Cognitive Rehabilitation

Evidence Reviewed as of before: 20-04-2017
Author(s)*: Tatiana Ogourtsova, MSc BSc OT; Adam Kagan, B.Sc.; Amy Henderson, PhD Student, Neuroscience; Nicol Korner-Bitensky PhD OT
Editor(s): Annabel McDermott, OT
Patient/Family Information Table of contents

Introduction

Cognitive skills are characterized as basic mental abilities, including a wide variety of mental processes. For example, perception, memory, problem solving, attention, body awareness in addition to many others. Cognitive abilities can be perceived as fundamental processes since they can shape social, emotional, as well as academic learning. In individuals who have sustained a stroke, these skills may be altered resulting in deficits in several areas of functioning such as communication, self-care, productivity and leisure. Cognitive rehabilitation is based upon scientific theories that have been derived from various disciplines including cognitive neuroscience, neuropsychology, neurolinguistics, and language and cognitive development. It is a treatment that comprises both medical and therapeutic services, specifically aimed at restoring as many cognitive functions as possible while proposing different compensatory strategies to more fully cope with cognitive deficits. The aim of this module is to address the effectiveness of cognitive rehabilitation for improving attention deficits and memory in patients who have suffered a stroke.

Patient/Family Information

What is cognitive rehabilitation?

Cognitive rehabilitation is a goal-oriented program that aims to improve cognitive functions (memory, attention, and concentration) and daily living skills (i.e. using the telephone, managing medication, and handling money) that may have been affected by your stroke. The rehabilitation program is developed according to each client’s specific needs. The goal is to improve performance in tasks that are important to you. Two approaches are usually adopted: the remedial (or restorative) approach and the compensatory approach.

www.brainsource.com/brain_rehabilitation.htm

Why use cognitive rehabilitation after a stroke?

Cognitive impairment, a problem involving the mind, is very common following a stroke. There are different kinds of cognitive impairment, such as forgetfulness, confusion, and/or disorientation, which can interfere with safety, productivity, independence and personal relationships.

Cognitive rehabilitation has been developed by physicians, scientists, and health professionals to improve cognitive function. This therapy also aims to help people with cognitive dysfunction deal with the impact it has on their lives. With the help of cognitive rehabilitation, many people can have a productive and satisfying life following a stroke.

What can I expect before I start therapy?

Your cognitive rehabilitation therapy treatment will be based on your own individual goals and will consider all of your strengths and weaknesses in cognitive function. There are several techniques that can help you to achieve the goals of your treatment, such as auditory and/or visual attentional tasks and memory training. You may be asked to take a variety of neuropsychological tests in order to determine your current cognitive functioning. This will help your therapists develop a suitable treatment plan. Some of these tests may seem to ask silly questions or you may feel nervous trying to answer correctly. Remember that the most important thing before starting therapy is for you and your therapist to understand where you need to focus your therapy efforts. So try to keep that in mind when doing the various tests.

How does the restorative (remedial) approach work?

The goal of this approach is to restore the cognitive functions that have been impaired by a stroke. It involves practicing the skills with which you have difficulty until you see improvement. The goal is for you to eventually be able to apply the skills you have learned in therapy to real life situations. The restorative approach involves 3 formats: Drill and practice This method is used to reinforce your cognitive capacities through repetitive practice. You can retrain yourself to perform tasks by practicing them over and over until you have mastered them. For example, to relearn a task such as making coffee, you would formulate a series of steps (filling the container with water, grinding the coffee, turning on the machine, etc) and then practice these steps until it becomes second nature once again.

Mnemonic Strategies These are tricks used to help remember specific information such as telephone numbers, vocabulary, appointments. They can also help you to learn new information. Your therapist will help you develop these tricks and you may already have some of your own that you have used in the past. Mnemonic strategies include: Verbal mnemonic strategies Words are used to aid memory. They encompass the use of:

  • Acronyms: These are abbreviations in which each letter stands for the first letter in the list of words you want to remember. For example, the word ‘HOMES’ can help you remember the names of the Great Lakes: Huron, Ontario, Michigan, Erie, and Superior.
  • Rhymes: Rhymes are useful in helping to remember facts, such as : “Fourteen hundred and ninety-two, Columbus sailed the ocean blue”
  • Songs: Songs like the “Alphabet Song” are great for learning and memory – a,b,c,d e,f,g, h,i, j, k, etc.
  • Acrostics: These are similar to acronyms, but instead of only one word per letter, there can be a sentence assigned to each letter.
  • Verbal stories: Often explaining something out loud as a story is a useful memory tool.
  • Coding methods: There are many ways of using code, such as transforming numbers into letters.
  • http://coe.jmu.edu/LearningToolbox/images/homes.gif

Imagery mnemonic strategies In this form of memory building, visual images are used to aid memory. The best known techniques are the list learning strategies. They include 4 methods:

  • The method of loci or place method: This is a mnemonic strategy that is very effective for remembering lists. To use this method you choose a place that you are very familiar with (your house for example). Think of different landmarks in that place (the bathroom, the kitchen, the hall, etc) and train yourself to go around the landmarks in a particular order. Let’s say you are trying to remember a shopping list. Imagine each of the items on the list in one of the landmarks you have in mind. For example, you may picture a giant carton of milk on the couch, or a huge banana in the bathtub.
  • The numeric Pegword method: This method is useful for remembering numbered or ordered information. It involves rhyming words for numbers, since the words may be easier to remember in association with what you are trying to learn. This way, instead of having to memorize numbers, you picture the word associated with them. For example:

    • one is bun
    • two is shoe
    • three is tree
    • four is door
    • five is hive etc.
  • The link method: This is when you make simple associations between items in a list, linking them with an image containing all of the items. For example, if the first item on the list was a dog and the second was a motorcycle, then you may try to visualize a dog riding a motorcycle. The fact that this image is bizarre and impossible will help you to remember it.
  • The visual story method: This involves linking items together in a memorable story. For example, you may try to remember the planets in order of distance from the sun: “As the heat comes off the SUN, the MERCURY in the thermometer rises. Then the thermometer explodes and the mercury droplets fall onto a beautiful goddess named VENUS. To hide form the mercury droplets, Venus digs a big hole in the EARTH….”. http://www.mindtools.com/pages/article/newTIM_01.htm

Computer-based tools Virtual reality Virtual reality is a technology that allows a user to interact with a computer-simulated environment. Examples of cognitive skills that can be improved using virtual reality a

  • Short-term memory: the capacity to remember information for a short period of time
  • Selective attention: the ability to concentrate on and perform activities while filtering out other distractions
  • Sustained memory: the ability to remain focused for a length of time.
  • Divided attention: the capacity to attend to two or more stimuli at the same time.

Other computerized tools Computer software exists to work on different cognitive abilities such as visual memory, verbal memory, attention to visual objects etc.. activities to work on these functions include the use of numbers, letters, words, and shape sequences. NOTE: Don’t be concerned if you are not familiar with computers – these programs work quite simply and your therapist can show you how to use them easily.

Is restorative therapy effective?

There has not been a lot of research on cognitive retraining for memory and attention. We need more studies before we can say how effective this treatment is for retraining cognitive skills after a stroke.

How does the compensatory approach work?

The compensatory approach is another type of cognitive rehabilitation used with people who have had a stroke. You or your therapist may turn to the compensatory approach when efforts to restore cognitive function are not working well. Compensatory strategies can be taught by an occupational therapist, a physiotherapist, or a speech-language pathologist. Family members can also help you find ways to facilitate daily activities. It is important to be creative when coming up with compensatory techniques. Let people know your preferences in terms of strategies when planning compensatory techniques. http://www.isabella.org/images/rehab-SpeechTherapy.jpg Compensatory strategies include making changes in your environment (home, school, workplace, etc) or adopting different methods of performing activities. As well, compensatory strategies involve making use of devices that help with remembering tasks, for example there are many options on wrist-watches and other innovative gadgets that can remind you about a scheduled activities (e.g. visiting a loved one). Other examples of compensatory strategies for memory might be to use an agenda book, a diary or a tape recorder to help to remember things to do.

Is compensatory therapy effective?

Compensatory strategies can possibly work for anyone who has experienced a stroke but may be more effective if the person is young and has only one or two cognitive issues (i.e. compensation strategies will work better for someone with only a memory problem than for someone with a memory and a concentration problem). One good quality research study looked at compensatory strategies and their effect on performance of everyday activities in people with stroke. The results showed improvement in the time and quality of performance of every day activities.

External links to helpful sites on cognitive rehabilitation

For further details on the different mnemonic strategies, please visit this link: http://www.memory-key.com/Mnemonics/mnemonics.htm

For the link and story method: http://www.mindtools.com/pages/article/newTIM_01.htm

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Currently, many approaches are used to restore cognitive processes in patients with post-stroke cognitive deficits. These methods include the Cognitive Orientation to daily Occupational Performance (CO-OP) approach, compensatory strategies (e.g. pager system), computer training, various types of attention training and memory training and more recently, virtual reality.

This review of cognitive rehabilitation following stroke includes six high quality RCTs, eight fair quality RCTs, one poor quality RCT and two non-randomized crossover study.

Studies that were not considered suitable for inclusion in this module are identified in the reference list. All outcomes measures referring to executive functions are not included in the in-depth review on this module; Please see the Executive Functions Intervention module for more details on these outcomes.

Results Table

View results table

Outcomes

Acute phase - Attention training + cutaneous electrical stimulation

Functional independence
Not effective
2A

One fair quality RCT (Giaquinto & Fraioli, 2003) investigated the effect of cognitive rehabilitation using attention training with electrical stimulation on functional independence in patients with acute stroke. This fair quality RCT randomized patients to receive attention training + cutaneous electrical stimulation or no training. Functional independence was measure by the Functional Independence Measure (FIM) post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that cognitive rehabilitation using attention training + cutaneous electrical stimulation is not more effective than no training in improving functional independence in patients with acute stroke.

Somatosensory function
Effective
2A

One fair quality RCT (Giaquinto & Fraioli, 2003) investigated the effect of cognitive rehabilitation using attention training with electrical stimulation on somatosensory function in patients with acute stroke. This fair quality RCT randomized patients to receive attention training + cutaneous electrical stimulation or no training. Somatosensory function (N140 event related potential) was measured by electroencephalographic signals (EEG) at post-treatment (3 weeks). Significant between-group differences were found, favoring attention training + cutaneous electrical stimulation vs. no training

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that cognitive rehabilitation using attention training + cutaneous electrical stimulation is more effective than no training in improving somatosensory function (N140 ERP) in patients with acute stroke.

Subacute phase - Memory retraining

Memory
Not effective
2A

One fair quality RCT (Doornhein & De Haan, 1998) investigated the effect of a cognitive rehabilitation memory retraining program on memory in patients with subacute stroke. This fair quality RCT randomized patients to receive cognitive rehabilitation using a memory retraining program or a non-specific memory training program. Memory was measured by the Name-Face Paired Associated Memory Test, the Stylus Maze Test, 15 Word Test and the Oxford Recurring Faces Test at post-treatment (4 weeks). A significant between-group difference was found in only one measure of memory (Name-Face Paired Associated Memory Test), favoring the memory retraining programme vs. the non-specific memory training program.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that a cognitive rehabilitation memory retraining programme is not more effective than a comparison intervention (non-specific memory training) in improving memory in patients with subacute stroke.

Self-reported memory
Not effective
2A

One fair quality RCT (Doornhein & De Haan, 1998) investigated the effect of a cognitive rehabilitation memory retraining program on self-reported memory in patients with subacute stroke. This fair quality RCT randomized patients to receive a cognitive rehabilitation memory retraining program or a non-specific memory training programme. Self-reported memory was measure by the 41-item Memory Questionnaire at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that cognitive rehabilitation memory retraining is not more effective than a comparison intervention (non-specific memory training) in improving self-reported memory in patients with subacute stroke.

Subacute phase - Sustained attention training

Alertness and attention
Effective
2B

One non-randomized study (Sturm et al., 1991) investigated the effect of sustained attention training on attention deficits in patients with subacute stroke. This non-randomized crossover study assigned patients to first receive sustained attention training or no training for three weeks, followed by a cross-over period for a further three weeks. Alertness and sustained attention were measured at 12-week follow-up using the Wiener Determinationsgerat, Wiener Reaktionsgerat, Wiener Vigilanzgerat and the Test d2. There was a significant improvement in one measure of alertness (Wiener Determinationsgerat) and one measure of sustained attention (Wiener Vigilanzgerat), in favour of attention training vs. no training.
Note: Results presented above were obtained from a systematic review by Lincoln et al., (2000), for the purpose of clarity.

Conclusion: There is limited evidence (Level 2b) from one non-randomized crossover study that cognitive rehabilitation using sustained attention training is more effective than no training in improving some measures of alertness and sustained attention in patients with subacute stroke.

Memory
Not effective
2B

One non-randomized study (Sturm et al., 1991) investigated the effect of sustained attention training on memory in patients with subacute stroke. This non-randomized crossover study assigned patients to first receive sustained attention training or no training for three weeks, followed by a cross-over period for a further three weeks. Memory was measured by the Cognitrone (pattern recognition), Wechsler Adult Intelligence Scale (similarities subscale), Intelligenz-Struktur-Test (similarity recognition) and the Raven Standard Progressive Matrices (pattern completion ability) at 12-week follow-up. No significant between-group differences were found.
Note: Results presented above are from a systematic review by Lincoln et al., (2000), for the purpose of clarity.

Conclusion: There is limited evidence (Level 2b) from one non-randomized crossover study that cognitive rehabilitation using sustained attention training is not more effective than no training in improving memory in patients with subacute stroke.

Reasoning
Not effective
2B

One non-randomized study (Sturm et al., 1991) investigated the effect of sustained attention training on reasoning in patients with subacute stroke. This non-randomized cross-over study assigned patients to first receive sustained attention training or no training for three weeks, followed by a cross-over period for a further three weeks. Reasoning was measured by the Leistungsprufsystern at 12-week follow-up. No significant between-group differences were found.
Note: Results presented above are from a systematic review by Lincoln et al., (2000), for the purpose of clarity.

Conclusion: There is limited evidence (Level 2b) from one non-randomized crossover study that cognitive rehabilitation using sustained attention training is not more effective than no training in improving reasoning in patients with subacute stroke.

Chronic phase - Attention process training

Attention
Effective
1B

One high quality RCT (Barker-Collo et al., 2009) investigated the effect of attention process training on attention in patients with chronic stroke. This high quality RCT randomized patients to receive attention process training or usual care. Attention was measured by the Integrated Visual Auditory Continuous Performance Test (IVA-CPT – Full Scale Attention Quotient, Auditory attention and Visual attention subtests) at post-treatment (4 weeks) and at 6-month follow-up. At post-treatment there were significant between-group differences in scores on the full attention scale and auditory attention subtest; at 6-month follow-up results remained significant for the measure of full attention only, favoring attention process training vs. usual care.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using attention process training is more effective than usual care in improving attention in patients with chronic stroke.
Note: There were no significant differences between groups in tests of visual attention.

One high quality RCT (Barker-Collo et al., 2009) investigated the effect of attention process training on auditory information processing speed in patients with chronic stroke. This high quality RCT randomized patients to receive attention process training or usual care. Auditory information processing speed was measured by the Paced Auditory Serial Addition Test at post-treatment (4 weeks) and 6-month follow-up. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using attention process training is not more effective than usual care in improving auditory information processing speed in patients with chronic stroke.

Auditory information processing
Not effective
1B

One high quality RCT (Barker-Collo et al., 2009) investigated the effect of attention process training on auditory information processing speed in patients with chronic stroke. This high quality RCT randomized patients to receive attention process training or usual care. Auditory information processing speed was measured by the Paced Auditory Serial Addition Test at post-treatment (4 weeks) and 6-month follow-up. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using attention process training is not more effective than usual care in improving auditory information processing speed in patients with chronic stroke.

Functional independence
Not effective
1B

One high quality RCT (Barker-Collo et al., 2009) investigated the effect of attention process training on functional independence in patients with chronic stroke. This high quality RCT randomized patients to receive attention process training or usual care. Functional independence was measured by the Modified Rankin Scale at 6-month follow-up; measures were not taken at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using attention process training is not more effective than usual care in improving functional independence in patients with chronic stroke.

Memory
Not effective
1B

One high quality RCT (Barker-Collo et al., 2009) investigated the effect of attention process training on memory in patients with chronic stroke. This high quality RCT randomized patients to receive attention process training or usual care. Self-reported memory failure was measured by the Cognitive Failure Questionnaire at 6-month follow-up; measures were not taken at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using attention process training is not more effective than usual care in improving self-reported memory failure in patients with chronic stroke.

Quality of life
Not effective
1B

One high quality RCT (Barker-Collo et al., 2009) investigated the effect of attention process training on quality of life in patients with chronic stroke. This high quality RCT randomized patients to receive attention process training or usual care. Quality of life was measured by the Short Form 36 (SF-36 – Physical Component Score, Mental Component Score) at post-treatment (4 weeks) and at 6-month follow-up, and by the General Health Questionnaire (GHQ-28) at follow-up (6 months) only. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using attention process training is not more effective than usual care in improving quality of life in patients with chronic stroke.

Unilateral spatial neglect
Not effective
1B

One high quality RCT (Barker-Collo et al., 2009) investigated the effect of attention process training on unilateral spatial neglect in patients with chronic stroke. This high quality RCT randomized patients to receive attention process training or usual care. Unilateral spatial neglect was measured by the Bells Test at post-treatment (4 weeks) and 6-month follow-up. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using attention process training is not more effective than usual care in improving unilateral spatial neglect in patients with chronic stroke.

