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6. Interventions for Cognition and Cognitive-Communication Post Acquired Brain Injury

Shawn Marshall MD MSc, Penny Welch-West (M.CI.Sc. SLP), Connie Ferri (MSc. SLP), Pavlina Faltynek MSc, Shannon Janzen MSc, Leanne Togher PhD, Robert Teasell MD

Abbreviations

ABI Acquired Brain Injury

APT Attention Process Training

CES Cranial Electrotherapy Stimulation

GH Growth Hormone

Met Methionine Allele

PASAT Paced Auditory Serial Addition Task

PDA Personal Digital Assistant

PTA Post Traumatic Amnesia

RCT Randomized Controlled Trial

TBI Traumatic Brain Injury

TPM Time Pressure Management

Val Valine Allele

Key Points


Drill and practice training may not be effective for the remediation of attention following an ABI.

Dual-task training has been shown to improve measures of attention to the extent that the ABI population does not significantly differ from healthy controls, however it is undetermined if the strength of these effects compared to non-dual-task training are greater

Computer-based interventions are no more effective than no intervention in improving measures of attention and concentration post ABI.

Repetitive virtual reality tasks which include repetition are effective in improving attention and concentration in ABI populations.

Goal management training is effective in assisting those who sustain an ABI learning to manage life goals through improved attention.

In general, a variety of non-specific attentional training programs appear to be effective for improving attentional scores following an ABI.

The addition of a therapy animal to an attentional training program may enhance concentration gains.

Therapies which focus on emotional regulation do not appear to be effective at improving attention post ABI, while mindfulness may improve some areas.

In order to determine if attentional training is effective in improving attention post-ABI standardized protocols must be developed to allow between study comparisons.

Tasks that involve mathematical skills may be effective at improving attention post ABI.

Transcranial direct current stimulation may be effective in remediating attentional deficits when combined with computer assisted training in ABI populations.

Repeated magnetic transcranial stimulation may be effective in remediating attentional deficits following an ABI.

It is unclear as to whether donepezil may improve attention in individuals with a moderate to severe ABI.

The effectiveness of methylphenidate treatment to improve cognitive function following brain injury is unclear.

Methylphenidate may be effective in improving reaction time for working memory.

Response to methylphenidate may depend on the presence of the Met genotype.

Bromocriptine does not appear to improve attention in those with an ABI.

Cerebrolysin may be beneficial for improving clinical outcomes and cognitive functioning following brain injury; however, controlled trials are needed to further evaluate its efficacy.

Rivastigmine may not be effective in treating attention deficits post ABI.

Amantadine may not be effective in treating attention deficits following an ABI.

Hyperbaric oxygen therapy may improve attention and processing speed following an ABI; however more prospective data is required in order to make a conclusion.

Dextroamphetamine may not be an effective treatment for attentional deficits following an ABI and may actually increase agitation.

Pager and voice-organizer programs may improve a patient’s ability to complete tasks post TBI.

Personal digital assistant (PDA) devices are superior to paper-based interventions at improving memory and task completion post TBI; specially when introduced using systematic instructions and in combination with occupational therapy. Patients who have used previous memory aids might benefit from this intervention the most.

Text message prompts sent to a patient’s smartphone, when used alone or in combination with other memory-improvement therapies, likely improve task completion post TBI. However, risk exists of device dependency exists.

A television assisted prompting (TAP) program may be superior to other methods of memory prompting in post TBI patients.

Automated prompting systems, such as Guide (audio-verbal interactive micro-prompting system) and a computerized tracking system, can reduce the number of prompts needed from support staff to patients to complete tasks post TBI.

Calendars may be effective tools for improving memory and task completion post ABI.

The use of a diary may help to improve memory and task completion post ABI.

Virtual reality programs may enhance the recovery of memory, learning, but there is currently limited evidence supporting the use of virtual reality programs. The evidence is unclear as to which specific programs benefit memory rehabilitation and whether or not they are superior to manual training therapies.

Internal strategies such as self-imagination, spaced retrieval and rehearsal, and multiple encoding are effective for improving memory following an ABI.

Memory-retraining programs appear effective, particularly for functional recovery although performance on specific tests of memory may or may not change.

Some specific computer-based software seem to be effective for improving memory post ABI.

Computer-based interventions may be as effective as therapist administered interventions.

Emotional self-regulation therapy may be effective for improving specific elements of memory.

Attention training programs may not be effective for improving memory, but memory training programs are.

Interventions which include multiple learning techniques such as modelling, observation, verbal instruction, etc. are more effective than interventions which include a singular learning method.

Cranial electrotherapy stimulation may not be effective at enhancing memory and recall abilities following TBI.

Donepezil likely improves memory following TBI.

Methylphenidate likely does not improve memory or learning following an ABI.

Sertraline has not been shown to improve learning, or memory within the first 12 months post TBI, and may be associated with side effects.

Amantadine is not effective for improving learning and memory deficits post ABI.

Pramiracetam might improve memory in males post TBI; however, additional studies are required.

Physostigmine may improve long-term memory in men with TBI, however more studies are required.

More studies are required to determine if the positive effects of bromocriptine on verbal memory seen so far are of potential value.

Cerebrolysin may be beneficial for the improvement of clinical outcome and cognitive functioning following brain injury; however, controlled trials are needed to further evaluate its efficacy.

The administration of growth hormone complexes likely does not improve learning and memory following an ABI.

Rivastigmine is not effective in treating memory deficits post ABI.

Hyperbaric oxygen therapy may be promising for improving memory following an ABI; however, more controlled studies are required.

Targeted hypnosis may improve memory, attention, and cognitive function in post TBI patients or stroke; however, only as long as the intervention is being administered.

Attention training programs likely do not improve executive functioning.

General cognitive training programs which include problem-solving appear to be effective for improving executive functioning following an ABI.

Virtual reality does not likely improve executive functioning following an ABI.

Computer or smartphone software programs (BrainHQ, Parrot Software, ProSolv app) may not be superior to common interventions at improving memory, attention, and problem-solving skills in patients post TBI.

Goal management training may be superior to motor skills training at improving everyday skills (meal preparation), but not intelligence or neuropsychological outcomes in patients post TBI.

Heart rate variability biofeedback may improve executive functions; however, more controlled studies are required to make further conclusions.

Group goal-oriented interventions are effective for the remediation of executive functions, including comprehension and problem solving.

Emotional regulation interventions delivered in a group setting may improve executive function in patients post TBI; however, it is unclear if it is superior at doing so compared to conventional cognitive remediation.

The SMART program appears to be effective for improving executive functioning following an ABI.

Touch screen-based games which include components of metacognition may be effective for improving self-awareness.

Metacognitive instruction does not appear to improve comprehension or abstract reasoning; however, more studies are needed to fully evaluate its effects.

General cognitive rehabilitation programs are effective for improving cognitive functioning following an ABI.

There is limited evidence that mindfulness based stress reduction is effective for improving cognitive functioning.

Corrective video feedback is more effective than verbal feedback alone for improving general cognitive function and self-awareness.

Remedial and adaptive occupational therapy are equally effective for improving general cognitive functioning.

Donepezil might improve attention, learning and short-term memory following TBI; however, side effects may incur from its use.

The effectiveness of methylphenidate to improve cognitive impairment following brain injury is unclear. Further studies with larger populations are required.

Sertraline has not been shown to improve cognitive functioning within the first 12 months post TBI and may be associated with side effects.

Amantadine is not effective at improving generalized cognition. Its impact on executive functioning should be studied further.

Bromocriptine may improve other measures of cognition such as attention, but its effects on generalized cognition are conflicting. More research is required.

The administration of human growth hormones appears to have positive (although sometimes limited effects) on general and executive functioning in those with an ABI.

Rivastigmine is not effective in treating general or executive dysfunction post ABI.

Hyperbaric oxygen therapy may be beneficial for improving general and executive functioning following an ABI; however, more research is needed.

Dextroamphetamine is moderate evidence to suggest that dextroamphetamine is not effective for the remediation of general functioning.

Communicating “yes/no” responses with consistent training and environmental enrichments does not improve communication responses in individuals post ABI.

Retrieval practice is effective for improving verbal communication in individuals with an ABI.

Targeted figurative language therapy improves communication and comprehension in individuals with TBI; although the severity of the injury may moderate these effects.

Text-to-speech technology improves reading rates in individuals with TBI, but not comprehension.

Training in social skills, social communication or pragmatics is effective in improving communication following brain injury.

Goal-driven interventions may be effective in improving social communication skills and goals following TBI.

Group Interactive Structured Treatment (GIST) is effective for improving social communication skills following an ABI.

Computer-based game programs which deliver cognitive-communication skills training may be effective for improving social skills.

Providing communication training to individuals who interact with people with TBI is effective and encourages two-way dialogue.

Providing training to the communication partner and the individual with TBI together is more effective than training the individual with TBI alone.

Facial affect recognition and emotional interference training improves emotional perception post ABI.

Short intervention designed to improve emotional prosody is not effective post ABI.

Cognitive Pragmatic Treatment (CPT) program is effective at improving comprehension and production of a communication act.

The Treatment for Impairments in Social Cognition and Emotion Regulation and Cogniplus protocols are effective for improving emotional processing and emotional intelligence in individuals with an ABI.

Introduction

Cognitive and cognitive-communication deficits are common sequelae of acquired brain injury (ABI) which can negatively affect many areas of cognition such as attention, memory, reasoning, problem solving and executive function, as well as areas of communication including verbal expression, auditory comprehension, reading, written expression and social communication skills. Each of these cognitive functions represents a unique area of cognition and communication that allows individuals to execute activities of daily living, which may include work, play, school and social exchange. Cognitive impairment can be caused not only by the initial trauma, but also by secondary inflammation or insult. Compared to mild traumatic brain injury (TBI), moderate/severe TBI is associated with more severe and persistent deficits, with about 65% of patients reporting long-term cognitive problems (Rabinowitz & Levin, 2014). The effects of TBI on overall cognitive and cognitive-communication functioning vary depending on time post injury (Schretlen & Shapiro, 2003). Even with good medical prognosis, both cognitive and cognitive-communication ability remain one of the best predictors of successful return to work and independent living (Zasler ND, 2013). Due to the complex nature of the brain, there are a multitude of ways that each trauma may impact cognition and cognitive-communication. As a result, there are a variety of interventions available to clinicians to help rehabilitate these deficits post ABI.

In the broadest sense, interventions may be classified as pharmacological and non-pharmacological. Pharmacological interventions use medication to remediate deficits. These types of medications usually moderate neurotransmitters in the brain that regulate cognitive functions. By influencing the concentration and absorption of either excitatory or inhibitory neurotransmitters these medications are able to influence functions such as memory, attention, and social behaviours among others (Zasler ND, 2013). Non-pharmacological interventions span a broader spectrum and can include anything from physical exercise to memory programs including those using assistive technology. However, there are multiple challenges when evaluating the effectiveness of interventions for cognition and cognitive-communication. First, there is no consensus regarding a definition of attention; currently, it is used as a general construct. Attention may also be divided into sub types (sustained, divided, focused, selective, vigilance, speed of information processing), however this is not always reflected in the literature. Second, researchers and clinicians may use different measures when reporting outcomes, making comparisons between interventions difficult. Third, a study may use the same outcome measures repeatedly, thereby confounding practice and treatment effects (e.g., performance on the Paced Auditory Serial Attention Task (PASAT) is known to improve with exposure). Finally, studies may not consider or account for the rate of spontaneous recovery following brain injury (i.e., natural recovery of function in the absence of treatment). For these reasons, assessing the efficacy of interventions for cognitive and cognitive-communication rehabilitation is more challenging compared to other modules due to the heterogeneous presentation within the population, plus variability in assessment of deficits. These challenges should be taken into consideration when interpreting concluding statements.

With respect to areas of cognitive-communication, and the role of the Speech-Language Pathologists (SLPs), there has been a significant expansion in the outcome research and clinical services over the past 15 years. It is apparent from this review that evidence-based research into therapeutic interventions is lagging in areas of cognitive-communication within the moderate to severe population. There is a limited number of high quality randomized controlled trials (RCTs) within the literature dedicated to cognitive-communication impairments in the moderate to severe ABI population and the therapies to assist with the improvement of these deficits. This is especially true for impairments related to linguistic organization, reading comprehension, written expression and information processing. In a review conducted by Perdices et al. (2006) on brain injury, it was found that the majority of studies (39%) were single subject designs, and only 21% were RCTs. Difficulties conducting RCTs with individuals who have sustained a moderate-severe ABI include the complexity of the disorder, the confounding effects of spontaneous recovery, the heterogeneity of this population, costs, specificity of treatment, the need for multifaceted integrated rehabilitation, and the informed consent procedure (Struchen, 2005; Wiseman-Hakes et al., 2010). Further, blinding participants to their treatment group, and team members who are responsible for providing the treatment is “nearly impossible” (Kennedy & Turkstra, 2006).

Bloom and Lahey (1978) define language as, “knowledge of a code for representing ideas about the world through a conventional system of arbitrary signals for communication.”  Language is comprised of some aspect of content or meaning that is coded or represented in a linguistic manner for the purpose of use in a particular context (Bloom & Lahey, 1978). Every aspect of language (content, form and use) includes cognitive processing. Impairment of any cognitive process may affect any or all components of language. It is the mutually dependent relationship between cognition and language that gives individuals the ability to generate, assimilate, retain, retrieve, organize, monitor, respond to and learn from the environment (Kennedy & Deruyter, 1991).

Traditionally, descriptions of communication disorders that exist within populations of individuals with ABI fall into four main groups: apraxia, aphasia, dysarthria and cognitive-communication. The term cognitive-communication disorder was adopted by the American Speech-Language-Hearing Association (American Speech-Language-Hearing Association, 1987) to distinguish the unique characteristics of communication post ABI from those of aphasia following stroke. The College of Audiologists and Speech-Language Pathologists of Ontario defines cognitive-communication disorders as: “…communication impairments resulting from underlying cognitive deficits due to neurological impairment. These are difficulties in communicative competence (listening, speaking, reading, writing, conversation, and social interaction) that result from underlying cognitive impairments (attention, memory, organization, information processing, reading, writing, problem solving and executive functions)” (p.4) (College of Audiologists and Speech Language Pathologists of Ontario, 2002). The study of language disorders following ABI has been challenging, conceivably more than any other area of communication disorders. SLPs are required to deal with issues of language use or pragmatics to a greater extent than for other acquired neurological communication disorders.  In some instances, the language disorders found among individuals with ABI are more than just a reflection of underlying cognitive deficits. At other times, precise language processing deficits occur in conjunction with cognitively associated communication disorders (Kennedy & Deruyter, 1991).

Many individuals with an ABI, unlike individuals with developmental communication disorders, have a history of normal learning, reading, writing, language understanding and speech. Typically, they are younger than stroke survivors, and have greater concerns regarding transitions back to school and work along with everyday life activities. The mechanism of injury is often more diffuse and is related to a collection of cognitive-communication disorders as a result. Therefore, it is important to consider individuals with ABI as a distinct group (Turkstra, 1998). This is especially true in the moderate to severely impaired ABI group that is the focus of this evidence-based review.

In ABI, communication challenges are often observed along with otherwise intact speech, fluency, comprehension and grammar (Ylvisaker M & SF, 1994). The communication style of those with an ABI has been described as “the language of confusion” (Halpern et al., 1973). In an older study, dysarthria was the most commonly diagnosed communication disorder (54%), followed by other cognitive communication deficits (16%), aphasia (4%) and apraxia of speech (4%) (Duffy, 2005).

Inappropriate/unconventional social behaviour or impaired executive function (e.g., self-awareness of strengths and weaknesses, goal setting, planning, self-initiating, self-inhibiting, self-monitoring, self-evaluating) are also common areas affected (American Speech-Language-Hearing Association, 1987).

This module addresses areas of cognition and cognitive-communication to the best of its ability in terms of organization and inclusion. It should be noted that these areas of functioning are closely intertwined not only because of dependence on the coordination of multiple areas of functioning to execute a specific task, but also because some areas of cognition and cognitive-communication remain poorly defined and understood.

6.0 Introduction

Cognitive and cognitive-communication deficits are common sequelae of acquired brain injury (ABI) which can negatively affect many areas of cognition such as attention, memory, reasoning, problem solving and executive function, as well as areas of communication including verbal expression, auditory comprehension, reading, written expression and social communication skills. Each of these cognitive functions represents a unique area of cognition and communication that allows individuals to execute activities of daily living, which may include work, play, school and social exchange. Cognitive impairment can be caused not only by the initial trauma, but also by secondary inflammation or insult. Compared to mild traumatic brain injury (TBI), moderate/severe TBI is associated with more severe and persistent deficits, with about 65% of patients reporting long-term cognitive problems (Rabinowitz & Levin, 2014). The effects of TBI on overall cognitive and cognitive-communication functioning vary depending on time post injury (Schretlen & Shapiro, 2003). Even with good medical prognosis, both cognitive and cognitive-communication ability remain one of the best predictors of successful return to work and independent living (Zasler ND, 2013). Due to the complex nature of the brain, there are a multitude of ways that each trauma may impact cognition and cognitive-communication. As a result, there are a variety of interventions available to clinicians to help rehabilitate these deficits post ABI.

In the broadest sense, interventions may be classified as pharmacological and non-pharmacological. Pharmacological interventions use medication to remediate deficits. These types of medications usually moderate neurotransmitters in the brain that regulate cognitive functions. By influencing the concentration and absorption of either excitatory or inhibitory neurotransmitters these medications are able to influence functions such as memory, attention, and social behaviours among others (Zasler ND, 2013). Non-pharmacological interventions span a broader spectrum and can include anything from physical exercise to memory programs including those using assistive technology. However, there are multiple challenges when evaluating the effectiveness of interventions for cognition and cognitive-communication. First, there is no consensus regarding a definition of attention; currently, it is used as a general construct. Attention may also be divided into sub types (sustained, divided, focused, selective, vigilance, speed of information processing), however this is not always reflected in the literature. Second, researchers and clinicians may use different measures when reporting outcomes, making comparisons between interventions difficult. Third, a study may use the same outcome measures repeatedly, thereby confounding practice and treatment effects (e.g., performance on the Paced Auditory Serial Attention Task (PASAT) is known to improve with exposure). Finally, studies may not consider or account for the rate of spontaneous recovery following brain injury (i.e., natural recovery of function in the absence of treatment). For these reasons, assessing the efficacy of interventions for cognitive and cognitive-communication rehabilitation is more challenging compared to other modules due to the heterogeneous presentation within the population, plus variability in assessment of deficits. These challenges should be taken into consideration when interpreting concluding statements.

With respect to areas of cognitive-communication, and the role of the Speech-Language Pathologists (SLPs), there has been a significant expansion in the outcome research and clinical services over the past 15 years. It is apparent from this review that evidence-based research into therapeutic interventions is lagging in areas of cognitive-communication within the moderate to severe population. There is a limited number of high quality randomized controlled trials (RCTs) within the literature dedicated to cognitive-communication impairments in the moderate to severe ABI population and the therapies to assist with the improvement of these deficits. This is especially true for impairments related to linguistic organization, reading comprehension, written expression and information processing. In a review conducted by Perdices et al. (2006) on brain injury, it was found that the majority of studies (39%) were single subject designs, and only 21% were RCTs. Difficulties conducting RCTs with individuals who have sustained a moderate-severe ABI include the complexity of the disorder, the confounding effects of spontaneous recovery, the heterogeneity of this population, costs, specificity of treatment, the need for multifaceted integrated rehabilitation, and the informed consent procedure (Struchen, 2005; Wiseman-Hakes et al., 2010). Further, blinding participants to their treatment group, and team members who are responsible for providing the treatment is “nearly impossible” (Kennedy & Turkstra, 2006).

Bloom and Lahey (1978) define language as, “knowledge of a code for representing ideas about the world through a conventional system of arbitrary signals for communication.”  Language is comprised of some aspect of content or meaning that is coded or represented in a linguistic manner for the purpose of use in a particular context (Bloom & Lahey, 1978). Every aspect of language (content, form and use) includes cognitive processing. Impairment of any cognitive process may affect any or all components of language. It is the mutually dependent relationship between cognition and language that gives individuals the ability to generate, assimilate, retain, retrieve, organize, monitor, respond to and learn from the environment (Kennedy & Deruyter, 1991).

Traditionally, descriptions of communication disorders that exist within populations of individuals with ABI fall into four main groups: apraxia, aphasia, dysarthria and cognitive-communication. The term cognitive-communication disorder was adopted by the American Speech-Language-Hearing Association (American Speech-Language-Hearing Association, 1987) to distinguish the unique characteristics of communication post ABI from those of aphasia following stroke. The College of Audiologists and Speech-Language Pathologists of Ontario defines cognitive-communication disorders as: “…communication impairments resulting from underlying cognitive deficits due to neurological impairment. These are difficulties in communicative competence (listening, speaking, reading, writing, conversation, and social interaction) that result from underlying cognitive impairments (attention, memory, organization, information processing, reading, writing, problem solving and executive functions)” (p.4) (College of Audiologists and Speech Language Pathologists of Ontario, 2002). The study of language disorders following ABI has been challenging, conceivably more than any other area of communication disorders. SLPs are required to deal with issues of language use or pragmatics to a greater extent than for other acquired neurological communication disorders.  In some instances, the language disorders found among individuals with ABI are more than just a reflection of underlying cognitive deficits. At other times, precise language processing deficits occur in conjunction with cognitively associated communication disorders (Kennedy & Deruyter, 1991).

Many individuals with an ABI, unlike individuals with developmental communication disorders, have a history of normal learning, reading, writing, language understanding and speech. Typically, they are younger than stroke survivors, and have greater concerns regarding transitions back to school and work along with everyday life activities. The mechanism of injury is often more diffuse and is related to a collection of cognitive-communication disorders as a result. Therefore, it is important to consider individuals with ABI as a distinct group (Turkstra, 1998). This is especially true in the moderate to severely impaired ABI group that is the focus of this evidence-based review.

In ABI, communication challenges are often observed along with otherwise intact speech, fluency, comprehension and grammar (Ylvisaker M & SF, 1994). The communication style of those with an ABI has been described as “the language of confusion” (Halpern et al., 1973). In an older study, dysarthria was the most commonly diagnosed communication disorder (54%), followed by other cognitive communication deficits (16%), aphasia (4%) and apraxia of speech (4%) (Duffy, 2005).

