Cognitive Rehabilitation

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 6 high quality RCTs, 8 fair quality RCTs, 1 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.

Please click here to see the Authors’ Results Table.

 

Acute phase - Attention training + cutaneous electrical stimulation

Functional independenceNot effective2a

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 functionEffective2a

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

MemoryNot effective2a

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 memoryNot effective2a

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 attentionEffective2b

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 ReaktionsgeratWiener 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.

MemoryNot effective2b

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.

ReasoningNot effective2b

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

AttentionEffective1b

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.

Auditory information processingNot effective1b

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 independenceNot effective1b

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.

MemoryNot effecitve1b

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 lifeNot effective1b

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 neglectNot effective1b

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 performanceEffective2a

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 recallNot effective1b

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.

DepressionNot effective1b

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-efficacyEffective1b

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 lifeNot effective1b

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 stroke education program) in improving quality of life in patients with chronic stroke.

Chronic phase - Pager system

MemoryEffective2a

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

AttentionEffective1b

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.

CognitionEffective1b

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.

MemoryNot effective1b

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 outcomesNot effective1b

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 participationEffective2a

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 performanceNot effective2a

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-efficacyEffective2a

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 outcomesEffective2a

Two fair quality RCTs (Wolf et al., 2016McEwen 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 performanceEffective2a

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

AttentionEffective1b

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.

CognitionNot effective1b

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.

MoodNot effective1b

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 skillsEffective1b

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 memoryEffective2b

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

FatigueNot effective1b

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 IndependenceNot effective1b

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 processingNot effective1b

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.

MemoryNot effective1b

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.

MoodNot effective1b

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 lifeNot effective1b

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

AttentionEffective2b

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.

MemoryEffective2a

One fair quality RCT (Rose et al., 1999) and one poor quality RCT (Gamito et al., 2015) 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

AttentionNot effective1b

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.

DrivingNot effective1b

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 neglectNot effective1b

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 attentionNot effective1b

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 perceptionNot effective1b

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.


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

 

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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.
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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.
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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 Injury21(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.