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Cognitive rehabilitation for executive dysfunction in adults with stroke or other adult non-progressive acquired brain damage

  1. Charlie SY Chung1,*,
  2. Alex Pollock2,
  3. Tanya Campbell3,
  4. Brian R Durward4,
  5. Suzanne Hagen2

Editorial Group: Cochrane Stroke Group

Published Online: 30 APR 2013

Assessed as up-to-date: 23 AUG 2012

DOI: 10.1002/14651858.CD008391.pub2


How to Cite

Chung CSY, Pollock A, Campbell T, Durward BR, Hagen S. Cognitive rehabilitation for executive dysfunction in adults with stroke or other adult non-progressive acquired brain damage. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD008391. DOI: 10.1002/14651858.CD008391.pub2.

Author Information

  1. 1

    NHS Fife, Department of Occupational Therapy, Kirkcaldy, Fife, UK

  2. 2

    Glasgow Caledonian University, Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow, UK

  3. 3

    Glasgow Caledonian University, Department of Occupational Therapy, School of Health and Social Care, Glasgow, UK

  4. 4

    NHS Education for Scotland, Edinburgh, UK

*Charlie SY Chung, Department of Occupational Therapy, NHS Fife, Ward 12 (Stroke Unit), Victoria Hospital, Kirkcaldy, Fife, KY2 5AH, UK. chungsongyau@aol.com.

Publication History

  1. Publication Status: New
  2. Published Online: 30 APR 2013

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Characteristics of included studies [ordered by study ID]
Amos 2002

MethodsRCT

Method of randomisation not documented


Participants24 participants with acquired brain injury (6 stroke, 16 traumatic brain injury and 2 others not specified) and 8 healthy control participants

Group 1: n = 8

Group 2: n = 8

Group 3: n = 8

Group 4: n = 8

Age 20-55 years, able to communicate and provide consent

Attention difficulty determined by neuropsychological profile and behavioural disturbance


InterventionsGroup 1: no intervention

Group 2: external inhibition: participants instructed to ignore specific features (compensative)

Group 3: salience: participants provided with information on the similarities of specific features (compensative)

Group 4: healthy control (restorative)


OutcomesWisconsin Card Sorting Test for concept formation


NotesThe healthy controls were selected from relatives of the participants

The mean age of the sample was 35.71 (9.77) years with 11.83 (2.01) years in educations. Separate group demographic data not given so unable to determine group differences


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskA non-involved person drew lots to allocate participants into the 3 brain injury groups

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNo details provided on assessor blinding

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs were reported

Other biasUnclear riskThe data of 1 participant with severe perseveration was removed from the study as the results were very different from the others

Carter 1980

MethodsRCT

Method of randomisation not documented


Participants14 participants with stroke and 4 non-stroke participants

Group 1: n = 10

Group 2: n = 8

Mean age 70.8 years (group 1) and 73 years (group 2)

Cognitive impairment was determined by a neuropsychological test with 5 domains, 1 of which was working memory from Digit Span Test


InterventionsGroup 1: 30-40 minute cognitive remediation sessions (restorative), 3 times per week for 4 weeks

Group 2: no cognitive intervention. Continued with standard physiotherapy, occupational therapy and speech therapy (restorative)


OutcomesDigit Span Test for working memory


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskAllocation concealment not documented

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot clear if assessors were blinded but rehabilitation staff were unaware of group allocation

Incomplete outcome data (attrition bias)
All outcomes
High riskThe 18 participants were reduced from an initial 37. Data from participants who dropped out or refused the post-test were not used in the analysis

Other biasHigh riskThe control group had a higher initial score than the experimental group. The control group did not have comparable time in placebo or control intervention so extra intervention time may be the cause of any improvement

Cheng 2006

MethodsRCT

Randomisation according to admission sequence


Participants21 participants with TBI

Group 1: n = 11

Group 2: n = 10

Stable, alert and able to communicate

Self awareness impairment diagnosed with SADI


InterventionsGroup 1: restorative intervention of self awareness training incorporating concrete feedback, education on the condition and self prediction and goal-setting training (11.7 session/week for 4 weeks)

Group 2: control intervention incorporating group ADL training, motor skills training in preparation for ADL and cognitive training (restorative) (11.6 sessions/week for 4 weeks)


OutcomesSADI (lower score = improvement)

FIM

Lawton Instrumental Activities of Daily Living Scale


NotesControl group participants were an average of 3.2 years older than the experimental group. 2 experimental group participants had received tertiary education compared with 0 participants in the control group. Control group acute stay was 4.7 weeks and experimental group was 6 weeks. Rehabilitation stay for the respective groups was 10 weeks and 7.5 weeks


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskIt is unclear from the study text whether allocation was concealed

Blinding (performance bias and detection bias)
All outcomes
Low risk"Scoring was primarily conducted by a therapist who was not involved in the programme implementation and blinded to the grouping of participants," which indicates low risk but "primarily conducted" may imply that not all assessments were conducted by this therapist. The study was single-blind as the participants were not blinded to their allocation

Incomplete outcome data (attrition bias)
All outcomes
Low riskComplete data on 21 participants were presented

Other biasLow riskNo other sources of bias identified

Chung 2007

MethodsRCT

Computer programme randomisation


Participants7 participants with stroke: 4 females, 3 males, 2 left hemisphere strokes and 5 right hemisphere strokes

Group 1: n = 3

Group 2: n = 4

First stroke, age range 55-95 years, able to provide informed consent, adequate visual acuity and sitting balance, Barthel score of 5 or less for the dressing component

Executive dysfunction determined by BADS and Hayling and Brixton Tests


InterventionsGroup 1: verbal feedback after upper body dressing task (compensative)

Group 2: video-feedback and verbal feedback after upper body dressing task (compensative)

6 x 30-minute sessions over 2 weeks


OutcomesBADS, Hayling and Brixton Tests, adapted Nottingham Stroke Dressing Assessment


NotesThe experimental group time mean time since stroke was 27 days (SD = 7.87) compared with 7.33 days (SD = 3.51) for the control group


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskComputer programme used to randomly assign to group with allocation concealed in sealed envelopes

Blinding (performance bias and detection bias)
All outcomes
Low riskThe assessor was blinded at pre and post assessment

Incomplete outcome data (attrition bias)
All outcomes
High riskAll participants completed the study but only 5 out of 7 participants were able to complete the verbal executive function outcome measures

