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ISSN: 0269-9052 (print), 1362-301X (electronic)

Brain Inj, 2014; 28(12): 1610–1616


! 2014 Informa UK Ltd. DOI: 10.3109/02699052.2014.934921

ORIGIANL ARTICLE

Efficacy of memory rehabilitation therapy: A meta-analysis of TBI and


stroke cognitive rehabilitation literature
Madison Elliott & Frederick Parente

Towson University, Towson, MD, USA

Abstract Keywords
Objective: To examine the efficacy of cognitive rehabilitation strategies specifically designed Cognitive rehabilitation, memory,
to improve memory after traumatic brain injury (TBI) and stroke vs. memory improvement with meta-analysis, neurorehabilitation,
the passage of time. remediation, stroke, TBI, working memory
Design and methods: A meta-analysis was performed on 26 studies of memory retraining and
recovery that were published between the years of 1985 and 2013. Effect sizes (ESs) from each History
study were calculated and converted to Pearson’s r and then analysed to assess the overall
effect size and the relationship among the ESs, patient demographics and treatment Received 15 May 2013
interventions. Revised 14 March 2014
Results: Results indicated a significant average ES (r ¼ 0.51) in the treatment intervention Accepted 6 June 2014
conditions, as well as a significant average ES (r ¼ 0.31) in the control conditions, in which Published online 21 July 2014
participants did not receive any treatment. The largest ESs occurred in studies of stroke patients
and studies concerning working memory rehabilitation.
Conclusions: Results showed that memory rehabilitation was an effective therapeutic
intervention, especially for stroke patients and for working memory as a treatment
domain. However, the results also indicated that significant memory improvement occurred
spontaneously over time.

Introduction to brain injury attempted to amalgamate this literature via published


rehabilitation practice guidelines for TBI and stroke. These
At least 5.3 million US citizens live with a permanent TBI- or
guidelines are based on findings from recently published
stroke-related disability. Health professionals consider TBI
systematic reviews, which generally examine a wide body of
to be one of the most debilitating injuries relative to
published studies that include diverse research designs [7].
other neurological disorders [1, 2]. Mar et al. [3] detailed
Systematic reviews construct valuable inferences about the
the devastating societal and individual impact of neuro-
efficacy of rehabilitation strategies; but what they achieve
logical trauma. Many factors contribute to a person’s recov-
in variety, they also lack in statistical rigour. Meta-analyses
ery trajectory and, in the past decade, rehabilitation of
must exclude studies that do not provide group data for effect
cognitive processes has become significant in the treatment
size (ES) and, therefore, cannot examine as many publications
course [4, 5].
as a systematic review. Nevertheless, meta-analyses are
Although cognitive rehabilitation is increasingly popular,
becoming increasingly popular in review methodology in
clinicians currently face major difficulties when identifying
psychological and brain sciences and are recognized as a
and treating cognitive impairments caused by brain injury or
statistically reliable manner of testing objective observations
stroke. This is because brain-injured populations typically
across studies [8]. The purpose of the present investigation is
are a heterogeneous group with a multitude of deficits [6].
to provide a meta-analytic review of cognitive rehabilitation
Evidence-based treatment guidelines are only as good as the
strategies for the domain of memory in individuals with TBI
research they rely on and published rehabilitation studies
and stroke. The authors’ goal is to contribute to future
tend to be both elaborate and ambiguous in nature. Several
guidelines, as well as augment existing qualitative review
professional committees, including members of the National
findings from memory rehabilitation literature.
Institutes of Health (NIH) and the Brain Injury-
Interdisciplinary Special Interest Group (BI-ISIG) of the
American Congress of Rehabilitation Medicine, have Cognitive rehabilitation of memory
Cognitive Rehabilitation Therapy (CRT) for brain injury and
stroke is diverse, with numerous treatment and theoretical
Correspondence: Madison Elliott, Psychology Department, Towson
University, 8000 York Road, Towson, MD 21252, USA. E-mail: models. Treatments can be process-specific, aimed at improv-
mellio4@students.towson.edu ing overall performance of a given activity, skill-based,
DOI: 10.3109/02699052.2014.934921 Efficacy of memory rehabilitation therapy 1611

