Author Year

Country

Research Design

PEDro

Sample Size

Dirette et al. (1999)

USA

RCT

PEDro=4

N=30

Population: TBI: Mean age=38yr; Gender: male-22, female-8; Time since injury range=2-12 months.

Intervention: Randomly assigned to remedial (without instruction, n=15) and compensatory strategy (verbalization, chunking and pacing) intervention (n=15) groups receiving a 45-minute session once a week for 4 weeks.

Outcome Measure: Pre and Post-test on the Paced Auditory Serial Addition Task (PASAT).

1.        Pre/post and weekly tasks significantly improved in both groups (p<0.01).

2.        No significant improvement due to intervention (p>0.05).

Grealy et al. (1999)

Scotland

RCT

PEDro=1

N=13

Population: TBI patients: Age Range: 19-64; Gender: male=8, female=5.

Intervention: Crossover design: patients were allocated to 4-week interventions of receiving a single bout of Virtual reality (VR) exercise or a no-exercise control condition.

Outcome Measure: Tests measuring attention, information processing, learning, memory, and reaction and movement times.

1.        Intervention group (n=13) performed significantly better than control group (n=320) on digit symbol (p<0.01), verbal (p>0.01) and visual (p<0.05) learning tasks.

2.        Reaction (p<0.01) and movement (p<0.05) times improved significantly after a single VR session.

Ruff et al. (1994)

USA

RCT

PEDro=3

N=15

Population: Severe head injury; Mean Age=26.9yr; Time Post Injury≥6mo.

Intervention: Participants were randomized to one of two treatment conditions: attention training followed by memory training (Group A; n=7) or vice versa (Group B; n=8). Training was provided from THINKable, a computer-based multi-media program. Training was terminated after either 20 hr (2hr/d) were completed, or 90% scores were achieved on the most advanced program. Patients were assessed before, during and after training.

Outcome Measure: 2 + 7 Selective Attention Test, WAIS-R Digit Symbol, Continuous Performance Test (CPT); Rey Auditory Verbal Learning Test, Corsi Block Learning Test.

1.        Computer-based attention training resulted in significant improvements for attention (p=0.003).

2.        Significant improvement in Memory II (p=0.021) but not Memory I or III.  Gains were significant for Rey Verbal (p=0.004) and Corsi Block Learning (p=0.03) total correct as well.

3.        Significant improvements in digital symbol scores (p<0.001) were noted as well, but no significant changes were found with CPT or 2+7 test scores.

Gray et al. (1992)

UK

PEDro=5

N=31

Population: Close Head Injury=17; Others=14. Experimental Group (n=17): Mean Age=26.18yr; Gender: Male=12, Female=5; Mean Time Post Injury=79wk. Control Group (n=14): Mean Age=34.14yr; Gender: Male=10, Female=4; Mean Time Post Injury=84wk.

Treatment: Participants in the experimental group received micro-computerized attentional training (1-1.5hr sessions for 3-9wk). The training covered reaction time training, rapid number comparison, digit symbol transfer, and divided attention tasks. The control group received recreational computing for a similar time period.

Outcome Measure: Digit Span, Backward Digit Span, Paced Auditory Serial Addition task (PASAT), Information Processing Rate (IRP), Longest string, Wisconsin Card Sorting Test, Wechsler Adult Intelligence Scale-Revised (WAIS-R) Arithmetic.

1.        At post-test assessment, the experimental group showed significant improvement on the WAIS-R picture completing (p=0.031) and the PASAT information processing rate (p=0.023).

2.        At the 6 mo follow-up, differences between the groups indicated significant improvement on the Backward Digit Span (p=0.007), the WAIS-R Arithmetic (p=0.014), information processing rate and the PASAT (p=0.011), longest string (p=0.009), IPR (p=0.019).

3.        For the experimental group, improvements from the intervention were found for IPR (p=0.004).

4.        In general, course improvement was seen in the experimental group during the intervention phase and was continued into follow-up.

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=40.3yr; Gender: Male=12, Female=3.

Intervention: Participants received the virtual reality (VR) intervention sessions (apartment and classroom) twice per week for a 4wk 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=51.3yr; Gender: Male=5, Female=2; Mean Time Post Injury=20.9yr; Etiology: TBI=5, CVA=2. Control Group (n=7): Mean Age=46.9yr; Gender: Male=7; Mean Time Post Injury=25.0yr.

Intervention: 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, 5d/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 3mo prior to intervention with 1wk 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 1wk 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=61yr; Gender: Male=10, Female=2.

Intervention: Participants received the computer-based cognitive retraining program, Parrot Software. The following eight modules were each completed in separate 1h 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=0.03) 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<0.01).

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

Gerber et al. (2014)

USA

Pre-Post

N=19

Population: TBI; Mean Age=50.4yr; Gender: Male=11, Female=8; Mean Time Post Injury=10yr; GCS=4-14; Severity: Severe=9, Moderate=1, Mild=7.

Intervention: Participants completed a series of virtual reality tasks in a standardized order utilizing a hepatic stylus; 1) Participants were asked to clear a workbench and mount tools on an upright pegboard (TOOL), then 2) spell as many 3-letter words as possible from a set of letter tiles (SPELL), then 3) prepare a virtual peanut butter and jelly sandwich (SAND), and finally 4) hammer in two nails and tighten two screws through tool use (TUSE). TOOL, SAND and TUSE tasks had a time limit of 5 minutes while SPELL task had a time limit of 2 minutes. Participants had 3 chances to perform each task (Baseline, 2^nd, Final).

