Author Year

Country

Research Design

PEDro

Sample Size

Tornas et al. (2016)

Norway

RCT

PEDro=9

N_Initial=70, N_Final=67

Population: TBI=45, Stroke=15, Tumour=6, Anoxia=2, Other=2. Mean Age=42.89 yr; Gender: Male=38, Female=32; Mean Time Post Injury=97.47 mo.

Intervention: Participants were randomized to receive Goal Management Training (TG) or Brain Health Workshop (CG) group sessions. GMT group (n=33) discussed distinctions between absentmindedness/presentmindedness, slip-ups in daily life, habitual responding, stopping and thinking, working memory, importance of goals, defining/splitting goals into subtasks, and checking. BHW control group (n=37) discussed brain function/dysfunction, brain plasticity, memory, executive function, and attention. Treatment was received one day every second week, for a total of eight two-hour sessions distributed over four days. Outcomes were assessed at baseline (T1), after treatment (T2), and at six-month follow-up (T3).

Outcome Measures: Behaviour Rating Inventory of Executive Function–Adult (BRIEF-A); Dysexecutive Questionnaire (DEX); Cognitive Failures Questionnaire (CFQ); Continuous Performance Test II (CPT-II); UCSD Performance-Based Skills Assessment (UPSA); Delis-Kaplan Executive Function System Battery–Colour-Word Interference Test (CWI), Verbal Fluency Test (VFT), and Tower Test (TT); Trail Making Test (TMT); Hotel Task (HT).

1.       In the TG, significant improvements were found on BRIEF-A, DEX, and CFQ at T3 (p<0.010).

2.       In the CG, significant improvements were found on only BRIEF-A at T2 (p<0.050).

3.       The TG showed significant improvements on BRIEF-A and DEX (p<0.010), but not CFQ, compared to the CG over time

4.       In the TG, significant improvements were found on CPT-II, CWI, TT, and HT at T2 and T3 (p<0.050), VFT at T3 (p<0.050), and UPSA at T2 (p<0.001).

5.       In the CG, significant improvements were found on CPT-II, TT, and HT at T2 and T3 (p<0.050), and VFT and UPSA at T2 (p<0.050).

6.       The TG showed a significant improvement on CWI, VFT, and TT (p<0.050), but not CPT-II, UPSA, and HT, compared to the CG over time.

7.       No significant differences were found on TMT within or between groups over time.

Cantor et al. (2014)

USA

RCT

PEDro=6

N=98

Population: TBI; Mean Age=45.3 yr; Gender: Male=37, Female=61; Mean Time Post Injury=12.6 yr; Severity: Mild=49, Moderate=19, Severe=30.

Intervention: Participants were randomly assigned to either immediate start (IS; n=49) or waitlist control (WL; n=49) groups. Participants received group sessions of emotional regulation (2 sessions, 45 min) and an individual problem-solving session of attention training (1 session, 60 min) per day (3 days/wk for 12 weeks). Group sizes were generally 4-6 participants.

Outcome Measure: Attention Rating and Monitoring Scale (ARMS), Behavioural Assessment of the Dysexecutive Syndrome, Difficulties in Emotion Regulation Scale (DERS), Executive Function Composite from Factor Analysis (EF index), Problem Solving Inventory (PSI), Frontal System Behavioural Scale (FrSBe).

1.       There was a significant treatment effect for the EF index favoring the IS group (p=0.008).

2.       There was no significant difference between groups in the DERS of ARMS.

3.       Secondary analysis revealed a significant treatment effects for the FeSBe scale (p=0.049) and the PSI (p=0.016).

4.       There were no other significant treatment effects. Variance of depression, age, severity and time since injury did not change treatment effects.

Vas et al. (2011)

USA

RCT

PEDro=6

N=28

Population: TBI: Strategic Memory and Reasoning Training (SMART) Group (n=14): Mean Age=39 yr; Gender: Male=9, Female=5; Mean Time Post Injury=16.71 yr. Brain Health Workshop Group (n=14): Mean Age=47 yr; Gender: Male=7, Female=7; Mean Time Post Injury=16.35 yr.

Intervention: Participants were randomly assigned to the SMART group or the BHW group. Participants received a total of 12 group sessions over an 8 wk period. The SMART group learned about strategies they could apply in their daily lives; homework was given at the end of each session. The BHW group sessions were designed to be information-based and reading assignments were given each week. Participants were assessed at baseline, post-training (3 weeks) and at a 6 month follow-up.