Inappropriate/unconventional social behaviour or impaired executive function (e.g., self-awareness of strengths and weaknesses, goal setting, planning, self-initiating, self-inhibiting, self-monitoring, self-evaluating) are also common areas affected (American Speech-Language-Hearing Association, 1987).

This module addresses areas of cognition and cognitive-communication to the best of its ability in terms of organization and inclusion. It should be noted that these areas of functioning are closely intertwined not only because of dependence on the coordination of multiple areas of functioning to execute a specific task, but also because some areas of cognition and cognitive-communication remain poorly defined and understood.

6.1 Rehabilitation of Attention, Concentration, and Information Processing Speed

Although there is no specific agreement on the definition of attention, it is usually measured using externally directed tests, such as instructing participants to focus their attention on a sequence of stimuli or attenuating to a particular stimulus.

In general, TBI populations demonstrate significant deficits compared to control populations. Dymowski et al. (2015) showed that mild to severe TBI participants performed significantly worse on speed of information processing tasks compared to a healthy control group. Dockree et al. (2006) and Hasegawa and Hoshiyama (2009) found that TBI patients made significantly more errors than their non-TBI counterparts on dual task experiments for sustained attention. However, a case series by Foley et al. (2010) found that level of injury severity as measured by the Glasgow Coma Scale or PTA did not play a role in who performed poorly on the dual task assignment given to participants. They found that only 27% of TBI study participants performed below the cut-off for normal performance.

Two studies assessing the reaction times of individuals demonstrated that those with a TBI were found to have slower reaction times than individuals who had not sustained a TBI (Azouvi et al., 2004; Stuss et al., 1989). Results of the visual analogue scale also indicated that mental effort was higher for those with a TBI than for the controls. The results of this study confirmed what previous studies had found: those with a TBI have greater difficulty when dealing with two simultaneous tasks (Azouvi et al., 2004).

To better understand the mechanism by which cognitive interventions can improve attention, concentration, and information processing, there needs to be a consensus as to the definition of specific cognitive processes, including attention.

6.1.1 Non-Pharmacological Interventions

6.1.1.1 Drill and Practice

Key Points

Drill and practice training may not be effective for the remediation of attention following an ABI.

The following studies examined the influence of “drill & practice” exercises (either computerized and/or paper-and-pencil) on attentional functioning. Drill and practice training targets attention skills through repetitive training of specific tasks involving attention.

Discussion

The two studies desmontrated no significant differences between groups for attentional, functional, and/or cognitive skills assessed (Lindelov et al., 2016; Novack et al., 1996). Novack et al. (1996) compared focused hierarchical attentional learning with an unstructured non-sequential, non-hierarchical  intervention, while Lindelov et al. (2016) compared N-back training with visual search training. Novack et al. (1996) found that there were no significant differences between groups at either time points; however, both groups significantly improved over time. Although the study by Lindelov et al. (2016) also found no significant treatment effects over time, in contrast to the previous study, no spontaneous recovery effects were found either. Overall, there is weak evidence in support of training programs as an effective rehabilitation intervention for attention.

Conclusions

There is level 2 evidence that drill, and practice training may not be effective for the remediation of attention compared to spontaneous recovery, regardless of the level of structure in the program for those with an ABI.

6.1.1.2 Dual-Task Training

Key Points

Dual-task training has been shown to improve measures of attention to the extent that the ABI population does not significantly differ from healthy controls, however it is undetermined if the strength of these effects compared to non-dual-task training are greater.

The following studies examined the effect of “dual-task” training on speed of processing. Dual-task training involves dividing attention between two stimuli in order to complete two tasks concurrently and successfully, such as walking while speaking.

Discussion

One RCT with a TBI population showed that attention and information processing outcomes could be improved within the dual task paradigm (Couillet et al., 2010). Couillet et al. (2010) found that dual-task training significantly improved attentional behaviour and reaction time compared to a non-specific cognitive program. Stablum et al. (2000) found that initially individuals with a closed head injury (CHI) performed poorly on dual-task measures; however, with additional training their completion time of dual-task measures significantly increased compared to the control group.

Conclusions

There is level 2 evidence that dual task training may be effective in improving attention task performance in ABI populations compared to non-specific training.

6.1.1.3 Technological Interventions

Key Points

Computer-based interventions are no more effective than no intervention in improving measures of attention and concentration post ABI.

Repetitive virtual reality tasks which include repetition are effective in improving attention and concentration in ABI populations.

A surge in technology has allowed for the development of more computer-based intervention solutions designed to improve attention, concentration, and information processing. Current treatment modalities include computer cognitive training programs and virtual reality sessions. Virtual reality is discussed in further detail in 6.2.1.1.3 where its effects on learning and memory are presented.

Discussion

An RCT by Dirette et al. (1999) found no significant differences in improvements between participants taught specific compensatory strategies and those that simply completed the computer tasks without instruction of compensatory strategies. However, both groups significantly improved over time, with those that used the compensatory strategies (whether taught or spontaneously acquired) performing better than those that did not (Dirette et al., 1999).   Similarly, Chen et al. (1997) studied the effect of computer assisted cognitive rehabilitation versus traditional therapy methods. While measures of attention significantly improved in both groups after treatment, no significant differences were observed between groups (Chen et al., 1997). Other studies with brand name computer-assisted cognitive rehabilitation have also shown limited effects. A small pre-post study examining the program LuminosityTM showed improvements in attention for a minority of participants; however, this improvement did not significantly differ from those who received Attention Process Training-III (Zickefoose et al., 2013). Parrot software showed mixed results with a pilot study reporting significant improvement in attention post-intervention (Li et al., 2013), but a subsequent study reported no significant changes on measures related to attention (Li et al., 2015). BrainHQ did not significantly improve attention outcomes over time or compared to no intervention (O’Neil-Pirozzi & Hsu, 2016). The lack of evidence supporting the efficacy of computer-based cognitive rehabilitation may be due to different programs and strategies used to train participants.

Repetition of tasks in virtual reality improved performance, both in terms of speed and accuracy (Dvorkin et al., 2013; Gerber et al., 2014). Gentle nudges corrected behaviour better than break-through or no feedback (Dvorkin et al., 2013). However, repetition of the Stroop test in different virtual reality environments showed limited improvement in performance on those specific tests (Dahdah et al., 2017). A virtual reality exercise program demonstrated significant benefits in reaction times but not attention after intervention; more high quality research is needed to confirm the efficacy of virtual reality exercise (Grealy et al., 1999).

Conclusions

There is level 2 evidence that neither general nor name brand computer-based rehabilitation intervention may improve attention outcomes compared to usual care in ABI populations.

There is level 4 evidence that attention performance can be improved in ABI populations through repetition of tasks, either through computer-based or virtual reality environments.

6.1.1.4 Attention Training Programs

Key Points

Goal management training is effective in assisting those who sustain an ABI learning to manage life goals through improved attention.

In general, a variety of non-specific attentional training programs appear to be effective for improving attentional scores following an ABI.

The addition of a therapy animal to an attentional training program may enhance concentration gains.

Therapies which focus on emotional regulation do not appear to be effective at improving attention post ABI, while mindfulness may improve some areas.

In order to determine if attentional training is effective in improving attention post-ABI standardized protocols must be developed to allow between study comparisons.

Tasks that involve mathematical skills may be effective at improving attention post ABI.

With regard to cognitive rehabilitation, therapy is typically patient-directed and driven by both long- and short-term goals (Carswell et al., 2004). The ability to self-direct towards goals is emphasized as a component of brain injury community reintegration programs and is integral in the completion of instrumental activities of daily living. The execution of these goals relies on an individual having the ability to focus attention on a given task.

Cicerone et al. (2005) recommended strategy training for persons with TBI for improving deficits of attention. It should be noted, however, that there was insufficient evidence to distinguish the effectiveness of specific attention training during acute stage rehabilitation from improvements made from spontaneous recovery or from more general cognitive interventions (Cicerone et al., 2005).

Discussion

Many studies examined the effects goal training or cognitive training (Boman et al., 2004; Chen et al., 2011; Laatsch et al., 1999; Novakovic-Agopian et al., 2011; Sohlberg et al., 2000). Levine et al. (2000) completed an RCT comparing patients using goal management training strategies to a control group exposed to only motor skills training. The treatment group improved on paper and pencil everyday tasks as well as meal preparation, which the authors used as an example of a task heavily reliant on self-regulation. Novakovic-Agonian et al. (2011), found similar results in an RCT crossover where participants were assigned to received goal-training followed by education or the reverse. The goal training first group saw a significant improvement in sustained attention compared to the education-first group, additionally the goal training first group maintained their gains over 10 weeks.

A more recent RCT (Dundon et al., 2015) examined the effect of adaptive training on dichotic listening tasks and attention, interestingly the adaptive training group had significantly higher scores on the listening task compared to non-adaptive training group; however, the non-adaptive training group surpassed the adaptive training group in Test of Everyday Attention (TEA) scores. Overall, both groups significantly improved on measures of attention as a result of time (Dundon et al., 2015).

Park et al. (1999) examined whether Attention Processing Training (APT) had a beneficial effect on attention measures (PASAT, Consonant Trigrams) in a  group with severe TBI (tested pre and post training approximately 7 months apart). They compared their results to a convenience sample of controls, given the same measures one week apart without training. Results suggested that the APT did not have a significantly beneficial effect as performance improved on all measures across both groups (indicating practice effects and possibly spontaneous recovery). A pre-post study (Boman et al., 2004) found that cognitive training for three weeks significantly improved attention task scores compared to pre-test scores. One study did demonstrate that cognitive training (although beneficial) may not be more beneficial than other interventions such as educational training with respect to processing speed (Chen et al., 2011). In this study both groups significantly improved in attention directed goal completion.

Another study comparing the effects of attentional training to physical exercise found that there was no significant difference between groups post-intervention, but there was a within subjects effect such that both groups reported significantly less cognitive failures (McMillan et al., 2002).  Attention process training, was also shown to have greater results in attention remediation compared to education alone (Sohlberg et al., 2000). One study examined the effects of a memory training program on attention and reported positive results; Hellgren et al. (2015) found that a memory training program was successful in improving attentional scores on the Paced-Auditory Serial Attention Test, as well as further enhancing memory in general which is discussed later in this chapter.

In a study directly comparing the effects of an attention training program with that of a memory training program, the authors found that the results were split, with individuals performing better on some measures of attention (Attention Test 2d) but not others (PASAT) (Neiman et al., 1990). The last study to use an attention training program sought to see if the presence of a therapy animal could enhance the effects of training (Gocheva et al., 2018). Both the animal therapy and non-animal therapy groups produced significant improvement on measures of attention and concentration; however, the animal therapy group had a significantly larger increase in concentration (Gocheva et al., 2018).

Emotional regulation was also examined as a potential intervention for the remediation of attention postABI (Cantor et al., 2014). However, this treatment was not seen to be effective in the recovery of attention, other significant effects on executive functioning from this study are discussed further in section 6.4.1.1. Another study which focused specifically on mindfulness (McHugh & Wood, 2013) found that mindful focused training significantly improved participants’s ability to correctly select stimuli compared to controls.

Fasotti et al. (2000) assessed the effectiveness of time pressure management (TPM) training compared to concentration training in patients with slowed processing speed as a result of traumatic brain injury. Though both groups showed improvements on information intake task performance, no significant differences between groups were observed even though specific time pressure management strategies were learned by the experimental group (Fasotti et al., 2000). “Cognitive pragmatic treatment’ has been found to significantly improve scores on the card sorting task; however, the specific details of this program were not stated (Bosco et al., 2018b).

The inconsistencies between studies may be due to a lack of standardized goal management training or attention process training protocols. The lack of a consensus on the definition of certain cognitive processes appears to be reflected in the interventions used to attempt to rehabilitate these deficits. Unfortunately, this decreases the ability to compare studies on a more specific level; however, general conclusions can still be made that specific training programs which intend to increase attentional capacity are effective, to what extent they are more beneficial than other training programs needs to be addressed in the future through comparative methodologies. Only one study (Serino et al., 2007) described the specific task that was successful in improving attention. This cognitive task involved mental addition in combination with two other standardized tasks and was an effective strategy for improving attention.

Conclusions

There is level 2 evidence that adaptive training is no more effective than non-adaptive training in remediating attention in ABI populations.

There is level 1b evidence that emotional regulation therapy is not effective in treating attentional disorders compared to wait list controls in ABI populations.

There is level 1b evidence that the addition of a therapy animal to attention training programs may enhance gains in concentration in those with an ABI.

There is level 2 evidence that mindfulness training compared to no intervention may improve an individual’s ability to correctly reject inappropriate stimuli post ABI.

There is level 2 evidence to suggest goal management training, when compared to education, may be effective at improving attention in individuals post ABI.

There is level 2 evidence that goal management training is more effective in remediating task completion times than motor skill training, however it is not more effective in treating attention deficits, in individuals post ABI.

There is conflicting (level 2) evidence that attentional control or processing training may not significantly improve attention in post ABI individuals compared to control training.

There is level 4 evidence that summation tasks may be effective at improving attention in individuals post ABI.

There is level 4 evidence that a working memory training program may remediate attention in individuals post ABI.

There is level 4 evidence that cognitive rehabilitation therapy may not be effective for improving attention post ABI.

6.1.1.5 Brain Stimulation Techniques

Key Points

 Transcranial direct current stimulation may be effective in remediating attentional deficits when combined with computer assisted training in ABI populations.

 Repeated magnetic transcranial stimulation may be effective in remediating attentional deficits following an ABI.

Transcranial Direct Current Stimulation (tDCS) is a technique that painlessly delivers electrical currents to specific regions of the brain. These electrical currents modulate neuronal activity through electrodes placed over the head at different regions. To our knowledge only one recent study has examined the effects of tDCS on cognitive functioning post-ABI.

Discussion

Two RCTs have examined brain stimulation techniques to improve attention following an ABI (Lee & Kim, 2018; Sacco et al., 2016). Only Sacco et al. 2016 examined the effects of transcranial direct current stimulation (tDCS) on attention in a population post ABI. The authors found that the addition of transcranial direct current stimulation to computer-assisted training was superior to sham stimulation for improving divided attention. However, more high-level studies are needed in order to fully examine the potential benefits of adding tDCS to traditional attentional therapies. The second study examined the effects of repetitive transcranial magnetic stimulation (rTMS) and found significant positive effects on attention and depression when compared to sham controls (Lee & Kim, 2018).

Conclusions

There is level 2 evidence that transcranial direct current stimulation when combined with an attention training program (compared to sham stimulation) may improve divided attention in individuals post ABI.

There is level 1b evidence that repeated transcranial magnetic stimulation compared to sham stimulation may improve attention following an ABI. 

6.1.2 Pharmacological Interventions

6.1.2.1 Donepezil

Key Points

It is unclear as to whether donepezil may improve attention in individuals with a moderate to severe ABI.

Donepezil, an acetylcholinesterase inhibitor, was originally developed for improving cognitive function and memory in people with Alzheimer’s disease (Cacabelos, 2007), by delaying cognitive impairment in (Takeda et al., 2006). Since evidence suggests that cholinergic dysfunction may contribute to persistent cognitive deficits for people after traumatic brain injury, improvements in attention, memory, and other aspects of cognition related to the acetylcholine system are expected when cholinergic function is reduced (Arciniegas, 2003).

Discussion

In an RCT, Zhang et al. (2004) demonstrated that donepezil was associated with significantly more improvement in tasks of sustained attention compared to placebo. These improvements were sustained even after the washout period. Once both groups had completed donepezil treatment there were no significant differences between groups on any measures of attention. Khateb et al. (2005) found that individuals performed significantly better on measures of divided attention after donepezil treatment; however, 4 of 15 participants stopped treatment due to negative side-effects. In contrast to the positive effects found by these studies, one prospective controlled trial found no significant effects of donepezil on any measures of cognition, including attention (Campbell et al., 2018). In both the Campbell et al. (2018) and Zhang et al. (2004) studies, individuals received donepezil for approximately the same duration.

Conclusions

There is conflicting level 1b (positive) and level 2 (negative) evidence that donepezil may improve attention compared to placebo post ABI.

6.1.2.2 Methylphenidate

Key Points

The effectiveness of methylphenidate treatment to improve cognitive function following brain injury is unclear.

Methylphenidate may be effective in improving reaction time for working memory.

Response to methylphenidate may depend on the presence of the Met genotype.

Methylphenidate is a central nervous stimulant (CNS) which inhibits the reuptake of dopamine and norepinephrine, resulting in increased dopaminergic activity. In healthy individuals, methylphenidate has been found to improve memory but not other cognitive functions such as attention, mood, or executive function (Repantis et al., 2010).  Methylphenidate is extensively used as a treatment for attention deficit disorder, as well as narcolepsy (Glenn, 1998). No serious side effects have been observed in clinical trials, though there is a lack of evidence for long term safety (Godfrey, 2009).

Discussion

The majority of studies evaluating the efficacy of methylphenidate have been RCTs. In an RCT, Whyte et al. (2004) indicated that speed of processing, attentiveness during individual work tasks and caregiver ratings of attention were all significantly improved with methylphenidate treatment. No treatment related improvement was seen in divided or sustained attention, or in susceptibility to distraction. Similarly, Plenger et al. (1996) and Pavlovskaysa (2007) found that methylphenidate significantly improved attention and concentration, and visuo-spatial attention, respectively. More recently, Kim et al. (2012) found that reaction time improved significantly while on the methylphenidate. This is in line with Willmott and Ponsford (2009) who found that administering methylphenidate to a group of patients during inpatient rehabilitation significantly improved the speed of information processing. A variety of studies with different dosing regimens and durations have found positive effects of methylphenidate (Gualtieri & Evans, 1988; Whyte et al., 1997; Zhang et al., 2004).

Speech et al. (1993) conducted a double blind placebo controlled trial evaluating the effects of methylphenidate following closed head injury. In contrast to the results noted by Whyte et al. (2004) and Plenger et al. (1996), methylphenidate did not demonstrate significant differences compared to placebo on measures of attention, information processing speed, or learning. Kim et al. (2006) examined the effects of a single-dose treatment of methylphenidate and, although a trend was found in favour of improved working and visuospatial memory for the treatment group, these results did not reach statistical significance. Conflicting results continue to be reported, as two high-quality RCTs reached different conclusions regarding methylphenidate use. While Dymowski et al. (2017) noted no improvements in any measures of attention and mental processing, Zhang et al. (2017) noted improvements in reaction time, arithmetic tests, and even mental health outcomes after intervention by methylphenidate.

A potential explanation for these conflicting results is proposed by Willmott et al. (2013). The authors hypothesized that an individuals’ response to methylphenidate depends on their genotype. More specifically, that individuals possessing the methionine (Met) allele at the catechol-O-methyltransferase (COMT) gene would confer greater response to methylphenidate compared to those with the valine (Val) allele. While both Met/Met and Val/Val carriers performed more poorly in various attentional tasks compared to healthy controls, Met/Met carriers did show greater improvements in strategic control in attention than Val/Val carriers. As well, the authors were able to identify one significant drug and genetic interaction between Met/Met carriers and performance on the Symbol Digit Modalities Test (SDMT). These findings suggest Met/Met carriers may in fact be more responsive to methylphenidate than individuals with the Val genotype. However, further studies are needed to draw firm conclusions.

Conclusions

There is conflicting level 1a evidence regarding the effectiveness of methylphenidate following brain injury for the improvement of attention and concentration in individuals post ABI.

There is level 1a evidence that methylphenidate improves reaction time of working memory compared to placebo in individuals post ABI.

There is level 1b evidence that individuals carrying the Met allele may be more responsive to methylphenidate than those without the Met allele when it comes to the ABI population.

6.1.2.3 Bromocriptine

Key Points

Bromocriptine does not appear to improve attention in those with an ABI.

Bromocriptine is a dopaminergic agonist which exerts its effects primarily through the binding of D2 receptors (Whyte et al., 2008). It has been suggested that dopamine is an important neurotransmitter for prefrontal function (McDowell et al., 1998). In a study looking at the effects of bromocriptine on rats, Kline et al. (2002) noted that the animals showed improvement in working memory and spatial learning; however, this improvement was not reflected in motor abilities. Two studies have been identified investigating the use of bromocriptine as an adequate treatment for the recovery of cognitive impairments following brain injury.

Discussion

The question of whether bromocriptine improves cognitive function in patients with ABI was explored in two RCTs (McDowell et al., 1998; Whyte et al., 2008). In an earlier investigation, low-dose bromocriptine (2.5 mg daily) improved functioning on tests of executive control including a dual task, Trail Making Test, the Stroop test, the Wisconsin Card Sorting Test and the controlled oral word association test (McDowell et al., 1998). However, bromocriptine did not significantly influence working memory tasks. However, a later study by Whyte et al. (2008) found that bromocriptine had little effect on attention and it was noted that several participants did experience moderate to severe drug effects and withdrew or were withdrawn from the study.

Although McDowell et al. (1998) demonstrated some benefits following administration of bromocriptine, there was only a single administration of bromocriptine and the dose was considerably lower than that given by Whyte et al. (2008). Spontaneous recovery may have been a factor leading to the improved abilities in individuals receiving a single dose (2.5 mg daily) of the medication; however, study results did not answer this question. Results from Whyte et al. (2008) noted that the placebo group demonstrated better (although not significant) trends in improvement on the various tasks administered.

Conclusions

There is conflicting evidence as to whether bromocriptine improves performance on attention tasks compared to placebo in patients post TBI.

6.1.2.4 Cerebrolysin

Key Points

Cerebrolysin may be beneficial for the improvement of clinical outcome and cognitive functioning following brain injury; however, controlled trials are needed to further evaluate its efficacy.

Cerebrolysin has been demonstrated to have neuroprotective and neurotrophic effects and has been linked to increased cognitive performance in an elderly population. As explained by Alvarez et al. (2003), “Cerebrolysin (EBEWE Pharma, Unterach, Austria) is a peptide preparation obtained by standardized enzymatic breakdown of purified brain proteins, and comprises 25% low-molecular weight peptides and free amino acids” (pg. 272).

Discussion

In an open-label trial of 20 patients with TBI Alvarez et al. (2003) found that cerebrolysin was associated with improved brain bioelectrical activity, as evidenced by a significant increase in fast beta frequencies. A brief neuropsychological battery (Syndrome Kurztest) consisting of nine subtests was administered to evaluate memory and attentional functions in patients undergoing treatment with cerebrolysin. There was an overall significant improvement in performance post treatment, suggesting patients experienced cognitive benefits from cerebrolysin treatment. Improvements in the Glasgow Outcome Scale were also observed (Alvarez et al., 2003). Together these findings suggest that cerebroylsin may represent an effective neuroprotective therapy with tangible cognitive benefits for individuals living with an ABI. However, controlled trials are necessary to further explore the efficacy of this drug.