Outcome Measure: Self-reported measures (engagement and frustration), Boredom Propensity Scale (BPS), Purdue Pegboard Test (PPT), and Neurobehavioural Symptom Inventory (NSI).

1.        All the participants reported a high level of engagement during the interactions.

2.        Thirty percent of participants reported a high level of frustration but were able to complete the tasks with short breaks.

3.        From baseline to final, TOOL mean time decreased by 60s, TUSE mean time decreased by 68s, SAND mean time decreased by 72s and SPELL means increased by 2.7 words.

4.        PPT correlated with TOOL (p=0.016) and TUSE (p=0.014) time during the final trial.

5.        SPELL correlated with the BPS (p=0.08) during the baseline and NSI (p=0.05) during the final trial.

Dvorkin et al. (2013)

USA

Pre-Post

N=21

Population: TBI; Mean Age=37.8yr; Gender: Male=17, Female=4; Mean Time Post Injury=10.3wk.

Intervention: Participants completed a virtual reality task and were instructed to hold the handle of a robot, moving the handle towards targets that appeared in the virtual environment. Patients reached to as many targets as they could within 4 minutes (1 block). Participants completed 6 blocks per day for 2 consecutive days. On each day, each pair of blocks included one haptic condition that affected the robotic handle and was either; 1) no haptic feedback (no force condition), 2) a break-through force, similar to popping a balloon (break-through condition) or 3) a gentle pulse of force (nudge condition).

Outcome Measure: Tolerance, attention (pauses, pause duration), number of targets reached, and Agitated Behaviour Scale (ABS).

1.        The interactive virtual environment was well tolerated by 18 of the 21 patients, 3 participants could not complete the 6 blocks in each visit due to fatigue or frustration.

2.        In 15 participants ABS was reduced on the second visit.

3.        Attention loss was reported before and during arm movements, however on the second visit patients exhibited significantly less pauses (p<0.0001) and shorter pause duration (p=0.007).

4.        Patients were able to reach more targets on the second visit compared to the first visit (p<0.0001).

5.        During the first visit, participants reached significantly less targets in the break-through and no force conditions compared to the nudge condition (p<0.02); the break-through and no force conditions were not significantly different.

6.        During the second visit, participants reached significantly more targets in the nudge and no force conditions compared to the break-through condition (p<0.002); the nudge and no force conditions were not significantly different.

7.        Break-through trials were significantly longer then the no force and nudge conditions on both the first and second day (p<0.0001).

8.        Participants acquired more targets during the second visit compared to the first (p=0.0003) and acquired more targets with each block (p<0.0001).

Li et al. (2013)

USA

Pre-Post

N=11

Population: ABI; Mean Age=49.45yr; Mean Time Post Injury=21.27yr.

Intervention: All participants completed eight 60-min sessions using the attention and memory sub programs of the computer-based cognitive retraining Parrot Software. The participants focused on one of the eight subprograms during each session with each subprogram containing 10 lessons with increasing difficulty. Assessments were conducted before and after intervention.

Outcome Measure: The cognitive assessment (attention & memory).

1.        There was a significant improvement in attention cognitive assessment scores from pre to post intervention (mean change=2.091; p<0.005).

2.        There was a significant improvement in memory cognitive assessment score from pre to post intervention (mean change=1.73; p<0.05).

Zickefoose et al. (2013)

USA

Pre-Post

N=4

Population: TBI; Mean Age=42.75yr; Gender: Male=4, Female=0; Mean Time Post Injury=17.5yr; Severity: Severe=4, Moderate=0.

Intervention: Participants engaged in computer-based brain games over the course of two 1-month treatment phases. Participants received Attention Process Training-3 (APT-3) or Lumosity^TM in phase 1, and then received the alternate treatment in phase 2. Both phases consisted of twenty 30-minute sessions. Outcomes were assessed at baseline and after each phase.

Outcome Measures: Test of Everyday Attention (TEA); Neurological Assessment Battery (NAB)–Numbers and Letters Test Parts B, C, and D; Perceptual rating scale (PRS).

1.        All four participants demonstrated significant progress in reaching new levels of difficulty on all tasks over the course of both treatments (p<0.01).

2.        NAB analysis showed that one participant demonstrated significant improvement on one sub-test, while two participants demonstrated non-significant improvement on one or more sub-tests. Improvements occurred during phase 1, regardless of treatment.

3.        TEA analysis showed that one participant demonstrated improvement on several sub-tests during both treatments, while the scores of the other three participants were inconsistent for either treatment.

4.        On the PRS, two participants showed strong enjoyment and willingness to continue APT-3, while the other two participants showed an equally strong rejection of ATP-3.

5.        On the PRS, all four participants showed strong enjoyment of Lumosity^TM, while only two participants showed a strong willingness to continue.

Chen et al. (1997)

USA

Case-Control

N=40

Population: Age=18+years; 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<0.05), with the CACR group making significant gains on 15 measures (p<0.05) 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.

Malec et al. (1984)

United States

RCT Crossover

PEDro=8

N=10

Population: Mean age=30yr; Gender: Male=8, Female=2; Mean time post injury=80dys.

Intervention: Individuals played two types of first-person shooter video games, one with no interfering targets and one with them present. Individuals were randomly assigned to treatment order. Video game conditions were 1 week-long and included twice daily sessions of video game play.

Outcomes: Stroop Test, Letter Cancellation task, Symbol Cancellation task, reaction time (RT).