Author Year

Country

Research Design

PEDro

Sample Size

Gocheva et al. (2018)

Switzerland

RCT Crossover

PEDro=7

N=19

Population: Non-traumatic etiology (N=13), traumatic etiology (N=9).

Intervention: All participants received both conditions in randomized order, each condition consisted of 12 sessions. The experimental condition consisted of speech, occupational or physical therapy sessions accompanied by a therapeutic animal, while the control condition consisted of the same rehabilitation interventions and did not include a therapeutic animal. All conditions were completed within 6 weeks.

Outcome Measures: Attention span, alertness, instances of distraction, and concentration (all outcomes were measured through behavioral analysis).

1.        Attention span did not differ significantly between experimental and control sessions.

2.        When in the animal therapy sessions individuals displayed significantly more instances of distraction compared to control sessions (p=0.001). Physiotherapy sessions were significantly more effected by distractions when animals were present (p=0.016). Further analysis demonstrated that those with higher initial FIM scores had significantly decreased instances of distraction in animal therapy sessions (p=0.003).

3.        During animal therapy sessions self-assessed alertness was significantly higher (p<0.001). There was also a significant main effect of therapy, with higher alertness in speech therapy sessions overall (p=0.012). Alertness was also significantly higher in the animal therapy session when individuals had higher initial FIM scores, than those that did not in animal sessions (p<0.001).

4.        Individuals had significantly higher rates of self-reported concentration during animal therapy sessions (p=0.014). Concentration was also seen to be significantly higher in speech therapy sessions regardless of animal presence (p=0.027), with therapy type overall having a significant effect (p<0.001), but no significant interaction effect. Individuals with higher initial FIM scores demonstrated higher concentration scores in sessions when animals were present compared to those who had lower initial FIM scores (p<0.001).

Dundon et al. (2015)

Ireland

RCT

PEDro=3

N=26

Population: TBI; Mean Age=38.96yr; Gender: Male=19, Female=7.

Intervention: Participants were assessed during a dichotic listening task (DLT) presented at 6 levels of distraction difficulty, and randomly received either adaptive training (AT, n=9), non-adaptive training (NAT, n=8), or no training (NT, n=9) between sessions (Study 2). Outcomes were assessed before and after training.

Outcome Measures: DLT performance; Test of Everyday Attention (TEA).

1.        For the DLT, there was a significant main effect of group (F=3.99, p=0.035), such that the AT group showed poorer performance than the NAT group (p=0.019) and the NT group (p=0.031).

2.        For the DLT, there was a significant interaction between group and time (F=4.38, p=0.026), such that improved performance was seen in the AT (p=0.036) and NAT (p=0.0025) groups over time, but not in the NT group (p=0.34).

3.        On the TEA, there was a significant main effect of group (F=2.45, p=0.13), such that the NT group showed better performance than the AT group (p<0.001) and the NAT group (p=0.036).

4.        On the TEA, there was a significant main effect of time (p=0.022), such that performance improved in all groups.

Cantor et al. (2014)

USA

RCT

PEDro=7

N=98

Population: TBI; Mean Age=45.3yr; Gender: Male=37, Female=61; Mean Time Post Injury=12.6yr; 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, 45min) and an individual problem-solving session of attention training (1 session, 60min) per day (3 days/wk for 12 weeks). Group sizes were generally 4-6 participants.

Outcome Measures: 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), and 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 FrSBe 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.

McHugh and Wood (2013)

Ireland

RCT

PEDro=5

N=24

Population: TBI. Mindfulness Group (N=12): Mean Age=28.45yr; Mean Time Post Injury=785.5d; Mean GCS=8.5. Control group (N=12): Mean Age=30.5yr; Mean Time Post Injury=664.7d; Mean GCS=7.42.

Intervention: Patients were randomly assigned to the control group or mindfulness group (focused attention). The mindfulness group received instructions (mindfulness induction) prior to completing experimental tasks. Participants then completed a memory load task (remembering the location of symbols) and an over-selectivity task and test.

Outcome Measures: Minimal Attention Awareness Scale (MAAS), Trail making test A and B (test of visual attention and task switching) and the Wechsler Test of Adult Intelligence.

1.        There was a significant decrease in stimulus over-selectivity after the mindfulness training compared to the control group (p<0.05, t (22) =1.74).

Chen et al. (2011)

USA

RCT

PEDro=5

N=12

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

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=0.02). 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=0.07).