Conclusions

There is level 4 evidence that cerebrolysin may improve attention scores post ABI.

6.1.2.5 Rivastigmine

Key Points

Rivastigmine may not be effective in treating attention deficits post ABI.

Rivastigmine is an acetylcholinesterase inhibitor which prevents the enzyme acetylcholinesterase from breaking down acetylcholine. This increases the concentration of acetylcholine in synapses. Acetylcholine has been most strongly linked with the hippocampus and memory impairments; however, it is also implicated in attentional processing.

Discussion

Three studies have concluded that rivastigmine most likely does not improve attention following an acquired brain injury (Silver et al., 2006; Silver et al., 2009; Tenovuo et al., 2009). In Silver’s (2009) follow-up open-label cohort study to their original RCT (Silver et al., 2006), participants (n=98) showed significant improvement on the CANTAB RVIP A’, the HVLT and the trail A and B scales at the end of 38 week study period; however, after further sub-analysis controlling for order effects no significant differences were found between groups. The third study by Tenovuo et al. (2009) found that rivastigmine significantly improved vigilance following doses of 12mg/day for eight weeks. Tenovuo et al. (2009) on average had higher doses and longer duration of rivastigmine administration compared to both Silver et al. studies; however, it is unclear whether this resulted in their conflicting results. The route of rivastigmine administration (injection versus oral administration) did not appear to influence its efficacy.

Conclusions

There is level 1b evidence that Rivastigmine compared to placebo is not effective for improving concentration or processing speed in post ABI individualsbut may increase vigilance.

6.1.2.6 Amantadine

Key Points

Amantadine may not be effective in treating attention deficits following an ABI.

Amantadine is a non-competitive N-methyl-D-aspartate receptor antagonist and has been used as an antiviral agent, prophylaxis for influenza A, treatment of neurological diseases such as Parkinson’s Disease, and the treatment of neuroleptic side-effects such as dystonia, akinthesia and neuroleptic malignant syndrome (Schneider et al., 1999).

Discussion

Presently, only one study has examined the effects of amantadine on attention and processing speed and found no significant effects on attention or processing speed following treatment. Any results which were found to be significant on other cognitive measures were not maintained at the 60-day follow-up (Hammond et al., 2018). Further studies are needed to examine whether or not amantadine may be a viable treatment for attention and processing speed deficits following an ABI.

Conclusions

There is level 1b evidence that amantadine is not effective for improving attention compared to placebo following an ABI.

6.1.2.7 Hyperbaric Oxygen Therapy

Key Points

Hyperbaric oxygen therapy may improve attention and processing speed following an ABI; however more prospective data is required in order to make a conclusion.

Hyperbaric oxygen therapy involves the inhalation of pure oxygen under pressure allowing the lungs to absorb more oxygen per breath. Currently hyperbaric oxygen therapy is used to treat decompression sickness, serious infections, and delayed wound healing as a result of a comorbid illness such as diabetes (The Mayo Clinic, 2019).

Discussion

From this single case series, hyperbaric oxygen therapy significantly improved both attention and processing speed following treatment five days a week (Hadanny et al., 2018). Also, general improvements in cognitive functioning and visual processing were also reported (Hadanny et al., 2018). However, without proper prospective experimental data it is challenging to make conclusions on the efficacy of this intervention.

Conclusions

There is level 4 evidence that hyperbaric oxygen therapy may improve both attention and processing speed following an ABI.

6.1.2.8 Dextroamphetamine

Key Points

Dextroamphetamine may not be an effective treatment for attentional deficits following an ABI and may actually increase agitation.

Dextroamphetamine is a central nervous stimulant; similar to methylphenidate, it is used to treat narcolepsy and attention deficit hyperactivity disorder. Dextroamphetamine is a noncatecholamine and sympathomimetic amine that acts as a stimulant, unfortunately more direct mechanisms of action are not currently known.

Discussion

Based on a single study, it does not appear that dextroamphetamine has any beneficial effects on attention or processing speed following an ABI. However, administration of dextroamphetamine did significantly increase agitation over time.

Conclusions

There is level 1b evidence that dextroamphetamine does not improve attention following an ABI.

6.2 Rehabilitation of Learning and Memory Deficits

Memory impairment is one of the most common symptoms following brain injury and it is estimated that time and cost of care would be reduced if effective treatments were found to improve memory (Walker et al., 1991). When evaluating intervention strategies to improve memory performance following brain injury, the literature indicates that there are two main approaches to rehabilitation: restoration/retraining of memory, and compensation of deficits. Compensation includes “training strategies or techniques that aim to circumvent any difficulty that arises as a result of the memory impairment.” (McLean et al., 1991). Compensatory techniques include internal aids, which are “mnemonic strategies that restructure information that is to be learned.” (McLean et al., 1991). Conversely, interventions for remediation of memory deficits range from assistive technology to visual imagery. Cappa and colleagues (2005) reviewed various strategies used to improve memory deficits without the use of electronic devices, external aids were judged to be “possibly effective.”, while specific learning strategies (e.g. errorless learning) were found to be “probably effective” depending upon the task used, the type of memory involved and the severity of the impairment. Several studies were identified examining interventions to improve learning and memory following ABI.

6.2.1 Non-Pharmacological Interventions

6.2.1.1 Assistive Devices

Assistive devices for aiding learning and memory can include anything from physical or external devices to internal memory strategies. The following section discusses a variety of aids that may be used to support individuals with memory or learning deficits as a result of an ABI.

6.2.1.1.1 External Technology Aids

Key Points

Pager and voice-organizer programs may improve a patient’s ability to complete tasks post TBI.

Personal digital assistant (PDA) devices are superior to paper-based interventions at improving memory and task completion post TBI; specially when introduced using systematic instructions and in combination with occupational therapy. Patients who have used previous memory aids might benefit from this intervention the most.

Text message prompts sent to a patient’s smartphone, when used alone or in combination with other memory-improvement therapies, likely improve task completion post TBI. However, risk exists of device dependency exists.

A television assisted prompting (TAP) program may be superior to other methods of memory prompting in post TBI patients.

Automated prompting systems, such as Guide (audio-verbal interactive micro-prompting system) and a computerized tracking system, can reduce the number of prompts needed from support staff to patients to complete tasks post TBI.

External aids, of which there are active or high tech (computers, personal digital assistants (PDAs), and mobile phones) and passive or low technology/no technology (e.g., calendars, diaries, lists, timetables and dictaphones) devices, have been shown to assist with memory (McDonald et al., 2011). As active aids become more readily available, there is a greater need to study their effectiveness in helping those with an ABI deal with prospective memory impairments. Included here are studies which examined how external aids, both active and passive, could be used to enhance memory following brain injury.

Cicerone et al. (2000) recommended that the use of memory notebooks or other external aids “may be considered for persons with moderate to severe memory impairments after TBI (and) should directly apply to functional activities, rather than as an attempt to improve memory function per se.”

Discussion

Many studies have been conducted examining the effectiveness of various active reminders used for those with memory impairment. With advances in technology, more sophisticated organizers integrating these tools into personal digital assistants (PDAs) and smartphones have been studied. Patients accustomed to using memory aids were more likely to make use of computerized organizers (Wright et al., 2001b). Dowds et al. (2011) found that two different PDAs improved task completion rates compared to a paper-based schedule book, while Lannin et al. (2014) found that the use of a PDA in addition to conventional occupational therapy significantly reduced memory failures and forgetting. Multiple other studies have also found positive effects for the use of PDAs on memory (De Joode et al., 2013; Gentry et al., 2008; Powell et al., 2012; Waldron et al., 2012). However, the variety of available electronic organizers and learning curve for use prevent clear conclusions across studies. An RCT by Powell et al. (2012) demonstrated the importance of systematic instruction, as they compared direct instructions to conventional, trial and error patient learning on a PDA. Those receiving systematic instruction were superior in the number and speed of correct PDA tasks compared to conventional trial and error learning group. No differences were found between groups based on PDA input (physical vs touch-screen keyboard), provided the three core memory aid components of appointment diary, notebook, and to-do list were maintained (Wright et al., 2001a).

Smartphones represent a relatively new area of accessible technology and provide the user with many benefits. Smartphones are already designed to send notifications about their use, as well as multiple companies design apps for each phone brand interface allowing individuals to keep their current devices and still access helpful applications. The most common advantages to smartphones are reminders/alarms and ability to combine a calendar, tasks list, contacts, mail, and phone on one device. Disadvantages include the loss of battery life and risk of dependency on the assistive device; however, these are minor inconveniences in comparison to the reported improvement in memory in some patients (Evald, 2015). The increasing availability of smartphones also creates the ability to enhance current therapies with text messages. A case series by Fish et al. (2007) demonstrated that participants could be trained to associate a text message with stopping and thinking about what needed to be done, with participants more likely to remember the instruction to call the investigators when texted the message “STOP”. On measures such as the Prospective and Retrospective Memory Questionnaire, the use of smartphones was shown to significantly reduce the number of self-reported errors (Evald, 2018). Gracey et al. (2017) also found that goal management training could be supplemented with text messages for improving achievement of everyday intentions, with individuals who received text prompt more likely to succeed in their goals compared to those not receiving prompts. This effect was not observable once the texts had stopped to both groups.

Wilson et al. (1997) found that a portable paging system, NeuroPage, could reduce everyday memory problems and improve task completion. A crossover RCT also demonstrated that the pager system significantly increased participants’ ability to carry out daily tasks, and successful task achievement was more efficient after the pager intervention was introduced (Wilson et al., 2005; Wilson et al., 2001). However, the need for a centralized system to send reminders reduces the feasibility of pagers since many people may be able to achieve the same results using other electronic reminder systems.

Voice organizers have also been shown to improve goal execution. In a study by Kim et al. (2000), 12 TBI patients were given palmtop computers programmed with scheduling software capable of generating audible reminder cues. Patient feedback suggested that the use of the palmtop computer was beneficial for their rehabilitation, and over half of the patients continued to use the device even after the conclusion of the study. In addition, one case series (van den Broek et al., 2000) and one RCT (Hart et al., 2002) found that voice organizers helped to improve recall of previously identified goals.

External memory aids can also be incorporated into an individual’s home or work environment. Lemoncello et al. (2011) developed a television assisted prompting (TAP) system that provided reminders of events to be completed through the television screen. This crossover RCT found that compared to traditional methods (paper planner, cell phones or computers), participants using the TAP system completed significantly more tasks (Lemoncello et al., 2011).

These external aids can also be adapted for use in an in-patient setting. O’Neill et al. (2017) developed an audio-verbal interactive micro-prompting system, Guide, designed to emulate the verbal prompts and questions provided by caregivers or support workers. The number of support workers prompts needed during their morning routine was reduced, even though there were no significant differences between groups in terms of the number of errors and satisfaction scores (O’Neill et al., 2017). An acute rehabilitation unit also showed efficacy for a computerized tracking system designed to locate patients and send reminders when patients moved in the wrong direction for appointments (Burke et al., 2001). By reducing the number of staff prompts needed, these systems can increase patient independence and help free-up support personnel for other tasks.

Conclusions

There is level 4 evidence that the NeuroPage system may increase a patient’s ability and efficiency to complete tasks post TBI.

There is level 2 evidence that voice organizer programs are effective at improving recall of goals and are found to be effective by post TBI patients.

There is level 1b evidence that the use of a personal digital assistant (PDA) in combination with conventional occupational therapy is superior to occupational therapy alone at improving memory in patients post TBI.

There is level 2 evidence that personal digital assistants (PDAs) are superior to a paper-based schedule book at improving task completion rates post TBI.

There is level 1b evidence that use of a personal digital assistant (PDA) after receiving systematic instructions is superior to PDA trial and error learning at improving the number and speed of correct tasks post TBI.

There is level 1b evidence that reminder text messages sent to patients through their smartphones, whether alone or in combination with goal management training, improves goal completion post TBI.

There is level 2 evidence that a television assisted prompting (TAP) system is superior to traditional methods of memory prompting (paper planners, cell phones, computers) at improving the amount of completed tasks post TBI.

 There is level 1b evidence that the audio-verbal interactive micro-prompting system, Guide, can reduce the amount of support-staff prompts needed for the patient to complete a task post TBI.

There is level 4 evidence that a computerized tracking system that sends reminders to patients when they are moving in the wrong direction reduces the amount of support-staff prompts needed for patients to complete a task post TBI.

6.2.1.1.1.2 Virtual Reality

Key Points

Virtual reality programs may enhance the recovery of memory, learning, but there is currently limited evidence supporting the use of virtual reality programs. The evidence is unclear as to which specific programs benefit memory rehabilitation and whether or not they are superior to manual training therapies.

Virtual reality (VR) allows individuals to interact with and experience a virtual environment in three-dimensions, realistically simulating different situations/environments/tasks through immersive (head-mounted display) or non-immersive (computer monitor or projector screen) multimedia (Sisto et al., 2002). VR systems are constantly evolving, providing a safe and motivating environment for practicing real life scenarios (Shin & Kim, 2015). A systematic review by Shin and Kim (2015) found that VR may be an effective cognitive therapy, though the limited low quality evidence has prevented strong conclusions. On observational study by Canty et al. (2014) demonstrated that VR might also be potentially helpful as an assessment tool. Individuals with a brain injury performed more poorly on a series of VR tasks compared to healthy controls (Canty et al., 2014).

Discussion

A 2013 RCT found that those who received virtual reality memory training showed a significant improvement in immediate recall of tasks and event-based performance (Yip & Man, 2013). Although the control group saw no improvements on items of memory evaluation there were no significant differences between groups on measures of community integration (Yip & Man, 2013). Sorita et al. (2013) found that practicing a route-learning task in a real urban environment or in a virtual stimulation of that environment showed similar improvements in route recall, suggesting that VR training improvements in functional tasks may be due to repetition and not the presented medium. Dahdah et al. (2017) also found that multiple Stroop tasks in VR environments resulted in improved performance on parts of those tasks. Virtual reality has been found to improve more than just memory as well, in an older RCT by Grealy et al. (1999), not only did individuals receiving VR exercise significantly improve on visual learning abilities, they also improved on reaction time.

Conclusions

There is level 4 evidence that virtual reality (VR) training may improve learning performance post ABI, even in the presence of distractions.

There is level 2 evidence that virtual reality training combined with exercise may be promising for improving memory outcomes and has a positive impact on visual and verbal learning when compared to no treatment.

There is level 2 evidence that virtual reality training may be superior to reading skills training at improving immediate and general components of memory for those with an ABI.

There is level 2 evidence that the format of route learning (either real or virtual reality based) does not significantly impact any improvements in memory as a result of route learning strategies for those with an ABI.

6.2.1.1.1.1 External Passive Technology or Non-Technology Aids

Key Points

Calendars may be effective tools for improving memory and task completion post ABI.

The use of a diary may help to improve memory and task completion post ABI.

Passive devices are those that do not require specific electronic programming for their use such as paper calendars, notebooks, and planners. A variety of studies have examined the effects of these standard tools on learning and memory; however, the amount of studies has been quickly outpaced by studies examining technology as it becomes more readily available.

Discussion

Multiple RCTs have examined the use of calendars and calendar tools on learning and memory (Bergquist et al., 2009; McDonald et al., 2011; Ownsworth & McFarland, 1999; Schmitter-Edgecombe et al., 1995; Watanabe et al., 1998). In one RCT by McDonald et al. (2011), the use of a Google calendar was compared to the use of diary tracking. It was found that although both groups achieved a fair number of desired tasks, those using the Google calendar had a significant increase in task completion through the use of automated reminders and messages. A second RCT also compared the use of a calendar to diary use (Bergquist et al., 2009). However, in this instance no significant between-group differences were found with both reporting positive results on memory. In another RCT (Ownsworth & McFarland, 1999), diary use was examined alone as well as with the combination of self-instructional training. On self-reported memory scales, all subjects reported improvements in memory, as well as significant increases in the degree of memory strategies used regardless of diary training. There were no significant differences between groups on memory performance however (Ownsworth & McFarland, 1999). Comparing the use of a memory tool (notebook) to generalized supportive therapy, the use of a notebook specifically was shown to result in a greater reduction in memory failures (Schmitter-Edgecombe et al., 1995); however, this effect was lost at 6-month follow-up. Lastly, Watanabe et al. (1998), found no significant effects of calendar use on a test of orientation, compared to no calendar use when individuals were still inpatients.

Conclusions

There is level 2 evidence the use of an electronic calendar is superior to the use of a diary for improving memory in individuals with an ABI.

There is level 2 evidence that the presence of a diary with or without self-instructional training improves memory following an ABI.

There is level 2 evidence that the presence of a calendar may not improve orientation post ABI.

There is level 2 evidence that diary training in combination with self-instructional training may be more effective than diary training alone at improving memory and task completion post ABI.

6.2.1.1.2 Internal Memory Strategies

Key Points

Internal strategies such as self-imagination, spaced retrieval and rehearsal, and multiple encoding are effective for improving memory following an ABI.

The following studies examined how different cognitive strategies could be used to enhance learning and memory following an ABI.

Discussion

A variety of internal memory strategies exist which attempt to remediate memory deficits following an acquired brain injury. As a result of the breadth of strategies attempted and evaluated, few studies overlap in methodology and protocol limiting the conclusions that can be made about each intervention.

Potvin et al. (2011) used one of the more common strategies; visual imagery techniques. Following visual imagery instruction, the scores on the Test Ecologique de Memoire Prospective significantly improved for those in the visual imagery group, this group also reported significantly fewer prospective memory errors and depression. Prospective memory is an area that has been found to be positively affected by more than one imagery technique. Another RCT found that self-imagery significantly improved prospective memory compared to information rehearsal (Grilli & McFarland, 2011). Imagery techniques in general have been found to be effective for improving general memory (Twum & Parente, 1994), as well as specific areas of memory like logical memory (Kaschel et al., 2002). Overall, there is strong evidence to support the use of imagery techniques to improve memory. One study used self-imagery in combination with a variety of other encoding techniques to determine its efficacy against other encoding strategies such as semantic elaboration (Grilli & Glisky, 2013). It was found that those in the self-imagining condition showed better free recall than the control condition, but also recalled more self-descriptive adjective words than the other control and experimental conditions (Grilli & Glisky, 2013).

Another common memory strategy is retrieval practice. A variety of different retrieval strategies have been studied, such as spaced retrieval, massed retrieval, and cued retrieval (Sumowski et al., 2014). The use of retrieval strategies has been shown to significantly improve goal mastery (Bourgeois et al., 2007), delayed recall (Hillary et al., 2003; Sumowski et al., 2010), and immediate recall (Hillary et al., 2003). Bourgeois et al. (2007) found that compared to didactic strategy instruction, spaced retrieval significantly improved goal mastery; however, both groups achieved significant improvements in memory and memory errors. In a follow-up study to Berg et al. (1991), which found significant improvements on all memory measures as a result of individual strategies, Milders et al. (1995) found that at four-year follow-up the group which experienced ‘drill and practice” retrieval strategies had the best long-term memory outcomes. Although a general trend has shown spaced retrieval and cued retrieval to be effective, it should be noted that the highlighted studies did not overlap in terms of their application of this strategy. Multiple studies have shown that massed retrieval or “cramming” is not an effective strategy for improving memory (Hillary et al., 2003; Sumowski et al., 2010).

Strategies which use multiple encoding techniques have also been found to be effective. Milders et al. (1998) examined performance on a name learning task by increasing the meaningfulness of people’s names with various strategies (e.g. when learning a new name-face association try to think of an occupation or object with the same name or a famous person with a similar name). This was shown to improve memory and recall (Milders et al., 1998). Also, learning procedures were more effective on one task (where subjects were required to learn the name-occupation-and town) compared to the other two tasks (famous-faces or name learning). Twum and Parente (1994) randomly assigned 60 patients with a TBI into one of four groups (one control and three mnemonic strategy groups) counterbalanced. The research demonstrated improved performance for subjects who were taught a strategy (either verbal labeling or visual imagery, or both) while learning paired-associations. Treatment groups showed greater efficiency in learning and greater delayed recall information. This conclusion is supported by other studies which have found general improvements in memory when combining multiple encoding cues such as visual imagery and verbal/written cues (Manasse et al., 2005). In a final study examining encoding, individuals were taught word association pairs and found that when primed with the first word of the pair, individuals were able to recall the second word more effectively (Schefft et al., 2008).

The remaining interventions have been explored in limited studies. Thoene and Glisky (1995) using a case series design also showed enhanced performance following the use of a mnemonic strategy (verbal elaboration and visual imagery) compared to vanishing cues and/or video presentation during paired associations. A pre-post study examined the type of errorless learning to take place (self-generated or examiner generated) and found that self-generated errorless learning resulted in significantly higher recall (Tailby & Haslam, 2003). However, examiner errorless learning was observed to be better than errorful learning. Lastly, an interaction effect was seen with regard to injury severity such that those of a mild to moderate ABI responded better to treatment than those with a severe injury (Tailby & Haslam, 2003). A combination of internal memory strategies was also found to be effective for improving memory compared to a convenience sample of controls (O’Neil-Pirozzi et al., 2010a). Similar to the previous study, it was seen that those with mild to moderate ABIs gained the most from treatment, while those with a severe injury were not able to perform as well over all (O’Neil-Pirozzi et al., 2010a).

Conclusions

There is level 1b evidence to support self-imagination as an effective strategy to improve memory compared to standard rehearsal for those with an ABI.

There is Level 2 evidence to support that spaced retrieval training is an effective memory strategy when compared to massed retrieval or rehearsal in ABI populations.

There is level 2 evidence that strategies that utilize methods of multiple encoding, compared to strategies which only use singular methods, are more superior for improving memory post ABI.

There is level 4 evidence that errorless learning is more effective than errorful learning when it comes to improving memory in ABI populations.

6.2.1.2 Learning and Memory Training Programs

Key Points

Memory-retraining programs appear effective, particularly for functional recovery although performance on specific tests of memory may or may not change.

Some specific computer-based softwares seem to be effective for improving memory post ABI.

Computer-based interventions may be as effective as therapist administered interventions.