Other biasHigh riskSmall sample size without statistical power

Cicerone 2008

MethodsRCT

Method of randomisation included the use of a "web-based statistical calculation page (www.statpages.org) to allocate 48 participants per condition" Randomisation occurred in blocked multiples of 4 and were stratified according to clinical or community referrals


Participants68 participants with TBI at least 3 months' postinjury

Group 1: n = 34

Group 2: n = 34

Adequate language and comprehension to participate in verbal group sessions, judged to require at least 4 months of rehabilitation, capable of attending 3 sessions/week, able to give informed consent

Participants were not assessed for executive dysfunction


InterventionsGroup 1: standard neurorehabilitation (restorative intervention) 15 hours/week for 15 weeks of individual, discipline specific therapies

Group 2: intensive neurorehabilitation (compensative intervention) 15 hours/week for 15 weeks of intensive cognitive rehabilitation emphasising the integration of cognitive, interpersonal and functional interventions and including training in self appraisal, prediction, self monitoring and self evaluation, which were not included in standard neurorehabilitation


OutcomesTrail Making Test-B for working memory

Booklet Category Test for concept formation

Vocational Integration Scale

Perceived Quality of Life Scale


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskAllocation was concealed in opaque envelopes

Blinding (performance bias and detection bias)
All outcomes
Low riskThe therapists were not blinded but were informed that it was uncertain which intervention was potentially more effective. Outcome measures were conducted by a blinded research assistant

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAll existing data analysed. 4 participants did not complete the standard neurorehabilitation protocol and 2 participants did not complete the intensive cognitive rehabilitation protocol. 2 participants in each group were lost to follow-up

Other biasLow risk

Dirette 1999

MethodsRCT

Participants were matched to a severity level (mild, moderate, severe) and randomised within these categories. Method of randomisation was not stated


Participants30 participants 2-12 months post acquired brain injury including 2 with stroke

Group 1: n = 15

Group 2: n = 15

Participants were aged 21-56 years, with mean age of 38 years

All participants were pretested with computer tests including the PASAT


InterventionsGroup 1: 6 x 1-hour weekly sessions training the strategies of verbalisation, chunking and pacing (compensative)

Group 2: 6 x 1-hour sessions of computer activities (restorative)


OutcomesPASAT for working memory


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskAllocation concealment was not documented

Blinding (performance bias and detection bias)
All outcomes
Low riskThe assessor was blinded to the participants' groups

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs were reported

Other biasLow risk

Fong 2009

MethodsMatched-pairs RCT. Each participant was matched to another participant of similar age, gender, diagnosis, educational level, time of injury and severity of injury. Following matching, a member of each pair was randomised into the control or experimental group. Method of randomisation not documented


Participants33 participants including 9 with stroke, 18 with TBI and 6 with other acquired brain injury. All were documented as having problem-solving difficulties

Group 1: n = 16

Group 2: n = 17

Participants were aged 18-55 years, literate, had at least 6 years' primary education and were able to comprehend written instructions and do simple arithmetic

Cognitive impairment was assessed using the Rancho Los Amigos Scale and Behavioural Memory Test


InterventionsGroup 1: metacomponential problem-solving training programme (restorative) involving the training of the primary metacomponents of problem solving which are: defining the problem, representing the problem, planning problem-solving strategies, monitoring selected strategies, and evaluating outcomes. Participants received standard cognitive rehabilitation and 22 sessions over 15 weeks with 45 minutes of metacomponential skills training and 30 minutes of computer training to apply the problem-solving skills learned

Group 2: standard cognitive rehabilitation programme (compensative) comprising residual function use for adaptive function


OutcomesSix Elements Test for problem solving

Key Search Tests for everyday problem solving

Social Problem-Solving Video Measure

Means-Ends Problem Solving Measure

Raven's Progressive Matrices

Metacomponential Interview


NotesThe experimental group also received standard neurorehabilitation and the duration and frequency of sessions was stated. However, the duration and frequency of the standard neurorehabilitation group was not stated and it is unclear whether the experimental group received more time in training


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskDetails were provided for the matching procedure but did not describe how participants were randomised and whether allocation was concealed

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNo details were provided

Incomplete outcome data (attrition bias)
All outcomes
Low riskAlthough the study reported participant attrition, this occurred after the postintervention data collection period and the existing data applies to all 33 participants

Other biasUnclear riskDuration and frequency of control intervention was not stated

Goverover 2007

MethodsRCT

Method of randomisation not documented


Participants20 participants with acquired brain injury including 12 with TBI and 8 with aneurysm

Group 1: n = 10

Group 2: n = 10

Participants' aged 18-55 years; medically stable living in the community and orientated to time, person and the community; independent in basic ADL and identified as having a self awareness problem by their therapist


InterventionsGroup 1: self awareness training with instrumental ADL (restorative)

Group 2: conventional training of instrumental ADL including corrective feedback by a therapist (restorative)

Each group received 2 sessions per week for 3 weeks of 45 minutes/session


OutcomesAssessment of Awareness of Disability for task-specific awareness and general awareness
Self-Regulation Skills Interview for metacognition

Assessment of Motor and Process Skills for instrumental ADL

Community Integration Questionnaire for home and social integration and productive activities


NotesThe table of brain injury type for the experimental group exceeded 100%, which may be an error but does not affect the overall analysis as the brain injury subgroups do not have separable data


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskMethod of randomisation and allocation concealment not documented

Blinding (performance bias and detection bias)
All outcomes
Unclear riskAlthough the participants were blinded to their group allocation, the study does not state whether the assessors were blinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskComplete data were presented for all study participants

Other biasLow risk

Hewitt 2007

MethodsRCT

Participants were randomised according to a predetermined allocation sequence


Participants30 severe TBI with post-traumatic amnesia of longer than 24 hours, 16-64 years of age, able to understand and read English, 1 year or more since injury

Group 1: n = 15

Group 2: n = 15

Executive dysfunction diagnosed by the Hayling and Brixton Tests and the Modified Six Elements Test


InterventionsGroup 1: general conversation (control)

Group 2: Autobiographical Episodic Memory Cueing Procedure (restorative)

Each group received 30 minutes' intervention


OutcomesEveryday Descriptions Task for planning


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskConcealment of allocation was not documented in the study text