Novakovic-Agopian et al. (2011)

USA

RCT Crossover

PEDro=5

N=16

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

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 5wk, participants were switched to the other intervention. All participants were assessed at baseline, Week 5 and again at Week 10.

Outcome Measures: 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>0.05).

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=0.01); learning (Mean=0.51 vs 0.08, p=0.02); and delayed recall (Mean 0.39 vs -0.27, p=0.01).

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=0.01); sustained attention (0.44 vs 0.27, p=0.01); memory (0.609 vs -0.10, p=0.02); learning (0.66 vs 0.08, p=0.05); and delayed recall (0.55 vs -0.27, p=0.02).

1.        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<0.04) and working memory (p<0.02).

McMillan et al. (2002)

UK

RCT

PEDro=5

N=130

Population: TBI; Attentional Control Training (ACT; n=44): Mean Age=34.6yr; Gender: Male=35, Female=9; Median GCS=9. Physical Exercise (PE) Group (n=38): Mean Age=31.4yr; Gender: Male=30, Female=8; Median GCS=10. Control Group (n=48): Mean Age=36.2yr; Gender: Male=36, Female=12; Median GCS=9.

Intervention: Patients were assigned to 1 of 3 groups. The ACT group received supervised practice (5, 45min session over 4wk) and were given an ACT audiotape to practice daily with. The PE group had the same amount of therapist contact, but the audiotape was based on physical training. The control group had no therapist contact. Assessments were done pre- and post-training, and 6 and 12mo.

Outcome Measures: Test of Everyday Attention, Adult Memory and Information Processing Battery, Paced Auditory Serial Addition Test, Trail Making Test, Sunderland Memory Questionnaire, Cognitive Failures Questionnaire.

1.        Results showed no significant differences in outcome measures among the 3 training groups at any of the assessment points.

2.        The exception to the above finding was the results of the Cognitive Failure Questionnaire where patients in both treatment groups (ACT and PE) had significantly greater reduction in self-reported cognitive failures compared to the control group at 12 mo follow-up (p<0.05).

Amos

(2002)

Australia

RCT

PEDro=4

N=32

Population: TBI=16, CVA=6, Other=2, Healthy Controls=8. Experimental Group (n=24): Mean Age=35.71yr; Gender: Male=17, Female=7; Mean Time Post Injury=5.96yr. Control Group (n=8): Mean Age=31.25yr; Gender: Male=2, Female=6.

Intervention: Patients with ABI were randomized into three treatment groups: unaided (n=8), external inhibition (n=8), and increased stimulus salience (n=8). All treatment groups were compared to the non-ABI controls (n=8).

Outcome Measures: Wisconsin Card Sorting Test (WCST).

1.        There were no significant differences in total errors between groups (p=0.138), but groups differed significantly in total number of trials (p=0.025), perseveration (p=0.033) and categories achieved (p=0.001).

2.        The unaided ABI group compared to the aided ABI group (inhibition and salience) had significantly more trials (p<0.001), preservative errors (p<0.006) and lower categories score (p<0.001).

3.        Comparisons between the inhibition and salience aid group revealed significance difference only for perseverative errors (p<0.045); the external inhibition group displayed much less.

Levine et al. (2000)

Canada

UK

RCT

PEDro=4

N=30

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

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 Measures: 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<0.05).

2.       The MST group also had significantly more errors during the everyday paper and pencil tasks (p<0.01).

3.       The GMT group significantly reduced their errors from pre-post training during the everyday paper and pencil tasks (p<0.01).

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<0.05).

Neuropsychological Tasks

1.       The GMT group was generally slower on timed neuropsychological tests: Stroop Interference Procedure, Trail Making Part A and B (p<0.05 and p<0.06, respectively).

2.       No significant differences between groups for the WAIS-R (p>0.05).

Sohlberg et al. (2000)

USA

RCT

PEDro=8

N=14

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

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 24hr over 10wk and the control group received 10hr over 10wk. All subjects worked directly with a therapist and assessed pre and post intervention.

Outcome Measures: 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<0.05).

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<0.05).

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<0.05).

Fasotti et al. (2000)

Netherlands

RCT

PEDro=5

N=22

Population: TBI; Experimental Group (n=12): Mean Age=26.1yr; Gender: Male=8, Female=4; Mean Time Post Injury=9.8mo. Control group (n=10): Mean Age=30.1yr; Gender: Male=7, Female=3; Mean Time Post Injury=8.3mo.

