Author Year

Country

Research Design

PEDro

Sample Size

Gracey et al. (2017)

UK

RCT

PEDro=6

N_Initial=74, N_Final=59

Population: CVA=23, Infection=3, TBI=33, Tumor=10, Missing=1. Control First (n=34): Mean Age=50.18 yr; Gender: Male=23, Female=11; Mean Time Post Injury=8.62 yr. Assisted Intention Monitoring (AIM, n=36): Mean Age=46.36 yr; Gender: males=23, females=13; Mean Time Post Injury=4.89 yr.

Intervention: Participants were randomized to receive AIM or control first. In the AIM-first group, participants received goal management training followed by text messages for improving achievement of everyday intentions. Control-first group received brain injury information, Tetris game, and non-informational text messages. After 3 wk, participants were crossed over with AIM-first group receiving usual care and control-first group receiving AIM.

Outcome Measures: Mean daily proportion of intentions achieved, Achievement of all goals excluding the phone call task, Profile of Mood States total mood disturbance (POMS MD), Hotel Task, Verbal Fluency.

1.       Participants achieved a greater proportion of intentions during the AIM intervention relative to control (p=0.040).

2.       Participants achieved a greater proportion of goal attainment (without the phone call task) during the AIM intervention relative to control (p=0.033).

3.       No significant Group x Time interaction effect was found for the POMS MD or Hotel Test.

4.       When only comparing group differences at post-intervention phase 1, intention to treat analysis showed no significant difference between groups for proportion of intentions achieved or achievement of goals excluding the phone task.

Lindelov et al. (2017)

Denmark

RCT

PEDro=7

N=68

Population: TBI=34, Stroke=20, Other=12, NA=2. Group A (n=27): Mean Age=45.2 yr; Gender: Male=12, Female=15; Mean Time Post Injury=5 yr. Group B (N=22): Mean Age=47.0 yr; Gender: males=8, females=25; Mean Time Post Injury=6.5 yr. Control Group (n=19): Mean Age=54.1 yr; Gender: males=8, females=11; Mean Time Post Injury=7 yr.

Intervention: Participants were randomly assigned to Group A or Group B; Control group was recruited separately and received no intervention. In Phase 1, Group A received the first version of a targeted hypnosis procedure (improving brain injury or working memory-relating abilities) and Group B received a non-targeted hypnosis procedure (4 weekly 1 h sessions). After a 7 wk break, Phase 2 occurred, with Group A receiving a second version of a targeted hypnosis procedure and Group B receiving the first version of a targeted hypnosis procedure.

Outcome Measure: Working Memory Index (WMI), B-A Trail Making Index (TMT).

1.       In Phase 1, there was significantly more improvement in Group A compared to Group B for WMI (Bayes factor=342) and TMT (Bayes factor=37.5).

2.       After the break, the WMI and MT showed no significant differences for either groups compared to before the break.

3.       In Phase 2, Group B crossed over to the targeted intervention and showed significant improvements in WMI (Bayes factor=535) and TMT (Bayes factor=72813). Group A showed a small improvement for WMI (Bayes factor=1.5) and TMT (Bayes factor=30).

4.       From baseline to last test, there were no significant difference in improvements between Group A and Group B for WMI and TMT.

Powell et al. (2017)

USA

RCT

PEDro=4

N=23

Population: TBI=17, Stroke/aneurysm=4, Other=6, More than 1 brain injury=3; Mean Age=44 yr; Gender: Male=11, Female=12; Mean Time Post Injury=4 yr.

Intervention: Coaches were randomly assigned to ProSolv intervention or usual care. Participants new to the outpatient rehabilitation programme were randomized to coaches and clients already working with coaches were offered the opportunity to participate in the study with that coach. In six 1 h sessions over 8wk, ProSolv group (n=14) received training on using ProSolv app and Usual Care group (n=9) received usual care including training in goal planning/management, time pressure management, and problem-solving skills. ProSolv group had access to the ProSolv app outside of the sessions as a resource for remembering steps to effective problem solving and creating personalized problem-solution lists.

Outcome Measure: Project-specific knowledge test, Problem Solving Questionnaire (PSQ clear thinking and emotional self-regulation subscales), Problem Solving Rating Scale (PSRS), TBI Self-Efficacy Questionnaire (TBI-SE), Satisfaction with Life Scale (SWLS), System Usability Scale (SUS).