Emotional self-regulation therapy may be effective for improving specific elements of memory.

Attention training programs may not be effective for improving memory, but memory training programs are.

Interventions which include multiple learning techniques such as modelling, observation, verbal instruction, etc. are more effective than interventions which include a singular learning method.

Following a brain injury, one of the most persistent problems are memory deficits (Hasegawa & Hoshiyama, 2009). Although the literature examining the efficacy of memory programs is limited, there is some support for training that stresses external memory strategies. Again the support for these programs is limited as many individuals post injury neglect their devices or simply stop using them (O’Neil-Pirozzi et al., 2010a).

Discussion

Similar to internal memory strategies, many potential interventions have been studied, with little overlap between studies themselves in terms of methodology. A variety of trademarked cognitive programs have been evaluated in an attempt to improve learning and memory following an ABI. Constantinidou et al. (2008) evaluated the Categorization Program for 13 weeks in an RCT, and found that although individuals who received the program performed better on measures of executive function, there were no significant improvements seen in learning or memory. Chiaravalloti et al. (2016) compared the efficacy of the modified Short Memory Technique to conventional therapy for the improvement of memory post TBI. Amongst the memory assessments quantified, significant improvements were seen only in two specific categories; the Memory Assessment Scale- Prose Memory (MAS-PM) and “hidden belonging task” of the Rivermead Behavioural Memory Test (RBMT). A follow-up study further recognized the lack of improvement in the treatment group compared to controls in terms of memory capacity; however, they did note that working memory capacity and long-term memory retainment were positively correlated with each other (Sandry et al., 2016). In a prospective cohort study, Johansson and Tornmalm (2012) examined the benefits of Cogmed QM (computerized training software) coaching, education and peer support to help improve the daily functioning of participants. Results show the Cogmed QM program helped to improve working memory and these benefits were seen at the 6-month follow up. RehaCom software has also been evaluated in a single study (Fernández et al., 2012). Individuals significantly improved on the Wechler Memory Scale for overall memory and also on measures of attention (Fernández et al., 2012). Recently, BrainHQ, a commercially available online computerized cognitive exercise program, did not significantly improve attention outcomes over time or compared to no intervention (O’Neil-Pirozzi & Hsu, 2016). Gabbatore et al. (2015) implemented a cognitive group rehabilitation program for patients post TBI, and discovered that compared to before the intervention, patient’s recall (IDR), attention (WCST), and communication skills (ABaCo) all significantly improved. Parrot Software is another computer-based cognitive retraining program, and was investigated by a pre-post study assessing the efficacy of using eight modules focussed on attention and memory (Li et al., 2015; Li et al., 2013).

While significant post-treatment improvements in attention and memory on the Cognistat assessment were found in a pilot study (Li et al., 2013), a subsequent study did not find significant improvements on the attention and memory subscales of the Montreal Cognitive Assessment (MoCA) or a medication-box sorting task despite significantly improved overall MoCA scores (Li et al., 2015). However, in one RCT Dou et al. (2006) demonstrated that computer assisted memory training may not be superior to therapist administered memory training as both groups improved on measures of memory over time compared to a no-treatment control group, but did not significantly differ from each other. Finally, Chen et al. (1997) studied the effect of computer assisted cognitive rehabilitation versus traditional therapy methods. While measures of attention significantly improved in both groups after treatment, no significant differences were observed between groups (Chen et al., 1997). Cumulatively, by observing studies from across a period of nearly 20 years, the literature reveals little support for the use of computer software programs for the improvement of executive function post TBI. It should be noted no specific software program was evaluated in more than one study; ,therefore limited conclusions can be made on their efficacy compared to therapist administered therapy or to each other. However, cognitive-based computer programs have generally been shown to be effective on measures of cognitive functioning (Johansson 2012).

Several specific non-computerized learning and memory interventions have also been evaluated in singular studies. In an RCT conducted by Vas et al. (2011), 28 individuals who had sustained a TBI and were at least 2 years post injury, were assigned to one of two groups: the strategic memory and reasoning training group or the Brain Health Workshop group. Each group received 15 hours of training over an eight-week period. Those in the strategic memory and reasoning training group were given information about brain injuries, were asked to read pieces of literature on brain injury and were given homework assignments to be completed for the next meeting. The strategic memory and reasoning training sessions were built around three strategies: strategic attention, integration (combining important facts to form higher order abstracted meaning) and innovation (derive multiple abstract interpretations). Those in the brain health workshop group participated in information sessions. Sessions for the brain health workshop groups included an introduction to brain anatomy, functions of the brain, neuroplasticity, and the effects of lifestyle on the brain (diets, exercises and cognitive changes following a TBI). Study results indicate that those assigned to the strategic memory and reasoning training group showed significant improvement on gist reasoning and measures of executive function.

With respect to attention process training, it was shown that individuals receiving attention remediation significantly improved in memory and attention measurements compared to controls who had education alone (Sohlberg et al., 2000). Conversely, two trials did not find significant differences between groups for attentional, functional, and/or cognitive skills assessed (Lindelov et al., 2016; Novack et al., 1996). Novack et al. (1996) compared focused hierarchical attentional learning with an unstructured non-sequential, non-hierarchical  intervention, while Lindelov et al. (2016) compared N-back training with visual search training. Two older RCTs have evaluated attention training programs directly to memory training programs with limited results. An RCT from 1990 evaluated a non-specified memory training program and compared it directly to an attention training program and found that neither program actually improved measures of memory (Niemann et al., 1990). However, the attention training program did improve some measures of attention, but this was not consistent across all measures of attention evaluated (Niemann et al., 1990). Ryan & Ruff (1988) found similar results where neither the applied memory training program nor the attentional program significantly improved measures of memory or learning in individuals. Overall there is weak evidence in support of training programs as an effective rehabilitation intervention for attention.

In another RCT, 45 individuals were randomly assigned into one of four treatment groups (Shum et al., 2011). The treatment groups consisted of four different intervention programs: self-awareness plus compensatory prospective memory training; self-awareness training plus active control; active control plus compensatory prospective memory training and active control only. Pre-intervention scores on the CAMPROMPT did not reveal any significant differences between any of the groups. Those assigned to the compensatory prospective memory training groups showed greater changes in strategies used to improve memory. Compensatory prospective memory training included use of a diary or organizational devices, and group members were encouraged to use written reminders, appointments and note taking. Although at total of 45 participants started the study, only 36 finished. Further support for emotional oriented intervention can be found in an earlier study by Rath et al. (2003). The group completed an RCT comparing two cognitive rehabilitation therapies: conventional (cognitive remediation and psychosocial components) versus an innovative rehabilitation approach focusing on emotional self-regulation and clear thinking. Outcomes were measured across multiple domains of cognition including attention, memory, reasoning, psychosocial functioning, and problem-solving measures. Significant changes comparing baseline to post intervention outcomes were seen for each group, however, the improvements were different for the interventions. No between-group comparisons were made.

The effects of hypnosis, as delivered in a targeted or non targeted manner, on memory, attention, and cognitive function in a mixed TBI and stroke population has been studied (Lindelov et al. 2017). The researchers showed that working memory, attention, and cognitive function could be transiently increased during targeted hypnosis, however the benefits of the treatment were not sustained when the treatment was discontinued. This last finding calls into question the practicality of the intervention, as it may not be feasible to deliver targeted hypnosis to patients post brain injury on a continual basis. Another unique intervention aimed at improving memory following an ABI was an RCT evaluating meatball making (Eakman & Nelson, 2001). Individuals received either hands-on or verbal instructions for making meatballs and were required to reproduce the meatballs at a later time. In this instance meatballs were used as an example to explore the benefits of modelling compared to verbal instruction only on memory consolidation. It was found that the hands-on meatball making group remembered significantly more steps in the making process compared to the verbal instruction only group (Eakman & Nelson, 2001) suggesting that modelling may be more effective than verbal instruction alone. Another study which compared the type of instruction given showed that asking individuals to describe procedures in detail and providing retrieval prompts was significantly more beneficial for recall than individuals training by describing procedures alone (Hewitt et al., 2006). These studies support the use of a combination of modelling and instructional techniques to improve memory.

Thickpenny-Davis and Barker-Collo (2007) randomly assigned 14 individuals to either the treatment or control group. Those in the treatment group participated in a memory rehabilitation program. The memory groups consisted of eight learning modules each 60 minutes long. They ran twice a week for 4 weeks. Memory improvement and difficulties were evaluated. Overall a reduction in memory impairment was noted at the end of the 4 weeks of intervention and again at the 1-month follow-up time period. Hellgren et al. (2015), found that a memory training program was successful in improving attentional scores on the Paced-Auditory Serial Attention Test, as well as further enhancing memory in general which is discussed later on in the chapter. Quemada et al. (2003) examined memory rehabilitation following severe TBI in 12 individuals (no controls). The program ran for 6 months (50-minute sessions 5 days a week for 5 months and then 3 days a week for one month) and followed a specified format utilizing behavioural compensation techniques, mnemonic strategies, and environmental adaptations, external and internal aides. Results indicated little improvement in standard measures of memory functioning, although patients and family members report meaningful functional gains (self-report and observed behaviour in everyday functioning).

Only one study (Serino et al., 2007) described a specific task that was successful in improving memory. This cognitive task involved mental addition in combination with two other standardized tasks and was an effective strategy for improving working memory. Boman et al. (2004) in a study of ten individuals with mild or moderate TBI, after completing 1 hour of an individual cognitive training three times a week for 3 weeks, significant improvement was noted on the Rivermead Behavioural Memory Test at 3-month follow-up compared to pre-test scores. Changes on the Claeson-Dahl Memory test did not increase pre to post to 3-month follow-up. The findings of the previous study support the findings of the study by Laatsch et al. (1999) where cognitive rehabilitation therapy was found to increase productivity and everyday functioning. This older study also had the benefit of reporting SPECT imaging results, which revealed increases in cerebral blood flow during the intervention. Similar findings were reported in an RCT by Novakovic-Agopian et al. (2011), which examined the effects of goals training and education in an RCT crossover study. While education was shown to minimally improve memory, specific goals training significantly improved working memory, mental flexibility, learning and delayed recall (Novakovic-Agopian et al., 2011). A Cognitive Pragmatic Treatment program was evaluated over the course of 24 sessions with participants being assessed at four different time points (Bosco et al., 2018a). The results showed strong effects on communication and activities of daily living, with verbal span only improving immediately following treatment but differences were not maintained at follow-up (Bosco et al., 2018a).

Specific interventions which were not shown to have positive effects on memory include time pressure management (Fasotti et al., 2000), individual versus group therapy (Leśniak et al., 2018), finger sequencing tasks (Korman et al., 2018), and the Intensive Neurorehabilitation Programme (Holleman et al., 2018b). Lesnaik et al. (2018), compared the effects of individual versus group therapy on memory and found that although both groups improved over time, there were no significant differences between groups. Similar to the previous study, time pressure management was not shown to significantly improve memory outcomes compared to control (Fasotti et al., 2000). With finger sequencing tasks, individuals who were trained versus untrained on the task showed no significant differences in the number of errors made, however the trained group saw a significant increase in performance speed compared to the control group (Korman et al., 2018). In a recent prospective controlled trial, a formal protocol for the Intensive Neurorehabilitation Programme showed no significant effects on the Rivermead Behavioral Memory Test, however depression and anxiety were seen to be significantly reduced (Holleman et al., 2018a).

General components of effective programs have been shown to be behavioral interventions, metacognitive strategies, and restorative approaches which tackle multiple areas of functioning and processes (Raskin et al., 2009). One study demonstrated that a memory program which included all of these components elevated memory scores in individuals with an ABI similar to that of healthy controls (Raskin 2009). A small 1991 RCT also provides support that memory programs which include memory strategies can also significantly decrease dependence on memory aids for those with an ABI {Jennett, 1991 #243}

Conclusions

There is level 1b evidence that hypnosis compared to no treatment may not be effective at improving memory in individuals post ABI.

There is level 1b evidence that individual memory therapy is no more effective than group memory therapy for those with an ABI.

There is level 2 evidence that programs involving multiple learning strategies (such as modelling, reciting, verbal instruction, and observation) are more effective than singular strategies for those with an ABI.

There is level 1b evidence that the Short Memory Technique may not be more effective than standard memory therapy at improving memory in individuals post ABI.

There is level 1b evidence that the Categorization Program, and Strategic Memory and Reasoning Training (SMART) may be effective for improving memory compared to standard therapy in individuals with an ABI.

There is level 2 evidence that time pressure management training is no more effective than concentration training at improving memory for those with an ABI.

There is level 2 evidence that N-back training compared to virtual search training is not effective for improving memory in those with an ABI.

There is level 4 evidence that Cognitive Pragmatic Treatment, Cogmed QM, and RehaCom software may improve memory and cognitive function in those with an ABI.

There is level 2 evidence that participation in a goals training program, followed by an educational program, may be more effective for improving memory in post ABI individualscompared to receiving the treatment conditions in reverse order.

There is level 2 evidence that finger sequence training, compared to no training, may not be effective for improving memory following an ABI.

There is level 1b evidence that compensatory memory strategies, self-awareness training, and participation in memory group sessions may be effective for improving memory in post ABI individualscompared to no treatment.

There is level 2 evidence that general memory rehabilitation programs are effective, compared to standard therapy, at improving memory for those with an ABI.

There is level 2 evidence that the Intensive Neurorehabilitation Programme is not effective for improving memory compared to controls in those with an ABI.

There is level 2 evidence that both computer-administered and therapist-administered memory training may be more effective than no treatment for improving memory in ABI participants. However, no treatment appears to be better than the other.

There is level 2 evidence that both cognitive remediation and emotional self-regulation may be effective at improving different elements of memory in individuals post ABI.

There is level 2 evidence that non-specific computer-based memory retraining compared, self-paced or otherwise, may not be effective at improving memory in those with an ABI.

There is conflicting level 1b evidence as to whether or not attention training programs may be effective for improving memory compared to no therapy, but positive level 1b evidence that it is not more effective than memory training programs.

There is level 2 evidence that BrainHQ is not an effective program for improving memory and learning compared to no intervention in individuals post ABI.

There is level 4 evidence that using mental representations and role-playing may not be effective at improving memory in individuals post ABI.

There is level 4 evidence that Cogmed training software may improve working memory performance and occupational performance in individuals post ABI.  

There is conflicting (level 4) evidence regarding whether or not Parrot software is effective at improving memory and learning in individuals post ABI.

There is level 4 evidence that mental addition tasks may improve working memory in individuals post ABI.                                         

There is level 4 evidence that the Wilson’s Structured Behavioral Memory Program is not effective for improving memory post ABI.

6.2.1.3 Cranial Electrotherapy Stimulation

Key Points

Cranial electrotherapy stimulation may not be effective at enhancing memory and recall abilities following TBI.

Cranial electrotherapy stimulation (CES) is the application of less than 1 mA of electric current to the cranium. This intervention has been used to treat a variety of disorders, including withdrawal of patients with substance abuse (Michals et al., 1993). The effect of CES for the improvement of memory following brain injury was investigated.

Discussion

Michals et al. (1993) studied cranial electrotherapy stimulation and its effect on post-traumatic memory impairment in clinical care patients with a closed head injury. Patients received CES or sham CES treatments for 40 minutes daily over a period of four weeks. The group receiving CES treatment did not improve in their memory performance, nor did their immediate or delayed recall improve. Further, with retesting, both the CES and the sham CES group showed a similarly significant trend with no group performing any better than the other. These results suggest that CES stimulation in brain-injured patients does not improve memory functioning.

Conclusions

There is level 1b evidence that cranial electrotherapy stimulation may not improve memory and recall compared to sham stimulation post TBI.

6.2.2 Pharmacological Interventions

6.2.2.1 Donepezil

Key Points

Donepezil likely improves memory following TBI.

The effectiveness of Donepezil, a cholinesterase inhibitor, in improving cognitive and memory functions following brain injury has been assessed. Cognitive impairments negatively impact patient autonomy, affecting one’s ability to return to work or school, and live alone (Masanic et al., 2001). When tested in individuals diagnosed with Alzheimer’s disease, Donepezil has been found to be useful in treating memory problems (Morey et al., 2003; Walker et al., 2004). Donepezil’s impact on cognitive function and memory in a TBI population is explored in the table below.

Discussion

In an RCT, Zhang et al. (2004) demonstrated that donepezil was associated with improvements in tasks of sustained attention and short-term memory, and that these improvements were sustained even after the treatment had finished. Benefits associated with donepezil were also documented in an open-label study by Masanic et al. (2001) who found that the treatment tended to improve both short- and long-term memory of patients living with TBI. Improvements in memory were also reported by Morey et al. (2003) in their retrospective study who demonstrated that donepezil led to significant benefits in visual memory function.

The most recent study, a pre-post by Khateb et al. (2005), found only modest improvement on the various neuropsychological tests used to measure executive function, attention, and learning and memory. Of note results from the learning phase of the Rey Auditory Verbal Memory Test (RAVMT) showed significant improvement (p<0.050). The Donepezil intervention also demonstrated improvement in executive function, as the results from the Stroop-colour naming test showed significant improvements (p<0.030). On the test for Attentional Performance a significant change was noted on the divided attention (errors) subsection of the test. Overall, donepezil was found to be effective in improving learning, memory, divided attention, and executive function. However, possible benefits of donepezil administration must be balanced against the observed side effects in 27% of the population. Further randomized control trials are required to better explore the efficacy of donepezil post TBI.

Conclusions

There is level 1b evidence that donepezil improves short-term memory compared to placebo post ABI.

There is level 4 evidence that donepezil may be effective in improving short-term, long-term, verbal, and visual memory post ABI.

6.2.2.2 Methylphenidate

Key Points

Methylphenidate likely does not improve memory or learning following an ABI.

Methylphenidate is a stimulant which inhibits the reuptake of dopamine and norepinephrine and increases activity in the prefrontal cortex. In the past, methylphenidate has been extensively used as a treatment for attention deficit disorder, as well as narcolepsy (Glenn, 1998). A total of four RCTs examined the efficacy of methylphenidate as a treatment for the recovery of cognitive deficits post ABI.

Discussion

Dymowski et al. (2017) investigated the effects of short-term, 7-week, methylphenidate administration (0.6 mg/kg/d) in post TBI patientscompared to a placebo (control). After analysis, it was concluded that there was no significant improvement, or difference between groups for various measures and tests of attention. More than two decades earlier, Speech et al. (1993) conducted a double blind placebo controlled trial evaluating the effects of methylphenidate (0.3 mg/kg, 2 ×/d, for 1 wk,) following closed head injury. Both studies arrived at similar conclusions, as the treatment and placebo group did not vary in any measurements of memory, intelligence, or attention. Conversely, Plenger et al. (1996) found methylphenidate administration (30 mg/kg, 2 x/d, 30 d) significantly improved scores on the Wechsler Memory Scale but for measures of attention and concentration only compared to a placebo. However, the positive results seen by Plenger’s group may be due to the use of much higher doses of methylphenidate (30 mg/kg/d vs. 0.6 mg/kg/d for the other studies). Although side effects were unreported, the literature suggests that high doses can lead to acute methylphenidate intoxication; a state comparable to acute amphetamine intoxication, which may cause psychological distress in patients. As a result, the group who most recently published on the topic were likely deterred from increasing the dose past a safely accepted value. Although methylphenidate has been shown to significantly improve measures of attention, no reliable effects on learning and memory have been shown specifically in studies examining ABI populations.

Conclusions

There is level 1b evidence that methylphenidate compared to placebo is not effective for improving memory following brain injury for post TBI patients.

6.2.2.3 Sertraline

Key Points

Sertraline has not been shown to improve learning, or memory within the first 12 months post TBI, and may be associated with side effects.

Sertraline, better known under its trade name Zoloft (Pfizer), is a selective serotonin reuptake inhibitor (SSRI) used for the treatment of depression and mood (Khouzam et al., 2003). The majority of sertraline research in the TBI population focuses on the prevention or treatment of major depressive symptoms. However, recent studies have shifted focus and begun to evaluate the benefits of sertraline at improving cognitive disorders (Banos et al., 2010).

Discussion

The effect of early administration of sertraline on cognitive functioning, intelligence and memory was evaluated by Banos et al. (2010) in an RCT. When comparing the sertraline group, who received 50 mg per day, to a control group (placebo), there were no significant between group differences on any of the neuropsychological tests. The assessments examined attention and concentration, speed of processing, memory, and executive function at 3, 6 and 12 months. Cognitive functioning was not found to improve following the administration of sertraline. Of note, more patients in the sertraline group dropped out of the study compared to the control group when this was quantified at all assessment points— indicating the potential side effects associated with the treatment. Combined with the lack of apparent benefit to using the drug, use of sertraline is not currently recommended.

Conclusions

There is level 1b evidence that sertraline may not improve memory compared to placebo in individuals who have sustained a moderate to severe TBI.

6.2.2.4 Amantadine

Key Points

Amantadine is not effective for improving learning and memory deficits post ABI.

Amantadine is a non-competitive N-methyl-D-aspartate receptor antagonist and has been used as an antiviral agent, prophylaxis for influenza A, treatment of neurological diseases such as Parkinson’s Disease, and the treatment of neuroleptic side-effects such as dystonia, akinthesia and neuroleptic malignant syndrome (Schneider et al., 1999). Amantadine is also thought to work pre- and post-synaptically by increasing the amount of dopamine in the synapse (Napolitano et al., 2005). Three studies have been identified that investigate the effectiveness of amantadine as a treatment for the remediation of learning and memory deficits and cognitive functioning following TBI.

Discussion

In a large sample RCT by Hammond et al. (2018) individuals either received 200 mg of amantadine or placebo for 60 days. Not only was it found that there was no significant effect of amantadine on learning and memory, the control group had significantly higher scores on the Learning and Memory Index (Hammond et al., 2018). In a smaller RCT by Schneider et al. (1999) patients received both placebo and amantadine as well, and no significant effects on learning and memory were found between groups.  Similarly, Kraus et al. (2005) demonstrated that the administration of amantadine over a 12-week treatment period does not improve memory deficits or attention; however, significant improvements in executive functioning were observed.

Conclusions

There is level 1b evidence that amantadine does not improve learning and memory deficits in patients post ABI.

6.2.2.5 Pramiracetam

Key Points

Pramiracetam might improve memory in males post TBI; however, additional studies are required.