Blinding (performance bias and detection bias)
All outcomes
Low riskThe assessor was blinded to group allocation

Incomplete outcome data (attrition bias)
All outcomes
Low riskThere were no drop-outs as the 1 intervention session and assessments were undertaken during the same session

Other biasUnclear riskThe intervention is very close to the outcome measure with the potential for the equivalent of direct training for outcome measure performance improvement

Hu 2003

MethodsRCT

Randomisation by computer program


Participants86 inpatients with stroke

Group 1: n = 44

Group 2: n = 42


InterventionsGroup 1: 45-minute session/day, 5 days/week of cognitive rehabilitation including the use of cards, use or practical objects, self programmed computer software and transition to ADL (restorative)

Group 2: medicine, occupational therapy and physiotherapy (restorative)


OutcomesNeurobehavioural Cognitive Status Examination for general cognition but with executive function subcomponents, Barthel Index


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskAllocation concealment not documented

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessor was blinded

Incomplete outcome data (attrition bias)
All outcomes
High riskNo data for the 8 participants who dropped out

Other biasHigh riskIf the cognitive rehabilitation sessions were in addition to standard therapies, the extra intervention may have had the positive effect rather than the content per se

Jorge 2010

MethodsRCT

Randomisation by computer program and non-involved individual


Participants129 participants with 3 months of stroke

Group 1: n = 45

Group 2: n = 43

Group 3: n = 41

Participants aged 50-90 years old, literate, no depression, and able to comprehend and make decisions


InterventionsGroup 1: placebo drug (no intervention)

Group 2: escitalopram (not cognitive rehabilitation)

Group 3: problem-solving training (restorative)


OutcomesTrail Making Test Part A and B for working memory

Stroop Test for flexibility


NotesTrial includes FIM baseline measurement but does not give final outcome measurement

Comparison used will be problem-solving therapy versus drug placebo


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskThe individual conducting the allocation was non-involved but no indication of blinding

Blinding (performance bias and detection bias)
All outcomes
Low riskAssessments carried out by blinded technician

Incomplete outcome data (attrition bias)
All outcomes
Low riskIntention-to-treat and regression analyses conducted for drop-outs

Other biasHigh riskProblem-solving group was older than the other groups and had lower initial outcomes

Levine 2000

MethodsRCT

Method of randomisation not stated


Participants30 participants, 3-4 years post TBI, ranging from mild to severe

Group 1: n = 15

Group 2: n = 15

All participants living independently but classified as good recovery (n = 24), or moderate disability (n = 6)


InterventionsGroup 1: goal management training (restorative)

Group 2: motor skills training (control)

Each group received 1 training session of 1-hour duration


OutcomesProofreading, Grouping and Room Layout for planning


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskNot documented in the text of the study

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot documented in the text of the study

Incomplete outcome data (attrition bias)
All outcomes
High riskThe data for 1 participant was missing from each group with no explanation provided

Other biasUnclear riskThe study was a part of a larger study of which no details are available but may have confounding variables

Lundqvist 2010

MethodsRandomised controlled cross-over trial

Randomisation undertaken using "drawing of lots"


Participants21 participants with acquired brain injury (1 TBI, 11 stroke, 5 encephalitis, 2 tumour and 2 subarachnoid haemorrhage), aged 20-65 years, passed postacute state (time since injury/illness 1 year)

Group 1: n = 10

Group 2: n = 11

Self reported working memory impairments and a significantly impaired working memory index compared with the index for verbal comprehension and/or index for perceptual organisation or a working memory index less than 80 using the Wechler Adult Intelligence Scale III, and reported motivation for training


InterventionsGroup 1: 45- to 60-minute sessions, 5 days/week for 5 weeks of computer working memory training with special feedback given once/week in addition to continuous statistical data provided on the computer screen (restorative)

Group 2: no intervention (precross-over control)

Groups crossed over after this first block of training and Group 2 received the training while Group 1 had no intervention


OutcomesPASAT for working memory


NotesAdditional outcomes included the EQ-5D and Canadian Occupational Performance Measure but these were only administered after both groups received training


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskAllocation undertaken through drawing of lots but the study did not state who undertook this task and how it was undertaken

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNo documentation of whether assessors, intervention providers or participants were blinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs at the end of the first phase of the cross-over trial

Other biasLow risk

Man 2006

MethodsRCT

The method of randomisation was not described


Participants103 participants (55 stroke, 13 TBI, 35 others), 18-55 years old, acquired brain injury at or within 6 months, adequate attention for 45-minute session, able to write with a pen in English or Chinese, fair verbal comprehension, medically stable, underwent rehabilitation, no psychiatric problems or mental handicap, not computer phobic

Group 1: n = 28

Group 2: n = 30

Group 3: n = 25

Group 4: n = 20

Executive dysfunction was not diagnosed but lower level cognition was assessed and participants were included if they demonstrated lower cognitive abilities


InterventionsGroup 1: problem-solving computer training (restorative)

Group 2: therapist training (restorative)

Group 3: online training with a therapist (restorative)

Group 4: control

Each of the intervention groups received 20 x 45-minute weekly sessions. The control condition was not described


OutcomesProblem Solving Questionnaire

Category Test of Halstead-Reitan Neuropsychological Test Battery for concept formation

Lawton Instrumental Activities of Daily Living Index


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskLots were drawn in 2 stages for randomisation but concealment was not stated

Blinding (performance bias and detection bias)
All outcomes
Low riskParticipants and assessors were blinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskThere were no drop-outs

Other biasUnclear riskControl group had no placebo, therefore, contact alone may still be contributing to improvements

O'Connor 2006

MethodsRCT

Method of randomisation not stated


Participants14 participants (7 stroke, 4 TBI, 3 others)

Group 1: n = 6

Group 2: n = 8

Information from abstract. No other details available


InterventionsGroup 1: goal management training including self instruction strategies, self monitoring exercises, simulated real-life tasks and homework (restorative)

Group 2: control intervention including support, information provision, group activities and homework

Each of the intervention groups received 20 x 45-minute weekly sessions. The control condition was not described


OutcomesTest of planning (not described in the abstract)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskNot described in abstract

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot described in abstract

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot described in abstract

Other biasUnclear riskNot clear as only abstract available

Rath 2003

MethodsRCT

Method of randomisation not stated


Participants60 participants with TBI, at least 1 year post injury with higher level cognitive function including 1 hour sustained attention, ability to take organised notes, give and receive feedback, adequate social skills to relate to others and state cognitive strengths and weaknesses