motor-based or restricted to a certain area of cognition like 17–19]. In their extensive review, Cicerone et al. [10, 17]
attention, language, executive function or memory. Overall evaluated 118 studies that used CRT, classifying them first
goals of treatment and treatment implementation are as varied in terms of methodological quality and then summarizing
as the treatments themselves [9]. This rehabilitation is broad consistency of findings. The highest ranked studies were
because of the unique nature of every brain injury. In the case those including randomized control trials (RCTs) (I), followed
of memory impairment, long-term, short-term and/or working by studies including non-randomized control prospective or
memory can be negatively affected. Rehabilitation tasks retrospective case-controls (II). The lowest ranked studies
and their outcome measures are often developed to improve or were those not including control groups or those that used
evaluate function within a specific type of memory [10]. data from case studies of single subjects (III). The study also
Memory impairment is commonly reported after brain injury categorized the research into various domains: attention,
or stroke and individuals who experience trauma localized in vision, perception, apraxia, language and communication,
the temporal lobes, hippocampus and amygdala are particu- working memory, executive functioning, problem-solving and
larly susceptible to memory impairment [10]. However, awareness and comprehensive holistic cognitive rehabilita-
the locus of the brain injury is not the sole determinant of tion. Some of the cognitive rehabilitation domains, such
memory problems; many factors contribute to each person’s as attention training, visual-spatial training and language-
unique outcome post-brain injury [2]. To explain the varying based interventions produced larger treatment effects than
nature of TBI, Kay [4] and McCrea et al. [5] have proposed others [17, 20].
integrated, multi-factorial neuropsychological models of brain More recently, Rohling et al. [8] performed a quantitative
injury outcome, including the determination of factors such meta-analysis of a select, well-controlled, literature set that
as neurological health, psychological health, physiological derived from Cicerone et al. [10, 17]. Rohling et al. [8]
health, as well as their interactions with individual subjective concluded there was ‘modest qualitative support’ for CRT
or objective cognitive functions. efficacy, as asserted by Cicerone et al. [10, 17] asserted in
Various behavioural treatment strategies for memory their original paper. Rohling et al. [8] found sufficient
rehabilitation have proven to be efficacious, such as the evidence that attention training after TBI, language and
internet-based tasks used in Bergquist et al. [11]. Other forms visual-spatial training for symptoms of stroke were effective.
of computerized training [12], awareness questionnaires [13] The authors concluded that, out of five major treatment-
and motive or incentive-based tasks [14] have also resulted effectiveness findings in Cicerone et al. [10, 17], their meta-
in effective treatment. However, relatively few articles have analysis results only supported three: attention-training,
been published that have documented successful pharmaceut- language-based training and visual-spatial training.
ical treatments for memory enhancement [15]. Rohling et al. [8] cautioned readers that Cicerone et al.
The typical behavioural rehabilitation efficacy study [10, 17] did not adequately estimate re-test effects from
evaluates memory differences for a control group vs. experi- studies with uncontrolled designs. One of the two major
mental group, pre- and post-intervention design. Outcome claims Rohling et al. [8] questioned was the efficacy of
measures vary greatly and include neuropsychological memory rehabilitation. Although their data showed a moder-
batteries, motor-function tests, brain imaging and various ate effect size (ES) for memory rehabilitation, it was not
self-report instruments. Observer versions of the self-report significant. This suggested that general neuroplasticity and
measures have been administered to participants’ family natural recovery were responsible for much of the docu-
members, professional supervisors or close friends to obtain mented memory recovery, even in the treatment conditions.
a more diverse understanding of their daily behavioural Due to the lack of significant ESs, the authors also could not
functioning [2]. definitively say that the memory rehabilitation had the desired
Although there are published reports of potentially effect- effect. However, very few of the 115 articles evaluated in
ive treatments, there is no conclusive evidence of an effective Rohling et al. [8] involved memory rehabilitation, so it is
standardized treatment programme for memory dysfunction. difficult to derive any conclusive evidence about the overall
Most treatments produce improvement in memory function- efficacy of memory therapy.
ing, but it is unclear whether some treatments are more The present meta-analysis reviewed studies published in
efficacious than others [16]. Furthermore, there is little 1985–2013 about memory rehabilitation in participants who
research to document enduring improvement over time for suffered a TBI or stroke, in order to build upon the
any treatment modality. There is some evidence, however, aforementioned findings by Cicerone et al. [10, 17] and
for treatment efficacy that exceeds the level of improvement Rohling et al. [8], regarding the domain of memory rehabili-
that occurs with the passage of time. In Rohling et al.’s [8] tation. The primary goal of the present meta-analysis was
meta-analytic re-examination of Cicerone et al.’s [10, 17] to update Rohling et al.’s [8] work by adding new studies.
review, the authors found a larger effect size for memory A secondary goal was to investigate new factors that may
improvement in TBI and stroke patients after clinical contribute to the recovery effects.
rehabilitation than in TBI and stroke patients who received Many neuro-rehabilitation techniques have changed and
no treatment. advanced since the Rohling et al. [8] meta-analysis. However,
the Rohling et al. [8] methodology for meta-analytic research
in this area is exemplary. Therefore, the methods for the
Memory rehabilitation efficacy
current study were adapted from Rohling et al. [8]. These
CRT after TBI and stroke has been the topic of a number procedures include adding the most recent publications, using
of major reviews evaluating treatment effectiveness [8, 10, the most rigorous and careful methods of the four major
1612 M. Elliott & F. Parente Brain Inj, 2014; 28(12): 1610–1616