Chronic phase - Cognitive Orientation to Occupational Performance (CO-OP)

Task performance
Effective
2A

One fair quality RCT (Polatajko et al., 2012) investigated the effect of the CO-OP approach on task performance in patients with chronic stroke. This fair quality RCT randomized patients to receive the CO-OP approach or conventional occupational therapy. Task performance was measured by the Performance Quality Rating Scale (PQRS) and the Canadian Occupational Performance Measure (COPM – Performance, Satisfaction) at post-treatment (10 sessions). Significant between-group differences in task performance were found at post-treatment (PQRS, COPM – Performance), favoring CO-OP vs. conventional occupational therapy.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that cognitive rehabilitation using the CO-OP approach is more effective than conventional occupational therapy in improving task performance in patients with chronic stroke.
Note: There were no significant between-group differences in participants’ satisfaction with task performance, as measured by the COPM.

Chronic phase - Memory self-efficacy training

Delayed recall
Not effective
1B

One high quality RCT (Aben et al., 2013) investigated the effect of memory self-efficacy (MSE) training on delayed memory recall in patients with chronic stroke. This high quality RCT randomized patients to MSE group training or a peer support stroke education program. Delayed recall was measured by the Auditory Verbal Learning Test and the Rivermead Behavioral Memory Test (story recall – delayed) subtests at post-treatment (approximately 5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using MSE group training is not more effective than a comparison intervention (peer support stroke education program) in improving delayed memory recall in patients with chronic stroke.

Depression
Not effective
1B

One high quality RCT (Aben et al., 2013) investigated the effect of memory self-efficacy (MSE) training on depression in patients with chronic stroke. This high quality RCT randomized patients to MSE group training or a peer support stroke education program. depression was measured by the Center of Epidemiological Studies – depression Scale at post-treatment (approximately 5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using MSE group training is not more effective than a comparison intervention (peer support stroke education program) in improving depression in patients with chronic stroke.

Memory self-efficacy
Effective
1B

One high quality RCT (Aben et al., 2013) investigated the effect of memory self-efficacy (MSE) training on MSE in patients with chronic stroke. This high quality RCT randomized patients to MSE group training or a peer support stroke education program. Memory self-efficacy was measured by the Metamemory-In-Adulthood Questionnaire at post-treatment (approximately 5 weeks). Significant between-group differences were found, favoring MSE training vs. a peer support education program.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using MSE group training is more effective than a comparison intervention (peer support stroke education program) in improving memory self-efficacy in patients with chronic stroke.

Quality of life
Effective
1B

One high quality RCT (Aben et al., 2013) investigated the effect of memory self-efficacy (MSE) training on quality of life in patients with chronic stroke. This high quality RCT randomized patients to MSE group training or a peer support stroke education program. Quality of life was measured by the EuroQol EQ5D Questionnaire (utility score and visual analogue scale) and the WhoQoL Brief Questionnaire (psychological quality of life, social quality of life scores) at post-treatment (approximately 5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using MSE group training is not more effective than a comparison intervention (peer support strokeeducation program) in improving quality of life in patients with chronic stroke.

Chronic phase - Pager system

Memory
Effective
2A

One fair quality randomized crossover trial (Fish et al., 2008) investigated the effect of a pager system on memory in patients with chronic stroke. This fair quality RCT randomized patients to use the NeuroPager system or no treatment in a crossover design. Memory was measured by memory diaries (percentage of tasks achieved) at T2 (7 weeks) and T3 (14 weeks). At both post-treatment time points there were significant between-group differences in favour of the group that had just completed the NeuroPager trial. Memory gains were not maintained over time without use of the NeuroPager system.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that cognitive rehabilitation using the NeuroPager system is more effective than no treatment in improving memory in patients with chronic stroke.

Chronic phase - Virtual reality

Attention
Effective
1B

One high quality RCT (Faria et al., 2016) investigated the effects of virtual-reality (VR)-based cognitive rehabilitation on attention in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based cognitive rehabilitation using the Reh@City simulation program or conventional cognitive rehabilitation. Attention was measured by the Addenbrooke Cognitive Examination (ACE – Attention) at post-treatment (4-6 weeks). Significant between-group differences were found, favoring VR-based cognitive rehabilitation vs. conventional cognitive rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based cognitive rehabilitation is more effective than a comparison intervention (conventional cognitive rehabilitation) in improving attention in patients with chronic stroke.

Cognition
Effective
1B

One high quality RCT (Faria et al., 2016) investigated the effects of virtual-reality (VR)-based cognitive rehabilitation on cognition in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based cognitive rehabilitation using the Reh@City simulation program or conventional cognitive rehabilitation. Cognition was measured by the Mini-Mental State Examination (MMSE) and the Addenbrooke Cognitive Examination (ACE – total score, fluency, language, visuospatial subscores) at post-treatment (4-6 weeks). Significant between-group differences were found (MMSE; ACE – total, fluency), favoring VR-based cognitive rehabilitation vs. conventional cognitive rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based cognitive rehabilitation is more effective than a comparison intervention (conventional cognitive rehabilitation) in improving cognition in patients with chronic stroke.

Memory
Not effective
1B

One high quality RCT (Faria et al., 2016) investigated the effects of virtual-reality (VR)-based cognitive rehabilitation on memory in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based cognitive rehabilitation using the Reh@City simulation program or conventional cognitive rehabilitation. Memory was measured by the Addenbrooke Cognitive Examination (ACE – memory) at post-treatment (4-6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based cognitive rehabilitation is not more effective than a comparison intervention (conventional cognitive rehabilitation) in improving memory in patients with chronic stroke.

Stroke outcomes
Not effective
1B

One high quality RCT (Faria et al., 2016) investigated the effects of virtual-reality (VR)-based cognitive rehabilitation on stroke outcomes in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based cognitive rehabilitation using the Reh@City simulation program, or conventional cognitive rehabilitation. stroke outcomes were measured by the stroke Impact Scale at post-treatment (4-6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based cognitive rehabilitation is not more effective than a comparison intervention (conventional cognitive rehabilitation) in improving stroke outcomes in patients with chronic stroke.

Phase not specific to one period - CO-OP

Community participation
Effective
2A

One fair quality RCT (McEwen et al., 2015) investigated the effect of the Cognitive Orientation to daily Occupational Performance (CO-OP) approach on community participation in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive CO-OP or conventional rehabilitation. Community participation was measured by the Community participation Indicator (CPI) (Importance of participation, Control over participation, Satisfaction with participation scales) at post-treatment (10 sessions) and at follow-up (3 months); the measure was not used at baseline. Comparison of change scores from post-treatment to follow-up revealed a medium effect size (CPI – Control over participation only), favoring CO-OP vs. conventional rehabilitation.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that the CO-OP approach is more effective than a comparison intervention (conventional rehabilitation) in improving an individual’s sense of control over community participation among patients with acute/subacute stroke.
Note: There were no significant differences in an individual’s perceived importance of, or satisfaction with, community participation.

Occupational performance
Not effective
2A

One fair quality RCT (McEwen et al., 2015) investigated the effect of the CO-OP approach on occupational performance in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive CO-OP or conventional rehabilitation. Occupational performance was measured by the Canadian Occupational Performance Measure (COPM – Performance trained and untrained tasks, Satisfaction trained and untrained tasks) at post-treatment (10 sessions) and at 3-month follow-up. Comparison of change scores from baseline to post-treatment indicated no significant treatment effect; scores at follow-up revealed only small effect sizes (COPM – Performance trained and untrained tasks, Satisfaction untrained tasks only), favouring CO-OP vs. conventional rehabilitation.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that cognitive rehabilitation using the CO-OP approach is not more effective than a comparison intervention (conventional rehabilitation) in improving occupational performance in patients with acute/subacute stroke.

Self-efficacy
Effective
2A

One fair quality RCT (McEwen et al., 2015) investigated the effect of the CO-OP approach on perceived self-efficacy in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive CO-OP or conventional rehabilitation. Perceived self-efficacy was measured by the Self Efficacy Gauge at baseline, at post-treatment (10 sessions) and at 3-month follow-up. While there was no significant effect from baseline to post-treatment, comparison of scores from post-treatment to follow-up revealed a medium treatment effect, favoring CO-OP vs. conventional rehabilitation.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that the CO-OP treatment is more effective than a comparison intervention (conventional rehabilitation) in improving self-efficacy in patients with acute/subacute stroke.

Stroke outcomes
Effective
2A

Two fair quality RCTs (Wolf et al., 2016, McEwen et al., 2015) investigated the effect of the CO-OP approach on stroke outcomes in patients with stroke.

The first fair quality RCT (Wolf et al., 2016) randomized patients with acute/subacute stroke to receive CO-OP or conventional occupational therapy. stroke outcomes were measured by the stroke Impact Scale (ADLs, Mobility, Hand Function, Strength, Recovery, Physical, Memory, Emotion, Communication) at post-treatment (10 sessions) and at 3-month follow-up. Results at post-treatment showed medium to large treatment effect sizes (SIS – ADLs, Hand Function, Strength, Recovery, Physical, Memory, Emotion, Communication), favoring CO-OP vs. conventional occupational therapy. At follow-up, medium effects were maintained for two stroke outcomes (SIS – Hand Function, Communication), favoring CO-OP vs. conventional occupational therapy.

The second fair quality RCT (McEwen et al., 2015) randomized patients with acute/subacute stroke to receive CO-OP or conventional rehabilitation. stroke outcomes were measured by the stroke Impact Scale (SIS – Participation subscale only) at post-treatment (10 sessions) and at 3-month follow-up; the measure was not used at baseline. Comparison of change scores from post-treatment to follow-up revealed a medium treatment effect size, favoring CO-OP vs. conventional rehabilitation.

Conclusion: There is limited evidence (Level 2a) from two fair quality RCTs that the CO-OP approach is more effective than a comparison intervention (conventional therapy) in improving aspects of stroke outcomes in patients with acute/subacute stroke.

Task performance
Effective
2A

One fair quality RCT (McEwen et al., 2015) investigated the effect of the CO-OP approach on task performance in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive CO-OP or conventional rehabilitation. Performance of self-selected activities was measured by the Performance Quality Rating Scale (PQRS – Trained tasks, Untrained tasks) at post-treatment (10 sessions) and at 3-month follow-up. Medium to large effect sizes were found for performance of trained and untrained tasks at post-treatment and at follow-up, favoring CO-OP vs. conventional rehabilitation.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that the CO-OP approach is more effective than a comparison intervention (conventional rehabilitation) in improving task performance in patients with acute/subacute stroke.

Phase not specific to one period - Computer training

Attention
Effective
1B

One high quality RCT (Prokopenko et al., 2013) and one non-randomized study (Sturm et al., 1997) investigated the effect of cognitive rehabilitation using computer training on attention in patients with stroke.

The high quality RCT (Prokopenko et al., 2013) randomized patients with acute/subacute stroke to receive neuropsychological computer training or conventional rehabilitation. Attention was measured by Shulte’s test at post-treatment (2 weeks). Significant between-group differences were found, favoring computer training vs. conventional rehabilitation.

The non-randomized study (Sturm et al., 1997) assigned patients with subacute/chronic stroke to receive computerized attention training. Participants received training that specifically targeted two domains of attention (alertness, vigilance, selective attention or divided attention), according to each participant’s two most impaired domains. Attention was measured at baseline and at post-treatment 1 and post-treatment 2 (i.e. after each 14-session training period) using a computerised attention test battery (alertness: response time with/without warning signal; vigilance: hit-rate, response with warning; selective attention: error rate, response time with warning; divided attention: error rate, response time with warning). There were significant improvements in attention (alertness: response time without warning signal; vigilance: hit-rate; selective attention: response time with warning; divided attention: error rate); results showed a domain-specific training effect (e.g. improved alertness was only achieved following alertness training).

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using computer training is more effective than a comparison interventions (conventional therapy) in improving attention in patients with stroke. A non-randomized study also reported improved attention skills following computerized attention training.

Cognition
Not effective
1B

One high quality RCT (Prokopenko et al., 2013) investigated the effect of computer training on cognition in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive neuropsychological computer training or conventional rehabilitation. Cognition was measured by the Mini-Mental State Examination and the Montreal Scale of Cognitive Assessment at post-treatment (2 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using neuropsychological computer training is not more effective than a comparison intervention (conventional therapy) in improving cognition in patients with stroke.

Mood
Not effective
1B

One high quality RCT (Prokopenko et al., 2013) investigated the effect of computer training on depression and anxiety in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive neuropsychological computer training or conventional rehabilitation. Mood was measured by the Hospital Anxiety and depression Scale at post-treatment (2 weeks). No significant between group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that neuropsychological computer training is not more effective than a comparison intervention (conventional therapy) in improving mood in patients with acute/subacute stroke.

Visuospatial skills
Effective
1B

One high quality RCT (Prokopenko et al., 2013) investigated the effect of computer training on visuospatial skills in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive neuropsychological computer training or conventional rehabilitation. Visuospatial skills were measured by the Clock Drawing Test at post-treatment (2 weeks). Significant between-group differences were found, favoring computer training vs. conventional rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that neuropsychological computer training is more effective than a comparison intervention (conventional therapy) in improving visuospatial skills in patients with acute/subacute stroke.

Phase not specific to one period - Global attention processing training

Visuospatial memory
Effective
2B

One fair quality RCT (Chen et al., 2012) investigated the effect of global attention processing training on visuospatial memory in patients with acute/subacute stroke. This fair quality RCT randomized patients to receive global attention processing training (i.e. global to local encoding strategy) or rote repetition training (no encoding strategy) to learn the Rey-Osterrieth Complex Figure (ROCF) in one training session. Visuospatial memory was measured with the ROCF – immediate recall, delayed recall and configural organization subtests: immediately post-training (ROCF – immediate recall/configural organization); at 30 minutes post-training (ROCF – delayed recall/configural organization); and at 1 day, 2 weeks and 4 weeks post-training (ROCF – immediate recall/delayed recall/configural organization). Significant between-group differences were found immediately post-training (ROCF – immediate recall), at 30 minutes post-training (ROCF – delayed recall), and at 1 day post-training (ROCF – immediate recall/configural organization), favoring global attention processing training vs. rote repetition training. There were no significant differences between groups on any measure of visuospatial memory at 2 weeks or 4 weeks post-training.

Conclusion: There is limited evidence (Level 2b) from one fair quality RCT that global attention processing training is more effective than a comparison intervention (rote repetition training with no encoding strategy) in improving visuospatial memory in patients with acute/subacute stroke.

Phase not specific to one period - Time pressure management

Fatigue
Not effective
1B

One high quality RCT (Winkens et al., 2009) investigated the effect of cognitive rehabilitation using a time pressure management approach on fatigue in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional rehabilitation. Fatigue was measured by the Fatigue Severity Scale at post-treatment (10 hours of treatment) and at 3-month follow-up. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using a time pressure management approach is not more effective than a comparison intervention (conventional rehabilitation) in improving fatigue in patients with subacute/chronic stroke.

Functional Independence
Not effective
1B

One high quality RCT (Winkens et al., 2009) investigated the effect of cognitive rehabilitation using a time pressure management approach on functional independence/ADLs in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional rehabilitation. Functional independence was measured by the Barthel Index at post-treatment (10 hours of treatment) and at 3-month follow-up. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using a time pressure management approach is not more effective than a comparison intervention (conventional rehabilitation) in improving functional independence in patients with subacute/chronic stroke.

Information processing
Not effective
1B

One high quality RCT (Winkens et al., 2009) investigated the effect of cognitive rehabilitation using a time pressure management approach on information processing in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional therapy. Information processing was measured at post-treatment (10 hours of treatment) and at 3-month follow-up using the Information Intake Task (IIT: no. of strategies used, reproduction scores), the Mental Slowness Observation Test (MSOT – no. of used strategies, no. of correct elements, time), the Mental Slowness Questionnaire, Symbol Digit Modalities Test and the Paced Auditory Serial Addition Task. Significant between-group differences were found on only one measure at post-treatment (ITT – number of strategies used) and at follow-up (MSOT – time), favoring time pressure management vs. conventional rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using a time pressure management approach is not more effective than a comparison intervention (conventional therapy) in improving information processing in patients with subacute/chronic stroke.

Memory
Not effective
1B

One high quality RCT (Winkens et al., 2009) investigated the effect of cognitive rehabilitation using a time pressure management approach on memory in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional rehabilitation. Memory was measured by the Auditory Verbal Learning Test at post-treatment (10 of hours of treatment) and at 3-month follow-up. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using a time pressure management approach is not more effective than a comparison intervention (conventional rehabilitation) in improving memory in patients with subacute/chronic stroke.

Mood
Not effective
1B

One high quality RCT (Winkens et al., 2009) investigated the effect of cognitive rehabilitation using a time pressure management approach on mood in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional rehabilitation. Depression was measured by the Center for Epidemiologic Studies Depression Scale at post-treatment (10 hours of treatment) and at 3-month follow-up. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using a time pressure management approach is not more effective than a comparison intervention (conventional rehabilitation) in improving mood in patients with subacute/chronic stroke.

Quality of life
Not effective
1B

One high quality RCT (Winkens et al., 2009) investigated the effect of cognitive rehabilitation using a time pressure management approach on quality of life in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional rehabilitation. Quality of life was measured by the EuroQol-5D at post-treatment (10 hours of treatment) and at 3-month follow-up. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a time pressure management approach is not more effective than a comparison intervention (conventional rehabilitation) in improving quality of life in patients with subacute/chronic stroke.