Intervention: Patients in the experimental group received Time Pressure Management (TPM) training (1hr, 2-3x/wk, 2-3wk). TPM training used videotaped short stories. The program was designed to increase awareness of errors and deficits, encourage the acceptance and acquisition of the TPM strategy, and emphasize strategy application and maintenance. The control group received concentration training (30min, 2-5hr/wk, 3-4hr). Mean training was 7.4hr and 6.9hr for the TPM and control groups, respectively. Patients were assessed 2wk prior to training, post-training, and at 6mo follow-up.

Outcome Measures: Waterbed (WB) and Harvard Graphics (HG) tasks, Rey’s 15-word test, Rivermead Behavioural Memory Test, Auditory Concentration Test, Paced Auditory Serial Addition Task, Visual Choice Reaction Time Task.

1.        Training improved performances in both HG and WB tasks, but differences were not significant relative to control.

2.        Scores on 2 of 3 standardized memory variables and all 3 attention variables increased significantly in the TPM group (p<0.05), whereas no memory variables and 1 of 3 attention variables increased significantly for the control group.

3.        Follow-up (6 mo) data for 10 from the TPM group and 9 from the control group indicated that there was a significant time effect (p<0.05) but no significant group time interaction (p=0.23); this suggests that there still was a significant improvement after 6 mo but that this improvement could not be attributed specifically to the treatment or control training.

Niemann et al.

(1990)

United States

RCT

PEDro=7

N=29

Population: Attention Group (N=13): Mean age=28.9yr; Mean time post-injury=41mo. Memory Group (N=13): Mean age=34.3yr; Mean time post-injury=37.1mo.

Intervention: Individuals were randomly assigned to either an attention training program or a memory training program. Both programs lasted 9 weeks and had two 2-hour sessions each week.

Outcomes: Attention Test d2, Paced Auditory Serial-Addition Task (PASAT), Divided Attention test (DAT), Trail Making Test-B (TMT-B), Rey Auditory Verbal Learning Test (RAVLT), Block Span Learning Test (BSLT), Ruff 2 & 7 Test, Logical Memory Subtest (Wechsler Memory Scale) (WMS-LM), Ruff-Light Trail Learning Test (RLTLT).

1.        There were no significant within-group differences on the Test d2, PASAT, DAT, RAVLTBSLT, Ruff 2 & 7 Tests, WMS-LM, or the RLTLT.

2.        Significant within group differences were seen on the TMT-B for both the attentional (p<0.01), and memory (p<0.01) groups.

3.        The attention group improved significantly more on the TMT-B compared to the memory group (p=0.05).

4.        The attention group improved significantly more than the memory group on the Attention Test d2 (p=0.02).

5.        No other significant differences were found.

Bosco et al.

(2018)

Italy

Pre-post

N=19

Population: Severe TBI: Mean age=38.5yr; Gender: Male=16, Female=3; Mean time post-injury=99.4 months; GCS<8.

Intervention: Groups of 5-6 participants met twice a week for 12 weeks for a total of 24 Cognitive Pragmatic Treatment (CPT) sessions. Participants were assessed at four time points, 3-months pretreatment, immediately before treatment, immediately following treatment, and 3-months post-treatment.

Outcome Measures: Assessment Battery for Communication (ABaCo), Communications Activities of Daily Living (CADL), Aachener Aphasie test, Attentional Matrices, Trail Making test, Verbal Span, Corsi’s Block-Tapping test, immediate and deferred recall test, Tower of London test, Modified Card Sorting test, Raven Colored Progressive Matrices, Sally & Ann, Strange Stories.

1.        There was a significant difference in scores on the ABaCO between pretreatment and posttreatment scores (p<0.001). There were no significant differences between the two initial time points or the two posttreatment timepoints.

2.        Similar results were seen for the CADL, with individuals showing a significant improvement in their functional communication skills following treatment (p=0.024).

3.        Between immediate pretreatment scores and immediate posttreatment scores significant differences were only seen on the Verbal Span (p=0.045), and the Modified Card Sorting test (p=0.004).

Hellgren et al. (2015)

Sweden

Case Series

N=48

Population: Cerebral infarction=23%, TBI=21%, Infection=19%, Intracerebral hemorrhage=13%, Subarachnoid hemorrhage=10%, Brain tumor=8%, Other=6%; Mean Age=43.7yr; Gender: Male=30, Female=18; Mean Time Post Injury=51.2mo.