Pramiracetam is a nootropic (cognitive) activator that is used to facilitate learning, memory deficiencies, and other cognitive problems. Pramiracetam produces an increased turnover of acetylcholine in hippocampal cholinergic nerve terminals and it is at least 100 times more potent than its original compound piracetam (McLean et al., 1991).

Discussion

McLean Jr. et al. (1991) conducted a study evaluating Pramiracetam in four males post brain injury. Improvements were found for memory and these improvements remained at one month following discontinuation of the drug. Given the small sample size and the lack of data reported to support the findings, future studies should be conducted.

Conclusions

There is level 2 evidence that pramiracetam may improve males’ memory compared to placebo post TBI. 

6.2.2.6 Physostigmine

Key Points

Physostigmine may improve long-term memory in men with TBI, however more studies are required.

Physostigmine is a cholinergic agonist that temporarily inhibits acetylcholinesterase. The inhibition of acetylcholinesterase in turn slows the destruction of acetylcholine, thus increasing the concentration of the neurotransmitter in the synapse. The use of physostigmine in Alzheimer’s disease has been examined at length, however it has also been proposed to improve memory in patients with head injury (McLean et al., 1987).

Discussion

In a double-blind, placebo-controlled randomized trial, oral physostigmine was administered to males with TBI as an active treatment (Cardenas et al., 1994). The authors found that physostigmine led to significant improvements in long-term memory scores in 44% (n=16) of study participants. Those who responded favourably to the treatment, as indicated by their performance on the Selective Reminding Test, also demonstrated improved balance compared to non-responders (Cardenas et al., 1994).

Conclusions

There is level 1b evidence that oral physostigmine may improve long-term memory compared to placebo in men with TBI, however more recent studies are required.

6.2.2.7 Bromocriptine

Key Points

More studies are required to determine if the positive effects of bromocriptine on verbal memory seen so far are of potential value.

Bromocriptine is a dopaminergic agonist which primarily exerts its actions through binding and activating D2 receptors (Whyte et al., 2008). It has been suggested that dopamine is an important neurotransmitter for prefrontal function, an important area of the brain that contributes to cognitive function, memory, intelligence, language, and visual interpretation (McDowell et al., 1998; Siddiqui et al., 2008). In an animal study looking at the effects of bromocriptine on rats, Kline et al. (2002) noted that the animals showed improvement in working memory and spatial learning; however, this improvement was not seen in motor abilities. Two studies have been identified investigating the use of bromocriptine as an adequate treatment for the recovery of cognitive impairments following TBI.

Discussion

The question of whether bromocriptine improves learning and memory in patients with ABI has been explored in one RCT (McDowell et al., 1998; Whyte et al., 2008), and one case series (Powell et al., 1996). In an earlier investigation, low-dose bromocriptine (2.5 mg daily) improved functioning on tests of executive control including a dual task, Trail Making Test, the Stroop test, the Wisconsin Card Sorting Test and the controlled oral word association test (McDowell et al., 1998). However, bromocriptine did not significantly influence working memory tasks, only verbal memory. Although McDowell et al. (1998) demonstrated some benefits following administration of bromocriptine, there was only a single dose administered. pontaneous recovery may have been a factor leading to the improved abilities in individuals receiving a single dose (2.5 mg daily) of the medication; however, study results did not answer this question. Powell et al. (1996) conducted a multiple baseline design on 11 patients with TBI or subarachnoid hemorrhage who received bromocriptine. Improvements were found on all measures assessed (i.e., verbal memory, attention, motivation spontaneity) except mood. In light of the fact that the last RCT investigating the effects of bromocriptine was conducted 20 years ago, new studies are required to build on the promising results of these very early conclusions.

Conclusions

There is level 2 evidence that bromocriptine may improve verbal memory in individuals with an ABI, however, more studies are required.

6.2.2.8 Cerebrolysin

Key Points

Cerebrolysin may be beneficial for the improvement of clinical outcome and cognitive functioning following brain injury; however, controlled trials are needed to further evaluate its efficacy.

Cerebrolysin has been demonstrated to have neuroprotective and neurotrophic effects and has been linked to increased cognitive performance in an elderly population. As explained by Alvarez et al. (2003), “Cerebrolysin (EBEWE Pharma, Unterach, Austria) is a peptide preparation obtained by standardized enzymatic breakdown of purified brain proteins, and comprises 25% low-molecular weight peptides and free amino acids” (pg. 272).

Discussion

In an open-label trial of 20 patients with TBI Alvarez et al. (2003) found that cerebrolysin was associated with improved brain bioelectrical activity, as evidenced by a significant increase in fast beta frequencies. A brief neuropsychological battery (Syndrome Kurztest test) consisting of nine subtests was administered to evaluate memory and attentional functions in patients undergoing treatment with cerebrolysin. There was an overall significant improvement in performance post treatment, suggesting patients experienced cognitive benefits from cerebrolysin treatment. Improvements were noted on the Glasgow Outcome Scale as well (Alvarez et al., 2003). Together these findings suggest that cerebroylsin may represent an effective neuroprotective therapy with tangible cognitive benefits for individuals living with an ABI. Controlled trials are necessary to further explore the efficacy of this drug.

Conclusions

There is level 4 evidence that cerebrolysin may improve memory function post ABI.

6.2.2.9 Growth Hormone (GH) Replacement Therapy

Key Points

The administration of growth hormone complexes likely does not improve learning and memory following an ABI.

Following an ABI, it is not uncommon for individuals to be diagnosed with hypopituitarism. As many as 25 to 40% of individuals with a moderate to severe ABI have demonstrated chronic hypopituitarism (Bondanelli et al., 2007; Kelly et al., 2006; Schneiderman et al., 2008). Despite this, few patients are screened for growth hormone deficiencies; thus, the link between cognitive impairment and growth hormone deficiencies has not yet been definitively established (High et al., 2010). There is very little literature available on the benefits of GH replacement therapy for cognitive deficits after ABI.

Discussion

A RCT compared the long term (6 months and 1 year) effects of rhGH administration to placebo in a TBI population (High Jr et al. 2010). Significant improvements were noted in processing speed, executive functioning (Wisconsin Card Sorting Test), and learning (California Verbal learning test II) for both the rhGH and placebo groups, with neither group being significantly different from the other. It is important to note while processing speed also improved in both groups at 6 months, the improvement was only sustained in the treatment group at 1 year. Similar results were reported in a more recent PCT by Moreau et al. (2013). Patient quality of life, instrumental activities of daily living, attention, memory and visuospatial ability improved over the treatment period in both the treatment and control group. However, the treatment group improved significantly more in the functional and personal subscales of quality of life assessments, but not memory. Reimunde et al. (2011) performed a cohort study examining the benefits of rhGH administration among those with moderate to severe TBI. Results of the study indicate that those receiving rhGH improved significantly on various cognitive subtests such as: understanding, digits, numbers and incomplete figures (p<0.05) as well as “similarities vocabulary”, verbal IQ, Manipulative IQ, and Total IQ (p<0.01). The control group also showed significant improvement but only in digits and manipulative intelligence quotient (p<0.05).  Of note IGF-I levels were similar between both groups at the end of the study.

Conclusions

There is level 1b evidence that recombinant human Growth Hormone (rhGH) is similar to placebo for improving memory and learning in patients post TBI.

There is level 2 evidence that growth hormone (GH) therapy is similar to placebo at improving memory ability in patients post TBI.

6.2.2.10 Rivastigmine

Key Points

Rivastigmine is not effective in treating memory deficits post ABI.

Rivastigmine is an acetylcholinesterase inhibitor which prevents the enzyme acetylcholinesterase from breaking down acetylcholine. This increases the concentration of acetylcholine in synapses. Acetylcholine has been most strongly linked with the hippocampus and memory deficits; however, it is also implicated in attentional processing.

Discussion

In two studies rivastigmine was administered to patients who had sustained a moderate to severe TBI (Silver et al., 2006; Silver et al., 2009). Results from both studies suggest that rivastigmine does not improve memory. In two RCTs Silver et al. (2006;2009) evaluated the effects of rivastigmine on verbal learning. Neither study yielded significant results for any cognitive measures compared to placebo.

Conclusions

There is level 1a evidence that rivastigmine is not effective when compared to placebo for improving memory in ABI populations.

6.2.2.11 Hyberbaric oxygen therapy

Key Points

Hyperbaric oxygen therapy may be promising for improving memory following an ABI; however, more controlled studies are required.

Hyperbaric oxygen therapy involves the inhalation of pure oxygen under pressure allowing the lungs to absorb more oxygen per breath. Currently hyperbaric oxygen therapy is used to treat decompression sickness, serious infections, and delayed wound healing as a result of a comorbid illness such as diabetes (The Mayo Clinic, 2019).

Discussion

One recent study has evaluated the effects of hyperbaric oxygen therapy on memory deficits following an ABI (Hadanny et al., 2018). The results of this study indicated that hyperbaric oxygen therapy may have positive effects on memory as individuals significantly improved on memory scores following 60-90 minutes of exposure five days a week. It should be noted that this study is retrospective and did not make use of a control group and therefore spontaneous recovery may have influenced recovery.

Conclusions

There is level 4 evidence that hyperbaric oxygen therapy may improve memory following an ABI.

6.3 Rehabilitation of Problem Solving, Executive and General Cognitive Functioning

Executive functions refer to higher-level cognitive functions that are primarily mediated by the frontal lobes. These functions include insight, awareness, judgment, planning, organization, problem solving, multi-tasking and working memory (Lezak, 2004). Executive deficits are particularly relevant following traumatic brain injury from both a pathophysiologic as well as a psychosocial perspective. The frontal lobes tend to be one of the brain areas most likely to be injured following trauma (Greenwald et al., 2003). Frequently bilateral frontal lobe injury occurs following TBI which in contrast to typically unilateral insults following vascular injury. Direct contusion to the frontal and temporal lobes can occur but also diffuse axonal injury sustained as a result of TBI affects executive functioning. Patients with a TBI often present with cognitive and behavioral deficits in the presence of little physical impairment.

Cicerone et al. (2000) reviewed 14 studies examining executive functioning and problem-solving (Table 6.13). Only three of the identified studies included a control group and were classified as a randomized controlled trial or non-randomized cohort study.

In later reviews by Cicerone et al. (2005; 2011) 9 and 18 additional studies, respectively, were identified. Some of these studies were not included in our review as they did not meet our inclusion criteria. Based on the results of the studies in their review, Cicerone et al. (2000) recommended, “training of formal problem-solving strategies and their application to everyday situations and functional activities”.

Executive function deficits are particularly relevant to brain injury survivors who tend to be younger (average age less than 40 years) and who often desire to re-integrate back into pre-injury life roles. Patients with executive function deficits may have the capacity to be independent for basic activities of daily living where actions tend to be more ingrained and one-dimensional. However, instrumental activities of daily living such as banking, scheduling and household activities require intact executive functions due to the increased cognitive complexity and variability of the tasks. Of particular importance are the advanced tasks such as return to driving and competitive employment which are of increased relevance to the younger age demographic associated with TBI (Miller et al., 2003).

6.3.1 Non-Pharmacological Interventions

6.3.1.1 Rehabilitation of Executive Functioning

Within the typical medical and rehabilitation settings, executive function deficits themselves are difficult to identify and evaluate since there is a tendency to focus on other cognitive functions such as memory and attention. It is vital to evaluate interventions for executive functioning as impairment can ultimately hinder successful community re-integration. Further to this, it is also important to address the issue of self-awareness which is particularly important in those who sustain moderate to severe TBI. If individuals are not aware they have a problem, they are less likely to work on compensating for it.

6.3.1.1.2 Group-based Interventions

Key Points

Group goal-oriented interventions are effective for the remediation of executive functions, including comprehension and problem solving.

Emotional regulation interventions delivered in a group setting may improve executive function in patients post TBI; however, it is unclear if it is superior at doing so compared to conventional cognitive remediation.

The SMART program appears to be effective for improving executive functioning following an ABI.

Touch screen-based games which include components of metacognition may be effective for improving self-awareness.

Metacognitive instruction does not appear to improve comprehension or abstract reasoning; however, more studies are needed to fully evaluate its effects.

Although executive function deficits are a common there is little overall research directly addressing the impact of rehabilitation on executive function. However, community integration and other similar group-based interventions are highly related to executive function and it is possible that programs and interventions presented in a group-based setting may in fact be focusing efforts on instrumental activities of daily living which may reflect (or are dependent on) executive functions. The efficacy of group-based interventions on cognitive and executive function are discussed below.

Discussion

Several studies have evaluated the effects of group goal management training. One study has compared the effect of group Goal Management Training (TG) to a group Brain Health workshop (CG) on cognitive outcomes post brain injury (Tornas et al. 2016). The study showed that individuals receiving goal management training improved significantly in cognitive and executive outcomes after treatment, and at 6-month follow-up. While this study showed promising results, it is important to remember that despite its rigorous methodology, the patient population was very heterogenous and it is unclear how different injuries impacted the outcomes. Similar results of goal management training were found in an RCT by Novakovic-Agopian et al. (2011), where a goals training group showed significant improvement on attention and executive function assessments compared to the educational group. Despite switching interventions at the 5-week mark to the educational intervention, the goal training group continued to improve significantly. Interestingly, an RCT published in the same year also demonstrated that goal training is beneficial for executive functions (Chen et al., 2011). In this study both groups significantly improved in attention directed goal completion. A final RCT evaluated group goal attainment interventions compared to educational interventions (Ownsworth et al., 2008). This study found that all individuals who received goal attainment interventions significantly improved over time on measures of executive functioning, regardless of group assignment at 3-month follow-up based on self-ratings, and relative’s ratings (Ownsworth et al., 2008).

Emotional regulation was also examined as a potential intervention for the remediation of attention and executive dysfunction post ABI (Cantor et al., 2014; Rath et al., 2003). While this treatment was not found to be effective in the recovery of attention, significant improvements on executive function were noted (EF, FeSBe, PSI) (Cantor et al., 2014). Further support for emotional oriented intervention can be found in an earlier study by Rath et al. (2003). The group completed an RCT comparing two cognitive rehabilitation therapies: conventional (cognitive remediation and psychosocial components) versus an innovative rehabilitation approach focusing on emotional self-regulation and clear thinking. Outcomes were measured across multiple domains of cognition including attention, memory, reasoning, psychosocial functioning, and problem-solving measures. Significant changes comparing baseline to post intervention outcomes were seen for each group on problem-solving measures; however, the improvements were different for the interventions. No between-group comparisons were made.

A pre-post study by Copley et al. (2015) investigated the effects of a Metacognitive Strategy Instruction (MSI) intervention on verbal and cognitive outcomes post ABI. The program was delivered individually, in a group-setting, and at home. Despite the multi-step process, no improvements were observed in cognitive or verbal abilities from baseline after the intervention. Gabbatore et al. (2015) implemented a cognitive group rehabilitation program for patients post TBI, and discovered that compared to before the intervention, patient’s recall (IDR), attention (WCST), and communication skills (ABaCo) all significantly improved. Specifically, the ABaCo was used to measure linguistic comprehension and context comprehension.

In addition to its use as a memory intervention the Strategic Memory and Reasoning Training (SMART) program is also an effective intervention for executive functioning. Vas et al. (2001) compared its use to that of a brain health workshop. The SMART group had significantly higher scores on the Test of Strategic Learning, and Wechsler Adult Intelligence Scale III for sections examining inhibition, non-verbal reasoning, and cognitive flexibility, demonstrating an overall improvement in metacognition and comprehension.

Only one study using a technology-based intervention met our inclusion criteria. Llorens et al. (2012) used an interactive touch screen game in an attempt to improve social skills and self-awareness following ABI. Although no formal statistical analysis took place, at the end of the treatment period all participants had an accurate perception of their deficits (compared to 4/10 at baseline), and six of ten participants showed alterations in their social skills (Llorens et al., 2012).

Parente and Stapleton (1999) compared brain injury survivors who completed a cognitive skills group to comparable controls. The cognitive skills group interventions included education regarding “thinking skills” such as problem solving, concentration/ attention, decision making, remembering names and faces, study skills, functional mnemonics, prosthetic memory devices, social cognition, organizational skills and goal setting. Other important aspects of the cognitive skills group included computer training, prosthetic aid training, interviewing skills training and focus on a model of clients teaching clients. There was no statistical analysis completed; however, the return to work rate for 13 of 33 participants assigned to the cognitive skills group training was 76% as compared to 58% for the control group. Competitive employment for the intervention group was maintained at 6-month follow up.

Conclusions

There is level 1b evidence that goal orientated group interventions are successful at improving cognitive and executive function in patients post ABI.

There is level 1b evidence that emotional regulation group interventions are effective at improving executive function in post TBI patientscompared to standard therapy.

There is level 1b evidence that the Strategic Memory and Reasoning Training program is more effective than a brain health workshop for improving executive function, metacognition, and comprehension following ABI.

There is level 4 evidence that metacognitive strategy instruction may not be effective for improving executive functioning following an ABI.

There is level 4 evidence that touch screen-based games (which include components of reasoning and problem-solving) may be effective for improving self-awareness and social skills following an ABI.

6.3.1.1.1 Individual Interventions

Key Points

Targeted hypnosis may improve memory, attention, and cognitive function in post TBI patientsor stroke; however, only as long as the intervention is being administered.

Attention training programs likely do not improve executive functioning.

General cognitive training programs which include problem-solving appear to be effective for improving executive functioning following an ABI.

Virtual reality does not likely improve executive functioning following an ABI.

Computer or smartphone software programs (BrainHQ, Parrot Software, ProSolv app) may not be superior to common interventions at improving memory, attention, and problem-solving skills in patients post TBI.

Goal management training may be superior to motor skills training at improving everyday skills (meal preparation), but not intelligence or neuropsychological outcomes in patients post TBI.

Heart rate variability biofeedback may improve executive functions; however, more controlled studies are required to make further conclusions.

Although executive function deficits post TBI are a common there is little overall research directly addressing the impact of rehabilitation on executive function. Individual interventions aimed at improving executive and general cognitive function are reviewed below.

Discussion

The effects of hypnosis, as delivered in a targeted or non targeted manner, on memory, attention, and cognitive function in a mixed TBI and stroke population has been investigated (Lindelov et al. 2017). The researchers showed that working memory, attention, and cognitive function could be transiently increased during targeted hypnosis; however, the benefits of the treatment were not sustained when the treatment was discontinued. With respect to attention process training, it was shown that this intervention may have indirectly improved executive function as individuals with higher vigilance achieved higher executive function scores, but it was not explicitly demonstrated that training resulted in increased vigilance (Sohlberg et al., 2000).

Dual-task training which is also used as a form of attention training was also evaluated in another RCT and although individuals were improved on measures of attention to a significantly greater extent than controls, no such relationship was found for measures of executive function (Couillet et al., 2010).

With the development of technology, the use of virtual-reality training and computer programs have gained traction as an intriguing tool used for improving executive function in patients post TBI. In terms of cognitive functioning, two RCTs found varying results for executive functioning outcomes after training in a virtual environment (Jacoby et al., 2013; Man et al., 2013). One RCT focusing on vocational problem-solving skills (Man et al., 2013) identified significant improvements in both VR intervention and conventional psychoeducation control groups; however, there were no significant between-group differences for cognitive or vocational outcomes except on WCST % errors and % conceptual level response (Man et al., 2013). Conversely, Jacoby et al (2013) found that patients receiving virtual reality training improved more on multi-tasking measures and executive function when compared to the control group who received general cognitive re-training treatment. In a pre-post study, Dadah et al. (2017) investigated virtual reality interventions in a mixed ABI population. The researchers found that repetition of the Stroop test in different virtual reality environments showed limited improvement in performance on those specific tests (Dahdah et al., 2017). As a result of the mixed results reported on the efficacy of virtual reality training post ABI, it is difficult to make a conclusive decision on what aspects of executive functioning virtual reality benefits, and to what degree.

As previously mentioned, computer software programs have also been investigated for their efficacy in improving executive dysfunctions post TBI. Recently, BrainHQ, a commercially available online computerized cognitive exercise program, showed mixed results for improving executive function post ABI (O’Neil-Pirozzi & Hsu, 2016). Although individuals self-reported improvements in daily functioning, no significant results were seen on objective measures (O’Neil 2016). Parrot Software is another computer-based cognitive retraining program, and was investigated by a pre-post study assessing the efficacy of using eight modules focussed on attention and memory (Li et al., 2015; Li et al., 2013).  While significant post-treatment improvements in attention and memory on the Cognistat assessment were found in a pilot study (Li et al., 2013), a subsequent study did not find significant improvements on the Montreal Cognitive Assessment (MoCA) or a medication-box sorting task despite significantly improved overall MoCA scores (Li et al., 2015). This lack of improvement compared to a control group was also reported by Powell et al. (2017) when the ProSolv smartphone application was used to improved pressure management and problem-solving skills. Finally, Chen et al. (1997) studied the effect of computer assisted cognitive rehabilitation versus traditional therapy methods. While measures of attention significantly improved in both groups after treatment, no significant differences were observed between groups on any measures related to executive function (Chen et al., 1997). Cumulatively, by observing studies from across a period of nearly 20 years, the literature reveals little support for the use of computer software programs for the improvement of executive function post TBI.

In an RCT, Spikman et al. (2010) randomly divided a group of individuals who had sustained a TBI to either a multifaceted strategy training group or a control group. Those in the treatment group were taught a comprehensive cognitive strategy which allowed them to tackle the issues and problems of daily living, compared to the control group which received a computerized training package that was aimed at improving general cognitive functioning. Overall, results indicate both groups improved on many aspects of executive functioning; however, those in the treatment group showed greater improvement in their ability to set and accomplish realistic goals and to plan and initiate real life tasks (Spikman et al., 2010). The findings of the previous experiment agree with the findings of the study by Laatsch et al. (1999) and Freeman et al. (1992), where cognitive rehabilitation therapy was found to increase productivity and everyday functioning. This older study (Laatsch et al., 1999) also had the benefit of reporting SPECT imaging results, which revealed increases in cerebral blood flow during the intervention. It should be noted that one study has found mixed results on measures of executive functioning after administering a cognitive training program, with individuals improving on some measures of executive functioning, such as metacognition, but not others (Fong & Howie, 2009). It should be noted that none of the above studies were completed by the same groups or had overlapping methodology and although the results suggest cognitive training programs are effective for improving executive functioning following an ABI, programs themselves should be considered unique.