Phase not specific to one period - Virtual Reality

Attention
Effective
2B

One poor quality RCT (Gamito et al., 2015) investigated the effect of virtual-reality (VR)-based cognitive rehabilitation on attention in patients with stroke. This poor quality RCT randomized patients with stroke (stage of stroke not specified) to receive VR-based cognitive rehabilitation or no treatment. Sustained attention was measured by the Toulouse-Pieron Test (work efficiency) at post-treatment (4-6 weeks). Significant between-group differences were found, favoring VR-based cognitive rehabilitation vs. no treatment.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that VR-based cognitive rehabilitation is more effective than no treatment in improving sustained attention in patients with stroke.

Memory
Effective
2A

One fair quality RCT (Rose et al., 1999) and one poor quality RCT (amito et al., 2015G) investigated the effect of virtual-reality (VR)-based cognitive rehabilitation on memory in patients with stroke.

The fair quality RCT (Rose et al., 1999) randomized patients with stroke (stage of stroke not specified) to receive active VR-based memory retraining program or passive VR-based memory retraining. Memory was measured using spatial and object recognition tests at post-treatment (1 training session). A significant between-group difference in one measure of memory (spatial recognition test) was found, favoring the active VR-based memory retraining program.

The poor quality RCT (Gamito et al., 2015) randomized patients with stroke (stage of stroke not specified) to receive VR-based cognitive rehabilitation or no treatment. Memory was measured by the Wechsler Memory Scale (WMS total score) and the Rey-Osterieth Complex Figure (ROCF – immediate recall) at post-treatment (4-6 weeks). Significant between-group differences in memory (WMS total score only) were found, favoring VR-based cognitive rehabilitation vs. no treatment.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT and one poor quality RCT that VR-based cognitive rehabilitation is more effective than comparison interventions (passive VR-memory retraining program, no treatment) in improving memory in patients with stroke.

Phase not specific to one period - Visual Attention Training

Attention
Not Effective
1B

One high quality RCT (Mazer et al., 2003) investigated the effect of visual attention training on attention in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Useful Field of View (UFOV) visual attention training or traditional computerized visuoperception training. Attention was measured by the Test of Everyday Attention at post-treatment (5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that UFOV visual attention training is not more effective than a comparison intervention (traditional computerized visuoperception training) in improving attention in patients with subacute/chronic stroke.

Driving
Not Effective
1B

One high quality RCT (Mazer et al., 2003) investigated the effect of visual attention training on driving abilities in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Useful Field of View (UFOV) visual attention training or traditional computerized visuoperception training. Driving abilities were measured by the on-road driving evaluation at post-treatment (5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that UFOV visual attention training is not more effective than a comparison intervention (traditional computerized visuoperception training) in improving on-road driving abilities in patients with subacute/chronic stroke.

Unilateral spatial neglect
Not Effective
1B

One high quality RCT (Mazer et al., 2003) investigated the effect of visual attention training on unilateral spatial neglect (USN) in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Useful Field of View (UFOV) visual attention training or traditional computerized visuoperception training. USN was measured by the Single and Double Letter Cancellation Test and the Bells Test at post-treatment (5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that UFOV visual attention training is not more effective than a comparison intervention (traditional computerized visuoperception training) in improving USN in patients with subacute/chronic stroke.

Visual attention
Not Effective
1B

One high quality RCT (Mazer et al., 2003) investigated the effect of visual attention training on visual attention in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Useful Field of View (UFOV) visual attention training or traditional computerized visuoperception training. Visual attention was measured by the UFOV test (total, processinSg speed, divided attention, selective attention), and the complex reaction timer (Charron Test) at post-treatment (5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that UFOV visual attention training is not more effective than a comparison intervention (traditional computerized visuoperception training) in improving visual attention in patients with subacute/chronic stroke.

Visual perception
Not Effective
1B

One high quality RCT (Mazer et al., 2003) investigated the effect of visual attention training on visual perception in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Useful Field of View (UFOV) visual attention training or traditional computerized visuoperception training. Visual perception was measured by the Motor-Free Visual Perception Test at post-treatment (5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that UFOV visual attention training is not more effective than a comparison intervention (traditional computerized visuoperception training) in improving visual perception in patients with subacute/chronic stroke.

References

Aben, L., Heijenbrok-Kal, M.H., van Loon, E.M.P., Groet, E., Ponds, R.W.H.M., Busschbach, J.J.V., & Ribbers, G.M. (2013). Training memory self-efficacy in the chronic stage after stroke: a randomized controlled trial. Neurorehabilitation and Neural Repair, 27(2), 110-7.

http://www.ncbi.nlm.nih.gov/pubmed/22895620

Barker-Collo, S.L., Feigin, V.I., Lawes, C.M.M., Parag, V., Senior, H., & Rodgers, A. (2009). Reducing attention deficits after stroke using attention process training. Stroke, 40, 3193-8.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Reducing+attention+deficits+after+stroke+using+attention+process+training

Chen, P., Hartman, A. J., Galarza, C. P., & DeLuca, J. (2012). Global processing training to improve visuospatial memory deficits after right-brain stroke. Archives of Clinical Neuropsychology, acs089.

https://academic.oup.com/acn/article/27/8/891/5377/Global-Processing-Training-to-Improve-Visuospatial

Doornhein K. & De Haan E.H.F. (1998). Cognitive training for memory deficits in stroke patients. Neuropsychological Rehabilitation, 8(4), 393-400.

http://www.tandfonline.com/doi/abs/10.1080/713755579#.V4wR0LgrI2w

Faria, A. L., Andrade, A., Soares, L., & i Badia, S. B. (2016). Benefits of virtual reality based cognitive rehabilitation through simulated activities of daily living: a randomized controlled trial with stroke patients. Journal of NeuroEngineering and Rehabilitation, 13(1), 96.

https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-016-0204-z

Fish J, Manly T, Emslie H, Evans J & Wilson B. (2008). Compensatory strategies for acquired disorders of memory and planning: differential effects of a paging system for patients with brain injury of traumatic versus cerebrovascular etiology. Journal of Neurology, Neurosurgery and Psychiatry, 79, 930-935.

http://www.ncbi.nlm.nih.gov/pubmed/18039889

Gamito, P., Oliveira, J., Coelho, C., Morais, D., Lopes, P., Pacheco, J., … & Barata, A. F. (2015). Cognitive training on stroke patients via virtual reality-based serious games. Disability and rehabilitation, 1-4.

http://www.tandfonline.com/doi/abs/10.3109/09638288.2014.934925

Giaquinto, S., & Fraioli, L. (2003). Enhancement of the somatosensory N140 component during attentional training after stroke. Clinical Neurophysiology, 114(2), 329-335.

http://www.sciencedirect.com/science/article/pii/S1388245702003243

Lincoln, N.B. & Flannaghan, T. (2003). Cognitive behavioral psychotherapy for depression following stroke: A randomized controlled trial. Stroke, 34, 111-115.

http://www.ncbi.nlm.nih.gov/pubmed/12511760

Lincoln NB, Majid MJ, Weyman N. (2000). Cognitive rehabilitation for attention deficits following stroke. Cochrane Database Syst Rev. 2000;(4):CD002842.

https://www.ncbi.nlm.nih.gov/pubmed/11034773

Mazer BL, Sofer S, Korner-Bitensky N, Gelinas I, Hanley J, Wood-Dauphinee S. (2003). Effectiveness of a visual attention retraining program on the driving performance of clients with stroke. Arch Phys Med Rehabil. 2003 Apr;84(4):541-50.

https://www.ncbi.nlm.nih.gov/pubmed/12690593

McEwen, S., Polatajko, H., Baum, C., Rios, J., Cirone, D., Doherty, M., & Wolf, T. (2015). Combined cognitive-strategy and task-specific training improve transfer to untrained activities in subacute stroke: an exploratory randomized controlled trial. Neurorehabilitation and Neural Repair, 29 (6), 526-36.

http://www.ncbi.nlm.nih.gov/pubmed/25416738

Polatajko, H.J., McEwen, S.E., Ryan, J.D., & Baum, C.M. (2012). Pilot randomized controlled trial investigating cognitive strategy use to improve goal performance after stroke. American Journal of Occupational Therapy, 66, 104-9.

http://www.ncbi.nlm.nih.gov/pubmed/22389945

Prokopenko, S.V., Mozheyko, E.Y., Petrova, M.M., Koryagina, T.D., Kaskaeva, D.S., CHernykh, T.V., Shvetzova, I.N., & Bezdenezhnih, A.F. (2013). Correction of post-stroke cognitive impairments using computer programs. Journal of Neurological Sciences, 325, 148-53.

http://www.ncbi.nlm.nih.gov/pubmed/23312291

Rose, D.F., Brooks, B. M., Attree, E. A., Parslow, D. M., Leadbetter, A. G., McNeil, J. E., & Potter, J. (1999). A preliminary investigation into the use of virtual environments in memory retraining after vascular brain injury: indications for future strategy?. Disability and Rehabilitation, 21(12), 548-554.

http://www.tandfonline.com/doi/abs/10.1080/096382899297206

Sturm, W. & Willmes K. (1991). Efficacy of a reaction training on various attentional and cognitive functions in stroke patients. Neuropsychological Rehabilitation, 1, 259-80.

http://www.tandfonline.com/doi/abs/10.1080/09602019108402258

Sturm, W., Willmes, K., Orgass, B., & Hartje, W. (1997). Do specific attention deficits need specific training? Neuropsychological Rehabilitation, 7(2), 81-103.

http://www.tandfonline.com/doi/abs/10.1080/713755526

Winkens, I., Van Heugten, C.M., Wade, D.T., Habets, E.J., & Faostti, L. (2009). Efficacy of time pressure management in stroke patients with slowed information processing: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 90, 1672-9.

http://www.ncbi.nlm.nih.gov/pubmed/19801055

Wolf, T.J., Polatajko, H., Baum, C., Rios, J., Cirone, D., Doherty, M., & McEwen, S. (2016). Combined cognitive-strategy and task-specific training affects cognition and upper-extremity function in subacute stroke: an exploratory randomized controlled trial. The American Journal of Occupational Therapy, 70(2), 1-10.

http://www.ncbi.nlm.nih.gov/pubmed/26943113

Excluded Studies

Cantagallo, A., Maini, M., & Rumiati, R.I. (2012). The cognitive rehabilitation of limb apraxia in patients with stroke. Neuropsychological Rehabilitation, 22 (3), 473-88.

Reason for Exclusion: Review

Gray JM, Robertson I, Pentland B, Anderson S. (1992). Microcomputer-based attentional retraining after brain damage: A randomised group controlled trial. Neuropsychological Rehabilitation, 2, 97-115.

Reason for Exclusion: Sample includes other etiology than stroke.

Hildebrandt, H., Bussmann-Mork, B., & Schwendemann, G. (2006). Group therapy for memory impaired patients: a partial remediation is possible. Journal of Neurology, 253(4), 512-519.

Reason for Exclusion: Sample includes other etiology than stroke.

Kaschel R., Della Sala S., Cantagallo A., Fahlbock A., Laaksonen R. & Kazen M. (2002). Imagery mnemonics for the rehabilitation of memory: a randomised group controlled trial. Neuropsychological Rehabilitation, 12(2), 127-53.

Reason for Exclusion: Participants with stroke represent less than 50% of overall studied sample.

Miller, L. A., & Radford, K. (2014). Testing the effectiveness of group-based memory rehabilitation in chronic stroke patients. Neuropsychological Rehabilitation, 24(5), 721-737.

Reason for Exclusion: Not a RCT, outcomes available in RCTs.

Mount, J., Pierce, S. R., Parker, J., DiEgidio, R., Woessner, R., & Spiegel, L. (2007). Trial and error versus errorless learning of functional skills in patients with acute stroke. NeuroRehabilitation, 22(2), 123-132.

Reason for Exclusion: Executive functions training, refer to executive function interventions module.

Ostwald, S. K., Godwin, K. M., Cron, S. G., Kelley, C. P., Hersch, G., & Davis, S. (2014). Home-based psychoeducational and mailed information programs for stroke-caregiving dyads post-discharge: a randomized trial. Disability and Rehabilitation, 36(1), 55-62.

Reason for Exclusion: Not cognitive rehabilitation.

Van de Ven, R., Schmand, B., Groet, E., Veltman, D.J., & Murrem J.M.J. (2015). The effect of computer-based cognitive flexibility training on recovery of executive function after stroke: rationale, design and methods of the TAPASS study. BMC Neurology, 15, 144.

Reason for Exclusion: Study protocol proposal without results.

Rand, D., Eng, J.J., Liu-Ambrose, T., & Tawashy, A.E. (2010). Feasibility of a 6-month exercise and recreation program to improve executive functioning and memory of individuals with chronic stroke. Neurorehabilitation and Neural Repair, 24(8), 722-9.

Reason for Exclusion: Not a RCT, outcomes available in RCTs.

Westerberg, H., Jacobaeus, H., Hirvikoski, T., Clevberger, P., Östensson, M. L., Bartfai, A., & Klingberg, T. (2007). Computerized working memory training after stroke–a pilot study. Brain Injury, 21(1), 21-29.

Reason for Exclusion: Executive functions training, refer to executive function interventions module.

Zagavec, B. S., Lesnik, V.M., & Goljar, N. (2015). Training of selective attention in work-active stroke patients. International Journal of Rehabilitation Research, 38, 370-2.

Reason for Exclusion: Not a RCT, outcomes available in RCTs.

Zedlitz, A.M.E.E., Rietveld, T.C.M., Geurts, A.C., & Fasotti, L. (2012). Cognitive and graded activity training can alleviate persistent fatigue after stroke. Stroke, 43, 1046-51.

Reason for Exclusion: Both study groups received cognitive rehabilitation.

Executive Function

Evidence Reviewed as of before: 19-08-2017
Author(s)*: Tatiana Ogourtsova, PhD Cand. MSc OT; Nicol Korner-Bitensky, PhD OT; Annabel McDermott, OT; Deirdre Dawson, PhD OT
Expert Reviewer: Valérie Poulin, OT,  PhD
Patient/Family Information Table of contents

Introduction

Executive functions (EF) refer to high-level cognitive functions that are responsible for the initiation, planning, sequencing, and monitoring of complex goal-directed behaviour. Disorders in EF after stroke are very common and can affect performance of activities of daily living and self-care, participation in social activities, and independence in more complex activities (e.g. returning to work, driving, caring for others). Executive functions include skills such as inhibition/impulse control, flexible thinking, emotional control, task initiation, memory and attention, planning, organisation of self and materials, and self-monitoring.

There are a variety of treatment approaches for EF deficits. Some interventions reviewed in this module focus on remediation of specific EF abilities affected by stroke (e.g. memory retraining using computer-based tasks, virtual reality programs). Other interventions use compensation approaches, for instance through cognitive strategies (e.g. Cognitive Orientation to daily Occupational Performance training, problem-solving training) or external mechanisms (e.g. electronic paging systems).

Patient/Family Information

Authors: Valérie Poulin, Nicol Korner-Bitensky, Annabel McDermott, Deirdre Dawson & Tatiana Ogourtsova

What is Executive Function (EF)?

Executive functions (EF) are complex mental skills and abilities that help us to manage our attention and behaviour so we can achieve our goals.

EF involve abilities such as:

  • starting tasks
  • planning tasks
  • paying attention
  • holding information in our mind while using it for a short period of time (e.g. remembering numbers as we dial a phone number)
  • stopping inappropriate actions
  • multitasking
  • solving problems
  • monitoring our own progress and adjusting our approach in new or unexpected situations

We use EF every day during common activities such as dressing or preparing a meal, as well as more difficult activities related to work and leisure.

EF can be affected by a stroke. A person who has had a stroke may have difficulties with simple self-care activities (e.g. grooming, dressing) and/or more complex activities (e.g. cooking, grocery shopping, driving, childcare, return to work) that require EF.

How frequent are EF problems after a stroke?

EF problems are very common, and happen in 19% to 75% of people after a stroke.

What are the potential consequences of EF problems?

When a person has EF problems after stroke it can affect their ability to do familiar activities such as caring for themselves, managing their home, working and driving a car. It can also affect a person’s ability to respond to new or unexpected situations.

For example, a person with EF problems might have difficulty preparing a meal because they forget to gather the correct ingredients or they mix up the order of steps when putting the foods together. They might forget to turn a hotplate on before cooking, or to turn the hotplate off after cooking. They might burn the meal because they got distracted during cooking.

As another simple example, a person with EF problems after stroke might have difficulty meeting up with a friend because they cannot figure out what time they need to leave their own house to get to the meeting place on time, or get distracted by another activity on his/her way to the meeting place.

There are strategies and approaches that can be used to help people with EF problems after stroke.

Can EF problems caused by a stroke be treated?

There are three different treatment approaches for EF problems after a stroke. They aim to:

  1. Restore the EF abilities affected by a stroke
  2. Teach strategies to compensate for EF abilities affected by the stroke
  3. Use external aids or environmental modifications

These approaches are described below.

1. Restoring EF abilities that have been affected by a stroke

This approach involves practicing the skills you have difficulty with until you see improvement. Interventions may involve computer-based training or face-to-face training with a therapist.

Computer-based training can be used to train skills such as:

  • working memory: the ability to hold information in our mind and work with it for a short period of time (e.g. dialing a phone number or doing mental calculations)
  • dual task: the ability to coordinate two tasks at once (e.g. turning the steering wheel and pressing the gas pedal at the same time while driving).

Computer activities to work on these skills use numbers, letters, words, and shapes, and also simulate daily life tasks.