Intervention: Participants received a working memory training program (Cogmed) consisting of various visuospatial and verbal working memory tasks. There were 4-5 sessions/wk for 5-7wk, consisting of 45-60min of intense exercise with one break. Occupational therapist coaches were present during every session and provided weekly feedback in addition to continuous feedback from the computer program.

Outcome Measures: Paced Auditory Serial Attention Test (PASAT 2.4), Forward and backward block repetition, Listening Span Task, Canadian Occupational Performance Measure (COPM performance and satisfaction), EuroQol descriptive (EQ-5D Index), EuroQol visual analogue scale (EQ-VAS), Working Memory Index (WM Index).

1.        At 20wk post-training, there were significant improvements in PASAT (p<0.001), Listening Span (p<0.001), Forward block repetition (p<0.001), Backward block repetition (p<0.001), COPM performance (p<0.001), COPM satisfaction (p<0.001), EQ-5D index (p=0.009), and EQ-VAS (p<0.001) compared to baseline.

2.        Compared to baseline, all participants significantly improved their WM Index at 20wk follow-up (p<0.001).

3.        No significant differences in treatment effect were found for all outcomes in terms of sex or time post-injury, except for ≤18 mo since injury exhibiting more improvement than >18mo in terms of WM index difference (p<0.05), COPM performance improvement (p<0.05), and COPM satisfaction improvement (p<0.05).

Serino et al. (2007)

Italy

Case Series

N=9

Population: TBI: Age range=16-57 yr; Gender: male=6, female=3; Time since injury=6-78 months.

Intervention: A long sequence of numbers is presented, and patients were asked to add each new number to the number preceding it and say the sum out loud. Two additional tests (the Months tasks and the Word tasks) were also administered in a similar way. The GST and the WMT were each 4 sessions/week, for 4 weeks.  To vary tasks and their level of difficulty, in the interstimulus interval was varied.

Outcome Measures: Working memory training (WMT); Paced Auditory Serial Addition Test (PASAT); Months task

1.        Study results indicate the greatest improvement in performance occurred from the intermediate to the final sessions (p<0.0005) after the WMT.

2.        Improvement from the initial to intermediate sessions did not show any significant improvement in working memory (p<0.46) after GST.

3.        Working memory (p<0.05), divided attention (p<0.05), executive function (p<0.05), and long-term memory (p<0.05) for subjects were significantly improved in the final session compared to the intermediate session.

4.        The same was not noted on the speed processing and sustained attention tasks (p>0.05). Working memory training tasks were also found to improve scores on various psychosocial outcomes.

Boman et al. (2004)

Sweden

Pre-Post

N=10

Population: TBI: Mean age=47.5yr; Gender: male=5, female=5; Time Post injury=9-40 months.

Intervention: Each participated in an individual cognitive training session for 1 hr/3x a week for 3 weeks at home or work. The program included attention process training (APT), generalization for training and teaching of compensatory strategies for self-selected cognitive problems.  Identification of cognitive problems in everyday life was also part of the compensatory strategy.

Outcome Measures: Digit Span Test; Claeson-Dahl test; Rivermead Behavioural Memory test (RBMT); Assessment of Motor and Process Skills; European Brain Injury Questionnaire.

1.        For the following: sustained attention, selective attention and alternating attention significant changes (p<0.05, P<0.05, p<0.01 respectively) were noted in the scores of the APT test and Digit Span task between the pre to post training session and the 3 mo follow up.

2.        Score increases (p<0.05) on the RMBT were found at the 3 mo follow up compared to the RMBT scores at the pretest.

3.        When looking at changes in the RBMT score pre to post training, changes were not found.

4.        No significant changes were found (pre to post and pre to 3 mo follow up) when looking at the scores on the Claeson-Dahl Memory

Park et al. (1999)

Canada

Case-Control

N=46

Population: TBI=23; Age matched controls=23.

Intervention: Attention process training program of 20 two-hour sessions for a total of 40 hr.

Outcome Measure: Paced Auditory Serial Addition Task (PASAT); Consonant Trigrams; Beck Depression Inventory (BDI).

1.        No statistically significant improvements on the BDI from pre- to post-treatment for the TBI group.

2.        TBI (p<0.01) and control (p<0.001) groups improved significantly in PASAT before/after tests.

3.        Performance declined with increases in delay (p<0.001), and study position (p<0.001) on the Consonant trigrams.