A specific cognitive program (Categorization Program) was evaluated in an RCT by Constantinidou et al. (2008). The authors found that after 13 weeks of therapy (mean 4.5 hr/day), individuals significantly improved on measures of executive functioning such as object recognition. Although the Categorization Program treatment group and standard therapy therapy group showed improvement on the community reintegration questionnaire and adaptability measures, there were greater executive function gains in the treatment group (Constantinidou et al., 2008). The Intensive NeuroRehabilitation Programme investigated by Holleman et al. (2018) resulted in significantly reduced depression and anxiety compared to the control group but did not improve measures of executive functioning.

Another unique study used heart rate variability biofeedback in an attempt to increase awareness and cognitive control (Kim et al., 2018). In this study it was noted that individuals who underwent heart rate biofeedback significantly improved scores of executive functioning on the Category Test. However, this study consisted of a pre-post design and lacked a control group for comparison, and as such results should be interpreted with caution.

Levine et al. (2000) completed an RCT comparing a group of patients using goal management training strategies to a control group who were received only motor skills training. The treatment group improved on paper and pencil everyday tasks as well as meal preparation-which the authors used as an example of a task heavily reliant on self-regulation in comparison to the motor treatment group. It is important to note, however, that the motor group performed superiorly on timed neuropsychological tests, and no differences were found between treatments in terms of intelligence. A second study also evaluating goal management training in 2009 and did not find any significant results suggesting that goal management training improves executive functioning following an ABI (Levack et al., 2009). A single older study reported positive affects of a goal setting program in its ability to help an individual achieve goals (Webb & Glueckauf, 1994). The execution of goals themselves requires executive functioning; however, no objective measures of executive function were directly evaluated in this study.

Conclusions

There is level 1b evidence that targeted hypnosis may transiently improve cognitive function in post TBI patientsor stroke.

There is level 1b evidence that an attention remediation intervention may not be superior to TBI education alone and improving executive function in patients post TBI.

There is level 2 evidence that dual-task training may improve not general cognitive functioning compared to a non-specific cognitive program in patients post TBI.

There is level 1b evidence that a comprehensive cognitive treatment strategy programs (which include problem solving), compared to controls, are effective for improving metacognition and goal achievement post TBI.

There is level 4 evidence that cognitive rehabilitation may increase productivity in everyday functioning, and cerebral blood flow during treatment in patients post TBI.

There is level 1b evidence that virtual-reality training is not superior to conventional cognitive training at improving cognitive and executive function outcomes post TBI.

There is level 1b evidence that the specific cognitive training program ProSolv, compared to standard therapy, does not improve measures of executive functioning following an ABI.

There is level 2 evidence that the Intensive NeuroRehabilitation programme, compared to no treatment, does not improve executive functioning following an ABI. 

There is level 2 evidence that computer or smartphone software programs, such as BrainHQ, Parrot Software, ProSolv app, may not be superior to no intervention at improving problem-solving skills and general functioning in patients post TBI.

There is level 4 evidence that heart rate biofeedback may improve executive functioning following an ABI, although higher level studies are required to fully determine this.

There is level 2 evidence that goal management training may be superior (compared to motor skills training or no treatment controls) for improving goal attainment or measures of intelligence following an ABI.

6.3.1.2 Rehabilitation of General Cognitive Functioning

Key Points

General cognitive rehabilitation programs are effective for improving cognitive functioning following an ABI.

There is limited evidence that mindfulness based stress reduction is effective for improving cognitive functioning.

Corrective video feedback is more effective than verbal feedback alone for improving general cognitive function and self-awareness.

Remedial and adaptive occupational therapy are equally effective for improving general cognitive functioning.

Interventions for the treatment of cognitive deficits post TBI tend to be diverse with variability between the interventions themselves and the outcome measures used to document results.

Gordon et al. (2006) conducted an extensive review of the TBI rehabilitation literature and identified 13 studies examining treatments for cognitive deficits. Studies included in that review had a multitude of inclusion criteria. Additionally, the studies identified were of limited methodological quality, but suggested that compensatory strategy training improved attention deficits and mild memory impairments (Gordon et al., 2006). Several researchers have noted that training-based therapies that target executive control, such as “attention, problem solving, and the use of metacognitive strategies” (Novakovic-Agopian et al., 2011) may improve functioning in those who sustain an ABI (Cicerone, 2002; Kennedy et al., 2008a; Sohlberg et al., 2003b). Studies included in this section have examined the effects of cognitive rehabilitation strategies.

Discussion

Seven studies investigating the remediation of general cognitive functioning were found meeting our inclusion criteria. Neistadt (1992) divided 45 patients into one of two groups: a remedial group who received individual training with parquetry block assembly, and an adaptive group who received functional skills training over a six-week period. Outcomes for the effect of treatment for constructional test performance revealed that the remedial group improved significantly more than the adaptive group on the Parquetry Block test. However, there were no significant differences on the WAIS-R Block Design subtest after treatment. Training-specific learning appears to be an effective approach to rehabilitation as demonstrated by the treatment effect.

Goverover et al. (2007) used an RCT to study individualized cognitive treatments (such as making lunch or a telephone call) on the ability to remediate self-awareness and generalized processing skills. Groups did not significantly differ at baseline; however, following treatment individuals in the treatment group experienced a significant increase in their self-regulation, and processing skills (Goverover et al., 2007). In a study, Rasquin and colleagues (2010) they investigated the effectiveness of a low intensity outpatient cognitive rehab program on those (n=27) who had sustained an ABI. All participants were in the chronic phase of recovery and all were asked to invite a caregiver to attend sessions with them (n=25). Sessions lasted 2.5 hours each week for a total of 15 weeks. All were assessed prior to the session beginning, immediately afterward and again 6 months later. Participants worked on developing strategies to assist them with their attention, memory and problem-solving difficulties. Social skills training sessions were also held. Changes were noted immediately after the cognitive rehab program ended and this improvement in goal attainment, and cognitive improvement was maintained at the 6-month follow-up. Laatsch et al. (1999) found similar results where cognitive rehabilitation therapy helped individuals increase productivity in their daily lives and found improvements on neuropsychological measures.

Two other RCTs have evaluated specific training programs attempting to improve generalized cognitive functioning (Linton & Kim, 2018) (Schmidt et al., 2013). The more recent RCT had individuals participate in the in-home program (Trabajadora de Salud) and found that although both groups improved on physical measures over time, only the experimental group saw a significant increase in cognitive FIM scores. The second study involved individuals receiving task completion instructions in a variety of formats to determine how feedback might influence general cognition (Schmidt et al., 2013). Those in the video feedback group (compared to verbal feedback) saw significant improvements in self-perception, and general awareness. The video feedback condition showed a recording of the individual performing the meal preparation task required with corrective feedback, compared to the verbal feedback group which only received verbal corrective feedback (Schmidt et al., 2013).

Mindfulness-based stress reduction was evaluated in an attempt to improve self-awareness and overall cognitive health (Combs et al., 2018). Individuals participated in weekly mindfulness sessions for 60 minutes and were asked to self-report on their general cognitive functioning. Individuals reported a significant reduction in cognitive symptoms which was positively correlated to the number of sessions they attended. This was true for both general cognitive functioning as well psychological wellbeing. Although this single pre-post study offers insight into the benefits of mindfulness-based stress reduction, more research is needed.

Conclusions

There is level 1b evidence that cognitive therapies compared to standard therapy are more effective than no therapy for improving generalized cognitive functioning, as well as self-perception following an ABI.

There is level 4 evidence that a low intensity outpatient cognitive rehabilitation program may improve goal attainment and cognitive impairment in patients post ABI.

There is level 2 evidence that the Trabajadora de Salud program may improve general cognitive functioning compared to standard therapy for those with an ABI.

There is level 1b evidence that corrective video feedback is more effective for improving generalized cognitive functioning and self awareness compared to verbal feedback only in those with an ABI.

There is level 1b evidence that remedial occupational therapy and adaptive occupational therapy may have equal effects on generalized cognitive function in those with an ABI.

There is level 4 evidence that mindfulness-based stress reduction may be effective for improving general cognitive functioning and psychological health for those with an ABI.

6.3.2 Pharmacological Interventions

6.3.2.1 Donepezil

Key Points

Donepezil might improve attention, learning and short-term memory following TBI; however, side effects may incur from its use.

The effectiveness of donepezil, a cholinesterase inhibitor, in improving cognitive and memory functions following brain injury was assessed. Cognitive impairments negatively impact patient autonomy, affecting one’s ability to return to work or school, and live alone (Masanic et al., 2001). When tested in individuals diagnosed with Alzheimer’s disease, donepezil has been found to be useful in treating memory problems (Morey et al., 2003; Walker et al., 2004). The impact of Donepezil impact on cognitive function and memory in a TBI population is explored in the table below.

Discussion

Khateb et al. (2005) found only modest improvement on the various neuropsychological tests used to measure executive function, attention, and learning and memory. Of note, results from the learning phase of the Rey Auditory Verbal Memory Test (RAVMT) showed significant improvement (p<0.050). The Donepezil intervention also demonstrated improvement in executive function, as the results from the Stroop-colour naming test showed significant improvements (p<0.030). On the test for Attentional Performance a significant change was noted on the divided attention (errors) subsection of the test. Overall, donepezil was found to be effective in improving learning, memory, divided attention, and executive function. However, possible benefits of donepezil administration must be balanced against the observed side effects in 27% of the population. Further randomized control trials are required to better explore the efficacy of donepezil post TBI.

Conclusions

There is level 4 evidence that donepezil is effective in improving learning, memory, divided attention, and executive function in patients post TBI.

6.3.2.2 Methylphenidate

Key Points

The effectiveness of methylphenidate to improve cognitive impairment following brain injury is unclear. Further studies with larger populations are required.

Methylphenidate is a stimulant which inhibits the reuptake of dopamine and norepinephrine and increases activity in the prefrontal cortex. In the past, methylphenidate has been extensively used as a treatment for attention deficit disorder, as well as narcolepsy (Glenn, 1998). A total of three RCTs examined the efficacy of methylphenidate as a treatment for the recovery of executive and general cognitive deficits post ABI.

Discussion

Dymowski et al. (2017) investigated the effects of short-term, 7-week, methylphenidate administration in post TBI patientscompared to a placebo control group. There was no significant improvement, or difference between groups for various measures and tests of attention and cognition. Speech et al. (1993) conducted a double blind placebo controlled trial evaluating the effects of methylphenidate following closed head injury and arrived at similar conclusions, as the treatment and placebo group did not vary in any measurements of memory, intelligence, or attention. Conversely, Zhang and Wang (2017) used a larger sample size to investigate the effects of long-term (30 wk) methylphenidate use in patients post TBI. While there was no difference between the groups at baseline, the treatment group had improved reaction time, cognitive ability, attention capacity, and depression when compared to the placebo group. The contradictory on methylphenidate use post TBI creates an interesting conflict, as all studies were conducted with high methodological quality and proper controls. Zhang and Wang (2017) used a fraction of the dose of methylphenidate compared to the Dymowski et al. (2017) study. Although methylphenidate has been found to be effective for the management of specific cognitive functions, such as attention, its effects on general and executive function remains inconclusive.

Conclusions

There is conflicting (level 1a) evidence regarding the effectiveness of the administration of methylphenidate, compared to placebo, following TBI for the improvement of general and executive functioning.

6.3.2.3 Sertraline

Key Points

Sertraline has not been shown to improve cognitive functioning within the first 12 months post TBI and may be associated with side effects.

Sertraline, better known under its trade name Zoloft (Pfizer), is a selective serotonin reuptake inhibitor (SSRI) used for the treatment of depression and mood (Khouzam et al., 2003; Jorge et al., 2016). The majority of sertraline TBI research focuses on the prevention or treatment of major depressive symptoms post brain injury. However, recent studies have shifted focus and begun to evaluate the benefits of sertraline at improving cognitive disorders (Banos et al., 2010). The study reviewed below investigated the effect of sertraline on cognitive outcomes post TBI.

Discussion

The effect of early administration of sertraline on cognitive functioning was evaluated by Banos et al. (2010) in an RCT. When comparing the sertraline group, who received 50 mg per day, to a control group (placebo), there were no significant between group differences on any of the neuropsychological tests. The assessments examined attention and concentration, speed of processing, memory and executive function at 3, 6 and 12 months. Cognitive functioning was not found to improve following the administration of sertraline. Of note, more patients in the sertraline group dropped out of the study compared to the control group when this was quantified at all assessment points indicating the potential side effects associated with the treatment. Combined with the lack of apparent benefit to using the drug, use of sertraline is not currently recommended.

Conclusions

There is level 1b evidence that sertraline does not improve cognitive functioning, compared to placebo, in individuals who have sustained a moderate to severe TBI.

6.3.2.4 Amantadine

Key Points

Amantadine is not effective at improving generalized cognition. Its impact on executive functioning should be studied further.

Amantadine is a non-competitive N-methyl-D-aspartate receptor antagonist and has been used as an antiviral agent, prophylaxis for influenza A, as a treatment of neurological diseases such as Parkinson’s Disease, and for the treatment of neuroleptic side-effects such as dystonia, akinthesia and neuroleptic malignant syndrome (Schneider et al., 1999). Amantadine is also thought to interact pre- and post-synaptically (Napolitano et al., 2005). Three studies were identified that investigated the effectiveness of amantadine as a treatment for the remediation of cognitive functioning following TBI.

Discussion

In a small sample RCT by Schneider et al. (1999) the effects of Amantadine on cognition and behaviours were assessed. In this six-week cross-over study, patients received both placebo and amantadine for 2 weeks each, with a 2-week washout period in between. No significant differences were found between groups on measures of executive or general cognitive functioning. A recent RCT reinforces these findings after finding no significant differences on measures of cognition following 6-weeks of amantadine treatment (Ghalaenovi et al, 2018). Similarly, Kraus et al. (2005) demonstrated that the administration of amantadine over a 12-week treatment period does not improve memory deficits or attention; however, significant improvements in executive functioning were observed. Given the quality and sample size of the current studies, future studies exploring the efficacy of amantadine for learning and memory are warranted.

Conclusions

There is level 1b evidence that Amantadine may not help to improve general functioning deficits in post TBI patientscompared to placebo.

6.3.2.5 Bromocriptine

Key Points

Bromocriptine may improve other measures of cognition such as attention, but its effects on generalized cognition are conflicting. More research is required.

Bromocriptine is a dopaminergic agonist which primarily exerts its actions through binding and activating D2 receptors (Whyte et al., 2008). It has been suggested that dopamine is an important neurotransmitter for prefrontal function, an important area of the brain that contributes to cognitive function, memory, intelligence, language, and visual interpretation (McDowell et al., 1998; Siddiqui et al., 2008). In a study looking at the effects of bromocriptine on rats, Kline et al. (2002) noted that the animals showed improvement in working memory and spatial learning; however, this improvement was not seen in motor abilities. Two studies have been identified investigating the use of bromocriptine as an adequate treatment for the recovery of cognitive impairments following TBI.

Discussion

The effect of bromocriptine on cognitive function in patients with ABI was explored in one RCT (McDowell et al., 1998), and one case series (Powell et al. 1996). Low-dose bromocriptine (2.5 mg daily) improved functioning on tests of executive control including a dual task, Trail Making Test, the Stroop test, the Wisconsin Card Sorting Test and the controlled oral word association test (McDowell et al., 1998). However, bromocriptine did not significantly influence working memory tasks. Although McDowell et al. (1998) demonstrated some benefits following administration of bromocriptine, there was only a single administration of bromocriptine and the dose was considerably lower than that given by other studies that did not meet our criteria. pontaneous recovery may have been a factor leading to the improved abilities in individuals receiving a single dose (2.5 mg daily) of the medication; however, study results did not answer this question. Powell et al. (1996) conducted a multiple baseline design on 11 patients with TBI or subarachnoid hemorrhage who received bromocriptine. Improvements were found on all measures assessed (memory, attention, motivation spontaneity) except mood, creating conflicting results between these two studies. The last RCT investigating the effects of bromocriptine was conducted 20 years ago; newer studies are required to fully determine the potential of bromocriptine as a treatment for general and executive cognitive functions.

Conclusions

There is conflicting level 2 (against) and level 4 (for) evidence as to whether or not bromocriptine may improve executive or general cognitive functioning following ABI.

 

6.3.2.6 Growth Hormone (GH) Replacement Therapy

Key Points

The administration of human growth hormones appears to have positive (although sometimes limited effects) on general and executive functioning in those with an ABI.

Following an ABI, it is not uncommon for individuals to be diagnosed with hypopituitarism. It is estimated that as many as 25 to 40% of individuals with a moderate to severe ABI demonstrate chronic hypopituitarism (Bondanelli et al., 2007; Kelly et al., 2006; Schneiderman et al., 2008). Despite this, few patients are screened for GH deficiencies; thus, the link between cognitive impairment and growth hormone deficiencies has not yet been definitively established (High et al., 2010). The benefits of GH replacement therapy on patient’s executive and general cognitive function post TBI is investigated below.

Discussion

A 2010 RCT compared the long term (6 months and 1 year) effects of rhGH administration to placebo in a TBI population (High Jr et al. 2010). Significant improvements were noted in processing speed, executive functioning (Wisconsin Card Sorting Test), and learning (California Verbal learning test II) for both he rhGH and placebo groups. It is important to note while processing speed also improved in both groups at 6 mo, the improvement was only sustained in the treatment group at 1 year. Further positive results were reported in a more recent PCT by Moreau et al. (2013). Patient quality of life, instrumental activities of daily living, attention, memory and visuospatial ability improved over the treatment period in both the treatment and control group. However, the treatment group improved significantly more in the functional and personal subscales of quality of life assessments. Reimunde et al. (2011) also examined the use of recombinant human growth hormone in a cohort study. Results of the study indicate that those receiving the rhGH improved significantly on the various cognitive subtests such as: understanding, digits, numbers and incomplete figures (p<0.05),  verbal IQ, Manipulative IQ, and Total IQ (p<0.01). The control group also showed significant improvement but only in digits and manipulative intelligence quotient (p<0.05).  Of note IGF-I levels were similar between both groups at the end of the study.

Conclusions

There is level 1b evidence that recombinant human Growth Hormone (rhGH) is superior to placebo at improving processing speed (6 mo), executive function and learning in patients post TBI.

There is level 2 evidence that growth hormone (GH) therapy is effective for improving quality of life, instrumental activities of daily living (iADL), attention, memory, and visuospatial ability in patients post TBI.

There is level 2 evidence that recombinant human Growth Hormone (rhGH) administration improves intelligence and other cognitive subtests in TBI patients with growth hormone deficiency compared to TBI patients without; however, insulin-like growth factor-1 (IGF-1) levels may be the same between groups.

6.3.2.7 Rivastigmine

Key Points

Rivastigmine is not effective in treating general or executive dysfunction post ABI.

Rivastigmine is an acetylcholinesterase inhibitor which prevents the enzyme acetylcholinesterase from breaking down acetylcholine. This increases the concentration of acetylcholine in synapses. Acetylcholine has been most strongly linked with the hippocampus and memory deficits; however, it is also implicated in attentional processing.

Discussion

In two studies rivastigmine was administered to patients who had sustained a moderate to severe TBI (Silver et al., 2006; Silver et al., 2009). Neither RCT found significant effects of rivastigmine on measures of general or executive function. However, after controlling for order-effects, there were no significant effects of treatment.

Conclusions

There is level 1b evidence that rivastigmine is not effective for improving general or executive cognitive functioning, compared to placebo, following an ABI.

6.3.2.8 Hyberbaric Oxygen Therapy

Key Points

Hyperbaric oxygen therapy may be beneficial for improving general and executive functioning following an ABI; however, more research is needed.

Hyperbaric oxygen therapy involves the inhalation of pure oxygen under pressure allowing the lungs to absorb more oxygen per breath. Currently hyperbaric oxygen therapy is used to treat decompression sickness, serious infections, and delayed wound healing as a result of a comorbid illness such as diabetes (The Mayo Clinic, 2019).

Discussion

One recent case series has evaluated the potential benefits of hyperbaric oxygen therapy on general and executive functioning (Hadanny et al., 2018). This study used NeuroTrax to evaluate all neurocognitive measures. Both measures of general and executive functioning saw a significant improvement over the treatment period. However, it should be noted that this study did not contain a control group and therefore it is difficult to separate the effects of the treatment from spontaneous recovery.

Conclusions

There is level 4 evidence that hyperbaric oxygen therapy may improve general and executive functioning following an ABI.

6.3.2.9 Dextroamphetamine

Key Points

Dextroamphetamine is moderate evidence to suggest that dextroamphetamine is not effective for the remediation of general functioning.

Dextroamphetamine is another central nervous stimulant, and similar to methylphenidate it is used to treat narcolepsy and attention deficit hyperactivity disorder. Dextroamphetamine is a non-catecholamine and sympathomimetic amine that acts as a stimulant, unfortunately more direct mechanisms of action are not currently known.

Discussion

One RCT has recently evaluated the effects of dextroamphetamine on general and executive functioning using a variety of outcomes (Hart et al., 2018). Although dextroamphetamine was seen to significantly reduce agitation compared to the placebo group, no significant effects were seen on measures of cognition. Given the use of dextroamphetamine in other attentional disorders such as attention deficit hyperactivity disorder, the lack of results on any cognitive measures between these two studies is unexpected.

Conclusions

There is level 1b evidence that dextroamphetamine is not effective for the remediation of general cognitive functioning following an ABI.

6.4 Verbal and Written Communication

Communication remediation focuses on one’s ability to improve expressive language, speech production, reading, writing, and cognition. Due to impairments in cognitive abilities following an ABI, difficulties in producing proficient discourse is commonplace. Previous treatments have focused on improving narrative and structured conversations post injury (Kilov et al., 2009). Established treatments often focus on the individual’s ability to communicate with a clinician or researcher but not in the presence of a friend or family member (Jorgensen & Togher, 2009). Whether an individual communicates with a friend, a family member or community member, rather than a trained clinician post brain injury, has had an effect on the language choices made by both partners (Jorgensen & Togher, 2009).

Group treatment may be an effective intervention for post ABI individuals with cognitive-communication deficits and may be used to target more complex and higher-level skills within the communication domain and with a wide array of communication partners. Within a group treatment setting, patients with ABI gain support and benefit from the experience of their peers within a non-judgmental environment to experiment with compensatory strategies and acquisition of appropriate interaction skills (College of Audiologists and Speech Language Pathologists of Ontario, 2002).