1.       No significant differences between groups were found for knowledge test, PSQ clear thinking, PSQ emotional self-regulation, TBI-SE, or SWLS.

2.       The average SUS score reported at post-test was 3.5 for the tutorial and 3.6 for the app, suggesting that on average, ProSolv participants were slightly higher than neutral on whether the programme components were usable.

Jacoby et al. (2013)

Israel

RCT

PEDro=7

N=12

Population: TBI; Experimental group (EG; n=6): Mean Age=27.83 yr; Gender: Male=4, Female=2; Mean Time Post Injury=126 d; Mean GCS=8. Control group (CG; n=6): Mean Age=30.67 yr; Gender: Male=4, Female=2; Mean Time Post Injury=100 d; Mean GCS=6.25.

Intervention: Participants were randomly assigned to the EG group or the CG group. All participants in the EG received 10 sessions of virtual reality (VR) training (45 min/session, 3-4 x/wk). The CG received general cognitive re-training treatment identical in length and duration to the EG.

Outcome Measure: Multiple Errands Test – Simplified Version (MET-SV), Executive Function Performance Test (EFPT).

1.       Participants in the EG group improved more in their final scores on the MET-SV relative to their initial scores compared to the CG group (p=0.046).

2.       Participants in the EG improved more in their final scores on the EFPT relative to their initial scores compared to the CG (p=0.046).

3.       Between group differences showed no significant difference at baseline.

Man et al.

(2013)

Hong Kong

RCT

PEDro=4

N=40

Population: TBI. Age Range=18-55yr; Gender: Unspecified; Time Post Injury: Unspecified; Mean GCS=10.

Intervention: Participants received twelve 20-25 minute sessions of a vocational problem-solving skill training program. Participants were randomized to either artificial intelligence virtual reality (treatment group, TG) or conventional psychoeducation (control group, CG). Outcomes were assessed before and after treatment, and at follow-up of 1, 3, and 6 months.

Outcome Measures: Wisconsin Card Sorting Test (WCST); Tower of London Test (TLT); Vocational Cognitive Rating Scale (VCRS); Self efficacy (SE); Vocational outcomes.

1.       Both groups showed significant improvements on WCST, TLT, VCRS, SE, and vocational outcomes after treatment compared to baseline (p<0.050).

2.       On WCST, the TG performed better than the CG after treatment (p<0.020). No other significant between-group differences were found.

Couillet et al. (2010)

France

RCT

PEDro=5

N=12

Population: severe TBI; Gender: Male=9, Female=3. Group 1 (n=5): Mean Age=23.8 yr; Mean GCS=4.8; Mean Time Post Injury=6.3 mo. Group 2 (n=7): Mean Age=26.7 yr; Mean GCS=4.8; Mean Time Post Injury=16.1 mo.

Intervention: Randomized AB versus BA design, where “A” represents the control phase and “B” represents the treatment (dual-task training) phase. In the dual-task phase, patients were trained to conduct two concurrent tasks simultaneously. Group 1 started with the control phase (AB) and Group 2 (BA) with the treatment phase. Each phase lasted 6 wk (4, 1 hr sessions/wk).

Outcome Measure: Test Battery for Attentional Performance (TAP: divided attention and flexibility subtests), Go-no go and Digit Span, Trail Making Test, Stroop Test, Brown-Peterson Paradigm, Rating Scale of Attentional Behaviour.

1.       Following training, there was a significant improvement in the 2 tasks that targeted divided attention (TAP-divided attention, Go-no go and Digit Span: p<0.0001 for both).

2.       The two groups differed significantly at 6 wk with those in the BA design doing better on TAP reaction times (p<0.010), the digit span dual-task (p<0.001), and the Rating Scale of Attentional Behaviour (p<0.010).

3.       There was a significant difference between groups at 6 wks on the Stroop test (p<0.001) and the flexibility subtest of the TAP (p<0.001), but not the Trail Making Test or the Brown-Peterson task.

4.       Experimental training had no significant effects on non-target measures.

Spikman et al. (2010)

Netherlands

RCT

PEDro=7

N=75

Population: Mean Age: 42.5 yr; Gender:  male=50, female=25; Condition: TBI=33, Stroke=32, Other=10.