Group 1: n = 32

Group 2: n = 28

Method of diagnosing higher level cognitive dysfunction: Wisconsin Card Sorting Test (Perseverative Response Score), Problem-Solving Inventory, Problem Solving Questionnaire, Problem Solving Roleplay Test


InterventionsGroup 1: group problem-solving intervention (restorative), 24 sessions of 1 x 2-hour group session/week

Group 2: conventional cognitive remediation (restorative), 2-3 hours/week of remediation and psychosocial components


OutcomesWisconsin Card Sorting Test for concept formation

Problem Solving Inventory (self appraisal)

Problem Solving Questionnaire (clear thinking and emotional self regulation)

Problem Solving Role Playing Test (response to face-to-face interpersonal problem)


NotesA 6-month follow-up for Group 1 (n = 18) and Group 2 (n = 13) was conducted


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskNo information provided in study text of allocation concealment

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNo information provided on assessors, participants or those providing the interventions being blinded

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk6-month follow-up data had 14 and 15 participants drop out for Groups 1 and 2, respectively. No statistical methods were used to determine the impact of these drop-outs

Other biasUnclear riskBaseline group characteristics were not given

Salazar 2000

MethodsRCT

Blocked randomisation used variable-sized blocks "to prevent investigators from guessing the code"


Participants120 participants with moderate-to-severe closed head injury (Glasgow Coma Scale of 13 or less) or post-traumatic amnesia lasting longer than 24 hours or CT/MRI scan showing contusion or haemorrhage, minimum Rancho Los Amigos score of 7, active duty military member, independent ambulation, home setting with at least 1 responsible adult and no prior severe brain injury

Group 1: n = 67

Group 2; n = 53

No specific assessment for executive function was undertaken. A Mini Mental Test was administered to all participants


InterventionsGroup 1: in-hospital based daily cognitive and physical exercise regimen with specific group based planning and organisation, cognitive skills, work rehabilitation and work placements (restorative). No specific times stated

Group 2: physical and cognitive exercises and weekly 30-minute telephone call from a psychiatric nurse (restorative). At 2 months, 76% reported 30 minutes/day on these exercises


OutcomesPASAT

Wisconsin Card Sorting Test

Outcomes were measured 12 months after study commencement


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskThis was not addressed in the text of the study. It is not known whether allocation was concealed or not

Blinding (performance bias and detection bias)
All outcomes
Unclear riskIt was not possible to blind treating therapists or participants due to them either being in hospital or at home. "Although treatments could not be blinded and study participation was recorded in the patients' chart, the specificity of Army regulations and the various levels of review helped protect against systematic biases in duty fitness determinations"

Incomplete outcome data (attrition bias)
All outcomes
Low riskIntention-to-treat analysis was undertaken for 7 participants in Group 1 and 6 participants in Group 2

Other biasLow risk

Spikman 2010

MethodsRCT

Randomisation was carried out by a non-involved individual who blindly allocated each balanced group of 4 to experimental or control conditions


Participants75 participants with TBI, 3 months' minimum post onset, aged 17-70 years living at home, outpatient with post-injury executive dysfunction from self report or observation

Group 1: n = 38

Group 2: n = 37

Method of diagnosing executive dysfunction: BADS and DEX


InterventionsGroup 1: multifaceted executive function training including goal management and problem-solving training (restorative)

Group 2: computerised cognitive training package of several repetitive exercises (restorative)

Both groups received 20-24 x 1-hour sessions, 2 times/week over 3 months


OutcomesBADS for general executive function

Trail Making Test for working memory

Stroop Test for flexibility

Tower of London Test for planning

Treatment Goal Attainment

DEX

EOS

Role Resumption List

Quality of Life after Brain Injury


NotesThis was a multicentre trial with outcomes measured immediately after treatment and at 6 months


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskRandomisation was by drawing lots of 4 which could mean that every fourth allocation was unblinded. A non-involved blinded individual to randomise blinded participants was used

Blinding (performance bias and detection bias)
All outcomes
Low riskThe assessor was blinded with the exception of the therapist-rated DEX and EOS

Incomplete outcome data (attrition bias)
All outcomes
Low risk3 participants were lost from the experimental group and 1 was lost from the control group at the 6-month assessment but all data were used

Other biasUnclear riskUnclear time allocated to each group

Westerberg 2007

MethodsRCT

Participants were randomised by selection of sealed envelopes


Participants18 participants, 12-36 months post stroke, scan confirmed stroke, aged 30-65 years (vocational age), daily personal computer access with Internet at home, and self reported attention deficits

Group 1: n = 9

Group 2: n = 9


InterventionsGroup 1: control (no training)

Group 2: computer working memory training (restorative), 40 minutes 5 days/week for 5 weeks


OutcomesPASAT for working memory

Digit Span (auditory working memory)

Span board (visuo-spatial working memory)

Stroop Test for flexibility

Raven's Progressive Matrices for concept formation


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskAllocation was concealed in sealed envelopes, which were prepared by individuals who were unrelated to the study

Blinding (performance bias and detection bias)
All outcomes
High riskAssessors and participants were not blinded to group allocation

Incomplete outcome data (attrition bias)
All outcomes
Low riskThere were no drop-outs and complete data were analysed for all participants

Other biasHigh riskThe passive control group does not rule out therapist contact being the cause of any changes rather than the intervention content

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Bushnik 2010No executive function outcome

Chen 1997Not an RCT but a matched design

Chen 2006Study does not include separable executive function outcome

Evans 2009No executive function outcome. Attention is the focus of this study

Fasotti 2007The intervention was found to be cognitive behavioural therapy and not cognitive rehabilitation

Hayashi 2012No executive function outcome

Jo 2009Transcranial direct current stimulation is not defined as cognitive rehabilitation

Lam 2006No executive function outcome. The main outcome was the use of an underground transport system