NOTE: Don’t be concerned if you are not familiar with computers – these programs work quite simply and your therapist will show you how to use them easily.

Face-to-face training with the therapist can be used to train skills such as:

  • verbal working memory: the ability to hold verbal information in our mind and work with it for a short period of time (e.g. reading long sentences). Training for verbal working memory uses different activities such as word spelling or sorting a series of words into alphabetic order.

2. Teaching strategies to compensate for EF abilities affected by the stroke

This approach may involve learning and applying strategies to solve everyday problems and to handle everyday situations in a more structured way.

Specific treatments that are being tried in recent years to help people with EF problems after a stroke include:

Problem-solving training, where the person learns to make use of a common every day task they are comfortable with to help them learn other similar tasks – by comparing one to the other and identifying similarities in “how to” perform the task.

Goal Management Training, where the person learns to take time to stop while doing an activity in order to reflect on the goal of their task and to self-monitor their performance. This training often includes some written materials, interactive tasks, a discussion with your clinicians of real-life concerns you are experiencing when doing specific tasks since your stroke etc.

Cognitive Orientation to daily Occupational Performance (CO-OP) approach, where your clinician helps you identify strategies that will make it easier for you to achieve goals that have become more difficult since your stroke. For example, you may find it harder to remember to organize your week and get to your scheduled appointments. Your clinician would help you to come up with strategies that work for you to make these activities easier to do.

3. Teaching the use of external aids / environmental modifications

This may involve using paging systems, step-by-step checklists or environmental modifications in order to complete daily activities:

Electronic paging systems consist of reminders sent to standard pagers to assist with memory & planning. You would receive electronic prompts to carry out tasks you want to accomplish such as taking medication or remembering appointments.

Paper and pencil checklists: With the clinician’s help, you would make a list of each step or task that needs to be done. You would tick off each task/step once it has been done and record the total time taken to complete the task.

Environmental modifications consist of changes to everyday objects or settings (e.g. use of a dosette box for medication, labelling things around the home or workplace, etc.).

Which EF treatments work?

There is limited but encouraging evidence to suggest that people with stroke can benefit from retraining specific EF abilities (e.g. computer-based training of working memory) and using compensatory strategies (e.g. Problem-solving strategies, goal management training, paging systems). These strategies may improve different aspects of EF and, possibly, a person’s ability to accomplish daily activities.

Who provides the treatment?

Occupational therapists (OT), neuropsychologists and speech language pathologists can provide this therapy at an acute care hospital, rehabilitation centre, or private clinic.

Are there any side effects/risks to EF treatments?

There are no specific risks and/or side effects involved in EF treatment post-stroke. You are encouraged to take breaks as needed and respect your level of fatigue when participating in EF training. Your treating health care professional will adjust the training according to your needs and abilities.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

A systematic literature review on the effectiveness of EF interventions post-stroke was conducted in January 2011 (please see the paper from Poulin, V., Korner-Bitensky, N., Dawson, D., & Bherer, L. (2012). Efficacy of executive function interventions after stroke: a systematic review.Topics in stroke Rehabilitation, 19(2), 158-171) and was updated in February 2013 and August 2017 for the purpose of this module.

Currently, 15 RCTs that meet the inclusion criteria are included in the module. Six of them are high quality studies, eight are fair quality RCTs and one is a low quality RCT.

In patients with acute stroke, EF intervention included computer interventions. Computer interventions were found to be more effective than comparison treatments in improving outcomes such as overall cognitive functions, selective attention, processing speed and complex attention, and working memory; but not outcomes related to frontal lobe function, functional independence, reasoning, verbal fluency/language and visuo-constructive abilities.

In patients with chronic stroke, EF interventions included computer interventions, paging system, strategy training and virtual reality. Computer interventions were found to be more effective than comparison treatments in improving attention, self-perceived health and memory; but not cognitive function, reasoning, occupational performance, processing speed and complex attention, and quality of life. Paging system was found to be more effective than comparison treatments in improving task completion. Strategy training was found to be more effective than comparison interventions in improving concept formation and cognitive flexibility; but not instrumental activities of daily living. Virtual reality was found to be more effective than comparison interventions in improving attention, cognitive function, verbal fluency/language; but not memory, processing speed and complex attention, reasoning, stroke outcomes, and visuospatial skills.

In patients with stage of stroke recovery not specific to one period, EF interventions included the CO-OP approach, computer interventions, strategy training, time pressure management, and virtual reality. The CO-OP approach was found to be more effective than comparison interventions in improving stroke outcomes; but not outcomes related to dysexecutive deficits, cognitive flexibility, life habits, occupational performance, processing speed and complex attention and working memory. Computer interventions were found to be more effective than comparison interventions in improving unilateral spatial neglect, frontal lobe function, processing speed and complex attention; but not mood, cognitive function, dysexecutive deficits, cognitive flexibility, life habits, occupational performance, and working memory. Strategy training was found to be more effective than comparison interventions in improving mood, cognitive flexibility and functional independence; but not inhibition. Time pressure management was found to be more effective than comparison interventions in improving information intake and speed of information processing; but not cognitive function, inhibition, attention, fatigue, functional independence, mood, processing speed and complex attention, quality of life and working memory. Virtual reality was found to be more effective than a comparison intervention in improving attention and working memory.

Results Table

View results table

Outcomes

Acute phase - Computer interventions

Cognitive function
Effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on cognitive function in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Cognitive function was measured by the Mini-Mental State Examination (MMSE) at post-treatment (4 weeks). Significant between-group differences were found, favoring computer executive function training vs. sham intervention.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is more effective than a comparison intervention (sham intervention) in improving cognitive function in patients with acute stroke.

Frontal lobe function
Not effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on frontal lobe function in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Frontal lobe function was measured by the Frontal Assessment Battery at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is not more effective than a comparison intervention (sham intervention) in improving frontal lobe function in patients with acute stroke.

Functional independence
Not effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on functional independence in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Functional independence was measured by the Functional Independence Measure at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is not more effective than a comparison intervention (sham intervention) in improving functional independence in patients with acute stroke.

Processing speed and complex attention
Effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on processing speed and complex attention in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Processing speed and complex attention were measured by the Trail Making Test A&B at post-treatment (4 weeks). Significant between-group differences were found, favoring computer executive function training vs. sham intervention.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is more effective than a comparison intervention (sham intervention) in improving processing speed and complex attention in patients with acute stroke.

Reasoning
Not effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on reasoning in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or a sham intervention. Non-verbal reasoning was measured by the Progressive Matrices 47 at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is not more effective than a comparison intervention (sham intervention) in improving non-verbal reasoning in patients with acute stroke.

Selective attention
Effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on visual selective attention in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Visual selective attention was measured by the Attentive Matrices at post-treatment (4 weeks). Significant between-group differences were found, favoring computer executive function training vs. sham intervention.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is more effective than a comparison intervention (sham intervention) in improving visual selective attention in patients with acute stroke.

Verbal fluency / language
Not effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on verbal fluency in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Verbal fluency was measured by the Phonological Fluency and Semantic Fluency Tests at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is not more effective than a comparison intervention (sham intervention) in improving verbal fluency in patients with acute stroke.

Visual-constructive abilities
Not effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effect of a computer-based intervention on visual-constructive abilities in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Visual-constructive abilities were measured by the Rey-Osterrieth Figure Copy Test at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is not more effective than a comparison intervention (sham intervention) in improving visual-constructive abilities in patients with acute stroke.

Working memory
Effective
1b

One high quality RCT (Zucchella et al., 2014) investigated the effects of a computer-based intervention on memory in patients with acute stroke. This high quality RCT randomized patients to receive therapist-guided computer executive function training or sham intervention. Measures of memory were taken at post-treatment (4 weeks) and included: (i) episodic memory, measured by the Rey Auditory Verbal Learning Test (RAVLT – immediate and delayed recall); (ii) verbal working memory, measured by the Digit Span Test; (iii) spatial memory, measured by Corsi’s Test; and (iv) logical memory, measured by the Logical Memory Test (immediate and delayed recall). At post-treatment there were significant between-group differences in episodic memory (RAVLT – delayed recall only) and logical memory (immediate and delayed), favoring computer executive function training vs. sham intervention. There were no significant differences in verbal memory or spatial memory.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer executive function training is more effective than a comparison intervention (sham intervention) in improving episodic and logical memory (but not verbal or spatial memory) in patients with acute stroke.

Chronic phase - Computer interventions

Attention
Effective
2a

Two fair quality RCTs (Westerberg et al., 2007; Lundqvist et al., 2010) investigated the effect of a computer intervention on attention in patients with chronic stroke.

The first fair quality RCT (Westerberg et al., 2007) randomized patients to receive home-based computer-assisted working memory training or no treatment. Attention was measured by the Stroop Interference Test and the Ruff 2&7 Test (selective attention), and the Paced Auditory Serial Attention Test (PASAT- Version A, sustained/divided attention) at post-treatment (5 weeks). There were significant between-group differences in one measure of selective attention (Ruff 2&7) and in measures of sustained/divided attention (PASAT – Version A) at post-treatment, in favour of computer-assisted working memory training vs. no training.

The second fair quality cross-over RCT (Lundqvist et al., 2010) randomized patients to receive a 5-week computer-assisted working memory training program or no therapy. Attention was measured by the PASAT, Listening Span Task and Picture Span Task at 4 weeks post-treatment (short-term follow-up) and at 20 weeks post-treatment (long-term follow-up). Between-group differences for attention were not reported.
Note: Combined results (i.e. at which time both groups received the intervention) showed significant improvement from baseline at both follow-up time points.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that computer-assisted working memory training is more effective than no treatment in improving attention in patients with chronic stroke. A second fair quality RCT also reported improvements following computer-assisted working memory training.

Cognitive flexibility
Insufficient evidence
5

One fair quality RCT (Lundqvist et al., 2010) investigated the effect of a computer intervention on cognitive flexibility in patients with chronic stroke. This fair quality cross-over RCT randomized patients to receive a 5-week computer-assisted working memory training program or no therapy. Cognitive flexibility was measured by the Delis-Kaplan Executive Function System – Colour Word Interference Test Condition 4 – Inhibition/Switching at 4 weeks post-treatment (short-term follow-up) and 20 weeks post-treatment (at long-term follow-up). Between-group differences in cognitive flexibility were not reported.
Note: Combined results (i.e. at which time both groups received the intervention) showed significant improvement from baseline at both follow-up time points.

Conclusion: There is insufficient evidence (Level 5) regarding the effect of computer-assisted working memory training on cognitive flexibility in patients with chronic stroke. However, a fair quality RCT found significant improvement in cognitive flexibility following computer-assisted working memory training.

Memory
Effective
2a

Three fair quality RCTs (Westerberg et al., 2007; Lundqvist et al., 2010; Lin et al., 2014) investigated the effect of computer interventions on memory in patients with chronic stroke.

The first fair quality RCT (Westerberg et al., 2007) randomized patients to receive home-based computer-assisted working memory training or no treatment. Memory outcomes included: (i) auditory working memory, measured by the Wechsler Adult Intelligence Scale – Revised NI (WAIS-R NI – Digit Span Test); (ii) delayed recall, measured by the Claeson-Dahl Word List Test – Delayed Recall; and (iii) visual-spatial working memory, measured by the WAIS-R NI – Span Board Test. Significant between-group differences in auditory working memory and visual-spatial working memory (WAIS-R NI – Digit Span Test, Span Board Test) were found at post-treatment, favoring computer-assisted working memory training vs. no treatment.

The second fair quality cross-over RCT (Lundqvist et al., 2010) randomized patients to receive a 5-week computer-assisted working memory training program or no therapy. working memory was measured by the WAIS-R NI – Block-Span-Board (forwards, backwards) at 4 weeks post-treatment (short-term follow-up) and at 20 weeks post-treatment (long-term follow-up). Between-group differences for memory were not reported. Combined results (i.e. at which time both groups received the intervention) showed significant improvement from baseline to both follow-up time points.

The third fair quality RCT (Lin et al., 2014) randomized patients to receive computer-assisted memory/executive function training or no therapy. working memory was measured by the Wechsler Memory Scale (WMS – information, orientation, mental control, logical memory, digits forward and backward, visual reproduction, associated learning, memory quotient) at post-treatment (10 weeks). Between-group differences in memory functions were not reported. There were significant within-group differences in memory functions (WMS – mental control, logical memory, digits forward and backward, visual reproduction, associated learning, memory quotient) from baseline to post-treatment in the computer-assisted memory/executive function training group, whereas significant gains were not seen in the group that received no training.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that home-based computer –assisted working memory training is more effective than no treatment in improving memory in patients with chronic stroke. Two other RCTs reported improvements following computer-assisted working memory training program.

Occupational performance
Insufficient evidence
5

One fair quality RCT (Lundqvist et al., 2010) investigated the effect of a computer intervention on occupational performance in patients with chronic stroke. This fair quality cross-over RCT randomized patients to receive a 5-week computer-assisted working memory training program or no therapy. Occupational performance was measured by the Canadian Occupational Performance Measure (COPM – performance and satisfaction scales) at 20 weeks after training. Between-group differences for occupational performance were not reported.
Note: Combined results (i.e. at which time both groups received the intervention) showed significant improvement from baseline to follow-up.

Conclusion: There is insufficient evidence (Level 5) regarding the effect of computer-assisted working memory training on occupational performance in patients with chronic stroke. However, a fair quality RCT found significant improvement in occupational performance following computer-assisted working memory training.

Processing speed and complex attention
Insufficient evidence
5

One fair quality RCT (Lin et al., 2014) investigated the effect of computer intervention on processing speed and complex attention in patients with chronic stroke. This fair quality RCT randomized patients to receive computer-assisted memory/executive function training or no computer training. Processing speed and complex attention were measured by the Trail Making Test A & B at baseline and post-treatment (10 weeks). Between-group differences in processing speed and complex attention were not reported; the group that received computer training demonstrated significant improvement on one measure of processing speed and complex attention (Trail Making Test A) from baseline to post-treatment.

Conclusion: There is insufficient evidence (Level 5) regarding the effect of computer-assisted memory and executive function training on processing speed and complex attention. However, a fair quality RCT found significant improvement in processing speed and complex attention following computer-assisted memory/executive function training.

Quality of life
Insufficient evidence
5

One fair quality RCT (Lundqvist et al., 2010) investigated the effect of a computer intervention on quality of life in patients with chronic stroke. This fair quality cross-over RCT randomized patients to receive a 5-week computer-assisted working memory training program or no therapy. Quality of life was measured by the EQ-5D at 20 weeks after training. Between-group differences for quality of life were not reported.
Note: Combined results (i.e. at which time both groups received the intervention) showed no significant improvement from baseline to follow-up.

Conclusion: There is insufficient evidence (Level 5) regarding the effect of computer-assisted working memory training on quality of life in patients with chronic stroke. Also, a fair quality RCT found no significant improvement in quality of life following computer-assisted working memory training.

Reasoning
Not effective
2a

One fair quality RCT (Westerberg et al., 2007) investigated the effect of computer interventions on reasoning in patients with chronic stroke. This fair quality RCT randomized patients to receive home-based computer-assisted working memory training or no treatment. Reasoning skills were measured by Raven’s Progressive Matrices at post-treatment (5 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that a home-based computer-assisted working memory training is not more effective than no treatment in improving reasoning skills in patients with chronic stroke.

Self-perceived cognitive health
Effective
2a

Two fair quality RCTs (Westerberg et al., 2007; Lundqvist et al., 2010) investigated the effect of a computer intervention on self-perceived health in patients with chronic stroke.

The first fair quality RCT (Westerberg et al., 2007) randomized patients to receive home-based computer-assisted working memory training or no treatment. Self-perceptive health (self-rated cognitive failures) was measured by the Cognitive Failure Questionnaire at post-treatment (5 weeks). Significant between-group differences in cognitive failures were found, favoring computer-assisted working memory training vs. no treatment,

The second fair quality cross-over RCT (Lundqvist et al., 2010) randomized patients to receive a 5-week computer-assisted working memory training program or no therapy. Self-perceived health was measured by Visual Analogue Scale (VAS) at 20 weeks after training. Between-group differences in self-perceived health were not reported.
Note: Combined results (i.e. at which time both groups received the intervention) showed significant improvement from baseline to follow-up.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that home-based computer assisted working memory training is more effective than no treatment in improving self-perceived health in patients with chronic stroke. A second fair quality RCT also reported significant improvements in self-perceived health following computer-assisted working memory training.

Chronic phase - Paging system

Task completion
Effective
2a

One fair quality RCT (Fish et al., 2008) investigated the effect of electronic cueing using a paging system on task completion in patients with chronic stroke. This fair quality cross-over RCT randomized patients to receive pager training or delayed pager training (no training). Task completion was measured according to percentage of tasks successfully completed, taken at post-treatment (7 weeks) and at follow-up (7 weeks after pager withdrawal). Both groups demonstrated a significant between-group differences in task completion immediately following their respective intervention phase; results deteriorated to baseline levels following a period of non-use of the pagers.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that the electronic cueing using a paging system is more effective than a comparison intervention (no pager training) in improving task completion in patients with chronic stroke, in the short term.