Some specific goals of group treatment post ABI include having individuals focus on having their basic needs met, improving word fluency, word usage and word finding, and, to have tools to help better organize ideas in conversation. Strategies to ensure meeting these goals is possible would be to implement the use of a yes/no response system, alphabet boards to serve as phonemic cueing for word retrieval, and word retrieval strategies. To improve clarity of speech and phonation, patients are encouraged to speak clearly and with vocal effort, all while receiving proper breath support. For clinical use, the Lee Silverman Voice treatment (LSVT®) would be the primary tool when addressing these issues.

6.4.1 Remediation of Verbal and Written Communication

Key Points

Communicating “yes/no” responses with consistent training and environmental enrichments does not improve communication responses in individuals post ABI.

Retrieval practice is effective for improving verbal communication in individuals with an ABI.

Targeted figurative language therapy improves communication and comprehension in individuals with TBI; although the severity of the injury may moderate these effects.

Text-to-speech technology improves reading rates in individuals with TBI, but not comprehension.

Several authors have reviewed a variety of studies focusing on cognitive-communication therapies used to assist those post ABI (Coelho et al., 1996; Kennedy et al., 2008b; MacDonald & Wiseman-Hakes, 2010). In a review conducted by Coelho et al. (1996), the concluding findings suggest that those who sustain an ABI benefit from the work of an SLP. Study authors found evidence to suggest that individuals undergoing therapy showed gains in receptive and expressive language, speech production, reading, writing, and cognition. Further they noted that patients with more severe cognitive-communication deficits are more effectively remediated when treatment is directed toward the development of compensatory rehabilitation strategies such as the use of memory aids (Coelho et al., 1996). Additionally, Coelho and colleagues (1996) reported that although interventions directed at particular cognitive deficits are important, clinicians must attend to broader issues of social skills retraining, timing of treatment during recovery, treatment location and its effectiveness (e.g. hospital, home, school, work). Study results from Mackay et al. (1992) suggest that intervention programs offered earlier post injury result in shorter rehabilitation stays. Further, for individuals with comparable disabilities, those who receive rehabilitation have better than average cost outcomes compared to those not receiving these services (Aronow, 1987).

Discussion

Barreca et al. (2003) compared two rehabilitation approaches that attempted to establish correct responses to yes/no questions. In addition to providing an enriched environment to the first group, a communicative disorders assistant provided yes/no training to the individuals. In addition, the assistant trained healthcare team members and families to follow scripted procedures to increase arousal/attention and to elicit yes/no responses. This was compared against standard care. Despite no significant differences on the Western Aphasia Battery, families reported on a satisfaction questionnaire that they were better able to communicate with their loved one (Barreca et al., 2003).

Another study examined retrieval practice, administered in person, compared to massed restudy and spaced restudy (Sumowski et al., 2014). In the retrieval practice intervention, the participants were first exposed to a verbal paired associate; the subsequent trials for that verbal paired associate were structured as cued recall tests. For individuals with severe TBI and memory-impairments, this retrieval practice was significantly more effective for memory recall than the massed restudy and spaced restudy interventions both immediately following the intervention and at 1 week post (Sumowski et al., 2014).

Technology interventions have also been used to improve communication post TBI. In a study conducted by Harvey et al. (2013) participants completed six sessions of computerized text-to-speech training. Results showed a significant improvement in reading rates during the text-to-speech conditions compared to the no text-to-speech conditions (Harvey et al., 2013). These findings suggest that text-to-speech technology is a useful tool in improving reading rates among individuals with a TBI. However, the authors note that while reading rates improved, comprehension of the written material was not affected.

Brownell et al. (2013) utilized therapy targeting deficiencies in figurative language. All participants completed 10 sessions of word task training resulting in significant improvements in oral metaphor interpretation (Brownell et al., 2013). Participants in the study were approximately eight years post injury suggesting that post TBI individuals are capable of advanced improvements in non-literal language even after the period of rapid and pronounced spontaneous recovery.

In a study by O’Neil-Pirozzi et al. (2010b), individuals with ABI participated in twelve 90-minute sessions which were held twice a week. The intervention included memory education, and to improve memory function the study emphasized internal strategy acquisition. Primary emphasis was placed on semantic association followed by semantic elaboration/chaining and imagery. Results from the Hopkins Verbal Learning Test (HVLT) indicated significant differences between the groups and those with a severe ABI performed more poorly than those with a moderate injury. Despite this finding, those with severe ABIs did perform better than those in the control group. In all, memory performance was seen to improve for all in the intervention group compared to the control group, however this relationship was slightly modified by injury severity.

Conclusions

There is level 1b evidence that yes/no training and an enriched environment does not significantly improve communication responses in individuals with an ABI.

There is level 4 evidence that retrieval practice is more effective for memory recall in individuals with an ABI than massed restudy (i.e., cramming) and spaced restudy (i.e., distributed learning).

There is level 4 evidence that targeted therapy towards figurative language improves communication in chronic TBI individuals.

There is level 4 evidence that text-to-speech technology improves reading rates post ABI but not reading comprehension.

There is level 4 evidence that cognitive-communication therapy targeting the interpretation of figurative language is effective for improving language and metaphor comprehension following an ABI.

 

6.5 Social Communication Skills Training for Individuals and Communication Partners

After an ABI, issues may present in either verbal or nonverbal communication skills; difficulties with conversation may include topic introduction, topic maintenance, topic choice, turn taking and perspective taking (College of Audiologists and Speech Language Pathologists of Ontario, 2002)

Pragmatics describe “a person’s ability to perceive, interpret and respond to the contextual and situational demands of conversation” (Wiseman-Hakes et al., 1998). In other words, pragmatics refers to the interaction between language behavior and the context in which language occurs (Strauss HM & RS, 1994).  Studies have shown that the conversations of individuals with ABI, compared to individuals without injury, have been rated as significantly less interesting, less appropriate, less rewarding, more effortful, and more reliant on conversation partners to maintain the flow of the conversation (Bond & Godfrey, 1997; Coelho et al., 1996). Since it is through conversation that we form and maintain relationships, impaired communication can have a significant negative impact on social competence, vocational competence and academic competence. Social communication deficits in ABI can result in social isolation, frustration, and a sense of helplessness (Kilov et al., 2009; Sarno et al., 1986).

6.5.1 Social Communication Skills Training

Key Points

Training in social skills, social communication or pragmatics is effective in improving communication following brain injury.

Goal-driven interventions may be effective in improving social communication skills and goals following TBI.

Group Interactive Structured Treatment (GIST) is effective for improving social communication skills following an ABI.

Computer-based game programs which deliver cognitive-communication skills training may be effective for improving social skills.

ABI can influence every aspect of life including physicality, cognitive function, emotional responses, and social functioning. Social communication training more specifically addresses social competence and removing barriers to returning to a meaningful and productive life, which includes having the ability to sustain interpersonal relationships (Braden et al., 2010). Communication remediation focuses on one’s ability to improve expressive language, speech production, reading, writing, and cognition.

Discussion

An RCT by Westerhof-Evers et al. (2017) compared the use of a Social cognition and Emotion regulation treatment (T-ScEmo) to a treatment for general cognitive gains (Cogniplus) (control group), to evaluate how participants performed on emotion perception, social understanding, and social behavior. The T-ScEmo group had statistically significant improvements on emotion perception (facial affect recognition), theory of mind, proxy-rated empathic behavior, societal participation, and treatment goal attainment, when compared with the Cogniplus group (Westerhof-Evers et al., 2017). Participants in the T-ScEmo group also reported higher quality of life and their life partners rated relationship quality to be higher than those in the Cogniplus group.

In an RCT conducted by Dahlberg et al. (2007) it was found that subjects in the experimental group, when exposed to twelve, 1.5 hour communication sessions, significantly improved their scores on the general participation in conversation subscale on the Profile of Functional Impairment in Communication and the Social Communication Skills questionnaire-adapted (Dahlberg et al., 2007). These improvements were also noted at 6- and 9-month follow-up periods. It’s worth noting that both Dahlberg et al. (2007) and Westerhof-Evers et al. (2017) interventions included components of emotional regulation.

Finch et al. (2017) conducted pre-post study in adults with brain injury aimed at improving and maintaining social communication skills, in particular, the study authors focused on improved perceived communication skills, and achievement of goals. The results from this study indicated that goal-driven and metacognitive strategy-based interventions may help individuals with TBI achieve social communication goals.

Braden et al. (2010) examined the efficacy of the Group Interactive Structured Treatment (GIST) for social competence in a cohort study examining 30 individuals greater than one year post ABI. The 13 week training reviewed the following topics: skills of the great communicator, self-assessment and goal setting, starting conversations, keeping conversations going and using feedback, assertiveness in solving problems, practice in the community, social confidence through positive self-talk, social boundaries, videotaping, video review, conflict resolution, closure and celebration (Braden et al., 2010). Overall, data gathered demonstrated significant positive effects of GIST on social communication. Further, the program seemed to be effective for individuals with TBI who also comorbidities had, as stratification revealed there were no significant differences between these groups in terms of outcome. Another study also examined the effects of group cognitive pragmatic therapy (Bosco et al., 2018). Individuals were seen to improve on measures of communication, communication in daily activities, and verbal span. Although this study demonstrated significant improvements in social and functional communication, there was no control group to determine the effects of this therapy compared to no or alternative therapies.

A final study used interactive touch screens to apply a game-based question activity, which included topics around knowledge, reasoning, action, and cohesion of thoughts (Llorens et al., 2012). Although formal statistical analysis was not performed, 6/10 participants initially showed altered levels of communication on the Social Skills Scale, compared to only 2/10 post-treatment.

Conclusions

There is level 1b evidence that the Social Cognition and Emotion Regulation protocol when administered by a neuropsychologist is more effective for the remediation of social communication skills than the Cogniplus protocol in individuals with an ABI.

There is level 1b evidence that a variety of communication skills training programs improve social communication skills in individuals with an ABI, as well as self-concept and self-confidence in social communications.

There is level 4 evidence suggesting that a goal-driven, metacognitive approach to intervention may be beneficial in assisting individuals with TBI to achieve social communication goals.

There is level 4 evidence that interactive touch screen games focused on areas of reasoning, knowledge and action may be effective for improving social skills following an ABI.

There is level 2 evidence that the Group Interactive Structured Treatment program (GIST) is effective for improving social communication skills in those with a TBI as well as other neuropsychological comorbidities.

 

6.5.2 Training Communication Partners

Key Points

Providing communication training to individuals who interact with people with TBI is effective and encourages two-way dialogue.

Providing training to the communication partner and the individual with TBI together is more effective than training the individual with TBI alone.

The success of communication interventions often relies on the understanding, compliance and competence of communication partners. Training of communication partners has become a central component of communication interventions with many populations. This development is consistent with the World Health Organization (2001) emphasis on context (environmental and attitudinal) as a determinant in health and disability outcomes. Training of communication partners has been shown to have a positive effect on communication effectiveness and reacquisition of communication skills in children with language disorders and developmental disabilities (Girolametto et al., 1994), adults with aphasia (Kagan et al., 2001), adults with dementia (Ripich et al., 1999), and adults with ABI (Togher et al., 2004).

Following an ABI individuals may have difficulty engaging in meaningful conversation with others. Training communication partners is particularly helpful in successfully facilitating communication with those with moderate to severe ABI. The strategies that are most useful in ensuring success of treatment include speaking in short, simple sentences, making and maintaining eye contact, and asking the patient to repeat the messages being conveyed (Behn et al., 2013). Also, asking patients to clarify that they understand the information and repeating the information when necessary, while allowing adequate time to receive an answer. Presenting the information in written form can also elicit a positive outcome from patients (Behn et al., 2013). Eliminating environmental distractions will be a tremendous aid to allow proper focus and attention for optimal results. Communication partners should present choices to patients and clarify the intent of the message being delivered. Using a variety of modes of communication (such as nonverbal) can also be a useful strategy (Behn et al., 2012, Togher et al., 2004, Togher et al., 2016, Sim et al., 2013, Togher et al. 2013).

Discussion

Studies examining communication partner training either focused on training individuals and their communication partners jointly (n=5), or independently (n=1). For the single study examining communication training interventions only for communication partners positive effects were still found (Togher et al., 2004). In a RCT conducted by Togher et al. (2004), the benefits of training individuals regarding how to effectively communicate with post ABI individualswas evident. Police officers were trained to respond to individuals with ABI, while the remaining officers who volunteered did not participate in the training. Overall, it was noted that trained officers significantly reduced the number of inquiries required to gain the necessary information from their callers, as well as spent less time establishing the nature of the service request and more time answering the questions being presented.

For studies using grouped training Behn et al. (2012) found that training allowed for caregivers to interact more easily with the individual with a TBI when strategies were used to encourage dialogue, this was compared to an untrained control group. The training in this study consisted of a number of didactic and performance-based approaches such as modeling, role-playing, feedback and rehearsal. As well, the strategies used were both elaborative and collaborative.

When examining training communication partners, the most efficacious way to improve interactions is to have both the individual with an ABI and their communication partner participate in training together. Two studies by Togher et al. (2013; 2016) found that those who completed social communication training together, made significantly greater gains in participation and overall communication compared to individuals with TBI who attended alone or those who received no training. In a similar study, providing training to communication partners allowed for their communication styles to be modified, which in turn allowed for the individual with TBI to improve their communication (Sim et al., 2013). This study highlighted the benefits of monitoring the two-way interaction using discourse analysis to ensure that information is given, received, and negotiated in an effective and appropriate way (Sim et al., 2013).

Conclusions

There is level 2 evidence to support the effectiveness of interventions that focus on training communication partners in the community, compared to no training, for improving interactions between responders and those with an ABI. 

There is level 2 evidence that providing training to both the communication partner and the individual with a TBI together is more effective than only training the individual with TBI alone or no training at all.

6.5.3 Non-Verbal Communication

Key Points

Facial affect recognition and emotional interference training improves emotional perception post ABI.

Short intervention designed to improve emotional prosody is not effective post ABI.

Cognitive Pragmatic Treatment (CPT) program is effective at improving comprehension and production of a communication act.

The Treatment for Impairments in Social Cognition and Emotion Regulation and Cogniplus protocols are effective for improving emotional processing and emotional intelligence in individuals with an ABI.

Emotional Intelligence

Goals of treatment regarding non-verbal communication post ABI include initiating conversation with others, learning to understand the emotion presented in verbal language, the ability to respond appropriately, and to maintain conversation. In order to achieve these goals, the necessary strategies to be employed consist of environmental and behavioural modification, counselling and support, pragmatic skills trailing, and targeted speech and language therapy. Patients will require positive reinforcement of the appropriate responses, as well as auditory/visual feedback by others.

Studies have shown that the conversations of individuals with ABI, compared to individuals without injury, have been rated as significantly less interesting, less appropriate, less rewarding, more effortful, and more reliant on conversation partners to maintain the flow of the conversation (Bond & Godfrey, 1997; Coelho et al., 1996). Since it is through conversation that we form and maintain relationships, impaired communication can have a significant negative impact on social competence, vocational competence and academic competence. Social communication deficits in ABI can result in social isolation, frustration, and a sense of helplessness (Kilov et al., 2009; Sarno et al., 1986).

Discussion

Westerhof-Evers et al. (2017) conducted an RCT describing social communication training. Not only did this study evaluate social understanding and social behaviour, it also examined emotional regulation and perception. On the emotional intelligence components of the study, the experimental group improved significantly on the facial affect recognition (Westerhof-Evers et al. 2017). Participants in the experimental group also reported higher quality of life and their life partners rated relationship quality to be higher than those in the control group (Westerhof-Evers et al. 2017).

A short treatment aimed at improving the ability to recognize emotional prosody was overall found to be ineffective (McDonald et al., 2013). Activities consisted of mostly games designed to focus on prosodic cues but found no change related to communication competence. Significance was approached for the treatment group in terms of improvements in the accuracy on the prosody task and ratings of intensity of emotions. However, participants in the treatment group self-reported that their ability to comprehend daily conversations had improved (McDonald et al., 2013).

Radice-Neumann et al. (2009) and Neumann et al. (2015) demonstrated that training focused on emotional processing (either by face affect recognition or by emotional inference training) can be effective when introduced to a group of individuals who had sustained an ABI. They assert that individuals with ABI can re-learn affective recognition skills. Two interventions to enhance emotion processing were utilized in both studies. The first intervention (Facial Affect Recognition), focused on attention to important visual information and attention to the participant’s own emotional experience. The second intervention (Stories of Emotional Inference) taught patients to read emotions from contextual cues presented in stories and then relate these stories to personal events. Participants who received Facial Affect Recognition training had more positive outcomes (Neumann et al., 2015). Participants were better at reading faces (emotions) and were more descriptive in relating how they or others would feel in a similar situation. Decreased level of aggression was an additional finding.

The Stories of Emotional Inference group produced fewer improvements; however, they were able to make more emotional inferences about how they would feel in a given context. Individuals were still unable to make improvements in their ability to infer how others would feel in a given situation. The authors hypothesized that this might be related to self-centeredness, a trait often attributed to post ABI individuals(Radice-Neumann et al., 2009). However, Neumann et al. (2015) noted that the ability to identify one’s own emotions is an important precursor to recognizing the emotions of others and therefore, should not be dismissed prematurely. The previous Radice-Neumann et al. (2009) RCT found slightly depressed effects compared to its 2015 follow-up. In 2009, groups were not significantly different from each other on the Diagnostic Assessment of Nonverbal Affect. However, both groups still significantly improved in their ability to infer emotions from contextual situations on the Levels of Emotional Awareness Scale (Radice-Neumann et al., 2009).

Gabbatore et al. (2015) evaluated a cognitive pragmatic rehabilitation program aimed at improving communicative-pragmatic abilities, in particular self-awareness and executive functioning. Study authors aimed at improving comprehension and production of a communication act. No improvements in comprehension were found from baseline to pre-training (p=0.41); however, significant improvements were demonstrated at post-training and follow-up (Gabbatore et al., 2015).

Conclusions

There is level 1b evidence that facial affect recognition training and emotional inference training is beneficial at improving the emotional perception of individuals with ABI.

There is level 1a evidence that the Treatment for Impairments in Social Cognition and Emotion Regulation and Cogniplus protocols are effective for improving emotional processing and emotional intelligence in individuals with an ABI.

There is level 1b evidence that short intervention designed to improve the ability to recognize emotional prosody was minimally effective in individuals with ABI. 

There is level 4 evidence that a Cognitive Pragmatic Treatment (CPT) program is effective in improving communicative-pragmatic abilities in individuals with ABI.

6.5.4 Alternative and Augmentative Communication

Following severe ABI, patients present with significant communication challenges that interfere with daily communication needs. Whereas those who sustain a mild or moderate ABI may be more readily able to communicate using natural speech with minor difficulties, those with severe ABI may not be able to meet communication needs through speech alone and may benefit from an augmentative or alternative communication (AAC) strategy (Bourgeois et al., 2001b; Burke et al., 2004; de Joode et al., 2012; Fager et al., 2006; Johannsen-Horbach et al., 1985). Many individuals eventually recover their speech abilities post ABI, but there are still many who remain unable to speak for extended periods of time (Fager et al., 2006). For this specific group, assessments and AAC interventions may be a continual process, ensuring that the individual’s level of function is matched appropriately with new systems as needed (Fager et al., 2006).

In the AAC domain, there are divisions of complexity that include simple, low-tech options (e.g. alphabet boards, picture-based communication boards, memory books, conversation books, day planners) and high tech options that include Voice Output Communication Aids (i.e., Dynavox, McCaw, Message Mate, Big Mack, Voice Pal and Boardmaker) (Fager et al., 2006). Notably, both low-tech and high-tech solutions to communication difficulties may have access that is either direct (i.e. touching/ pointing) or indirect (i.e. switch access or partner-assisted scanning).

Clinicians working in the area of AAC or Assistive/Enabling Technology are well acquainted with the recent explosion of technology options available. Presently, clinicians and patients have access to an extensive set of devices and peripherals including but not limited to iPad, Android, and Windows based tablets as well as a wide variety of associated applications and software (e.g. Proloquo2go, Talking Tiles). Changes in cost, improved ease of access/availability in mainstream retail, and rapid changes in the technology itself and associated applications have resulted in AAC clinical practice that is both invigorating and exhausting. Given that we are in the midst of unprecedented technology growth, the research in this area is lagging and limited.

In this particular area, difficulties sustained post ABI include verbal expression and severe dysarthria, with the primary goal of treatment being to allow individuals with severe ABI to efficiently access and communicate effectively via AAC. Particular treatment strategies for ACC may be to complete an initial assessment of the individuals needs from access and communication perspectives. From there, clinicians are able to determine the best device and method of access for individuals on a one-to-one basis (taking into account age and gender), and to allow time for training and teaching of both patient and communication partners (i.e. facilitator).

While there is a great deal of discussion around the importance of AAC, there is limited literature supporting the effectiveness of the strategies currently available for ABI populations. Further research is required in order to understand how these communication approaches or alternatives work to benefit individuals with an ABI and their care giving team.

6.5.4.1 Organizational Word Retrieval Strategies

Burke et al. (2004) studied the use of three organizational word retrieval strategies for adults with ABI who use AAC. These organizational strategies included semantic topic, geographic place, and first letter of alphabet. While the subjects retrieved words more accurately when using the alphabet organization strategy, they expressed the preference for use of the semantic topic strategy. Clinicians may consider providing these three strategies for clients using AAC and assisting with identification of the most beneficial and preferred strategy for the individual client.

6.5.4.2 Non-Electronic Communication Board

Assistive devices for AAC range in their properties and capabilities. Non-electronic communication boards, along with electronic counterparts, can aid post ABI individualswith messages and symbols depicted on the display. However, the number of messages they can display are limited, and they do not have the capacity for speech output (Iacono et al., 2011). This option would be ideal for people with complex communication needs, as they are easy to access, less expensive, and generally easier to use by patients, caregivers and clinicians.

6.5.4.3 Eye-Gaze Communication Board

Assistive technologies aim to improve outcomes in individuals with physical and cognitive impairments. Gaze-based communication boards use computers controlled by the individual’s eyes. This device replaces keyboard and mouse with eye gaze for those who have physical impairments that prevents the use of upper limb motor function (Borgestig et al., 2016). By using their eyes, individuals can control the computer and gain access to communication and activities, including playing games, music, and perform a range of activities that they would not otherwise be physically able to do (Borgestig et al., 2016). The limitation of this technology is that is not as cost effective as other AAC devices, and novice users may experience fatigue quickly, as there is a substantial learning curve with the type of specific eye movements needed to operate the communication board (it does not mimic natural/intuitive eye movements required for daily activities) (Borgestig et al., 2016).