Levine 2011Study is a controlled trial with no randomisation

Lundqvist 2010aNot an RCT

McEwen 2011Ongoing randomised trial with no executive function outcome

Novakovic-Agopian 2011Study was a non-randomised cross-over trial

Oftinowski 2006Not an RCT

Pachalska 2012Study was a controlled trial with no randomisation

Pereira 2012Not an RCT

Polatajko 2012Study does not include an executive function outcome

Rios 2011Not an RCT

Skidmore 2011Study was a controlled trial with no randomisation

Tam 2004The outcome was memory and not executive function

Tang 2005Not fully randomised, use of matched block design. No executive function outcome

von Cramon 1991Not an RCT. Allocation to group based on admission sequence

 
Characteristics of studies awaiting assessment [ordered by study ID]
Chen 2011

MethodsRandomised cross-over trial

Participants12 participants (9 with traumatic brain injury, 1 leukoencephalopathy, 1 right temporal-parietal tumour resection, 1 basal ganglia stroke), 6 months to 6 years post event, 24-63 years old, 5 male, 7 female

Group 1: n = 5

Group 2: n = 7

InterventionsGroup 1: goals training

Group 2: education

OutcomesAttention and executive function domain score comprising: design and verbal fluency switching, Trails B and Stroop Test

NotesZ change scores only reported. Baseline and postintervention data not included in the article

Dawson 2010

MethodsExperimental, controlled trial, randomisation uncertain

Participants12 community dwelling adults, at least 1 year post-traumatic brain injury

Group 1: n = 6 (3 male, 3 female), mean age 31.7 years

Group 2: n = 6 (3 male, 3 female), mean age 30.0 years

InterventionsGroup 1: problem-solving training

Group 2: waiting list control

OutcomesSelf and significant other report of performance change of goals

NotesAbstract only available and is unclear as to whether an executive function outcome was included

Kim 2008

MethodsControlled trial, randomisation uncertain from abstract

Participants50 participants with stroke

Group 1: n = 30

Group 2: n = 20

InterventionsGroup 1: Rehacom computerised cognitive training 30 minutes, 5 times/week for 4 weeks

Group 2: intervention not stated

OutcomesComputerised Neuropsychological Test

Lowenstein Occupational Therapy Cognitive Assessment

NotesAbstract only available

Matz 2008

MethodsRCT

Participants32 participants with first lacunar stroke. Numbers allocated to experimental and control groups are not stated on the abstract

InterventionsGroup 1: cognitive training sessions for 3 months

Group 2: standard care

OutcomesUnspecified neuropsychological test battery to assess memory, speed of cognitive processing, executive functions, attention and visuo-spatial functions

NotesAbstract only available

Rizkalla 2011

MethodsRCT

Participants18 participants with acute stroke

Group 1: n = 9

Group 2: n = 9

InterventionsGroup 1: visuospatial/visuomotor training programme 20 hours over 4 weeks

Group 2: control

OutcomesTrails B for working memory

Disability Assessment for Dementia for ADL

NotesAbstract only available. Control intervention not stated in abstract

Wood 2012

MethodsRCT

ParticipantsTotal number of participants uncertain from abstract

Group 1: n = 21 (acquired brain injury)

InterventionsGroup 1: goal management training with implementation intentions for prospective memory

Group 2: goal management training with visual imagery (control)

OutcomesJAAM virtual reality task for executive function with a measure for prospective memory

NotesAbstract only available

Zhu 2011

MethodsExperimental controlled trial, randomisation uncertain from abstract

Participants46 participants with brain injury

Group 1: n = 26

Group 2: n = 20

InterventionsGroup 1: traditional rehabilitation training 30-40 minutes twice/day and 30 minutes' computer-assisted training twice/day for 5 weeks

Group 2: traditional rehabilitation training 30-40 minutes twice/day for 5 weeks

OutcomesNeurobehavioural Cognitive Status Examination

Clock drawing test

Reasoning ability

NotesAbstract only available

 
Characteristics of ongoing studies [ordered by study ID]
Dawson 2011

Trial name or titleManaging Dysexecutive Syndrome

MethodsRCT

ParticipantsAdults with moderate-to-severe traumatic brain injury or complicated mild traumatic brain injury

InterventionsGroup 1: novel behavioural intervention

Group 2: conventional rehabilitation

Both interventions 1 hour, 2 times/week for 15 sessions

OutcomesCanadian Occupational Performance Measure for functional performance, instrumental ADL profile and the DEX for executive function

Starting dateMarch 2012

Contact informationDeidre D Dawson, ddawson@rotman-baycrest.on.ca

Alison M Douglas, adaouglas@rotman-baycrest.on.ca

Notes

de Joode 2008

Trial name or title"NeuroCue". A Randomised Controlled Study into the Use of an Electronic Cognitive Aid in Patients with Acquired Brain Injury

MethodsRCT

Participants1. Participants with acquired brain injury in either a subacute or a chronic phase
2. Participants are referred for cognitive rehabilitation
3. Aged 18-75 years
4. Adequate comprehension of the Dutch language
5. Experienced problems in daily life functioning as a consequence of brain damage; insight into cognitive deficits; sufficient IQ level to benefit from treatment according to the rehabilitation physician or psychologist

InterventionsThe experimental group will receive the PDA for a period of 16 weeks, the control group will receive 'care-as-usual', defined as calendar training or other types of strategy training to cope with their cognitive disabilities. Both groups will receive an equal amount of therapy time, namely 15-20 hours in total

OutcomesPrimary

1. The efficiency on target behaviours measured with an interview

2. Subjective cognitive problems in daily life, self efficacy, and social and instrumental activities

3. Experiences of participants and carers with the use of the PDA

4. The effectiveness of device usage

Secondary

1. Levels of distress and depression for the user
2. Levels of distress, strain and depression for the carers
3. Quality of life for participants and close family members

Starting date1 May 2008

Contact informationTrial website: www.np.unimaas.nl/neurocue

Notes

Hoffman 2009

Trial name or titleEvaluation of Brief Interventions for Enhancing Early Emotional Adjustment Following Stroke: a Pilot Randomised Controlled Trial

MethodsRCT comparing a self management intervention with a coping skills intervention and a control group

ParticipantsParticipants with stroke

Interventions8 sessions of self management intervention conducted by an occupational therapist will include: (1) provision and reinforcement of individualised written information; (2) activities to learn problem-solving skills, perform functional tasks and adjust to life poststroke

8 sessions of coping skills intervention conducted by a clinical psychology trainee will include: (1) cognitive and behavioural exercises to prepare individuals for discharge and to adjust postdischarge including psychoeducation, self monitoring, graduated activity participation and cognitive restructuring

