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6. Interventions for Cognition and Cognitive- Communication Post Acquired Brain Injury Shawn Marshall MD MSc Penny Welch-West (M.CI.Sc. SLP) Connie Ferri (MSc. SLP) Pavlina Faltynek MSc Shannon Janzen MSc Leanne Togher PhD, Robert Teasell MD erabi.ca Version 13.0 Key Points Drill and practice training may not be effective for the remediation of attention following an ABI. Dual-task training has been shown to improve measures of attention to the extent that the ABI population does not significantly differ from healthy controls, however it is undetermined if the strength of these effects compared to non-dual-task training are greater. Computer-based interventions are no more effective than no intervention in improving measures of attention and concentration post ABI. Repetitive virtual reality tasks which include repetition are effective in improving attention and concentration in ABI populations. Goal management training is effective in assisting those who sustain an ABI learning to manage life goals through improved attention. In general, a variety of non-specific attentional training programs appear to be effective for improving attentional scores following an ABI. The addition of a therapy animal to an attentional training program may enhance concentration gains. Therapies which focus on emotional regulation do not appear to be effective at improving attention post ABI, while mindfulness may improve some areas. In order to determine if attentional training is effective in improving attention post-ABI standardized protocols must be developed to allow between study comparisons. Tasks that involve mathematical skills may be effective at improving attention post ABI. Transcranial direct current stimulation may be effective in remediating attentional deficits when combined with computer assisted training in ABI populations. Repeated magnetic transcranial stimulation may be effective in remediating attentional deficits following an ABI. It is unclear as to whether donepezil may improve attention in individuals with a moderate to severe ABI. The effectiveness of methylphenidate treatment to improve cognitive function following brain injury is unclear. Methylphenidate may be effective in improving reaction time for working memory. Response to methylphenidate may depend on the presence of the Met genotype. erabi.ca Version 13.0 Bromocriptine does not appear to improve attention in those with an ABI. Cerebrolysin may be beneficial for improving clinical outcomes and cognitive functioning following brain injury; however, controlled trials are needed to further evaluate its efficacy. Rivastigmine may not be effective in treating attention deficits post ABI. Amantadine may not be effective in treating attention deficits following an ABI. Hyperbaric oxygen therapy may improve attention and processing speed following an ABI; however more prospective data is required in order to make a conclusion. Dextroamphetamine may not be an effective treatment for attentional deficits following an ABI and may actually increase agitation. Pager and voice-organizer programs may improve a patient’s ability to complete tasks post TBI. Personal digital assistant (PDA) devices are superior to paper-based interventions at improving memory and task completion post TBI; specially when introduced using systematic instructions and in combination with occupational therapy. Patients who have used previous memory aids might benefit from this intervention the most. Text message prompts sent to a patient’s smartphone, when used alone or in combination with other memory-improvement therapies, likely improve task completion post TBI. However, risk exists of device dependency exists. A television assisted prompting (TAP) program may be superior to other methods of memory prompting in post TBI patients. Automated prompting systems, such as Guide (audio-verbal interactive micro-prompting system) and a computerized tracking system, can reduce the number of prompts needed from support staff to patients to complete tasks post TBI. Calendars may be effective tools for improving memory and task completion post ABI. The use of a diary may help to improve memory and task completion post ABI. Virtual reality programs may enhance the recovery of memory, learning, but there is currently limited evidence supporting the use of virtual reality programs. The evidence is unclear as to which specific programs benefit memory rehabilitation and whether or not they are superior to manual training therapies. Internal strategies such as self-imagination, spaced retrieval and rehearsal, and multiple encoding are effective for improving memory following an ABI. Memory-retraining programs appear effective, particularly for functional recovery although performance on specific tests of memory may or may not change. erabi.ca Version 13.0 Some specific computer-based software seem to be effective for improving memory post ABI. Computer-based interventions may be as effective as therapist administered interventions. Emotional self-regulation therapy may be effective for improving specific elements of memory. Attention training programs may not be effective for improving memory, but memory training programs are. Interventions which include multiple learning techniques such as modelling, observation, verbal instruction, etc. are more effective than interventions which include a singular learning method. Cranial electrotherapy stimulation may not be effective at enhancing memory and recall abilities following TBI. Donepezil likely improves memory following TBI. Methylphenidate likely does not improve memory or learning following an ABI. Sertraline has not been shown to improve learning, or memory within the first 12 months post TBI, and may be associated with side effects. Amantadine is not effective for improving learning and memory deficits post ABI. Pramiracetam might improve memory in males post TBI; however, additional studies are required. Physostigmine may improve long-term memory in men with TBI, however more studies are required. More studies are required to determine if the positive effects of bromocriptine on verbal memory seen so far are of potential value. Cerebrolysin may be beneficial for the improvement of clinical outcome and cognitive functioning following brain injury; however, controlled trials are needed to further evaluate its efficacy. The administration of growth hormone complexes likely does not improve learning and memory following an ABI. Rivastigmine is not effective in treating memory deficits post ABI. Hyperbaric oxygen therapy may be promising for improving memory following an ABI; however, more controlled studies are required. erabi.ca Version 13.0 Targeted hypnosis may improve memory, attention, and cognitive function in post TBI patients or stroke; however, only as long as the intervention is being administered. Attention training programs likely do not improve executive functioning. General cognitive training programs which include problem-solving appear to be effective for improving executive functioning following an ABI. Virtual reality does not likely improve executive functioning following an ABI. Computer or smartphone software programs (BrainHQ, Parrot Software, ProSolv app) may not be superior to common interventions at improving memory, attention, and problem-solving skills in patients post TBI. Goal management training may be superior to motor skills training at improving everyday skills (meal preparation), but not intelligence or neuropsychological outcomes in patients post TBI. Heart rate variability biofeedback may improve executive functions; however, more controlled studies are required to make further conclusions. Group goal-oriented interventions are effective for the remediation of executive functions, including comprehension and problem solving. Emotional regulation interventions delivered in a group setting may improve executive function in patients post TBI; however, it is unclear if it is superior at doing so compared to conventional cognitive remediation. The SMART program appears to be effective for improving executive functioning following an ABI. Touch screen-based games which include components of metacognition may be effective for improving self-awareness. Metacognitive instruction does not appear to improve comprehension or abstract reasoning; however, more studies are needed to fully evaluate its effects. General cognitive rehabilitation programs are effective for improving cognitive functioning following an ABI. There is limited evidence that mindfulness based stress reduction is effective for improving cognitive functioning. Corrective video feedback is more effective than verbal feedback alone for improving general cognitive function and self-awareness. erabi.ca Version 13.0 Remedial and adaptive occupational therapy are equally effective for improving general cognitive functioning. Donepezil might improve attention, learning and short-term memory following TBI; however, side effects may incur from its use. The effectiveness of methylphenidate to improve cognitive impairment following brain injury is unclear. Further studies with larger populations are required. Sertraline has not been shown to improve cognitive functioning within the first 12 months post TBI and may be associated with side effects. Amantadine is not effective at improving generalized cognition. Its impact on executive functioning should be studied further. Bromocriptine may improve other measures of cognition such as attention, but its effects on generalized cognition
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