reviews listed and replicating the Rohling et al. [8] selection The other 12 studies contained a treatment intervention, but
criteria. no control condition. Studies not cited in article, but included
A re-examination of new memory rehabilitation studies, in the meta-analysis are listed [30–51].
and those in Rohling et al.’s [8] database, revealed several
new variables that were significant factors during a patients’
Procedural analysis
recovery. The following variables were identified based
on their prevalence and statistical availability: average age Meta-analytic procedures using the MIX 2.0 for Microsoft
of the patients (paediatric vs. adult), year of publication, Excel meta-analysis software package were used to evaluate
type of brain injury, type of memory targeted by the the ESs computed from the available statistics in each
rehabilitation strategy, type of intervention (computerized published study. These ESs (calculated as the Pearson’s r)
vs. not-computerized) and sample size. were subsequently analysed to determine whether the average
ESs were significantly different from zero. The researchers
Meta-analysis and effect size measures chose to use r because of several advantages listed in
Rosenthal and Dimatteo [21]. These authors stated that
A meta-analytic review is a manner of statistically aggregat- converting to r is advantageous because this ES, in its point
ing and evaluating previously conducted studies. Generally, biserial form, better represents the relationship between levels
the purpose of a meta-analysis is to examine the overall effect of the independent variable and dependent variable scores.
of a specific variable in available literature. Meta-analyses use Additionally, converting a continuous r to dichotomous d
research studies as a unit of measure to evaluate central results in a loss of statistical information. Researchers may
tendency and variability of the ESs across the sample of use degrees of freedom contrast techniques to analyse trends
chosen studies. Rohling et al. [8] used a widely accepted across a greater number of groups with r and it requires
procedure extracting ESs from published studies; the ESs no computational adjustments when examining different
measure of the amount of variance the effect controls in a types of t-test samples. There is also a well-accepted public
given experiment. Their meta-analysis was a quantitative familiarity with r and its practical importance is established in
evaluation of the extent to which covariates of interest control the field of psychology [21]. Magnitude of ES (small,
significant portions of the ESs in the study sample. According moderate, large) was interpreted according to the guidelines
to the standards used by Rohling et al.’s [8], the overall effect published in Cohen [22].
of the variable is considered reliable if the average ES is ESs from control conditions estimated how much memory
significantly different from zero. The goal of the present improvement was not attributable to an experimental inter-
study was to follow Rohling et al.’s [8] example and to reduce vention, but instead attributable to the passage of time and
the relevant statistical information in each published study non-specific neuroplasticity. ESs from intervention conditions
to standard units of ES and then evaluate whether the ESs were subsequently analysed and used to estimate how much
co-vary with any of several other variables that describe the memory improvement could be attributed to a cognitive
conditions of the original experiments. rehabilitation effort. The final analytic procedure compared
the first (control analysis) to the second (intervention
Method analysis) in order to determine whether cognitive rehabilita-
tion interventions yield significantly larger ESs compared to
Sample of studies
control conditions, where no intervention has taken place.
Studies were identified using combinations of the search The Q statistic was calculated to evaluate the significance
terms: ‘working memory’, ‘rehabilitation’, ‘remediation’, of the overall effect size and to assess the significance of the
‘memory’, ‘training’, ‘brain injury’, ‘TBI’ and ‘stroke’ in difference between the treatment ES once the control ES was
the following research databases: Medline, Pub Med, removed. The Q statistic and forest plots were also calculated
PsycINFO, PsycArticles and Google Scholar. Once pertinent initially to assess the homogeneity of the ESs across the
articles were identified through these databases, their refer- various studies. The observed heterogeneity of ESs in both
ence lists were reviewed to locate other potentially relevant control and intervention group conditions was used to justify
studies for inclusion. Based on Rohling et al.’s [8] criteria, the selection and use of a random effects model for the
excluded studies (1) did not contain a memory-rehabilitative analysis. This model allows for comparisons to be generalized
intervention; (2) merely described treatment approaches or beyond studies in the current sample and studies identical to
theories; (3) were review articles; (4) presented unspecified those in the current sample [21]. A random effects model
or unmeasured interventions; (5) lacked a diagnosis or was considered superior to a fixed effects model for analysing
assessment of TBI or stroke; (6) were case studies of a the current set of studies because fixed effect models are
single participant with no empirical data; (7) were non-peer used when the sample of studies are considered homogenous
reviewed articles; (8) included exclusively-pharmacological and of the same population [23]. Although MIX 2.0 analytic
interventions; and (9) were not written in English. Rohling procedures weighted ESs by their sample size, Begg’s
et al. [8] mention that single papers may include multiple Test statistics also were calculated to assess whether or
analysable studies, with ‘unique non-overlapping samples not sample sizes affected the reported ESs. The degree
of participants’ (p. 22). In total, 26 published memory of dissemination bias, i.e. the extent to which the published
rehabilitation studies met selection standards and could be studies over-estimate the size of the effect, was also examined
used for the analysis. Fourteen of the studies compared using a funnel plot. Covariates of the ESs, including
a treatment intervention condition to a control group. the average age of the patients (paediatric vs. adult), ratio
DOI: 10.3109/02699052.2014.934921 Efficacy of memory rehabilitation therapy 1613