Standard care including medical assessment and treatment, nursing care, assessment and/or treatment from allied health staff, discharge planning and any information or education associated with this treatment

Outcomes1. Presence or absence, and severity of anxiety and depressive symptoms as determined by structured interview based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) and HADS 

2. Functional performance as measured by the modified BI and the Nottingham Extended ADL Scale 

3. Cognitive appraisal ability as measured by the Stress Appraisal Coping Measure 

4. Stroke knowledge as measured by the Knowledge of Stroke Questionnaire 

5. Quality of life as measured by the Stroke and Aphasia Quality of Life Scale

6. Treatment expectations as measured by the Treatment Expectations Scale 

7. Self awareness of deficits as measured by the Self-Perceptions in Rehabilitation Questionnaire

Starting date15 October 2009

Contact informationwww.anzctr.org.au/

Notes

Singh 2008

Trial name or titleThe Study of Mental Activity and Regular Training for the Prevention of Cognitive Decline in at Risk Individuals: the SMART Trial

MethodsRCT

ParticipantsParticipants with stroke

Interventions1. Cognitive training: the SMART trial suite of cognitive training exercises aimed at computer-based multi-modal, multi-domain and taskload-graded training in the areas of memory, executive function, attention and speed of information processing

2. Combined cognitive and exercise combination: cognitive and exercise training on the same day (90-minute sessions), 3 sessions/week for 26 weeks

3. Resistance training intervention: the PRT will be conducted 3 days/week, 45 minutes/session, for 26 weeks

4. Sham cognitive and sham exercise control groups: in these groups, participants will receive ineffective versions of cognitive and physical exercise programmes, 3 sessions/week for 26 weeks

Participants randomised to: (1) cognitive training + sham PRT; (2) PRT + sham cognitive training; (3) cognitive training + PRT; (4) sham cognitive + sham PRT

OutcomesPrimary outcomes

1. Cognitive performance: involves assessing attention, memory, language, problem solving, and speed through clinician and participant-administered questionnaires: Mini-Mental State Examination, Clinical Dementia Rating Scale, Alzheimer's Disease Assessment Scale-cognitive subscale, Matrices and Similarities, Trail Making Test, Symbol Digit Modalities Test, Logical Memory, Benton Visual Retention Test, Category fluency, Controlled Oral Word Association Test, Memory Awareness Rating Scale

Secondary outcomes

1. functional independence assessed by the Participant and Informant Bayer-Activities of Daily Living questionnaire

2. Psychological outcomes including, Short Form 36, Quality of Life Scale, Life Satisfaction Scale, Scale of Psychological Well-being, and Depression Anxiety and Stress Scale
3. Physical testing including: exercise stress test, exercise capacity, body composition, blood pressure (ankle-brachial index, orthostatic blood pressure), muscle strength, balance, gait speed, nutritional biochemistry, insulin resistance and glucose homeostasis, genetic polymorphism, cortisol stress response, inflammatory biomarkers, habitual levels of physical activity and sleep

4. Self reported size and satisfaction of social support, and community health services utilisation

Starting date1 September 2009

Contact informationwww.strokecenter.org/trials/

Notes

 
Comparison 1. Cognitive rehabilitation versus standard care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Components of executive function1Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Concept formation
186Mean Difference (IV, Random, 95% CI)-0.43 [-0.76, -0.10]

 2 Activities of daily living186Mean Difference (IV, Random, 95% CI)-28.28 [-33.50, -23.06]

 
Comparison 2. Cognitive rehabilitation versus no treatment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Components of executive function4Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Concept formation
268Std. Mean Difference (IV, Random, 95% CI)-0.03 [-0.52, 0.45]

    1.2 Planning
130Std. Mean Difference (IV, Random, 95% CI)-0.39 [-1.11, 0.33]

    1.3 Flexibility
2104Std. Mean Difference (IV, Random, 95% CI)-0.11 [-0.90, 0.67]

 2 Working memory2104Std. Mean Difference (IV, Random, 95% CI)-0.10 [-1.39, 1.18]

 3 Activities of daily living1Mean Difference (IV, Random, 95% CI)Subtotals only

    3.1 Extended activities of daily living
150Mean Difference (IV, Random, 95% CI)0.07 [-3.09, 3.23]

 
Comparison 3. Experimental cognitive rehabilitation versus standard cognitive rehabilitation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Global executive function282Std. Mean Difference (IV, Random, 95% CI)-0.41 [-0.85, 0.03]

 2 Components of executive function8Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 Inhibition
15Std. Mean Difference (IV, Random, 95% CI)-0.83 [-2.93, 1.28]

    2.2 Concept formation
7313Std. Mean Difference (IV, Random, 95% CI)-0.16 [-0.44, 0.11]

    2.3 Planning
2108Std. Mean Difference (IV, Random, 95% CI)-0.30 [-0.68, 0.08]

    2.4 Flexibility
175Std. Mean Difference (IV, Random, 95% CI)-0.39 [-0.85, 0.07]

 3 Working memory3263Std. Mean Difference (IV, Random, 95% CI)-0.12 [-0.36, 0.13]

 4 Activities of daily living3Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    4.1 Activities of daily living
348Std. Mean Difference (IV, Random, 95% CI)-0.52 [-1.11, 0.06]

    4.2 Extended activities of daily living
121Std. Mean Difference (IV, Random, 95% CI)-0.49 [-1.36, 0.38]

 5 Quality of life2143Std. Mean Difference (IV, Random, 95% CI)-0.11 [-0.44, 0.22]

 6 Vocational activities3163Std. Mean Difference (IV, Random, 95% CI)-0.00 [-0.37, 0.37]

 7 Vocational activities (dichotomous)168Odds Ratio (M-H, Random, 95% CI)0.29 [0.10, 0.85]

 
Comparison 4. Type of cognitive rehabilitation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Concept formation6194Std. Mean Difference (IV, Random, 95% CI)-0.04 [-0.32, 0.24]