Chronic phase - Strategy training

Cognitive flexibility (self-reported)
Effective
2a

One fair quality RCT (Man et al., 2006) investigated the effect of strategy training on cognitive flexibility in patients with chronic stroke. This fair quality RCT randomized patients to receive strategy training in the form of online (videoconference) training, self-directed computer-assisted training, face-to-face therapist-directed training or no training. Self-reported cognitive flexibility was measured by the Problem-solving Self-Efficacy Scale at baseline and at post-treatment (20 treatment sessions over 2 months). Significant between-group differences were found at post-treatment, favoring face-to-face therapist training vs. online (videoconferencing) training, and favoring face-to-face therapist training vs. self-directed computer-assisted training.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that strategy training in the form of face-to-face therapist training is more effective than comparison interventions (online interactive Problem-solving training, computer-assisted Problem-solving training) in improving self-reported cognitive flexibility in patients with chronic stroke.

Concept formation ability
Not effective
2a

One fair quality RCT (Man et al., 2006) investigated the effect of strategy training on concept formation ability in patients with chronic stroke. This fair quality RCT randomized patients to receive strategy training in form of online (videoconferencing) training, self-directed computer-assisted training or face-to-face therapist-directed training, or no training. Concept formation ability was measured by the Category Test at baseline and at post-treatment (20 treatment sessions over 2 months). No significant differences were found between any groups.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that strategy training in the form of online interactive training, computer-assisted training or face-to-face therapist training is not more effective than no treatment in improving concept formation ability in patients with chronic stroke.

Instrumental activities of daily living (IADLs)
Not effective
2a

One fair quality RCT (Man et al., 2006) investigated the effect of strategy training on instrumental activities of daily living (IADLs) in patients with chronic stroke. This fair quality RCT randomized patients to receive strategy training in the form of online (videoconference) training, self-directed computer-assisted training or face-to-face therapist-directed training, or no training. IADLs were measured by the Chinese Version of the Lawton Instrumental activities of Daily Living Scale at baseline and at post-treatment (20 treatment sessions over 2 months). No significant differences were found between any groups.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that strategy training in the form of online interactive training, computer-assisted training or face-to-face therapist training is not more effective than no treatment in improving IADLs in patients with chronic stroke.

Chronic phase - Virtual reality

Attention
Effective
1b

One high quality RCT (Faria et al., 2016) investigated the effect of virtual-reality (VR) -based rehabilitation on attention in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Attention was measured by the Addenbrooke Cognitive Examination (ACE – Attention) at post-treatment (4-6 weeks). Significant between-group differences in attention were found at post-treatment, favoring VR-based rehabilitation vs. conventional cognitive rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is more effective than a comparison intervention (conventional cognitive rehabilitation) in improving attention in patients with chronic stroke.

Cognitive function
Effective
1b

One high quality RCT (Faria et al., 2016) investigated the effect of virtual-reality (VR) -based rehabilitation on cognitive function in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Cognitive function was measured by the Addenbrooke Cognitive Examination (ACE – total score) and the Mini-Mental State Examination (MMSE) at post-treatment (4-6 weeks). Significant between-group differences were found in both measures of cognitive function at post-treatment, favoring VR-based rehabilitation vs. conventional cognitive rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is more effective than a comparison intervention (conventional cognitive rehabilitation) in improving cognitive function in patients with chronic stroke.

Memory
Not effective
1b

One high quality RCT (Faria et al., 2016) investigated the effect of virtual-reality (VR) -based rehabilitation on memory in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Memory was measured by the Addenbrooke Cognitive Examination (ACE – Memory) at post-treatment (4-6 weeks). No significant between-group differences in memory were found at post-treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is not more effective than a comparison intervention (conventional cognitive rehabilitation) in improving memory in patients with chronic stroke.

Processing speed and complex attention
Not effective
1b

One high quality RCT (Faria et al., 2016) investigated the effects of virtual-reality (VR) -based rehabilitation on processing speed and complex attention in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Processing speed and complex attention were measured by the Trail Making Test A & B at post-treatment (4-6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is not more effective than a comparison intervention (conventional cognitive rehabilitation) in improving processing speed and complex attention in patients with chronic stroke.

Reasoning
Not effective
1b

One high quality RCT (Faria et al., 2016) investigated the effect of virtual-reality (VR) -based rehabilitation on reasoning in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Logical/sequential reasoning was measured by the WAIS III Picture Arrangement test at post-treatment (4-6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is not more effective than a comparison intervention (conventional cognitive rehabilitation) in improving reasoning in patients with chronic stroke.

Stroke outcomes
Not effective
1b

One high quality RCT (Faria et al., 2016) investigated the effects of virtual-reality (VR) -based rehabilitation on stroke outcomes in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. stroke outcomes measured by the stroke Impact Scale at post-treatment (4-6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is not more effective than a comparison intervention (conventional cognitive rehabilitation) in improving stroke outcomes in patients with chronic stroke.

Verbal fluency / language
Effective
1b

One high quality RCT (Faria et al., 2016) investigated the effects of virtual-reality (VR) -based rehabilitation on verbal fluency/language in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Verbal fluency/language was measured by the Addenbrooke Cognitive Examination (ACE – Fluency, Language) at post-treatment (4-6 weeks). At post-treatment there were significant between-group differences in ACE Fluency scores only, favoring VR-based rehabilitation vs. conventional cognitive rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is more effective than a comparison intervention (conventional cognitive rehabilitation) in improving verbal fluency in patients with chronic stroke.
Note:
There were no significant between-group differences in language scores.

Visuospatial skills
Not effective
1b

One high quality RCT (Faria et al., 2016) investigated the effect of virtual-reality (VR)-based rehabilitation on visuospatial skills in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based rehabilitation or conventional cognitive rehabilitation. Visuospatial skills were measured by the Addenbrooke Cognitive Examination (ACE –Visuospatial) at post-treatment (4-6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based rehabilitation is not more effective than a comparison intervention (conventional cognitive rehabilitation) in improving visuospatial skills in patients with chronic stroke.

Phase not specific to one period - Cognitive Orientation to Daily Occupational Performance (CO-OP)

Cognitive flexibility
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of the CO-OP treatment approach on cognitive flexibility in patients with stroke. This fair quality partial RCT randomized patients with subacute/chronic stroke to receive the CO-OP treatment approach or computer-assisted working memory training. Cognitive flexibility was measured by the Delis-Kaplan Executive Function System (D-KEFS) Colour-Word Interference Test at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that CO-OP training is not more effective than a comparison intervention (computer-assisted working memory training) in improving cognitive flexibility in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the Computer interventions section below.

Dysexecutive deficits
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of the CO-OP treatment approach on dysexecutive deficits in patients with stroke. The fair quality partial RCT randomized patients with subacute/chronic stroke to receive the CO-OP treatment approach or computer-assisted working memory training. Dysexecutive deficits were measured by the Dysexecutive Questionnaire at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that CO-OP training is not more effective than comparison interventions (computer-based memory training) in improving dysexecutive deficits in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the Computer interventions section below.

Life habits
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of the CO-OP treatment approach on life habits in patients with stroke. This fair quality partial RCT randomized patients with subacute/chronic stroke to receive the CO-OP treatment approach or computer-assisted working memory training. Life habits were measured by the Assessment of Life Habits at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that CO-OP training is not more effective than a comparison intervention (computer-assisted memory training) in improving life habits in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the Computer interventions section below.

Occupational performance
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of the CO-OP treatment approach on occupational performance in patients with stroke. This fair quality partial RCT randomized patients with subacute/chronic stroke to receive the CO-OP treatment approach or computer-assisted working memory training. Occupational performance was measured by the Canadian Occupational Performance Measure (COPM – performance and satisfaction scales for trained and untrained tasks/significant others’ ratings) and the Self-Efficacy Scale for Performing Life Activities Post-Stroke at post-treatment (8 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.
Note: The CO-OP group demonstrated significant within-group differences on most COPM – performance and satisfaction scores (trained and untrained tasks), and on the Self-Efficacy Scale for Performing Life Activities Post-Stroke at both time points.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that CO-OP training is not more effective than a comparison intervention (computer-assisted memory training) in improving occupational performance in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the Computer interventions section below.

Processing speed and complex attention
Conflicting
4

Two fair quality RCTs (Poulin et al., 2016; Wolf et al., 2016) investigated the effect of the CO-OP treatment approach on processing speed and complex attention in patients with stroke.

The first fair quality partial RCT (Poulin et al., 2016) assigned patients with subacute/chronic stroke to receive the CO-OP treatment approach or computer-assisted working memory training. Processing speed and complex attention were measured by the Trail Making Test A&B at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

The second fair quality RCT (Wolf et al., 2016) randomized patients with acute/subacute stroke to receive the CO-OP treatment approach or conventional occupational therapy. Processing speed and complex attention was measured by the Delis-Kaplan Executive Function System Trail Making Test at baseline, at post-treatment (10 weeks) and at follow-up (3 months). Change scores from baseline to post-treatment and baseline to follow-up revealed medium effect sizes, favoring CO-OP vs. conventional occupational therapy.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of the CO-OP approach on processing speed and complex attention in patients with stroke. One fair quality partial RCT found that an 8-week CO-OP training program was not more effective than computer-assisted working memory training, whereas a second fair quality RCT found that a 10-week CO-OP training program was more effective than conventional rehabilitation.
Note: The study by Poulin et al. (2016) is also reviewed in the Computer interventions section below.

Stroke outcomes
Effective
2a

One fair quality RCT (Wolf et al., 2016) investigated the effect of cognitive rehabilitation using the CO-OP approach on stroke outcomes in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive the CO-OP treatment approach or conventional occupational therapy. stroke outcomes were measured by the stroke Impact Scale (SIS – ADLs, Mobility, Hand Function, Strength, Recovery, Memory, Emotion, Communication, Physical) at post-treatment (10 sessions) and at follow-up (3 months). Change scores from baseline to post-treatment revealed medium to large effect sizes for most stroke outcomes (Recovery, ADLs, Hand Function, Strength, Communication, Memory, Emotion, Physical), favoring CO-OP vs. conventional occupational therapy. At follow-up, medium to large effect sizes were maintained in two stroke outcomes (Hand Function, Communication), favoring CO-OP vs. conventional occupational therapy.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that the CO-OP approach is more effective than a comparison intervention (conventional occupational therapy) in improving stroke outcomes in patients with stroke.

Working memory
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of the CO-OP treatment approach on working memory in patients with stroke. This fair quality partial RCT randomized patients with subacute/chronic stroke to receive the CO-OP treatment approach or computer-assisted working memory training. working memory was measured by the Wechsler Adult Intelligence Scale-IV (WAIS-IV) Digit Span test at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that CO-OP training is not more effective than a comparison intervention (computer-assisted memory training) in improving working memory in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the Computer interventions section below.

Phase not specific to one period - Computer interventions

Cognitive flexibility
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of a computer intervention on cognitive flexibility in patients with stroke. This fair quality partial RCT randomized patients with subacute/chronic stroke to receive computer-assisted working memory training or the CO-OP treatment approach. Cognitive flexibility was measured by the Delis-Kaplan Executive Function System (D-KEFS) Colour-Word Interference Test at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that computer-assisted working memory training is not more effective than a comparison intervention (CO-OP treatment approach) in improving cognitive flexibility in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the CO-OP section above.

Cognitive function
Not effective
1b

One high quality RCT (Prokopenko et al., 2013) and one fair quality RCT (Akerlund et al., 2013) investigated the effect of computer interventions on cognitive function in patients with stroke.

The high quality RCT (Prokopenko et al., 2013) randomized patients with acute/subacute stroke to receive computer-assisted attention and working memory training or conventional therapy. Cognitive function was measured by the Mini-Mental Status Examination (MMSE) and the Montreal Cognitive Assessment (MOCA) at post-treatment (2 weeks). No significant between-group differences were found on either measure of cognitive functions.

The fair quality RCT (Akerlund et al., 2013) randomized patients with subacute/chronic stroke to receive computer-assisted working memory training with conventional rehabilitation or conventional rehabilitation alone. Cognitive function was measured by the Barrow Neurological Institute Screening for Higher Cerebral Functions at baseline, at post-treatment (1 week following a 5-week treatment), and at follow-up (18 weeks, 24 weeks). Significant between-group differences were found in changes of cognitive function scores from baseline to post-treatment, favoring computer-assisted working memory training with conventional rehabilitation vs. conventional rehabilitation alone. Results did not remain significant at either follow-up time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer-assisted attention and working memory training is not more effective than a comparison intervention (conventional therapy) in improving cognitive function in patients with acute/subacute stroke. However, one fair quality RCT found that computer-assisted working memory training with conventional rehabilitation was more effective than conventional rehabilitation alone in improving cognitive function in patients with subacute/chronic stroke.
Note:
Differences in the type and duration of the intervention and outcome measures used may account for the discrepancy in results between studies.

Dysexecutive deficits
Not effective
2a

Two fair quality RCTs (Akerlund et al., 2013; Poulin et al., 2016) investigated the effect of computer training on dysexecutive deficits in patients with stroke.

The first fair quality RCT (Akerlund et al., 2013) randomized patients with subacute/chronic stroke to receive computer-assisted working memory training with conventional rehabilitation or conventional rehabilitation alone. Dysexecutive deficits were measured by the Dysexecutive Questionnaire at post-treatment (1 week following a 5-week treatment) and at follow-up (18 weeks, 24 weeks). No significant between-group differences in dysexecutive deficits were found at any time point.

The second fair quality partial RCT (Poulin et al., 2016) randomized patients with subacute/chronic stroke to receive computer-assisted working memory training or the CO-OP treatment approach. Dysexecutive deficits were measured by the Dysexecutive Questionnaire at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from two fair quality RCTs that computer-assisted memory training is not more effective than comparison interventions (conventional rehabilitation alone, CO-OP) in improving dysexecutive deficits in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the CO-OP section above.

Frontal lobe function
Effective
1b

One high quality RCT (Prokopenko et al., 2013) investigated the effect of a computer intervention on frontal lobe function in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive computer-assisted attention and working memory training or conventional therapy. Frontal lobe function was measured by the Frontal Assessment Battery at post-treatment (2 weeks). Significant between-group differences were found at post-treatment, favoring computer-assisted attention and working memory training vs. conventional therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer-assisted attention training is more effective than a comparison intervention (conventional therapy) in improving frontal lobe function in patients with stroke.

Life habits
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of a computer intervention on life habits in patients with stroke. This fair quality partial RCT randomized patients with subacute/chronic stroke to receive computer-assisted working memory training or the CO-OP treatment approach. Life habits were measured by the Assessment of Life Habits at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time points.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that computer-assisted working memory training is not more effective than a comparison intervention (CO-OP) in improving life habits in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the CO-OP section above.

Mood
Not effective
1b

One high quality RCT (Prokopenko et al., 2013) and one fair quality RCT (Akerlund et al., 2013) investigated the effect of computer interventions on mood in patients with stroke.

The high quality RCT (Prokopenko et al., 2013) randomized patients with acute/subacute stroke to receive computer-assisted attention and working memory training or conventional therapy. Mood was measured by Hospital Anxiety and Depression Scale (HADS – Anxiety, Depression) at post-treatment (2 weeks). No significant between-group differences were found.

The fair quality RCT (Akerlund et al., 2013) randomized patients with subacute/chronic stroke to receive computer-assisted working memory training with conventional rehabilitation or conventional rehabilitation alone. Anxiety and Depression were measured by the HADS (Anxiety, Depression) at post-treatment (1 week following a 5-week treatment) and at follow-up (18 weeks, 24 weeks). There were no significant differences in anxiety at any time point or between intervention and control groups. There was a significant between-group difference in Depression at post-treatment, favoring computer-assisted training group vs. conventional rehabilitation alone (Group C1, see below). Differences did not remain significant at either follow-up time point.
Note: The control group was subsequently offered computer training at the end of the study and results were analysed according to individuals who sought the intervention (Group C1) and those who refused the intervention (Group C2). Group C1 presented with significantly more depressive symptoms vs. Group C2 at baseline.

Conclusion: There is moderate evidence (Level 1b) from one high and one fair quality RCT that computer-assisted working memory training is not more effective than a comparison intervention (conventional rehabilitation alone) in improving mood in patients with stroke.

Occupational performance
Not effective
2a

One fair quality RCT (Poulin et al., 2016) investigated the effect of a computer intervention on occupational performance in patients with stroke. This fair quality partial RCT randomized patients with subacute/chronic stroke to receive computer-assisted working memory training or the CO-OP treatment approach. Occupational performance was measured by the Canadian Occupational Performance Measure (COPM – performance and satisfaction scales for trained and untrained tasks/significant others’ ratings) and the Self-Efficacy Scale for Performing Life Activities Post-Stroke) at post-treatment (8 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that computer-assisted working memory training is not more effective than a comparison intervention (CO-OP) in improving occupational performance in patients with stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the CO-OP section above.

Processing speed and complex attention
Effective
1b

One high quality RCT (Prokopenko et al., 2013) and one fair quality RCT (Poulin et al., 2016) investigated the effect of a computer intervention on processing speed and complex attention in patients with stroke.

The high quality RCT (Prokopenko et al., 2013) randomized patients with acute/subacute stroke to receive computer-assisted attention and working memory training or conventional therapy. Attention was measured by Shulte’s Table at post-treatment (2 weeks). Significant between-group differences in attention were found at post-treatment, favoring computer-assisted attention training vs. conventional therapy.

The fair quality partial RCT (Poulin et al., 2016) randomized patients with subacute/chronic stroke to receive computer-assisted working memory training or the CO-OP treatment approach. Processing speed and complex attention were measured by the Trail Making Test A&B at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computer-assisted working memory training is more effective than a comparison intervention (conventional therapy) in improving processing speed and complex attention in patients with acute/subacute stroke. However, a fair quality RCT did not find any between-group differences on attention in patients witch acute/subacute stroke.
Note: The study by Poulin et al. (2016) is also reviewed in the CO-OP section above.