Intervention: Individuals were randomly assigned to either the experimental group which comprised of multifaceted strategy training (n=38) or the control group (n=37). The primary goal of the treatment group was to improve 8 aspects of executive functioning.

Outcome Measure: Role resumption list (RRL); treatment goal attainment (TGA) and Executive Secretarial Task (EST).

Levack et al. (2009)

(Levack et al., 2009)

New Zealand

RCT

PEDro=5

N=34

Population: GMT (N=12): Median age=29; Gender: Male=10, Female=2; Median time post-injury=5yr. IOGT (N=10): Median age=28yr; Gender: Male=9, Female; Median time post-injury=5yr. Usual Care (N=12): Median age=40; Gender: Male=8, Female=4; Median time post-injury=7.

Intervention: Individuals were assigned to either no treatment, goal management training, or identity oriented goal training.

Outcomes: Goal Attainment Scale, behavioral observations.

Constantinidou et al. (2008)

United States

RCT

PEDro=8

N=14

Population: Experimental Group (N=21): Mean age=32.1yr; Mean time post-injury=9.74 mo. Control Group (N=14): Mean age=27.57yr; Mean time post-injury=10.55 yr.

Intervention: Individuals received either the Categorization Program intervention for 13 weeks averaging 4.5 hours of therapy per week, or ‘regular therapy’ (control group).

Outcomes: CP Test 1 (object recognition/memory), CP Test 2 (executive functioning), CP Probe Tasks (executive functioning), Community Reintegration Questionnaire (CIQ), Mayo-Portland Adaptability Inventory (MPAI-3), California Verbal Learning Test (CVLT), Rey Complex Figure Test (RCF), Wechsler Memory Scale (WMS-III), Woodcock Johnson (WJ-III), Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI).

1.       The experimental group significantly improved on CP Test 1 (object recognition) compared to the control group (p=0.039).

2.       Individuals in the experimental group performed significantly better on the CP Test 2 (executive functioning) compared to the control group post-intervention (p=0.010).

3.       Individuals in the experimental group performed significantly better on the probe tasks, compared to controls, post-treatment (p=0.008).

4.       Individuals in both groups significantly improved performance on the CIQ and MPAI-3 (p<0.05).

5.       The experimental group had greater improvement on the CVLT-R.

6.       There were no differences in scores between groups on the RCF, WMS-III, WJ-III, SCATBI.

Levine et al. (2000)

Canada

UK

RCT

PEDro=4

N=30

Population: TBI: Goal Management Training (GMT) Group (n=15): Mean Age=29.0 yr; Gender: Male=5, Female=10; Mean GCS=10.7; Mean Time Post Injury=3.7 yr. Motor Skill Training (MST) Group (n=15): Mean Age=30.8 yr; Gender: Male=9, Female=6; Mean GCS=10.8; Mean Time Post Injury=3.8 yr.

Intervention: Patients were randomized into the GMT or MST group. The GMT was comprised of five steps: 1) orienting and alerting to task, 2) goal selection, 3) partitioning goals into sub-goals, 4) encoding and retention of sub-goals, and 5) monitoring. The MST was training that was unrelated to goal management: reading and tracing mirror-reversed text and designs. Participants were tested on everyday paper and pencil tasks that focused on holding goals in mind, sub-goal analysis and monitoring.

Outcome Measure: Goal Neglect (Everyday paper and pencil tasks), Stroop Interference Procedure, Trail Making A and B, Wechsler Adult Intelligence Scale Revised (WAIS-R).

Everyday paper and pencil Task

1.      The GMT group compared to the MST group had significantly greater accuracy on the everyday paper and pencil tasks post-training (p<0.050).

2.      The MST group also had significantly more errors during the everyday paper and pencil tasks (p<0.010).

3.      The GMT group significantly reduced their errors from pre-post training during the everyday paper and pencil tasks (p<0.010).

4.      The GMT also devoted significantly more time to proofreading and the room-layout tasks than the MST group from pre to post-training (p<0.050).

Neuropsychological Tasks

1.      The GMT group was generally slower on timed neuropsychological tests: Stroop Interference Procedure, Trail Making Part A and B (p<0.050 and p<0.060, respectively).