    1.1 Restorative versus compensative interventions
4126Std. Mean Difference (IV, Random, 95% CI)-0.04 [-0.39, 0.31]

    1.2 Restorative versus other interventions
268Std. Mean Difference (IV, Random, 95% CI)-0.03 [-0.52, 0.45]

 2 Working memory3172Std. Mean Difference (IV, Random, 95% CI)-0.00 [-0.62, 0.61]

    2.1 Restorative versus compensative interventions
168Std. Mean Difference (IV, Random, 95% CI)-0.02 [-0.50, 0.45]

    2.2 Restorative versus other interventions
2104Std. Mean Difference (IV, Random, 95% CI)-0.10 [-1.39, 1.18]

 3 Activities of daily living227Std. Mean Difference (IV, Random, 95% CI)-0.19 [-1.60, 1.22]

    3.1 Restorative versus compensative interventions
227Std. Mean Difference (IV, Random, 95% CI)-0.19 [-1.60, 1.22]

 
Table 1. Interventions and comparisons

StudyCountryCognitive rehabilitation interventionClassification of type of interventionComparisonClassification of type of comparison

Amos 2002AustraliaSalienceCompensativeNo assistancen/a

Carter 1980USACognitive remediationRestorativeStandard caren/a

Cheng 2006Hong KongAwareness interventionRestorativeStandard caren/a

Chung 2007UKVideo-feedbackCompensativeVerbal feedbackRestorative

Cicerone 2008USAIntensive neurorehabilitationCompensativeStandard neurorehabilitationRestorative

Dirette 1999USACompensatory strategy trainingCompensativeComputer activitiesn/a

Fong 2009Hong KongProblem-solving skills trainingRestorativeStandard neurorehabilitationCompensative

Goverover 2007USASelf awareness trainingRestorativeDirective feedbackCompensative

Hewitt 2007UKAutobiographical memory cueing for problem solvingRestorativeGeneral conversationn/a

Hu 2003ChinaStandard neurorehabilitationRestorativeStandard caren/a

Jorge 2010USAProblem-solving skills trainingRestorativeNo interventionn/a

Levine 2000CanadaGoal management trainingRestorativeStandard caren/a

Lundqvist 2010SwedenComputer working memory trainingRestorativeNo interventionn/a

Man 2006Hong KongProblem-solving skills trainingRestorativeNo interventionn/a

O'Connor 2006CanadaGoal management trainingRestorativeStandard neurorehabilitationRestorative

Rath 2003USAGroup problem-solving trainingRestorativeStandard neurorehabilitationRestorative

Salazar 2000USAHospital cognitive rehabilitationRestorativeHome-based cognitive rehabilitationRestorative

Spikman 2010NetherlandsProblem-solving skills trainingRestorativeComputer cognitive rehabilitationRestorative

Westerberg 2007SwedenComputer working memory trainingRestorativeNo interventionn/a

 n/a: not applicable
 
Table 2. Outcome measurement tools and related outcomes

Outcome measureStudiesMain executive function componentProtocol-related component

Behavioural Assessment of Dysexecutive SyndromeChung 2007

Spikman 2010
Global executive functionGlobal executive function

Category test of Halstead-Reitan Neuropsychological Test BatteryMan 2006Abstract reasoningConcept formation

Digit SpanCarter 1980

Westerberg 2007
Auditory working memoryWorking memory (not on protocol)

Dysexecutive Questionnaire (DEX)Spikman 2010Executive problems in everyday life (self and proxy)Global executive function

Executive Observation ScaleSpikman 2010Therapist rated scaleGlobal executive function

Hayling and Brixton TestChung 2007Inhibition and concept formationInhibition and concept formation

Lawton Instrumental ADL IndexCheng 2006

Man 2006
Extended ADLExtended ADL

Paced Auditory Serial Addition Test (PASAT)Dirette 1999

Lundqvist 2010

Salazar 2000

Westerberg 2007
Auditory working memoryWorking memory (not on protocol)

Problem Solving InventoryRath 2003Self appraisal of problem-solving behavioursConcept formation

Problem Solving QuestionnaireMan 2006

Rath 2003
Self monitoring and logical thinkingConcept formation

Problem Solving Role Playing TestRath 2003Face-to-face interpersonal problem solvingConcept formation

Proof readingLevine 2000Holding goals in mind, monitoringPlanning

Quality of Life after Brain Injury (QOLIBRI)Spikman 2010Quality of lifeQuality of life

Raven's Progressive MatricesFong 2009

Westerberg 2007
Non-verbal reasoningConcept formation

Role Resumption ListSpikman 2010Changes in amount and quality of activitiesParticipation in vocational activities

Span-BoardWesterberg 2007Visuo-spatial working memoryWorking memory (not on protocol)

Stroop TestJorge 2010

Spikman 2010

Westerberg 2007
Cognitive flexibilityFlexibility

Tower of London Test Spikman 2010Strategy formationPlanning

Trail Making TestCicerone 2008

Jorge 2010

Spikman 2010
Visual working memoryWorking memory (not on protocol)

Treatment Goal AttainmentSpikman 2010The extent of goal achievementPlanning

Wisconsin Card Sorting TestAmos 2002

Rath 2003

Salazar 2000
PerseverationConcept formation

Assessment of Awareness of Disability  Goverover 2007Discrepancy between task awareness and performanceConcept formation

Assessment of Motor and Process SkillsGoverover 2007Motor and process skills of ADLADL

Booklet Category TestCicerone 2008Abstract reasoning – concept formationConcept formation

Category Test of the Halstead Reitan Neuropsychological Test BatteryMan 2006Postulate hypothesis regarding similarities and differencesConcept formation

Community Integration QuestionnaireGoverover 2007Home and social integration and productive activitiesParticipation in vocational activities

Everyday Descriptions TaskHewitt 2007PlanningPlanning

Functional Independence MeasureCheng 2006Independence with ADLADL

GroupingLevine 2000Holding goals in mind, subgoal analysis, monitoringWorking memory

Key Search TestFong 2009Problem solving (planning, strategy formation, monitoring metacognition)Planning

Means-Ends Problem Solving MeasureFong 2009Interpersonal problem solvingConcept formation

Metacomponential InterviewFong 2009Reasoning-concept formationConcept formation

CognistatHu 2003Similarities and judgement sectionsConcept formation

Perceived Quality of Life ScaleCicerone 2008Quality of lifeQuality of life

Problem Solving QuestionnaireMan 2006Identifying solutions to problemsConcept formation

Room LayoutLevine 2000Subgoal analysis, monitoringWorking memory

Self Awareness of Deficits InterviewCheng 2006Self awareness of deficits, implications and goalsConcept formation

