule. Interestingly, only vlPFC connectivity was significantly associated with WM performance across the samples. In conclusion, we found primarily overlapping patterns of reduced rsFC in WM brain regions in both mTBI and PTSD groups. Our finding of decreased vlPFC connectivity associated with WM is consistent with previous clinical and neuroimaging studies. Overall, these results provide support for shared neural substrates of WM in individuals with either mTBI or PTSD.

Effect of computerized cognitive rehabilitation in comparison between young and old age after traumatic brain injury

INTRODUCTION

Cognitive dysfunction reduces patients' quality of life and social participation with traumatic brain injury (TBI). Computerized cognitive rehabilitation is increasingly being used for cognitive therapy in TBI patients. The purpose of this study was to investigate the influence of age on the effect of computerized cognitive rehabilitation in cognitive dysfunction after TBI.

MATERIAL AND METHODS

A total of 34 patients with cognitive dysfunction after TBI were enrolled. Participants performed 30 sessions of computerized cognitive rehabilitation (Comcog) for 6 weeks. A cognitive evaluation was performed before and after treatment with Mini-Mental State Examination (MMSE) and Computerized Neurophyschologic Test (CNT).

RESULTS

There were no cognitive tests that differed between the young group and the old group at baseline. However, after computerized cognitive rehabilitation, the young group showed significant improvement compared to the old group in verbal memory, visual memory, attention, and visuo-motor coordination tests. The young group showed improvement in MMSE, verbal and visual memory, and visuo-motor coordination tests after computerized cognitive rehabilitation. In contrast, the old group showed significant improvement only in MMSE and visual learning test, one of the visual memory tests.

CONCLUSION

Our findings demonstrate that age may be an important factor related to the effect of computer cognitive rehabilitation on cognitive dysfunction after TBI. Methodologically more ordered studies with larger sample sizes are needed in the future.

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

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

The Effect of Repetitive Transcranial Magnetic Stimulation (rTMS) on Cognition in Patients With Traumatic Brain Injury: A Protocol for a Randomized Controlled Trial

Cognitive impairment, defined as a decline in memory and executive function, is one of the most severe complications of traumatic brain injury (TBI). Patients with TBI are often unable to return to work due to cognitive impairment and their overall quality of life is reduced. TBI can bring a serious economic burden to patient's families and to society. Reported findings on the efficacy of repetitive transcranial magnetic stimulation (rTMS) in improving cognitive impairment following TBI are inconsistent. The purpose of the proposed study is to investigate whether rTMS can improve memory and executive function in patients with TBI. Herein, we propose a prospective randomized placebo-controlled (rTMS, sham rTMS, cognitive training), parallel-group, single-center trial. 36 participants with a TBI occurring at least 6 months prior will be recruited from an inpatient rehabilitation center. Participants will be randomly assigned to the real rTMS, sham rTMS, or cognitive training groups with a ratio of 1:1:1. A 20-session transcranial magnetic stimulation protocol will be applied to the left and right dorsolateral prefrontal cortices (DLPFC) at frequencies of 10 Hz and 1 Hz, respectively. Neuropsychological assessments will be performed at four time points: baseline, after the 10th rTMS session, after the 20th rTMS session, and 30 days post-intervention. The primary outcome is change in executive function assessed using the Shape Trail Test (STT). The secondary outcome measures are measures from neuropsychological tests: the Hopkins Verbal Learning Test (HVLT), the Brief Visuospatial Memory Test (BVMT), the Digit Span Test (DST). We report on positive preliminary results in terms of improving memory and executive function as well as beneficial changes in brain connectivity among TBI patients undergoing rTMS and hypothesize that we will obtain similar results in the proposed study.

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.

Neuropsychiatric Treatment for Mild Traumatic Brain Injury: Nonpharmacological Approaches

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Development and Application of Medicine-Engineering Integration in the Rehabilitation of Traumatic Brain Injury

The rapid progress of the combination of medicine and engineering provides better chances for the clinical treatment and healthcare engineering. Traumatic brain injury (TBI) and its related symptoms have become a major global health problem. At present, these techniques has been widely used in the rehabilitation of TBI. In this review article, we summarizes the progress of the combination of medicine and industry in the rehabilitation of traumatic brain injury in recent years, mainly from the following aspects: artificial intelligence (AI), brain-computer interfaces (BCI), noninvasive brain stimulation (NIBS), and wearable-assisted devices. We believe the summary of this article can improve insight into the combination of medicine and industry in the rehabilitation of traumatic brain injury.