2.       No significant differences between groups for the WAIS-R (p>0.050).

Sohlberg et al. (2000)

USA

PEDro=8

N=14

Population: TBI=11, ABI=1, Other=2. Attention Process Training (APT) Group (n=7): Mean Age=33.1 yr; Mean Time Post Injury=7.5 yr; Control Group (n=7): Mean Age=38.1 yr; Mean Time Post Injury=1.6 yr.

Intervention: Patients were randomized to receive either the APT training (treatment) or the brain injury education and supportive listening (control), in a cross over design. APT was 24 hr over 10 wk and the control group received 10 hr over 10 wk. All subjects worked directly with a therapist and assessed pre and post intervention.

Outcome Measure: Trail Making Test, Paced Auditory Serial Addition Task (PASAT), Gordon Diagnostic Vigilance and Distraction, Controlled Oral Word Association Task (COWAT), Stroop Task, Attention Questionnaire.

1.       Those in the APT group reported significantly more changes than the control group (0.91 and 0.58 respectively, p<0.050).

2.       The effect of type of change was significant (p<0.0001); a greater number of memory/ attention changes were reported for the APT group, whereas more psychological changes were reported for the control.

3.       Changes in PASAT scores corresponded with perceived cognitive improvement in the interview; changes in PASAT scores were greater for those who reported >2 cognitive changes (p<0.050).

4.       Results of the PASAT, Stroop Task, Trail Making Test B, and COWAT also found that those with higher levels of vigilance had improved scores (p<0.01).

5.       For the aforementioned tasks, there were also specific improvements in performance associated with APT that were greater than those associated with brain injury education (p<0.050).

Webb & Glueckauf (Webb & Glueckauf, 1994)

United States

RCT

PEDro=6

N=16

Population: Mean age=27.4yr; Mean time post-injury=8.7yr; Mean coma duration=88.9dy.

Intervention: Participants were randomly assigned to a high involvement goals setting program or a low involvement program for 8 weeks meeting 1 hour per week. Individuals were assessed pre-intervention, post-intervention, and at 2-month follow-up.

Outcomes: Goal Attainment Scale (GAS).

1.       There were no significant between group differences at baseline.

2.       Both groups significantly improved on the GAS over time regardless of condition (p<0.001) post-treatment.

3.       The high involvement group showed significant additional gains on the GAS compared to the low involvement group at 2-month follow-up (p<0.05).

Hollerman et al. (2018)

Netherlands

PCT

N=75

Population: Experimental Group (N=42): Mean age=43.3yr; Gender: Male=27, Female=15; Mean time post-injury=7.9yr. Control Group (N=33): Mean age=40.7yr; Gender: Male=20, Female=13; Mean time post-injury=6.9yr.

Intervention: Participants were either assigned to the Intensive NeuroRehabilitation programme or the control group. The programme took place over the course of 16 weeks and consisted of 2 groups of 7 weeks of training with a 2-week break in between. Individuals had 5 hours of training 4 days a week in a group setting.

Outcomes: Symptom checklist (SCL), Beck Depression Inventory-II (BDI-II), Hospital Anxiety and Depression Scale (HADS), Zelfbeeldenvragenlijst-trait (ZBV), Quality of Life in Brain Injury (QOLIBRI), Trail making test Part A, Stroop test, Wechsler Adult Intelligence Scale-III (WAIS-III), Rey Auditory Verbal Learning Test, Rivermead Behavioural Memory Test, Groninger Intelligentie Test 2, Trail making test Part B.

1.       There were no significant between group differences pre-intervention on any measures.

2.       Following the intervention, the experimental group had significantly lower SCL scores indicating a reduction in overall symptoms (p=0.005).

3.       On measures of neuropsychological functioning, the experimental group reported significantly lower scores on the BDI-II (p=0.001), HADS (p<0.01), and ZBV-trait (p=0.002) showing improvement on these neuropsychological measures.

4.       The experimental group reported significantly higher scores for quality of life on the QOLIBRI (p<0.05).

5.       On measures of cognitive functioning no significant differences were seen for any outcome measures.

Kim et al. (2018)

United States

Pre-post

N=13

Population: Median age=40yrs; Gender: Male=7, Female=6; Median time post-injury=23yr.