Outcome Measure: Test of Strategic Learning (TOSL); Working memory listening span task; Community Integration Questionnaire (CIQ); Wechsler Adult Intelligence Scale III (WAIS III).

1.       The SMART group had significantly greater TOSL scores compared to the control group post-training (SMART Mean=19.76, BHW Mean=13.69, p=0.030).

2.       The SMART group had significant improvements in TOSL scores: post-training (Mean=19.76, p=0.007) and at 6-month follow-up (Mean=21.15, p=0.004) from baseline (Mean=14).

3.       The SMART group had significantly greater improvements than the control group on the working memory listening span task post-training (SMART Mean=4.23, BHW Mean=2.59, p<0.001).

4.       The SMART group had significant improvements post-training in the working memory listening span task (Mean=4.23, p=0.005) and at 6-month follow-up (Mean=4.96, P=0.0001) compared to baseline (Mean=2.76).

5.       The SMART group had significantly greater improvements on CIQ compared to the BHW group (SMART Mean=18.73, BHW Mean=16.45, p=0.020).

6.       The SMART group had significant improvements in the CIQ at the 6-month (Mean=19.88, p=0.010) follow-up from baseline (Mean=15.19).

7.       Those in the SMART group showed significant improvement on 3 executive functions following training (inhibition: p=0.010; nonverbal reasoning: p=0.001; and cognitive flexibility: p=0.010) on the WAIS-III.

Chen et al. (2011)

USA

RCT

PEDro=5

N=12

Population: TBI=9, Other=3: Mean Age=48 yr; Gender: Male=5, Female=7; Time Post-Injury Range=6 mo-6 yr.

Intervention: Participants were randomized to receive either the goals training intervention (n=7) or education intervention (n=5) for 5 wk, after which they switched to the other condition for another 5 wk. The goals training was spread over 5 wk and involved: group, individual and home-based training. The education program was a 5 wk didactic educational instruction regarding brain injury.

Outcome Measures: Letter number sequencing, Wechsler Adult Intelligence Scale-III, Auditory consonant trigrams, Digit Vigilance Test, Design and Verbal Fluency Switching, Trails B, Stroop Inhibition, Hopkins Verbal Learning Test, Brief Visual Memory Test Revised, Trails A test, Visual Attention Task.

1.       On the domain of attention and executive functions, all participants in the goal training intervention showed an increase from pre to post goals training; while only 7/12 in the education intervention showed an increase from pre to post education (p<0.0001).

2.       For learning and memory performance scores increased an average of 0.70 units after participation in goals training than after participation in education intervention (p=0.020). 11/12 participants improved in the goals training group while 4/12 improved in the education group (p=0.009).

3.       Tests of motor speed of processing showed no significant differences between the two interventions with a non-significant trend for greater improvements in goal-training compared to education (p=0.070).

Novakovic-Agopian et al. (2011)

USA

RCT Crossover

PEDro=5

N=16

Population: TBI=11, Stroke=3, Other=2: Mean Age=50.4 yr; Gender: Male=7, Female=9; Time Post Injury Range=1-23 yr.

Intervention: Participants were randomized to 5 wk interventions consisting of a goals training program (n=8) or an educational instruction group (n=8). Goal training focused on mindfulness-based attentional regulation and goal management strategies for participant-defined goals. Educational training was didactic instructional sessions about brain injury. At the end of 5 wk, participants were switched to the other intervention. All participants were assessed at baseline, Week 5 and again at Week 10.

Outcome Measure: Auditory Consonant Trigrams, Letter Number Sequencing (working memory); Digit Vigilance Test (sustained attention); Stroop Inhibition Delis-Kaplan Executive Function System (Inhibition); Trails B, Design Fluency-switching (mental flexibility), Hopkins Verbal Learning Test-Revised, Brief Visual Memory Test-Revised.

1.       At the end of wk 5 participants in the goals-edu group showed significant improvement on measures of attention and executive function from baseline (p<0.0001), while the edu-goals group showed no change or minimal change (p>0.050).