Unilateral spatial neglect
Effective
1b

One high quality RCT (Prokopenko et al., 2013) investigated the effect of a computer intervention on unilateral spatial neglect (USN) in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive computer-assisted attention and working memory training or conventional therapy. USN was measured by the Clock Drawing Test at post-treatment (2 weeks). Significant between-group differences in USN were found at post-treatment, favoring computer-assisted attention training vs. conventional therapy.

Conclusion: There is moderate evidence (Level 1b) that computer-assisted attention training is more effective than a comparison intervention (conventional therapy) in improving USN in patients with acute/subacute stroke.

Working memory
Not effective
2a

Two fair quality RCTs (Akerlund et al., 2013; Poulin et al., 2016) investigated the effect of computer interventions on working memory in patients with stroke.

The first fair quality RCT (Akerlund et al., 2013) randomized patients with subacute/chronic stroke to receive computer-assisted working memory training with conventional rehabilitation or conventional rehabilitation alone. working memory was measured by the Wechsler Adult Intelligence Scale-III NI (Digit Span: forwards, reversed, scaled; Span Board: forwards, reversed, scaled; working memory scaled score) at baseline, at post-treatment (1 week following a 5-week treatment) and at follow-up (18 weeks, 24 weeks). There were no significant between-group differences on any measure of working memory at post-treatment. At follow-up (18 weeks only) there were significant between-group differences in two measures of working memory (WAIS III NI – Digit Span forward, reversed change scores from baseline), favoring computer-assisted working memory training with conventional rehabilitation vs. conventional rehabilitation alone.

The second fair quality partial RCT (Poulin et al., 2016) randomized patients with subacute/chronic stroke to receive computer-assisted working memory training or CO-OP treatment approach. working memory was measured by the WAIS-IV Digit Span test at post-treatment (8 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from two fair quality RCTs that computer-assisted working memory training is not more effective than comparison interventions (conventional rehabilitation alone, CO-OP treatment approach) in improving working memory in patients with stroke. However, one fair quality RCT found that working memory training did improve at follow-up only, in favour of computer-assisted working memory training with conventional rehabilitation vs. conventional rehabilitation alone.
Note: The study by Poulin et al. (2016) is also reviewed in the CO-OP section above.

Phase not specific to one period - Strategy training

Cognitive flexibility
Effective
1b

One high quality RCT (Skidmore et al., 2015a) investigated the effect of strategy training using the Canadian Occupational Performance Measure (COPM) on cognitive flexibility in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive COPM strategy training or attention training for the duration of hospitalization (approx. 1-3 weeks). Cognitive flexibility was measured by the Delis-Kaplan Executive Functioning System (D-KEFS) Color Word Interference Test (cognitive flexibility scale) at 3 and 6 months after study admission. Significant between-group differences in cognitive flexibility were found at both follow-up time points, favoring COPM strategy training vs. attention training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that strategy training using the COPM is more effective than a comparison intervention (attention training) in improving cognitive flexibility in patients with stroke.

Functional independence
Effective
1b

One high quality RCT (Skidmore et al., 2015a) investigated the effect of strategy training using the Canadian Occupational Performance Measure (COPM) on functional independence in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive COPM strategy training or attention training for the duration of hospitalization (approx. 1-3 weeks). Functional independence was measured by the Functional Independence Measure (FIM) at 3 and 6 months after study admission (follow-up). Significant between-group differences in functional independence were found at both follow-up time points, favoring COPM strategy training vs. attention training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that strategy training using the COPM is more effective than a comparison intervention (attention training) in improving functional independence in patients with stroke.

Inhibition
Not effective
1b

One high quality RCT (Skidmore et al., 2015a) investigated the effect of strategy training using the Canadian Occupational Performance Measure (COPM) on inhibition in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive COPM strategy training or attention training for the duration of hospitalization (approx. 1-3 weeks). inhibition was measured by the Delis-Kaplan Executive Functioning System (D-KEFS) Color Word Interference Test (inhibition scale) at 3 and 6 months after study admission. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that strategy training using the COPM is not more effective than a comparison intervention (attention training) in improving inhibition in patients with stroke.

Mood
Effective
1b

A secondary analysis (Skidmore et al., 2015b) of one high quality RCT (Skidmore et al., 2015a) investigated the effect of strategy training using the Canadian Occupational Performance Measure (COPM) on apathy in patients with stroke. The high quality RCT (Skidmore et al., 2015a) randomized patients with acute/subacute stroke to receive strategy training using the COPM or attention training for the duration of hospitalization (approx. 1-3 weeks duration). Apathy was measured by the Apathy Evaluation Scale at 3 and 6 months after study admission. Significant between-group differences in apathy were found at 3 months after study admission only, favoring strategy training using the COPM vs. attention training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that strategy training using the COPM is more effective than a comparison intervention (attention training) in improving apathy in patients with acute/subacute stroke.

Phase not specific to one period - Time pressure management

Cognitive function
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on cognitive function in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. Cognitive impairment was measured by the Symbol Digit Modalities Test at post-treatment (10 hours of treatment) and at follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving cognitive impairment in patients with stroke.

Fatigue
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on fatigue in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. Fatigue was measured by the Fatigue Severity Scale at post-treatment (10 of hours of treatment) and at follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving fatigue in patients with stroke.

Functional independence
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on functional independence in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional therapy. Functional independence was measured by the Barthel Index at post-treatment (10 of hours of treatment) and at follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving functional independence in patients with stroke.

Information intake
Effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on information intake in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. Information intake was measured by an information intake task (no. of strategies used, reproduction scores) at post-treatment (10 hours of treatment) and at follow-up (3 months). Significant between-group differences in information intake (no. of used strategies) were found at post-treatment, favoring time pressure management training vs. conventional therapy. These between-group differences were not maintained at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is more effective than a comparison intervention (conventional therapy) in improving information intake in patients with stroke.

Inhibition / attention
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on inhibition/attention in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. inhibition/attention was measured by the Stroop Color Word Task at post-treatment (10 of hours of treatment) and at follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving inhibition /attention in patients with stroke.

Mental slowness processing
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on mental slowness processing in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. Mental speed was measured by the Mental Slowness Observation Test (MSOT – no. of used strategies, no. of correct elements, time), and perceived consequence of mental slowness was measured by the Mental Slowness Questionnaire. Measures were taken at post-treatment (10 hours of treatment) and at follow-up (3 months). There were no significant between-group differences on either measure at post-treatment. There was a significant between-group difference in one measure of mental speed (MSOT – time) at follow-up, favoring time pressure management vs. conventional therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving mental speed in patients with stroke. However, there was a long-term benefit resulting from time pressure management training.

Mood
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on depression in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. depression was measured by the Center for Epidemiologic Studies depression Scale at post-treatment (10 of hours of treatment) and at follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving depression in patients with stroke.

Processing speed and complex attention
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on processing speed and complex attention in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. Processing speed and complex attention were measured by the Trail Making A & B Test at post-treatment (10 of hours of treatment) and at follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving processing speed and complex attention in patients with stroke.

Quality of life
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on quality of life in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management training or conventional therapy. Quality of life was measured by the EuroQol-5D at post-treatment (10 of hours of treatment) and at follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving quality of life in patients with stroke.

Working memory
Not effective
1b

One high quality RCT (Winkens et al., 2009) investigated the effect of time pressure management training on working memory in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional therapy. working memory was measured by the Rey Auditory Verbal Learning Test and the Paced Auditory Serial Addition Test at post-treatment (10 of hours of treatment) and at follow-up (3 months). No significant between-group differences were found on either measure of working memory at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that time pressure management training is not more effective than a comparison intervention (conventional therapy) in improving working memory in patients with stroke.

Phase not specific to one period - Virtual reality

Attention
Effective
2b

One poor quality RCT (Gamito et al., 2017) investigated the effect of virtual-reality (VR)-based rehabilitation on attention in patients with stroke. This poor quality RCT randomized patients (stage of stroke not specified) to receive immediate VR-based cognitive rehabilitation or delayed VR-based cognitive rehabilitation (no training). Attention was measured by the Toulouse-Pieron Test (work efficiency) at post-treatment (4-6 weeks). Significant between-group differences in attention were found at post-treatment, favoring VR-based cognitive rehabilitation vs. no training.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that VR-based cognitive rehabilitation is more effective than no training in improving attention in patients with stroke.

Working memory
Effective
2b

One poor quality RCT (Gamito et al., 2017) investigated the effect of virtual-reality (VR)-based rehabilitation on working memory in patients with stroke. This poor quality RCT randomized patients (stage of stroke not specified) to receive immediate VR-based cognitive rehabilitation or delayed VR-based cognitive rehabilitation (no training). working memory was measured by the Wechsler Memory Scale (WMS – total score) and the Rey-Osterrieth Complex Figure test (ROCF – Immediate recall) at post-treatment (4-6 weeks). There were significant between-group differences in one measure of working memory (WMS total score) at post-treatment, favoring VR-based cognitive rehabilitation vs. no training.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that VR-based cognitive rehabilitation is more effective than no training in improving working memory in patients with stroke.

Clinician How-To

Authors: Valérie Poulin, Nicol Korner-Bitensky, Annabel McDermott, Deirdre Dawson & Tatiana Ogourtsova 

Executive function e-learning module

Please visit our Executive function e–learning modulehttp://strokengine.org/elearning/executivefunction/module.php

What is executive function (EF)?

Executive function refers to “high-level cognitive functions that provide control and direction of lower-level, more automatic functions” (Stuss, 2009, p. 8) and encompasses cognitive processes including:
Initiation,
Planning,
Sequencing,
Problem-solving,
Monitoring,
Inhibition,
Working memory
Divided attention,
Flexibility,
Judgement/Decision-making

(Anderson, 2008; Godefroy & Stuss, 2007; Lezak, 1989; Stuss, 2009).

Which parts of the brain are involved in EF?

The frontal lobes of the brain, especially the prefrontal cortex (i.e. the part of the frontal lobes located just behind the forehead), are known to be highly involved in executive functioning (Stuss, 2009). Executive functions can also be impaired by diffuse brain lesions and various network disconnections resulting from white matter damage or impairment to other brain regions (Stuss et al., 2002).

Please see the following website for further information on brain anatomy (including pictures of the brain lobes):
http://thebrain.mcgill.ca/flash/d/d_01/d_01_cr/d_01_cr_ana/d_01_cr_ana.html

What are the potential consequences of EF problems?

Initiation:

The ability to spontaneously start a task or activity (Grieve & Gnanasekaran, 2008)

Potential impact on everyday activities:

  • Poor self-care unless prompted
  • Requires prompting to start household tasks (e.g. cleaning, laundry, watering the plants, etc…)
  • Difficulty initiating conversation with other people
  • Difficulty keeping in touch with friends or family (e.g. the person no longer calls family members or friends as he/she used to do)
  • Poor participation in leisure activities (e.g. sitting around at home most of the day long and watching TV)

Planning:

« Planning ability involves anticipating future events, formulating a goal or endpoint, and devising a sequence of steps or actions that will achieve the goal or endpoint » (Anderson, 2008, p. 17)

Potential impact on everyday activities:

  • Reduced efficiency/competence in achieving daily tasks (e.g. self-care, meal preparation, grocery shopping, etc…)
  • Difficulty planning meals (e.g. difficulty identifying alternatives and selecting the most appropriate alternative according to their particular needs, taste, available ingredients, etc…)
  • Difficulty meeting deadlines (e.g. at work or for bill payment)
  • Difficulty scheduling and keeping appointments

Sequencing:

« The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step » (Lezak, 1989; as cited in – Baum, Morrison, Hahn & Edwards, 2007)

Potential impact on everyday activities:

  • Dressing in usual order (e.g. putting on shoes before pants)
  • Transferring from wheelchair to bed
  • Taking a shower (e.g. turning off the water before rinsing off all the soap)
  • Meal preparation (e.g., putting pasta in the pot before the water boils)

Problem-solving:

« Goal-directed cognitive activity that arises in situations for which no response is immediately apparent or available » (Luria, 1966; as cited in — Rath et al., 2004)

Potential impact on everyday activities:

  • Unable to deal with unforeseen problems (e.g. losing wallet, losing keys, car breakdown)
  • May need supervision and/ or assistance for making a major purchase (e.g. furniture) or for financial Planning
  • May have difficulty operating new electrical appliances
  • Difficulty applying newly learned skills to new situations or unfamiliar environments (e.g. using a public toilet in the mall versus at home)

Monitoring:

« The process of checking the task over time for ‘quality control’ and the adjustment of behavior » (Stuss, 2009, p. 9-10)

Potential impact on everyday activities:

  • Difficulty perceiving and/or correcting errors while performing a task (e.g. buying the wrong items at the grocery store, letting the cake burn or not letting it cook long enough, etc…)
  • Difficulty following instructions (e.g. the person stops referring to the written plan or is disrupted by environmental stimuli)

Inhibition:

The ability to suppress automatic actions that are inappropriate in a given context that interfere with a certain behavior (Grieve & Gnanasekaran, 2008)

Potential impact on everyday activities:

  • Social relationships and conversations with other people are affected by doing or saying embarrassing things
  • Driving: A driver with reduced inhibition may see a traffic light and come to a complete stop, yet the light is green. Or, he may come to a complete stop at the warning sign of a stop sign ahead

Working memory:

Executive process responsible for the temporary storage and manipulation of information in both simple (e.g. recalling a series of digits such as a phone number) and complex cognitive tasks (e.g. coordinating two tasks simultaneously – Van der Linden, 2007)

Potential impact on everyday activities:

  • Difficulty understanding and reading long sentences
  • Holding a conversation involving several persons
  • Using the phone (e.g. recalling and dialling a phone number)
  • Grocery shopping (e.g. the person forgets some of the items he/she had put in the shopping cart and has to check if indeed the item is already in the cart; difficulty manipulating money or credit card for shopping)
  • Leisure activitiesthat involve the visual and spatial organisation of items or keeping the score” (e.g. playing board games / puzzles / cards) (Grieve & Gnanasekaran, 2008)

Divided attention:

« The allocation of attentional resources across more than one task » (Ponsford, 2008, p. 514)

Potential impact on everyday activities:

  • Talking to a friend while walking/driving
  • Meal preparation (e.g. chopping vegetables while periodically checking food on the stove)
  • Group meetings at work
  • Looking after young children while preparing supper
  • Driving (e.g. integrating information from different targets such as a pedestrian on the sidewalk, an upcoming traffic light and the proximity of another vehicle; all while maintaining proper vehicle positioning and speed)
  • Crossing busy streets while watching for any cars and moving through dense pedestrian traffic

Flexibility:

The ability to shift between different thoughts and actions so that when a problem arises, one can draw upon past mistakes and successes and use this knowledge to plan solutions (Anderson, 2008)

Potential impact on everyday activities:

  • Playing games / cards (e.g. a person lacking mental flexibility may have difficulty changing his/her strategies in response to the actions of other players)
  • Conversations with a group of people (e.g. difficulty shifting from topic to topic in conversation)
  • Meal preparation that requires multiple task switching
  • Driving (e.g. a driver lacking mental flexibility may come to a complete stop by slamming on the brakes when faced with an unexpected obstruction on a one-way street that he is used to driving on and may have difficulty finding a quick alternative solution)

– Judgement / Decision-making:

The assessment and ‘ordering of various competing actions and goals’ (Barnes & Thagard, 1996)

Potential impact on everyday activities:

  • Avoiding unsafe situations when cooking, taking a bath, crossing busy streets, driving, etc…
  • Following treatment instructions / therapists’ recommendations (e.g. using a wheelchair to move around)
  • Inappropriate choice of clothes (not taking into consideration weather, context, etc…)

Why is it critical to assess EF post-stroke?

Disorders in EF after stroke are very common and affect participation in rehabilitation (Skidmore et al., 2010) and recovery (Lesniak, Bak, Czepiel, Seniow & Czlonkowska, 2008) with high risk of functional dependence (Lesniak et al., 2008), failure to return to work (Ownsworth & Shum, 2008) and poor social participation (McDowd, Filion, Pohl, Richards & Stiers, 2003).

Given that executive dysfunction can result in serious functional limitations, and that promising interventions exist for EF rehabilitation, all patients should be quickly screened or assessed for EF problems post-stroke. Patients identified with the presence of EF problems should receive interventions aimed at reducing impairment and/or maximizing everyday functioning.

Who should be assessed?

Disorders in EF are common cognitive sequelae of stroke, with reported occurrence in 19 to 75 percent of patients (Lesniak et al., 2008; Riepe, Riss, Bittner & Huber, 2004; Zinn, Bosworth, Hoenig & Swartzwelder, 2007). The complexity of EF makes them very sensitive to brain changes resulting from stroke (Levine et al., 2008). Thus, routine screening for EF problems in persons with stroke is important.

Can EF problems be treated?

There are three different treatment approaches for EF deficits after a stroke. They aim to:

  1. Restore the EF abilities that have been affected by a stroke;
  2. Teach cognitive strategies to compensate for EF abilities that have been affected by the stroke;
  3. Teach the use of external aids and environmental modifications

These approaches are described below.