Intervention: Heart rate variability biofeedback training was conducted for 10 1-hour sessions. After the fourth session individuals were given a portable biofeedback device to take home and self-monitor.

Outcomes: Category Test (CT), Heart rate variability index (HRV), Positive Affect and Negative Affect Schedule (PANAS).

1.       HRV biofeedback significantly improved CT scores (p<0.05), this effect was magnified by those experiencing positive affects during treatment as measured by the PANAS.

2.       No other significant results were found.

Dahdah et al. (2017)

USA

Pre-Post

N_Initial=21

N_Final=15

Population: CVA=6, TBI=5, Tumor=2, Anoxia brain injury=2; Mean Age=40.3 yr; Gender: Male=12, Female=3.

Treatment: Participants received the virtual reality (VR) intervention sessions (apartment and classroom) twice per week for a 4 wk period. Sessions 1 and 8 included all types of distractors, sessions 2 and 3 included no distracting stimuli, sessions 4 and 5 included only auditory distracting stimuli, and sessions 6 and 7 included only visual distracting stimuli.

Outcome Measure: Woodcock-Johnson, 3^rd edition (WJ-III pair cancellation subtest), Delis-Kaplan Executive Function System (D-KEFS Color-Word Interference subtest), Automated Neuropsychological Assessment Metrics (ANAM Go/No-Go and unimodal Stroop subtests), VR Stroop task (apartment and classroom).

1.       No statistically significant performance differences were found from baseline to conclusion of the study for the VR apartment Stroop or D-KEFS Stroop test.

2.       For the VR classroom, participants’ shortest response time on the word-reading condition was significantly reduced by session 8 (p=0.0383). All other VR classroom Stroop variables did not show significant differences.

3.       No significant differences from session 1 to session 8 were found for all pair cancellation subtest scores.

4.       From session 1 to 8, the ANAM Stroop word-reading percentage of items with a correct response (p=0.0293), ANAM Stroop word-reading number of correct responses per minute (p=0.0321), and ANAM Go/No-Go number of impulsive/bad responses (p=0.0408) significantly increased. All other ANAM variables did not show significant differences.

O’Neil-Pirozzi and Hsu (2016)

PCT

N_Initial=14

N_Final=12

Population: TBI=4, CVA=2, Brain tumour=1; Severity: moderate/severe. Experimental Group (n=7): Mean Age=51.3 yr; Gender: Male=5, Female=2; Mean Time Post Injury=20.9 yr; Etiology: TBI=5, CVA=2. Control Group (n=7): Mean Age=46.9 yr; Gender: Male=7; Mean Time Post Injury=25.0 yr.

Treatment: Experimental group participants received BrainHQ, a commercially available online computerized cognitive exercise program (Attention, Brain Speed, Memory, People Skills, Intelligence, and Navigation) for 5 mo, 5 d/wk. Control group participants did not have a private computer and received no intervention.

Outcome Measure: Number/Percentage of Sessions Completed, Number/Percentage of Sessions Initiated by Participants, Number/Percentage of Sessions Completed Independently by Participants, Mean Amount of External Cures Provided for Session Completion, Wisconsin Card Sorting Test (WCST), Hopkins Verbal Learning Test-Revised (HVLT-R immediate, delayed), Controlled Oral Word Association Test-FAS (COWAT), Trail Making Test (TMT A and B accuracy and speed), Satisfaction with Life Scale (SWLS), Semi-structured interview questions.

1.       Of the five experimental group participants that completed the study, they completed an average 87% of sessions, initiated an average 25% of sessions, and independently completed an average 7% of sessions. Two participants needed minimum external cues, two participants needed moderate external cures, and one participant needed maximum external cues.

2.       Comparing 3 mo prior to intervention with 1 wk prior to intervention, there were no significant differences within either group for WCST, HVLT-R, COWAT, TMT A or B, or SWLS.

3.       There were no significant differences between groups at 1 wk prior to intervention (baseline) for WCST, HVLT-R, COWAT, TMT A or B, or SWLS.

4.       Compared to baseline, experimental group showed significant improvement post-intervention for HVLT-immediate (p=0.0255) and SWLS (p=0.0075). There were no significant improvements for WCST, HVLT-delayed, or TMT A or B.

5.       Compared to baseline, control group did not show significant differences post-intervention for WCST, HVLT, TMT A or B, or SWL.