2.       The goals-edu group had significantly greater improvements than the edu-goals group on the following at wk 5: working memory (Mean 1.12 vs -0.12, p<0.0001); mental flexibility (Mean 0.64 vs 0.04, p=0.009); inhibition (Mean 0.62 vs 0.04, p=0.005); sustained attention (Mean 0.96 vs 0.27, p=0.010); learning (Mean=0.51 vs 0.08, p=0.020); and delayed recall (Mean 0.39 vs -0.27, p=0.010).

3.       At wk 10, the edu-goals group significantly improved compared to wk 5 on: attention and executive function (0.79 vs 0.03, p<0.0001); working memory (1.31 vs -0.12, p<0.0008); mental flexibility (0.66 vs 0.04, p<0.0008); inhibition (0.50 vs 0.04, p=0.010); sustained attention (0.44 vs 0.27, p=0.010); memory (0.609 vs -0.10, p=0.020); learning (0.66 vs 0.08, p=0.050); and delayed recall (0.55 vs -0.27, p=0.020).

4.       Those in the goals-edu group who had completed the training session were able to maintain their gains and there were significant improvements in attention and executive function (p<0.040) and working memory (p<0.020).

Ownsworth et al. (2008)

Australia

RCT

PEDro=9

N=35

Population: TBI=21, Other=14; Mean Age=43.89yr; Gender: Male=19, Female=16; Mean Time Post Injury=5.29yr.

Treatment: Participants were randomized to receive one of three 8wk intervention groups for goal attainment: individual (n=10), group (n=11), or combined (n=10). Individual treatment occurred in participant homes and community while also focusing on client-centered goals. Group-based treatment involved education, peer and facilitator feedback, and goal setting. The combined group received the equivalent amount of individual and group therapy.

Outcome Measure: Canadian Occupational Performance Measure (COPM): performance self-rating, satisfaction self-ratings, relatives’ performance ratings, and relatives’ satisfaction ratings.

1.       There were significant improvements on performance self-ratings between pre-post intervention for the individual (4.08 to 6.78, p<0.01) and combined interventions (5.04 to 6.98, p<0.01) but not the group intervention (4.68 to 6.10, p=0.029). At follow-up, all interventions had significant improvements from pre-intervention (p<0.01).

2.       There were significant improvements on the satisfaction self-ratings between pre-postintervention for all three interventions: individual (3.75 to 7.22, p<0.001), group (4.51 to 5.95, p<0.025) and combined (4.35 to 7.47, p<0.01).

3.       There were significant improvements for relatives’ rating of performance between pre-post intervention for the individual (3.94 to 6.53, p<0.01) and combined interventions (4.37 to 5.32, p<0.025) but not the group intervention (4.78 to 5.93, p=0.028). At follow-up, all interventions had significant improvements (p<0.01).

Rath et al. (2003)

USA

RCT

PEDro=2

N=46

Population: TBI: Mean Age=43.6 yr; Gender: Male=23, Female=37; Mean Time Post Injury=48.2 mo.

Intervention: Patients were randomized into the innovative (n=32) or conventional (n=28) treatment groups. The innovative group received 24, 2 hr sessions focusing on emotional self-regulation and clear thinking. The conventional group received 24, 2-3 hr sessions focusing on cognitive remediation and psychosocial groups.

Outcome Measure: Weinberg Visual Cancellation Test, Stroop Color–Word Task, FAS—Controlled Oral Word Association Test, Will-Temperament Scale, Visual Reproduction, Immediate and Delayed recall, Watson-Glaser Critical Thinking Appraisal, Wechsler Adult Intelligence Scale—III.

1.       The innovative group showed significant improvements in visual memory immediate recall (p<0.001).

2.       The conventional and the innovative group showed significant improvements: on logical memory recall (p<0.001), logical memory delayed recall (p=0.010), and visual memory delayed recall (p=0.010).

3.       The conventional group had significant improvements in reasoning (p<0.050).

4.       The innovative group had significant improvements in executive function (p<0.050); problem-solving self-appraisal (p=0.005); self-appraised clear thinking and emotional self-regulation (p<0.010); and observer ratings of roleplayed scenarios (p<0.005).

Copley et al. (2015)

Australia

Pre-Post

N=8

Population: ABI; Mean Age=44.5 yr; Gender: Male=5, Female=3; Mean Time Post Injury=12 mo; Severity: Moderate-Severe.