  1. Restoring EF abilities that have been affected by stroke. These interventions are oriented toward targeted remediation of specific EF abilities, for example, through retraining on computer-based tasks or face-to-face training with a therapist. Specific interventions have recently been developed and used with people with stroke including:
    • Computerized training for Working memory (Lundqvist et al., 2010; Westerberg et al., 2007):
      • Tasks involve presentations of auditory and visuo-spatial stimuli.
      • Treatment schedule: 40 to 60 minute sessions, 5 days per week for 5 weeks.
    • Computerized dual-task training (Stablum et al., 2000):
      • Tasks involve coordinating the execution of 2 responses; patients have to identify the position (right or left) of 2 letters on the computer screen, and determine whether the 2 letters are the same or different
      • Treatment schedule: 1 session per week for 5 weeks.
    • Verbal working memory training (Vallat et al., 2005):
      • Face-to-face training using activities such as word spelling or sorting a series of words into alphabetic order.
      • Treatment schedule: 60 minute sessions, 3 days per week over 6 months.
  2. Teaching cognitive strategies to compensate for EF abilities affected by stroke. This may involve learning and applying strategies to solve everyday difficulties and to handle everyday situations in a more structured way. Specific interventions have recently been developed and used with people with stroke including:
    • Analogical problem-solving training (Man et al., 2006):
      • Patients are presented with common everyday problems and are taught to draw analogies to solve similar problems (Man et al., 2006).
      • Treatment schedule: 20 sessions of 45 minutes.
        NOTE: The use of problem solving strategies was also incorporated in small pilot studies using different training tasks and procedures (Honda, 1999; Rand et al., 2009).
    • Goal Management Training (GMT) (Levine et al., 2011; Schweizer et al., 2008):
      • Patients learn to periodically stop ongoing behaviour in order to reflect on the goal and the subgoals of their task and self-monitor their performance. This training consists of instructional material, interactive tasks, discussion of patients’ real-life difficulties, and homework assignments.
      • Treatment schedule: weekly 2-hour sessions over 7 weeks.
      • Please visit the https://shop.baycrest.org/collections/the-goal-management-training-program for more information on the administration of GMT; a GMT video is also available on this website.
    • Cognitive Orientation to daily Occupational Performance (CO-OP) approach (Polatajko & Mandich, 2004):
      • “CO-OP is a client-centred, performance-based, problem-solving approach that enables skill acquisition through a process of strategy use and guided discovery” (Polatajko & Mandich, 2004, p. 2). Clients learn to use a global problem-solving strategy to perform self-identified functional tasks that they want to improve. The therapist guides the client to discover solutions to their performance problems; the intervention is conducted through talking about plans and strategies for skill acquisition, through doing functional tasks and/or through homework.
      • Treatment schedule: 10 to 20 sessions lasting 45-60 minutes each.
      • Please visit the http://www.ot.utoronto.ca/coop/index.html for more information on the CO-OP approach.
  3. Teaching the use of external aids or environmental modifications. This may involve using external aids (e.g. paging systems and task-specific checklists) or other environmental modifications in an attempt to improve performance of daily activities. As you read the short vignette below, try to think of external compensatory strategies that you would typically use to help this client compensate for her difficulties and to facilitate the accomplishment of her everyday activities. Mrs. P who had her stroke 4 months ago is now home and is walking around her apartment and dressing herself with reminders from her husband. He is concerned that she has not resumed her usual activities – playing bingo, gardening, calling her best friend in the morning to touch base about going for a walk, etc. While Mrs. P’s physical recovery has been good and her husband is thankful to have her at home, he is finding her “not like she used to be” in terms of the way she thinks and initiates activities. He has asked for a home visit by an occupational therapist to help Mrs. P get back her “old habits and activities”.

Below are examples of different external compensatory strategies that can be used to improve performance of daily activities in persons with EF problems.

Which executive function abilities are affected?

Initiation

Impact:

  • Poor self-care unless prompted
  • Requires prompting to start household tasks (e.g. cleaning, laundry, watering the plants, etc…)
  • Difficulty initiating conversation with other people
  • Difficulty keeping in touch with friends or family (e.g. the person no longer calls his/her family members or friends as he/she used to do)
  • Poor participation in leisure activities(e.g. sitting around at home most of the day long and watching TV)

External compensatory strategies:

  • External cues/reminders:
    • Electronic paging systems (Evans et al., 1998; Fish et al., 2008a,b)
    • Alarm watches (Zoltan, 2007)
    • Mobile phones & smartphones
  • To-do lists
  • Visual cues in the person’s environment (e.g. keeping a laundry basket filled with clothes that need to be washed in a visible place)
  • Reminders / cues from significant others
  • Developing a daily routine (Zoltan, 2007)

Planning:

Impact:

  • Reduced efficiency/competence in achieving daily tasks (e.g. self-care, meal preparation, grocery shopping, etc…)
  • Difficulty planning meals (e.g. difficulty identifying alternatives and selecting the most appropriate alternative according to their particular needs, taste, available ingredients, etc…)
  • Difficulty meeting deadlines (e.g. at work or for bill payment)
  • Difficulty scheduling and keeping appointments

External compensatory strategies:

  • Electronic paging systems (Evans et al., 1998; Fish et al., 2008a,b)
  • Personal digital assistants / smartphone applications
  • Appointment calendars (Zoltan, 2007)
  • Checklists of steps to be done (Evans et al., 1998; Fish et al., 2008a)
  • Step by step directions / written instructions
  • Timers with auditory / verbal reminders
  • Reorganizing the client’s living environment (e.g. separate shelves for each category of items, written labels, etc…) (Zoltan, 2007)

Sequencing:

Impact:

  • Dressing in usual order (e.g., putting on shoes before pants)
  • Transferring from wheelchair to bed
  • Taking a shower (e.g. turning off the water before rinsing off all the soap)
  • Meal preparation (e.g., putting pasta in the pot before the water boils)

External compensatory strategies:

  • Step by step written directions and/or sequence of visually illustrated steps
  • Adapt the client’s environment: “arrange items according to the sequence of use before starting a task” (Zoltan, 2007, p. 256) (e.g. laying out clothes on the bed before dressing)
  • Cues from family/carers

Problem-solving:

Impact:

  • Unable to deal with unforeseen problems (e.g. losing wallet, losing keys, car breakdown)
  • May need supervision and/ or assistance for making a major purchase (e.g. furniture) or for financial Planning
  • May have difficulty operating new electrical appliances
  • Difficulty applying newly learned skills to new situations or unfamiliar environments (e.g. using a public toilet in the mall versus at home)

External compensatory strategies:

  • Step-by-step written instructions
  • Cues from family/carers
  • Delegate responsibilities to other family members
  • Adapt the client’s environment to facilitate problem-solving (e.g. limit irrelevant visual and/or auditory information) (Zoltan, 2007)

Monitoring:

Impact:

  • Difficulty perceiving and/or correcting errors while performing a task (e.g. buying the wrong items at the grocery store, letting the cake burn or not letting it cook long enough, etc…)
  • Difficulty following instructions (e.g. the person stops referring to the written plan or is disrupted by environmental stimuli

External compensatory strategies:

  • Auditory cues to remind the person to self-monitor his/her behavior (Manly et al., 2002) (e.g. timers, smartphone functions, pagers)
  • Alarms (e.g. reminder-alarms in kitchen equipment)
  • Checklists (e.g. the person has to tick off each step once it has been done)
  • Reminders / cues from family/carers

Inhibition:

Impact:

  • Social relationships and conversations with other people are affected by doing or saying embarrassing things
  • Driving: A driver with reduced inhibition may see a traffic light and come to a complete stop, yet the light is green. Or, he may come to a complete stop at the warning sign of a stop sign ahead.

External compensatory strategies:

  • Verbal prompts or cues from family/carers

Working memory:

Impact:

  • Difficulty understanding and reading long sentences
  • Holding a conversation involving several persons
  • Using the phone (e.g. recalling and dialling a phone number)
  • Grocery shopping (e.g. the person forgets some of the items he/she had put in his shopping cart and has to check if indeed the item is already in the cart; difficulty manipulating money for shopping)
  • Leisure activities that involvethe visual and spatial organisation of items or keeping the score (e.g. playing board games / puzzles / cards) (Grieve & Gnanasekaran, 2008)

External compensatory strategies:

  • Note taking (brief and in point form)
  • Checklists / step by step written instructions
  • Audio taping / digital recorders (to record and replay important material)
  • Speed dialling buttons on the telephone, smartphones
  • Reminders from significant others

Divided attention:

Impact:

  • Talking to a friend while walking/driving
  • Meal preparation (e.g. chopping vegetables while periodically checking food on the stove)
  • Group meetings at work
  • Looking after young children while preparing supper
  • Driving (e.g. integrating information from different targets such as a pedestrian on the sidewalk, an upcoming traffic light and the proximity of another vehicle; all while maintaining proper vehicle positioning and speed)
  • Crossing busy streets while watching for any cars and moving through dense pedestrian traffic

External compensatory strategies:

  • “Reduce distractions (e.g., work in a quiet room, […], reduce interruptions and background noise, clear workspace)” (Ponsford, 2008, p. 516)
  • “Tasks may be modified to reduce speed demands or the amount of information to be processed” (Ponsford, 2008, p. 516) [e.g., going to the mall during weekdays and/or when there is low traffic]
  • Attempt one task completely prior to initiating another
  • Allocate enough time to complete the tasks one at a time in sequence
  • “More complex tasks may be scheduled at the time of the day when fatigue levels are lower” (Ponsford, 2008, p. 516)
  • Verbal prompts or cues from family/carers

Flexibility:

Impact:

  • Playing games / cards (e.g. a person lacking mental flexibility may have difficulty changing his/her strategies in response to the actions of other players)
  • Conversations with a group of people (e.g. difficulty shifting from topic to topic in conversation)
  • Financial Planning
  • Meal preparation that requires multiple task switching
  • Driving (e.g. a driver lacking mental flexibility may come to a complete stop by slamming on the brakes when faced with an unexpected obstruction on a one-way street that he is used to driving on and may have difficulty finding a quick alternative solution).

External compensatory strategies:

  • Verbal prompts or cues from family/carers to assist the person to move from one task to the other
  • Delegate some previously held responsibilities to other family members
  • Step-by-step written instructions (to assist the person to move from one task to the other)

-Judgement / decision-making:

Impact:

  • Avoiding unsafe situations when cooking, taking a bath, crossing busy streets, driving, etc…
  • Following treatment instructions / therapists’ recommendations (e.g. using a wheelchair to move around)
  • Inappropriate choice of clothes (not taking into consideration weather, context, etc…)

External compensatory strategies:

  • Written guidelines and/or visual cues
  • Sensors and alarms (e.g. chair sensor pad with alarm, reminder-alarms in kitchen equipment)
  • Automatic controls (e.g. heating, shower water temperature, etc…)
  • Adapt the client’s environment to facilitate decision-making / limit irrelevant information (e.g. only keep clothes that are relevant to the season in the closet)
  • Supervision or assistance from a caregiver

Which EF treatments work?

A systematic literature review on the effectiveness of EF interventions post-stroke was conducted in January 2011 (please see the paper from Poulin, V., Korner-Bitensky, N., Dawson, D., & Bherer, L. (2012) –  Efficacy of executive function interventions after stroke: a systematic review – Topics in stroke Rehabilitation, 19 (2), 158-171), and was updated in February 2013 for the purpose of this module.

Twelve studies met inclusion criteria, 1 evaluating treatment in the subacute stage of stroke recovery (using a pre-post controlled group design) and 11 in the chronic stage (including 4 fair quality randomized controlled trials (RCT), 1 controlled group study, 4 single-subject design studies and 2 pre-post design studies). At this early stage of research there is limited evidence at the subacute (level 2b) and chronic (level 2a) stages of stroke recovery supporting the use of remedial (e.g. computerized working memory training) and compensatory interventions (e.g. problem-solving strategies, paging system) for improving executive functioning and, possibly, functional abilities.

Intervention Findings Level of Evidence
Problem-solving training Effective 2a
Cognitive orientation to daily occupational performance (CO-OP)*

– impact on executive functioning

No evidence 5
Computerized dual-task training Effective 2b
Computerized working memory training Effective 2a
Goal management training Effective 2b
Paging system Effective 2a
Smartphone applications** No evidence 5
Task-specific checklists Effective 2b

*Several pilot studies have reported improvements in motor and functional skills for persons with chronic stroke (Henshaw et al., 2011; McEwen et al., 2009, 2010a, 2010b; Polatajko et al., 2012) and acute stroke (Skidmore et al., 2011) receiving the Cognitive orientation to daily occupational performance (CO-OP) intervention. The impact of CO-OP on measures of EF has not been specifically examined in previous studies, but some trials are currently being conducted to address this question.
** Further research is needed to evaluate the effectiveness of new technologies (e.g. smartphone applications).

When is the best time to receive treatments for EF problems?

EF interventions can be provided during the acute, subacute, and chronic stages post-stroke.

What type of client is EF treatment for?

EF treatment can be offered to individuals of all ages with mild, moderate or severe EF deficits but should be carefully matched to the patient’s deficits, residual strengths and goals. Clients must be able to understand instructions and follow simple commands. Some interventions also require that clients have sufficient expressive language abilities to verbalize strategies and sufficient insight to be able to identify some day-to-day difficulties they want to improve. The therapist may have to adapt some of the training tasks according to the client’s cognitive, motor or linguistic impairments.

Please see the short vignettes below regarding two patients with executive dysfunction and how the clinician adapted therapy to suit their needs.

Mr G, a 55 years old engineer who had a left middle cerebral artery stroke 2 months ago, is presenting with mild EF problems, minor aphasic impairment and right sided weakness. He has now resumed most of his previous daily activities, except for driving and working. Also, it is still difficult for him to:

  • hold a conversation involving several persons
  • remember codes and phone numbers
  • perform two tasks simultaneously (e.g. taking notes while talking on the phone)

He is currently participating in a computer-based EF training program, in addition to other rehabilitation interventions.

Clinician management: His therapist selected computer-based tasks that target working memory and high-level attention (also see the Review of computer-based programs and videogames for executive function retraining). The therapist carefully analyzed the computer-based tasks to make sure the language and motor demands (e.g. using the mouse and keyboard) were appropriate.

Mrs S, a 70 years old lady who had a right middle cerebral artery stroke 4 months ago, is living at home with her husband and is presenting with left sided hemiparesis and mild to moderate cognitive/EF problems. She is independent for basic self-care activities (e.g. dressing, grooming) but she has difficulty planning and organizing things and perceiving errors while performing more complex instrumental activities of daily living tasks (e.g. preparing a meal). Also, it is difficult for her to deal with unexpected situations and she sometimes gets anxious in unfamiliar environments (e.g. when visiting friends, going to the shopping center, etc…). She is currently receiving a problem-solving training intervention, which consists of learning and applying strategies to solve her everyday problems.

Clinician management: To facilitate transfer and generalization of strategy use at home, several training sessions are conducted in her home and community environment with her spouse present. 

Who offers these treatments?

Occupational therapists (OT), neuropsychologists and speech language pathologists can provide intervention for EF problems at an acute care hospital, rehabilitation centre, or private clinic.

Info Pocket Booklet

Pocket card for executive function

View the “Review of computer-based programs and videogames for executive function retraining” in PDF Format

References

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Polatajko, H. J., & Mandich, A. (2004). Enabling Occupation in Children: The Cognitive Orientation to daily Occupational Performance (CO-OP) Approach.Ottawa, Ontario: CAOT Publications.

Polatajko, H. J., McEwen, S. E., Ryan, J. D., Baum, C. M. (2012). Pilot randomized controlled trial investigating cognitive strategy use to improve goal performance after stroke.Am J Occup Ther, 66(1), 104-9.

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Poulin, V., Korner-Bitensky, N., Bherer, L., Lussier, M., & Dawson, D.R. (2016). Comparison of two cognitive interventions for adults experiencing executive dysfunction post-stroke: a pilot study. Disability and Rehabilitation, ISSN: 0963-8288.
https://www.ncbi.nlm.nih.gov/pubmed/26750772

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Excluded Studies:

Hildebrandt, H., Bussmann-Mork, B., & Schwendemann, G. (2006). Group therapy for memory impaired patients: a partial remediation is possible. Journal of Neurology253(4), 512-519.
Reason for exclusion: All groups received a form of memory training with varying intensities/strategies.

Jorge, R.E., Acion, L., Moser, D., Adams, Jr H.P., Robinson, R.G. (2010). Escitalopram and enhancement of cognitive recovery following stroke. Archives of General Psychiatry, 67(2), 187-96.
Reason for exclusion: Main intervention is a medicament.

Lannin, N.A., Schmidt, J., Carr, B., Allaous, J., Falcon, A., & Tate, R. (2014). Occupational therapy training to use handheld personal digital assistant (PDA) devices to address memory and planning difficulties after acquired brain injury: a randomised controlled trial. Stroke, 45(12), 296.
Reason for exclusion: 5/42 patients are with stroke (i.e. <50%).

Poulin, V., Korner-Bitensky, N., Dawson, D.R., & Bherer, L. (2012). Efficacy of executive function interventions after stroke: a systematic review. Topics in Stroke Rehabilitation, 19(2), 158-71.
Reason for exclusion: Review.

Rozental-Iluz, C., Zeiling, G., Weingarden, H., & Rand, D. (2016). Improving executive function deficits by playing interactive video-games: secondary analysis of a randomized controlled trial for individuals with chronic stroke. European Journal of Physical and Rehabilitation Medicine, 52(4), 508-15.
Reason for exclusion: Nature of the intervention.

Music Therapy

Evidence Reviewed as of before: 19-07-2017
Author(s)*: Tatiana Ogourtsova, PhD Candidate MSc BSc OT; Elissa Sitcoff, BA BSc; Sandy Landry, BSc OT; Virginie Bissonnette, BSc OT; Anne-Julie Laforest, BSc OT; Jolyann Lavoi, BSc OT; Valérie Parenteau, BSc OT; Annabel McDermott, OT; Nicol Korner-Bitensky, PhD OT
Patient/Family Information Table of contents

Introduction

Music interventions are used to optimize an individual’s emotional well-being, physical health, social functioning, communication abilities, and cognitive skills. This module reviews studies that incorporate music as the primary type of intervention.