6.       Compared to control group, experimental group showed significantly higher post-intervention improvements on HVLT-immediate (p=0.0068) and COWAT (p=0.0310). No significant differences between groups were found for changes in WCST, HVLT-delayed, TMT A or B, or SWL.

7.       Of the experimental group participants who completed the study, 60% reported improved everyday thinking abilities, 60% reported improved memory, and 20% reported improved attention, organization, and/or problem solving skills, but 60% reported they would not continue with exercise program post-study completion.

Li et al. (2015)

USA

Pre-Post

N_Initial=13

N_Final=12

Population: Stroke=5, TBI=5, Brain tumor=2; Mean Age=61 yr; Gender: Male=10, Female=2.

Treatment: Participants received the computer-based cognitive retraining program, Parrot Software. The following eight modules were each completed in separate 1 h sessions: Visual Instructions, Attention Perception and Discrimination, Concentration, and Visual Attention Training, Remembering Written Directions, Remembering Visual Patterns, Remembering Written Letters, and Remembering Written Numbers.

Outcome Measure: Montreal Cognitive Assessment (MoCA overall, attention, memory), Medication-box sorting task.

1.       Compared to baseline, there was a significant mean increase in overall MoCA of 3.25 (p=0.030) post-intervention. However, the attention and memory subscales did not show significant differences.

2.       There were no significant differences before and after intervention for the medication-box sorting task.

3.       Participants with previous computer-based cognitive retraining experience had significantly more MoCA improvement than those without (p<0.010).

4.       Age, education level, or type of ABI diagnosis did not have any significant effects on MoCA or medication-box scores.

Fong & Howie (2009)

China

PCT

N=33

Population: Mean age=33.4yr; Gender: Male=27, Female=6; Mean time post-injury=12.3 mo.

Intervention: The experimental group received an enhanced cognitive training program in addition to the standard cognitive rehabilitation training program received by the control group.

Outcomes: Key Search test, Social Problem-Solving Video Measure (SPSVM), Means-Ends Problem-Solving Measure (MEPSM), Raven’s Progressive Matrices (RPM), Metacomponential Interview (MI).

1.       No significant differences were found on the Key Search test, the SPSVM, RPM, or the MEPSM between groups following intervention.

2.       There were significant between group differences on two of the categories for the MI; correctness of representation scores (p=0.041), and total average correct scores (p=0.009). No other significant differences were found.

Laatsch et al. (1999)

USA

Case Series

N=5

Population: TBI; Age Range=18-65 yr; Time Post-Injury=2-48 months;

Intervention: Cognitive rehabilitation therapy (CRT) programme in a longitudinal protocol involving a resting SPECT and neuropsychological evaluation are pre-treatment, post-treatment and post non-treatment intervals.

Outcome Measure:  Neuropsychological measures.

1.       NP measures: WAIS-R, WMS-R, CVLT, RCFT, SCWT, WCST or ACT, SPECT image.

2.       SPECT data revealed significant increases in cerebral blood flow during the treatment period (p<0.050).

3.       CRT was found to be effective in improving both NP and everyday functioning. All patients were able to be more productive in their lives following treatment.

Chen et al. (1997)

USA

Case-Control

N=40

Population: Age=18+ yr; Gender: male=27, female=13; Condition: TBI.

Intervention: Divided retrospectively into computer-assisted rehabilitation (CACR) and tradition therapy groups

Outcome Measure: Neurophysiological Test Scores (WAIS-R; WMS).

1.       Both groups made significant post-treatment gains on the neurophysiological test scores (p<0.050), with the CACR group making significant gains on 15 measures (p<0.050) and the comparison group making significant gains on seven measures (p<0.005).

2.       However, no significant difference was found between groups on their post-treatment gains.

Freeman et al. (1992)

United States

PCT

N=12

Population: Experimental Group (N=6): Mean age=38.5yr; Mean time post-injury=33.33mo. Control Group (N=6): Mean age=47.83yr; Mean time post-injury=11.83mo.

Intervention: The intervention consisted of being enrolled in a 6-month cognitive rehabilitation programme which met 3x weekly, for 2 hours. The control group received no such treatment.

Outcomes: Wechsler Adult Intelligence Scale for Children (WAIS-R)