Self-Regulation Skills InterviewGoverover 2007Self monitoring, problem recognition and anticipationConcept formation

Six Elements TestFong 2009Problem solving (planning, strategy formation, monitoring metacognition)Planning

Social Problem-Solving Video MeasureFong 2009Real-life problem solvingConcept formation

Test of PlanningO'Connor 2006PlanningPlanning

Vocational Integration ScaleCicerone 2008Vocational and educational outcomesParticipation in vocational activities

 ADL: activities of daily living
Cognistat: Neurobehavioural Cognitive Status Examination
DEX: Dysexecutive Questionnaire
PASAT: Paced Auditory Serial Addition Test
QOLIBRI: Quality of Life after Brain Injury
 
Table 3. Outcome measure selection rationale

StudyOutcome measuresSelected for reviewRationale

Amos 2002Wisconsin Card Sorting TestWisconsin Card Sorting TestThe only executive function measure

Carter 1980Digit Span TestDigit Span TestThe only measure related to working memory and hence, executive function

Cheng 2006Self Awareness of Deficits Interview

Functional Independence Measure

Lawton Instrumental Activities of Daily Living Scale
Self Awareness of Deficits Interview

Functional Independence Measure

Lawton Instrumental Activities of Daily Living Scale
The only measure of self awareness

The FIM measures basic ADL, and the Lawton measures advanced ADL

Chung 2007BADS

Hayling and Brixton Tests

Adapted Nottingham Stroke Dressing Assessment
BADS

Hayling and Brixton Tests

Adapted Nottingham Stroke Dressing Assessment
BADS is a global executive function measure whereas the Hayling test measures inhibition while the Brixton Test measures concept formation

The Adapted Nottingham Stroke Dressing Assessment was the only ADL assessment used

Cicerone 2008Trail Making Test B

COWAT

Booklet Category Test

Perceived Quality of Life Scale

Community Integration Questionnaire

 
Trail Making Test B

 

Booklet Category Test

 

 

 

 

  

Perceived Quality of Life Scale

Community Integration Questionnaire

 
Working memory measure

Concept formation test preferred to the COWAT due to the latter's weighting on semantic memory strategies and less about actual concept formation

Quality of life measure

Vocational components included

Dirette 1999PASATPASATThe only working memory measure

Fong 2009Six Elements Test for problem solving

Key Search Tests for everyday problem solving

SPSVM

MEPSM

Raven's Progressive Matrices

Metacomponential Interview

 
Raven's Progressive Matrices

Key Search
This has established reliability and validity for concept formation. The SPSVM, MEPSM and Metacomponential Interview all relate to concept formation but the author of the SPSVM stated that it requires further reliability studies for people with brain injury, the MEPSM was validated for psychiatric patients and the Metacomponential Interview scoring is based partly on interviewer prompts and no reliability figures are given. Thus, Raven's Progressive Matrices appears to be the most valid and reliable outcome measure for concept formation. The Six Elements and Key Search are both planning measure. As the Six Elements relates to competing tasks, the Key Search outcome possibly has a more concrete end point of finding the key than the Six Elements, which is about the completion of part tasks

Goverover 2007AAD

SRSI
AADBoth measures are related to concept formation but the AAD measure discrepancy between self rating and observed function rating whereas the SRSI is based on self evaluation. The AAD appears to be a stronger option as it seems to be more valid for picking up instances of reduced self awareness

Hewitt 2007Everyday Descriptions TaskEveryday Descriptions TaskThe only post measure used. The effectiveness component of the outcome measure was used as number of steps could potentially be a positive or negative factor

Hu 2003CognistatCognistatExecutive function components of the only measure used. These are similarities and judgement, which are reasoning components, and will be under concept formation for this review

Jorge 2010Stroop Test

Trail Making Test
Stroop Test

Trail Making Test
The only measures used for cognitive flexibility and working memory respectively

Levine 2000Grouping

Room Layout

Proof Reading
Room Layout

Proof Reading
Both Grouping and Room Layout measure working memory, but the Room Layout Task has a stronger relationship to a real-life task, whereas, grouping is closer to an alternating attention task

Proof reading was the only measure of planning

Lundqvist 2010PASATPASATThe only working memory measure

Man 2006Problem Solving Questionnaire

Category Test of the Halstead Reitan Neuropsychological Test Battery
Category Test of the Halstead Reitan Neuropsychological Test BatteryAuthor's state that it is supported by extensive research compared with the Problem Solving Questionnaire that had just been validated for the study

O'Connor 2006Test of PlanningTest of PlanningThe only planning test

Rath 2003Wisconsin Card Sorting Test

Problem Solving Inventory

Problem Solving Questionnaire

Problem Solving Role Playing Test
Wisconsin Card Sorting Test

 
All the measures appear to have undergone validation processes but the Wisconsin Card Sorting Test was chosen due to its widespread use and advantage to this meta-analysis

Salazar 2000PASAT

Wisconsin Card Sorting Test
PASAT

Wisconsin Card Sorting Test
The only measures for working memory and concept formation respectively

Spikman 2010BADS

Trail Making Stroop

Tower of London

Treatment Goal Attainment

DEX

EOS
BADS

Trail Making

Stroop Test

Tower of London Test

 
The selected measures are established tests whereas Treatment Goal Attainment was developed for the study and the DEX and EOS and self rating and observational rating scales that do not involve participant performance of actual tasks

von Cramon 1991Tower of HanoiTowers of HanoiThe only planning measure

Westerberg 2007PASAT

Digit Span

Span board

Stroop Test

Raven's Progressive Matrices
PASAT

Stroop Test

Raven's Progressive Matrices
The first 3 measures are for working memory and the analysis has not subdivided working therefore, the widest and most established was chosen

The Stroop Test and Raven's  Progressive Matrices were the only measures of flexibility and concept formation

 AAD: Assessment of Awareness of Disability
ADL: activities of daily living
BADS: Behavioural Assessment of Dysexecutive Syndrome
Cognistat: Neurobehavioural Cognitive Status Examination
COWAT: Controlled Oral Word Association Test
DEX: Dysexecutive Questionnaire
EOS: Executive Observation Scale
FIM: Functional Independence MeasureMEPSM: Means-Ends Problem Solving Measure
PASAT: Paced Auditory Serial Addition Test
SPSVM: Social Problem-Solving Video Measure
SRSI: Self Regulation Skills Interview