Patient/Family Information

Authors*: Erica Kader; Elissa Sitcoff, BA BSc; Sandy Landry, BSc OT; Virginie Bissonnette, BSc OT; Anne-Julie Laforest, BSc OT; Jolyann Lavoi, BSc OT; Valérie Parenteau, BSc OT; Nicol Korner-Bitensky, PhD OT

What is music therapy?

Music therapy is a specific form of rehabilitation that is typically facilitated by an accredited music therapist and uses music in a variety of ways to help achieve therapeutic goals. Music therapy has been found to be helpful for people who have had a stroke. Since music is emotionally and intellectually stimulating, this form of therapy can help to maintain or improve one’s physical and mental health, quality of life, and well-being.

Are there different kinds of music therapy?

Music therapy can be provided in different forms, depending on your needs and preferences. Various ways of conducting music therapy and its benefits include:

  • Active listening – develops attention, memory, and awareness to your environment.
  • Composing/songwriting – can be a way of sharing your feelings and being able to express yourself.
  • Improvising movements to music – a creative, non-verbal way of expressing feelings. Since improvisation does not require any previous musical training anyone can participate.
  • Rhythmic movements and dancing – improves movement, speed, balance, breathing, stamina, relaxation of muscles, and walking.
  • Playing instruments – increases coordination, balance, and strength. As an example, hitting a tambourine with a stick is a good exercise to improve your hand-eye coordination and develop strength in your arms and hands. This is a great activity whether or not you have previous experience playing instruments.
  • Singing – improves communication, speech, language skills, articulation, and breathing control. Singing is particularly useful after a stroke for those who are unable to speak, because sometimes even though speech is affected, the individual is still able to sing. This happens because the speech center located in the brain is in a different location than the brain area used for singing. So, someone may have damage to the brain area responsible for speech, but no damage to the area responsible for singing.
With permission of the Music Therapy Association of British Columbia

Is music therapy offered individually or in a group?

Music therapy can be offered either way, so it is your choice. You and your music therapist can plan your music therapy sessions together. Benefits to participating in a group includes improving communication and social skills, making new friends, and the opportunity to share feelings and experiences. Playing instruments in a group can help develop cooperation and attention, as well as improve self-esteem and well-being. Composing and songwriting is another activity that works well in a group, as it allows you to communicate and work along with others. If you are not comfortable working in a group, music therapy sessions can also be offered on an individual basis. Individual sessions may lead to group sessions later on in the rehabilitation process, or the treatment plan may involve a combination of both. For people who are restricted to bed, music therapy can even be offered at their bedside with portable instruments.

Why use music therapy after a stroke?

Music therapy has the ability to help in the rehabilitation of individuals who have had a stroke. The research on the effects of this intervention is still quite new. There is some limited evidence suggesting that music therapy can help improve the movement of the arms, walking, pain perception, mood, and behaviour after stroke.

Courtesy of the Institute for Music and Neurologic Function

Do music-based treatments work in post-stroke rehabilitation?

Researchers have studied how different music-based treatments can help patients with stroke:

In individuals with ACUTE stroke (up to 1 month after stroke), studies found that:

  • Listening to music is MORE helpful than comparison treatment(s) in improving attention, memory, mood and affect. It is AS helpful as comparison treatment(s) in improving executive functions (cognitive processes that assist in managing oneself and one’s resources in order to achieve a goal), language, music cognition, quality of life, and the ability to identify visual and spatial relationships among objects.
  • Music-movement therapy is MORE helpful than comparison treatment(s) in improving mood and affect, and range of motion. It is AS helpful as comparison treatment(s) in improving functional independence in self-care activities (e.g. dressing, feeding), and muscle strength.
  • Rhythmic music interventions are MORE helpful than comparison treatment(s) in improving walking ability.

In individuals with SUBACUTE stroke (1 month to 6 months after stroke), studies found that:

  • Music training is MORE helpful than a comparison treatment in improving hand and arm function.

In individuals with CHRONIC stroke (more than 6 months after stroke), studies found that:

  • Music therapy + occupational therapy is MORE helpful than comparison treatment(s) in improving functional independence in self-care activities (e.g. dressing, feeding), quality of life, sensation, and arm function. It is AS helpful as comparison treatment(s) in improving consequences of stroke, and arm movement quality.
  • Melodic intonation therapy is AS helpful as a comparison treatment in improving language.
  • Rhythmic music interventions are MORE helpful than comparison treatment(s) in improving balance, behavior, walking ability, grip strength, interpersonal relationships, quality of life, legs range of movement, consequences of stroke, and mood and affect. They are AS helpful as comparison treatment(s) in improving cognitive functions (e.g. attention), dexterity, language, musical behavior, occupational performance, arm function, memory, and walking endurance.

In individuals with stroke (acute, subacute and/or chronic), studies found that:

  • Melodic intonation therapy is MORE helpful than a comparison treatment in improving language.
  • Music performance is AS helpful as comparison treatment(s) in improving dexterity and arm range of motion and function.
  • Rhythmic music interventions are MORE helpful than comparison treatment(s) in improving balance, and walking ability. They are AS helpful as comparison treatment(s) in improving dexterity, sensation, strength, stroke consequences, arm function and activity.

Who provides the treatment?

Many hospitals and rehabilitation centers have music therapy programs that are conducted by accredited music therapists. The music therapist will meet with you to assess your needs and discuss preferences, so that he or she can design a program specific to your needs. In some centers it may be a recreational therapist or leisure therapist who provides music therapy. Ask your health professional or family members to help you find out more about the music therapy services offered in your hospital, rehabilitation center or community.

Are there any side effects or risks?

You do not face any risks when participating in music therapy after a stroke, as long as activities are practiced in a manner that fits your abilities. Consult your physician or rehabilitation healthcare professional for the best advice on how to participate safely. This is especially important if you are going to incorporate dancing or rhythmic movements into your music sessions and have some balance difficulties. *Family members/friends: it is important to help the person who has had a stroke seek out new activities such as music therapy that may be both pleasant and therapeutic.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

This module reviews 24 studies that use music as a primary means of rehabilitation; of these, 12 are high quality RCTs, seven are fair quality RCTs, one is a poor quality RCT and four are non-randomized studies.

This module reviews the following types of music-based interventions:

Listening to music: Participants listening to music.

Music therapy + occupational therapy: Participants playing instruments (e.g. drums, bells, shakers, mallets, chimes, piano, harp) with the affected upper limb to encourage proximal and distal upper limb movements, with attention to positioning and movement quality.

Melodic intonation therapy: Participants singing phrases and tap to the rhythm of the phrases; this intervention has been shown to improve outcomes related to language/aphasia.

Music-movement therapy: Participants performing movements of lower and upper extremities while listening to music.

Music performance: Participants playing acoustic musical instruments and/or iPads with touchscreen musical instruments as part of fine/distal exercise.

Music training: Participants are taught to play a musical instrument.

Rhythmic music interventions: Participants performing matching upper and/or lower extremity movements or gait patters to musical rhythm.

Results Table

View results table

Outcomes

Acute phase - Listening to music

Attention
Effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on attention in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Measures of attention were taken at 3 and 6 months post-stroke, and outcomes included: (1) attention, measured by the CogniSpeed reaction time software; (2) focused attention, measured by the mental subtraction and Stroop subtests (number correct and reaction time); and (3) sustained attention, measured by the vigilance (number correct, reaction time) and simple reaction time subtests. Significant between-group differences in focused attention were found at 3 months post-stroke, favoring the music group vs. the control group. Significant between-group differences in focused attention were found at 6 months post-stroke, favoring the music group vs. the audio book group, and favoring the music group vs. the control group. There were no significant between-group differences in other measures of attention at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is more effective than comparison interventions (listening to audio books, no training) in improving focused attention in patients with acute stroke. However, no between-group differences were found on measures of attention or sustained attention.

Auditory sensory memory
Not effective
1b

One high quality RCT (Sarkamo et al., 2010) investigated the effect of music interventions on auditory sensory memory in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Auditory sensory memory was evaluated by the magnetically-measured mismatch negativity (MMNm) responses to change in sound frequency and duration from baseline to 3 and 6 months post-stroke. There were no significant differences between groups at 3 months post-stroke. At 6 months post-stroke, there were significant between-group differences in auditory sensory memory (frequency MMNm only), favoring the music group vs. the control group.
Note: Comparison of the audio book group vs. the control group revealed significant differences favoring the audio book group in frequency MMNm (left and right lesions) and duration MMNm (right lesions only) at 6 months post-stroke.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving auditory sensory memory among patients with acute stroke in the short term.
Note:
However, this high quality RCT showed that patients who listened to music demonstrated significantly better auditory sensory memory several months following treatment than patients who received conventional rehabilitation alone.

Executive function
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on executive function in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Executive function was measured by the Frontal Assessment Battery at 3 and 6 months post-stroke. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving executive function in patients with acute stroke.

Language
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on language in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Language was measured by the Finnish version of the Boston Diagnostic Aphasia Examination (word repetition, sentencing repetition, reading subtests), the CERAD battery (verbal fluency, naming subtests) and the Token Test at 3 and 6 months post-stroke. No significant between-group differences were found at either time point on any of the measures.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving language in patients with acute stroke.

Memory
Effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on memory in patients with acute stroke. This high quality RCT randomized patients to a music group that listened to music for a minimum 1 hour/day, a language group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Measures of memory were taken at 3 and 6 months post-stroke and outcomes included: (1) verbal memory, measured by the Rivermead Behavioral Memory Test (story recall subtests) and an auditory list learning task; and (2) short-term working memory, measured by the Wechsler Memory Scale – Revised (digit span subtest) and a memory interference task. Significant between-group differences in verbal memory were found at 3 months post-stroke, favoring the music group vs. the audio book group, and favoring the music group vs. the control group. Similarly, significant between-group differences in verbal memory were found at 6 months post-stroke, favoring the music group vs. the audio book group. There were no significant between-group differences in short-term working memory at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is more effective than comparison interventions (listening to audio books, no training) in improving verbal memory in patients with acute stroke. However, no between-group differences were found on measures of short-term working memory.

Mood
Effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on mood in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Mood was measured by a shortened Finnish Version of the Profile of Mood States at 3 and 6 months post-stroke. Significant between-group differences in mood (depression score only) were found at 3 months post-stroke favoring the music group vs. the control group.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is more effective than comparison interventions (listening to audio books, no training) in improving mood in patients with acute stroke.

Music cognition
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on music cognition in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Music cognition was measured by the Montreal Battery of Evaluation of Amusia (scale and rhythm subtests) at 3 months post-stroke. No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving music cognition in patients with acute stroke.

Quality of life
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on quality of life in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Quality of life was measured by the stroke and Aphasia Quality of Life Scale – 39 (self-rated, proxy rated) at 3 and 6 months post-stroke. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (audio therapy, no training) in improving quality of life in patients with acute stroke.

Visuospatial skills
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on visuospatial skills in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Visuospatial skills were measured by the Clock Drawing Test, Figure Copying Test, Benton Visual Retention Test (short version), and Balloons Test (subtest B) at 3 and 6 months post-stroke. No significant between-group differences were found at either time point on any of the measures.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving visuospatial skills in patients with acute stroke.

Acute phase - Music-movement therapy

Behavioral outcomes
Effective
2b

One poor quality RCT (Jun et al., 2012) investigated the effect of music interventions on mood and affect in patients with acute stroke. This poor quality RCT randomized patients to receive music-movement therapy or no training; both groups received standard care. Behavioral outcomes were assessed according to: 1) mood measured by the Korean version of the Profile of Mood States Brief Instrument; and 2) depression, measured by the Center for Epidemiologic Studies depression Scale at post-treatment (8 weeks). Significant between-group differences were found for mood favoring music-movement therapy vs. no training.  

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that music-movement therapy is more effective than no training in improving behavioral outcomes (mood) in patients with acute stroke.

Functional independence
Not effective
2b

One poor quality RCT (Jun et al., 2012) investigated the effect of music interventions on functional independence in patients with acute stroke. This poor quality RCT randomized patients to receive music-movement therapy or no training; both groups received standard care. Functional independence was measured by the Korean modified Barthel Index at post-treatment (8 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that music-movement therapy is not more effective than no training in improving functional independence in patients with acute stroke.

Muscle strength
Not effective
2b

One poor quality RCT (Jun et al., 2012) investigated the effect of music interventions on muscle strength in patients with acute stroke. This poor quality RCT randomized patients to receive music-movement therapy or no training; both groups received standard care. Muscle strength of the affected upper and lower extremities was measured by the Medical Research Council Scale at post-treatment (8 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that music-movement therapy is not more effective than no training in improving muscle strength in patients with acute stroke.

Range of motion
Effective
2b

One poor quality RCT (Jun et al., 2012) investigated the effect of music interventions on range of motion (ROM) in patients with acute stroke. This poor quality RCT randomized patients to receive music-movement therapy or no training; both groups received standard care. ROM of the affected side (shoulder/elbow/wrist flexion, hip/knee flexion) was measured by goniometer at post-treatment (8 weeks). Significant between-group differences in ROM were found (shoulder/elbow flexion, hip flexion), favoring music-movement therapy vs. no training.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that music-movement therapy is more effective than no training in improving range of motion of the proximal joints of patients with acute stroke.

Acute phase - Rhythmic music interventions

Gait parameters
Effective
2a

One fair quality RCT (Schneider et al., 2007) investigated the effect of music interventions on dexterity in patients with subacute stroke. This fair quality RCT randomized patients to receive music training (drum and/or piano) + conventional rehabilitation or conventional rehabilitation alone. Dexterity was measured by the Box and Block Test and the Nine Hole Peg Test at post-treatment (3 weeks). Significant between-group differences were found on both measures of dexterity, favoring music training + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that music training + conventional rehabilitation is more effective than conventional rehabilitation alone in improving dexterity in patients with subacute stroke.

Subacute phase - Music training

Dexterity
Effective
2a

One fair quality RCT (Schneider et al., 2007) investigated the effect of music interventions on dexterity in patients with subacute stroke. This fair quality RCT randomized patients to receive music training (drum and/or piano) + conventional rehabilitation or conventional rehabilitation alone. Dexterity was measured by the Box and Block Test and the Nine Hole Peg Test at post-treatment (3 weeks). Significant between-group differences were found on both measures of dexterity, favoring music training + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that music training + conventional rehabilitation is more effective than conventional rehabilitation alone in improving dexterity in patients with subacute stroke.

Upper extremity motor function
Effective
2a

One fair quality RCT (Schneider et al., 2007) investigated the effect of music interventions on upper extremity motor function in patients with subacute stroke. This fair quality RCT randomized patients to receive music training (drum and/or piano) + conventional rehabilitation or conventional rehabilitation alone.  Upper extremity motor function was measured by the Action Research Arm Test, Arm Paresis Score, and computerized hand/fingers movement analysis (velocity and frequency profile) at post-treatment (3 weeks). Significant between-group differences were found on all measures of upper extremity motor function, favoring music training + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that music training + conventional rehabilitation is more effective than conventional rehabilitation alone in improving upper extremity motor function in patients with subacute stroke.

Chronic phase - Melodic intonation therapy

Language
Not effective
1b

One high quality RCT (van Der Meulen et al., 2016), investigated the effect of music interventions on language in patients with chronic stroke. This high quality cross-over design RCT randomized patients to receive melodic intonation therapy (MIT) or no treatment. Language was measured by the Sabadel story retell task, Amsterdam-Nijmegen Everyday Language Test, Aachen Aphasia Test (naming, repetition, auditory comprehension), and MIT task (trained/untrained items) at post-treatment (6 weeks) and at follow-up (12 weeks). Significant between-group differences were found on only one measure of language (MIT task – trained items) at post-treatment favoring MIT vs. no treatment. These differences were not maintained at follow-up.
Note: When the control group crossed-over to receive the MIT treatment, no significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that melodic intonation therapy is not more effective than no treatment in improving language in patients with chronic stroke.

Chronic phase - Music therapy and occupational therapy

Functional independence
Effective
2b

One quasi-experimental design study (Raghavan et al., 2016) investigated the effect of music interventions on functional independence in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper limb training. Functional independence was measured by the Modified Rankin Scale at baseline, post-treatment (6 weeks) and follow-up (1 year). Significant improvements were found at both time points.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is effective in improving functional independence in patients with chronic stroke.

Quality of life
Effective
2b

One quasi-experimental design study (Raghavan et al., 2016) investigated the effect of music interventions on quality of life in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper limb training. Quality of life was measured by the World Health Organization Well-Being Index at baseline, post-treatment (6 weeks) and follow-up (1 year). Significant improvements were found at both time points.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is effective in improving quality of life in patients with chronic stroke.

Sensation
Effective
2b

One quasi-experimental design study (Raghavan et al., 2016) investigated the effect of music interventions on sensation in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper limb training. Sensation was measured by the Two-Point Discrimination Test at baseline, post-treatment (6 weeks) and follow-up (1 year). Significant improvements were found at both time points.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is effective in improving sensation in patients with chronic stroke.

Stroke outcomes
Not effective
2b

One quasi-experimental design study (Raghavan et al., 2016) investigated the effect of music interventions on stroke outcomes in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper limb training. stroke outcomes were measured by the stroke Impact Scale (SIS activities of daily living, participation