Intervention: All participants completed a treatment consisting of metacognitive strategy instruction (MSI) during 3 components. 1) Individualized sessions (IS) consisted of identifying language based goals and strategies to accomplish them (2 hr x2 sessions). 2) Group sessions (GS) where participants work on their goals in a group setting completing auditory and written comprehension tasks (1.5 hrs). 3) Daily home practice sessions (HS) involved transferring the skills learnt in the first 2 components into everyday life by teaching the significant other how to implement MSI.

Outcome Measure: Measure of Cognitive-Linguistic Abilities Subtests: Paragraph Comprehension, Story Recall, Verbal Abstract Reasoning, Functional Reading, Factual Comprehension, Inferential Reasoning Skills (Low Level and High Level).

1.       There was no significant difference in pre-post scores for paragraph comprehension (p=0.340).

2.       There was no significant difference in pre-post scores for story recall (p=0.028).

3.       There was no significant difference in pre-post scores for verbal abstract reasoning (p=0.111).

4.       There was no significant difference in pre-post scores for functional reading (p=0.204).

5.       There was no significant difference in pre-post scores for factual comprehension (p=0.891).

6.       There was no significant difference in pre-post scores for inferential reasoning skills, both low level (p=0.125) and high level (p=0.020).

Gabbatore et al. (2015b)

Italy

Pre-Post

N_Initial=20, N_Final=15

Population: TBI; Mean Age=36.7 yr; Gender: Male=10, Female=5; Mean Time Post Injury=76.1 mo; Mean GCS=4.5.

Intervention: Participants completed a cognitive group rehabilitation program focussed on mental representations underlying one’s behaviours (2 x/week for 3 months). Each session consisted of comprehension activities (discussing specific communication modalities) and production activities (role-playing activities). Participants were assessed at T0 (3 months before intervention (regular activities during this time), T1 (before intervention), T2 (after intervention) and T3 (3 month follow-up – regular activities during this time). Total study duration was 9 months.

Outcome Measure: : Assessment Battery for Communication (ABaCo-comprehension, production, linguistic, extralinguistic, paralinguistic, and context), Verbal Span Task (VST), Spatial Span Task (SST), Attentive Matrices Test (AMT), Trail Making Test (TMT), Tower of London Test (TOL), Colored Progressive Matrices Raven (CPM Raven), Aachener Aphasie Test-Denomination Scale (AAT), Sally-Ann Task, Strange Stories Task, Immediate and Deferred Recall Test (IDR), Wisconsin Card Sorting Test (WCST).

1.       No significant improvements in ABaCo (production and comprehension) were observed from T0 to T1.

2.       Participants showed significant improvements from T1 to T2 for ABaCo comprehension (p<0.001), production (p<0.001), linguistic (p=0.005), extralinguistic (p=0.008), paralinguistic (p=0.02), and context (p=0.01).

3.       The improvements made during the treatment period were stable between T2 and T3 for both Comprehension (p=0.86) and Production (p=0.32). At T3, AbaCo scores did not show significant differences from T2.

4.       There was no significant difference between T1 and T2 on the VST (p=0.49), SST (p=0.74), AMT (p=0.35), TMT (p=0.45), TOL (p=0.50), CPM Raven (p=0.09), AAT (p=0.22), Sally-Ann (p=0.58), or strange stories task (p=1.00).

5.       There was a significant improvement between T1 and T2 on the IDR (p=0.01) and WCST (p=0.003).

Llorens et al. (2012)

Spain

Pre-Post

N=10

Population: ABI=10; Mean Age=41.1yr; Gender: Male=7, Female=3; Mean Time Post Injury=402.2d.

Intervention: Participants underwent sessions (1hr/wk for 8mo) using an interactive touch screen based game asking questions related to knowledge, reasoning, action, and cohesion in groups of ≤4. Testing of participants occurred at baseline and post intervention.

Outcome Measure: Self-Awareness Deficits Interview (SADI), Social Skills Scale (SSS).

1.       On the SADI, after treatment all participants perceived their deficits properly compared to only 4 participants at baseline; 2 participants had difficulty perceiving their disability post treatment compared to 7 participants at baseline and 5 participants had difficulty establishing realistic goals post treatment compared to 7 at baseline.

2.       On the SSS at baseline, 6 participants showed altered levels in social skills, compared to 2 following treatment.

Parente & Stapleton (1999)

USA

Case-Control

N=33

Population: ABI.

Intervention: A one year measure of group cognitive skills (CSG) training module.

Outcome Measure: Return to work.