6.5.4.4 Bliss Symbols

Bliss symbols or boards have been available and utilized for several years. The use of these symbols has been found to be very effective with those who have been diagnosed with aphasia or Broca’s aphasia (Rajaram et al., 2012). However, there is little in the literature specifically pertaining to individuals with an ABI.

6.5.4.5 Pictograms

Pictorgrams allow individuals to express their thoughts, emotions, wants and needs with pictures, as there is not a verbal explanation of all words. Pictogram-based ACC has been used for over 30 years and has been shown to help learn new linguistic skills(Pahisa-Solé & Herrera-Joancomartí, 2017).

6.5.4.6 Picture/Symbol Based Boards

Despite the surge in technology, picture and symbol-based boards remain in high use today (e.g. pictograms, Boardmaker). These symbols or pictures may represent a concept, object, activity, place or event. Symbols, pictures, and boards in general may be used with minimal training and software may be individualized (Bhatnagar SC & F, 1999). The selection of symbols should be appropriate to the individual’s communicative needs. Picture/symbol software is also available for computers, iPads, and iPhones.

6.5.4.7 Alphabet Boards

Individuals with dysarthria or who are non-verbal may benefit from an alphabet board. These boards are helpful for spelling single word or short phrase messages. Board sizes may vary depending on the person’s abilities, necessity, or access (Bhatnagar SC & F, 1999). A lexical communication board is another type of AAC that uses common words such as nouns, pronouns, verbs and adjectives to improve sentence formation in patients, however this is not supported by academic sources and therefore requires further research.

6.5.4.8 Memory Aids

The use of memory aids as an AAC tool has been studied extensively in patients with dementia and Alzheimer’s, however their use in individuals with an ABI are not well documented. There are a number of different aids that can be used to compensate for memory loss and decline of cognitive and linguistic skills. Memory books are amongst the most popular and capitalize on procedural memory skills (page turning and reading aloud), they also promote transfer of information and increase social closeness (Bourgeois et al., 2001a). Memory aids help compensate for memory loss by helping to access stored information and memories, therefore they can be an extremely effective tool that are easily accessible and straightforward to use from a patient’s perspective (Bourgeois et al., 2001a).

6.5.4.9 Synthetic Voice

Synthetic voice, or synthesized speech uses computer-generated text-to-speech synthesis to extract speech and sound components from words and then combine them to form a natural sounding voice (JL Flaubert, 2017). This differs from digitized speech, which uses human voices stored as segments of sounds waves. Synthesized speech is ideal because it allows greater message flexibility and accuracy of what the individual is trying to convey (JL Flaubert, 2017).

6.5.4.10 Sign Language

Key Points

Augmentative and alternative communication interventions designed to assist with organization, access, and efficiency of communication may be beneficial for individuals with severe ABI.

All the above AAC treatments are considered to be “aided” forms of communication, meaning they require external support by way of auxiliary materials (communication board, printed words, etc.) (Sigafoos & Drasgow, 2001). In contrast, natural gestures and sign language are forms of “unaided” AAC (Sigafoos & Drasgow, 2001)American Sign Language is the most commonly used, however there are other systems including Pidgin Signed English (PSE), and Signed Exact English (SEE). The advantages of sign language as an AAC are that it is portable (it does not require materials or devices), and it can be easier to teach than speech; communication partners, and clinicians can help individuals with hand formations (Sigafoos & Drasgow, 2001). There is no literature to support use of sign language in brain injured populations specifically, therefore more research in this field is required to make conclusions about its efficacy as a potential therapy.

 

6.6 Conclusions

Cognitive interventions target a large variety of cognitive and cognitive-communication functions and deficits. The rehabilitation of these functions is complicated by the lack of consensus on the definition of attention, cognition, and general and executive functioning.

Comparing the efficacy of various remediation efforts is also complicated by cross-study variability in treatment duration (e.g. from 30 minutes once a day for 5 days to 5 hours, every day for 6 weeks). Severity of injury and time since injury may also fluctuate from study to study. Over the past several years, Cicerone et al. (2000; 2005; 2011) reviewed a series of studies investigating the effectiveness of attentional retraining interventions during rehabilitation following traumatic brain injury and stroke. Not all patients respond equally to all intervention strategies and only a limited number of studies in the current review indicated whether severity of injury was related to the efficacy of a given intervention.

Communication impairments among this group are generally described as non-aphasic in nature (Ylvisaker M & SF, 1994). This is a different type of communication impairment than that seen following stroke, and this distinction is an important one. Communication deficits in individuals with ABI may also include aphasic-like symptoms such as naming errors and word-finding problems, impaired self-monitoring, and auditory recognition impairments. These constraints may also be coupled with other cognitive-communication impairments, such as attention and perception difficulties, impaired memory, impulsivity, and severe impairment of the individual’s overall communicative proficiency within functional situations. These constraints can prevent individuals with ABI from exhibiting even simple communication skills (Lennox & Brune, 1993). (Amos, 2002)

Technology has increased the availability of external aids, although some seem more feasible to use than others (e.g., cell phones or hand-held recorders). Unfortunately, the studies reviewed did not specify the length of time subjects required to master compensatory strategies or the nature of the long-term effects. Generally, if these electronic appliances are used before the injury, they are more likely to be used post-injury as well. It was unclear from the studies if any of the participants had previous knowledge of these tools.

Most studies examined only tasks of word list recall and paired-associate learning suggesting that the mnemonic strategies reviewed may not generalize to other types of information (particularly real-world or functional information outside the laboratory). Errorless learning appears to be one procedure that can be used to enhance learning conditions. One study highlighted the difference between severity of impairment and ability to benefit from internal strategies.

Frequency of intervention has an impact on learning and retention, although the exact parameters of this are unclear at the present time. The optimal duration of a program is also open for speculation. No studies reviewed examined the number of sessions required for memory groups to be effective and only one study evaluated a difference in effectiveness between mild and severely impaired individuals after sessions.

 

Summary


There is level 2 evidence that drill, and practice training may not be effective for the remediation of attention compared to spontaneous recovery, regardless of the level of structure in the program for those with an ABI.

There is level 2 evidence that dual task training may be effective in improving attention task performance in ABI populations compared to non-specific training.

There is level 2 evidence that neither general nor name brand computer-based rehabilitation intervention may improve attention outcomes compared to usual care in ABI populations.

There is level 4 evidence that attention performance can be improved in ABI populations through repetition of tasks, either through computer-based or virtual reality environments.

There is level 2 evidence that adaptive training is no more effective than non-adaptive training in remediating attention in ABI populations.

There is level 1b evidence that emotional regulation therapy is not effective in treating attentional disorders compared to waitlist controls in ABI populations.

There is level 1b evidence that the addition of a therapy animal to attention training programs may enhance gains in concentration in those with an ABI.

There is level 2 evidence that mindfulness training compared to no intervention may improve an individual’s ability to correctly reject inappropriate stimuli post ABI.

There is level 2 evidence to suggest goal management training, when compared to education, may be effective at improving attention in individuals post ABI

There is level 2 evidence that goal management training is more effective in remediating task completion times than motor skill training, however it is not more effective in treating attention deficits, in individuals post ABI.

There is conflicting (level 2) evidence that attentional control or processing training may not significantly improve attention in post ABI individuals compared to control training.

There is level 4 evidence that summation tasks may be effective at improving attention in individuals post ABI.

There is level 4 evidence that a working memory training program may remediate attention in individuals post ABI.

There is level 4 evidence that cognitive rehabilitation therapy may not be effective for improving attention post ABI.

There is level 2 evidence that transcranial direct current stimulation when combined with an attention training program (compared to sham stimulation) may improve divided attention in individuals post ABI 

There is level 1b evidence that repeated transcranial magnetic stimulation compared to sham stimulation may improve attention following an ABI. 

There is conflicting level 1b (positive) and level 2 (negative) evidence that donepezil may improve attention compared to placebo post ABI.

There is conflicting level 1a evidence regarding the effectiveness of methylphenidate following brain injury for the improvement of attention and concentration in individuals post ABI.

There is level 1a evidence that methylphenidate improves reaction time of working memory compared to placebo in individuals post ABI.

There is level 1b evidence that individuals carrying the Met allele may be more responsive to methylphenidate than those without the Met allele when it comes to the ABI population.

There is conflicting evidence as to whether bromocriptine improves performance on attention tasks compared to placebo in patients post TBI.

There is level 4 evidence that cerebrolysin may improve attention scores post ABI.

There is level 1b evidence that Rivastigmine compared to placebo is not effective for improving concentration or processing speed in post ABI individuals but may increase vigilance.

There is level 1b evidence that amantadine is not effective for improving attention compared to placebo following an ABI.

There is level 4 evidence that hyperbaric oxygen therapy may improve both attention and processing speed following an ABI.

There is level 1b evidence that dextroamphetamine does not improve attention following an ABI.

There is level 4 evidence that the NeuroPage system may increase a patient’s ability and efficiency to complete tasks post TBI.

There is level 2 evidence that voice organizer programs are effective at improving recall of goals and are found to be effective by post TBI patients.

There is level 1b evidence that the use of a personal digital assistant (PDA) in combination with conventional occupational therapy is superior to occupational therapy alone at improving memory in patients post TBI.

There is level 2 evidence that personal digital assistants (PDAs) are superior to a paper-based schedule book at improving task completion rates post TBI.

There is level 1b evidence that use of a personal digital assistant (PDA) after receiving systematic instructions is superior to PDA trial and error learning at improving the number and speed of correct tasks post TBI.

There is level 1b evidence that reminder text messages sent to patients through their smartphones, whether alone or in combination with goal management training, improves goal completion post TBI.

There is level 2 evidence that a television assisted prompting (TAP) system is superior to traditional methods of memory prompting (paper planners, cell phones, computers) at improving the amount of completed tasks post TBI.

There is level 1b evidence that the audio-verbal interactive micro-prompting system, Guide, can reduce the amount of support-staff prompts needed for the patient to complete a task post TBI.

There is level 4 evidence that a computerized tracking system that sends reminders to patients when they are moving in the wrong direction reduces the amount of support-staff prompts needed for patients to complete a task post TBI.

There is level 2 evidence the use of an electronic calendar is superior to the use of a diary for improving memory in individuals with an ABI.

There is level 2 evidence that the presence of a diary with or without self-instructional training improves memory following an ABI.

There is level 2 evidence that the presence of a calendar may not improve orientation post ABI.

There is level 2 evidence that diary training in combination with self-instructional training may be more effective than diary training alone at improving memory and task completion post ABI.

There is level 4 evidence that virtual reality (VR) training may improve learning performance post ABI, even in the presence of distractions.

There is level 2 evidence that virtual reality training combined with exercise may be promising for improving memory outcomes and has a positive impact on visual and verbal learning when compared to no treatment.

There is level 2 evidence that virtual reality training may be superior to reading skills training at improving immediate and general components of memory for those with an ABI.

There is level 2 evidence that the format of route learning (either real or virtual reality based) does not significantly impact any improvements in memory as a result of route learning strategies for those with an ABI.

There is level 1b evidence to support self-imagination as an effective strategy to improve memory compared to standard rehearsal for those with an ABI.

There is Level 2 evidence to support that spaced retrieval training is an effective memory strategy when compared to massed retrieval or rehearsal in ABI populations.

There is level 2 evidence that strategies that utilize methods of multiple encoding, compared to strategies which only use singular methods, are more superior for improving memory post ABI.

There is level 4 evidence that errorless learning is more effective than errorful learning when it comes to improving memory in ABI populations.

There is level 1b evidence that hypnosis compared to no treatment may not be effective at improving memory in individuals post ABI.

There is level 1b evidence that individual memory therapy is no more effective than group memory therapy for those with an ABI.

There is level 2 evidence that programs involving multiple learning strategies (such as modelling, reciting, verbal instruction, and observation) are more effective than singular strategies for those with an ABI.

There is level 1b evidence that the Short Memory Technique may not be more effective than standard memory therapy at improving memory in individuals post ABI.

There is level 1b evidence that the Categorization Program, and Strategic Memory and Reasoning Training (SMART) may be effective for improving memory compared to standard therapy in individuals with an ABI.

There is level 2 evidence that time pressure management training is no more effective than concentration training at improving memory for those with an ABI.

There is level 2 evidence that N-back training compared to virtual search training is not effective for improving memory in those with an ABI.

There is level 4 evidence that Cognitive Pragmatic Treatment, Cogmed QM, and RehaCom software may improve memory and cognitive function in those with an ABI.

There is level 2 evidence that participation in a goals training program, followed by an educational program, may be more effective for improving memory in post ABI individuals compared to receiving the treatment conditions in reverse order.

There is level 2 evidence that finger sequence training, compared to no training, may not be effective for improving memory following an ABI.

There is level 1b evidence that compensatory memory strategies, self-awareness training, and participation in memory group sessions may be effective for improving memory in post ABI individuals compared to no treatment.

There is level 2 evidence that general memory rehabilitation programs are effective, compared to standard therapy, at improving memory for those with an ABI.

There is level 2 evidence that the Intensive Neurorehabilitation Programme is not effective for improving memory compared to controls in those with an ABI.

There is level 2 evidence that both computer-administered and therapist-administered memory training may be more effective than no treatment for improving memory in ABI participants. However, no treatment appears to be better than the other.

There is level 2 evidence that both cognitive remediation and emotional self-regulation may be effective at improving different elements of memory in individuals post ABI.

There is level 2 evidence that non-specific computer-based memory retraining compared, self-paced or otherwise, may not be effective at improving memory in those with an ABI.

There is conflicting level 1b evidence as to whether or not attention training programs may be effective for improving memory compared to no therapy, but positive level 1b evidence that it is not more effective than memory training programs.

There is level 2 evidence that BrainHQ is not an effective program for improving memory and learning compared to no intervention in individuals post ABI.

There is level 4 evidence that using mental representations and role-playing may not be effective at improving memory in individuals post ABI.

There is level 4 evidence that Cogmed training software may improve working memory performance and occupational performance in individuals post ABI.

There is conflicting (level 4) evidence regarding whether or not Parrot software is effective at improving memory and learning in individuals post ABI.

There is level 4 evidence that mental addition tasks may improve working memory in individuals post ABI.     

There is level 4 evidence that the Wilson’s Structured Behavioral Memory Program is not effective for improving memory post ABI.

There is level 1b evidence that cranial electrotherapy stimulation may not improve memory and recall compared to sham stimulation post TBI.

There is level 1b evidence that donepezil improves short-term memory compared to placebo post ABI.

There is level 4 evidence that donepezil may be effective in improving short-term, long-term, verbal, and visual memory post ABI.

There is level 1b evidence that methylphenidate compared to placebo is not effective for improving memory following brain injury for post TBI patients.

There is level 1b evidence that sertraline may not improve memory compared to placebo in individuals who have sustained a moderate to severe TBI.

There is level 1b evidence that amantadine does not improve learning and memory deficits in patients post ABI.

There is level 2 evidence that pramiracetam may improve males’ memory compared to placebo post TBI. 

There is level 1b evidence that oral physostigmine may improve long-term memory compared to placebo in men with TBI, however more recent studies are required.

There is level 2 evidence that bromocriptine may improve verbal memory in individuals with an ABI, however, more studies are required.

There is level 4 evidence that cerebrolysin may improve memory function post ABI.

There is level 1b evidence that recombinant human Growth Hormone (rhGH) is similar to placebo for improving memory and learning in patients post TBI.

There is level 2 evidence that growth hormone (GH) therapy is similar to placebo at improving memory ability in patients post TBI.

There is level 1a evidence that rivastigmine is not effective when compared to placebo for improving memory in ABI populations.

There is level 4 evidence that hyperbaric oxygen therapy may improve memory following an ABI.

There is level 1b evidence that targeted hypnosis may transiently improve cognitive function in post TBI patients or stroke.

There is level 1b evidence that an attention remediation intervention may not be superior to TBI education alone and improving executive function in patients post TBI.

There is level 2 evidence that dual-task training may improve not general cognitive functioning compared to a non-specific cognitive program in patients post TBI.

There is level 1b evidence that a comprehensive cognitive treatment strategy programs (which include problem solving), compared to controls, are effective for improving metacognition and goal achievement post TBI.

There is level 4 evidence that cognitive rehabilitation may increase productivity in everyday functioning, and cerebral blood flow during treatment in patients post TBI.

There is level 1b evidence that virtual-reality training is not superior to conventional cognitive training at improving cognitive and executive function outcomes post TBI.

There is level 1b evidence that the specific cognitive training program ProSolv, compared to standard therapy, does not improve measures of executive functioning following an ABI.

There is level 2 evidence that the Intensive NeuroRehabilitation programme, compared to no treatment, does not improve executive functioning following an ABI. 

There is level 2 evidence that computer or smartphone software programs, such as BrainHQ, Parrot Software, ProSolv app, may not be superior to no intervention at improving problem-solving skills and general functioning in patients post TBI.

There is level 4 evidence that heart rate biofeedback may improve executive functioning following an ABI, although higher level studies are required to fully determine this.

There is level 2 evidence that goal management training may be superior (compared to motor skills training or no treatment controls) for improving goal attainment or measures of intelligence following an ABI.

There is level 1b evidence that goal orientated group interventions are successful at improving cognitive and executive function in patients post ABI.

There is level 1b evidence that emotional regulation group interventions are effective at improving executive function in post TBI patients compared to standard therapy.

There is level 1b evidence that the Strategic Memory and Reasoning Training program is more effective than a brain health workshop for improving executive function, metacognition, and comprehension following ABI.

There is level 4 evidence that metacognitive strategy instruction may not be effective for improving executive functioning following an ABI.

There is level 4 evidence that touch screen-based games (which include components of reasoning and problem-solving) may be effective for improving self-awareness and social skills following an ABI.

There is level 1b evidence that cognitive therapies compared to standard therapy are more effective than no therapy for improving generalized cognitive functioning, as well as self-perception following an ABI.

There is level 4 evidence that a low intensity outpatient cognitive rehabilitation program may improve goal attainment and cognitive impairment in patients post ABI.

There is level 2 evidence that the Trabajadora de Salud program may improve general cognitive functioning compared to standard therapy for those with an ABI.

There is level 1b evidence that corrective video feedback is more effective for improving generalized cognitive functioning and self awareness compared to verbal feedback only in those with an ABI.

There is level 1b evidence that remedial occupational therapy and adaptive occupational therapy may have equal effects on generalized cognitive function in those with an ABI.

There is level 4 evidence that mindfulness-based stress reduction may be effective for improving general cognitive functioning and psychological health for those with an ABI.

There is level 4 evidence that donepezil is effective in improving learning, memory, divided attention, and executive function in patients post TBI.

There is conflicting (level 1a) evidence regarding the effectiveness of the administration of methylphenidate, compared to placebo, following TBI for the improvement of general and executive functioning.

There is level 1b evidence that sertraline does not improve cognitive functioning, compared to placebo, in individuals who have sustained a moderate to severe TBI.

There is level 1b evidence that Amantadine may not help to improve general functioning deficits in post TBI patients compared to placebo.

There is conflicting level 2 (against) and level 4 (for) evidence as to whether or not bromocriptine may improve executive or general cognitive functioning following ABI.

There is level 1b evidence that recombinant human Growth Hormone (rhGH) is superior to placebo at improving processing speed (6 months), executive function and learning in patients post TBI.

There is level 2 evidence that growth hormone (GH) therapy is effective for improving quality of life, instrumental activities of daily living (iADL), attention, memory, and visuospatial ability in patients post TBI.

There is level 2 evidence that recombinant human Growth Hormone (rhGH) administration improves intelligence and other cognitive subtests in TBI patients with growth hormone deficiency compared to TBI patients without; however, insulin-like growth factor-1 (IGF-1) levels may be the same between groups.

There is level 1b evidence that rivastigmine is not effective for improving general or executive cognitive functioning, compared to placebo, following an ABI.

There is level 4 evidence that hyperbaric oxygen therapy may improve general and executive functioning following an ABI.

There is level 1b evidence that dextroamphetamine is not effective for the remediation of general cognitive functioning following an ABI.

There is level 1b evidence that yes/no training and an enriched environment does not significantly improve communication responses in individuals with an ABI.

There is level 4 evidence that retrieval practice is more effective for memory recall in individuals with an ABI than massed restudy (i.e., cramming) and spaced restudy (i.e., distributed learning).

There is level 4 evidence that targeted therapy towards figurative language improves communication in chronic TBI individuals.

There is level 4 evidence that text-to-speech technology improves reading rates post ABI but not reading comprehension.

There is level 4 evidence that cognitive-communication therapy targeting the interpretation of figurative language is effective for improving language and metaphor comprehension following an ABI.

There is level 1b evidence that the Social Cognition and Emotion Regulation protocol when administered by a neuropsychologist is more effective for the remediation of social communication skills than the Cogniplus protocol in individuals with an ABI.

There is level 1b evidence that a variety of communication skills training programs improve social communication skills in individuals with an ABI, as well as self-concept and self-confidence in social communications.

There is level 4 evidence suggesting that a goal-driven, metacognitive approach to intervention may be beneficial in assisting individuals with TBI to achieve social communication goals.

There is level 4 evidence that interactive touch screen games focused on areas of reasoning, knowledge and action may be effective for improving social skills following an ABI.

There is level 2 evidence that the Group Interactive Structured Treatment program (GIST) is effective for improving social communication skills in those with a TBI as well as other neuropsychological comorbidities.

There is level 2 evidence to support the effectiveness of interventions that focus on training communication partners in the community, compared to no training, for improving interactions between responders and those with an ABI. 

There is level 2 evidence that providing training to both the communication partner and the individual with a TBI together is more effective than only training the individual with TBI alone or no training at all.

There is level 1b evidence that facial affect recognition training and emotional inference training is beneficial at improving the emotional perception of individuals with ABI.

There is level 1a evidence that the Treatment for Impairments in Social Cognition and Emotion Regulation and Cogniplus protocols are effective for improving emotional processing and emotional intelligence in individuals with an ABI.

There is level 1b evidence that short intervention designed to improve the ability to recognize emotional prosody was minimally effective in individuals with ABI. 

There is level 4 evidence that a Cognitive Pragmatic Treatment (CPT) program is effective in improving communicative-pragmatic abilities in individuals with ABI.

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