of males to females in the sample, year of publication, type have contributed to the inconsistency of methods used among
of brain injury, type of memory targeted by the rehabilita- the control studies.
tion strategy, type of intervention (computerized vs. not- Begg’s Test statistics were computed to determine whether
computerized) and sample size were also evaluated to publication bias was present in the sample of studies used.
determine whether or not they predicted memory recovery Smaller samples with fewer degrees of freedom often produce
in either group. inflated ESs and may indicate the existence of unpublished
studies with lower ESs. The Begg’s statistics computed on
Results these data indicated the presence of publication bias among
Control conditions analysis the chosen studies.
Funnel plots can be used to illustrate dissemination bias.
The average effect size for this condition of r ¼ 0.31 was If there is little or no dissemination bias, a funnel plot will
significant (Z ¼ 10.00, p50.05), which indicated a moderate show all the dots distributed randomly around the synthesis
and significant improvement in memory, that was not estimate line and they will also fall between the confidence
attributable to a rehabilitation intervention. Figure 1 is a interval funnel lines on each side of the plot. The funnel
forest plot displaying the ESs for all included control studies. plot from the present analysis, as seen in Figure 2, indicates
The plot displays the ES and 95% confidence interval for each the presence of dissemination bias in control condition
included study. The extent to which the horizontal lines studies. This also means that there is a possibility of
overlap is an indication of the homogeneity of the ESs across unpublished studies with lower ESs existing and reinforces
studies. This visual representation of the data demonstrates the Begg’s test results that published studies contain inflated
that the studies were generally not homogenous in their ESs which are possibly over-estimating the effect of recovery
reported ESs, with two possible outliers. The outliers may without an intervention condition.
be due to different methodology or sample characteristics,
as suggested by Control Group Q statistic and selectivity Intervention conditions analysis
funnel plot results.
The average effect size for this group of studies was r ¼ 0.51
A significant Q statistic (73.259, p ¼ 0.00) also indicates
(Z ¼ 20.62, p50.05), which was significantly different
that the studies included are heterogeneous. The I2 statistic
from zero. The confidence interval for the overall ES
estimates the percentage of within-study variance among the
(0.462–0.558), did not include the average ES for the control
studies due to non-random factors. The I2 statistic 82.25%
studies (r ¼ 0.31). The results, therefore, indicated that,
also suggests heterogeneity among the ESs. It is important
overall, a moderate and significant improvement in memory
to note that when k520, as in the present analysis, both the Q
was apparent in the cognitive measures used in these studies.
and I2 tests should be interpreted with caution [24].
This change in memory function cannot be attributed solely to
Nevertheless, this statistic suggests that it may be worthwhile
the passage of time.
to explore characteristics of the various experiments that may
Figure 3 is a forest plot for the intervention condition
studies. The visual representation of the data here demon-
strates intervention studies were somewhat less heterogeneous
than the controls in their reported ESs. These outliers may
be due to different methodologies or publication bias,
as suggested by the Intervention Group Q statistic and
selectivity funnel plot results.
The significant Q statistic indicated significant heterogen-
eity of the ESs (Q ¼ 81.50, p50.05). The I2 statistic of

Figure 1. Forest plot of ESs in control group studies. Figure 2. Funnel plot for control group studies.
1614 M. Elliott & F. Parente Brain Inj, 2014; 28(12): 1610–1616

group conditions indicated that studies of stroke rehabilitation


produced significantly larger ESs compared to mixed brain
injury and TBI studies (p50.05). Confidence intervals were
also used to assess ES differences between the intervention
(experimental group) and the control group in studies that
included both. The discrepancy between these confidence
intervals indicated a significant difference between the
experimental and the control group ESs (p50.05). A third
confidence interval analysis indicated that studies of working
memory produced significantly higher ESs relative to studies
of other memory processes. There was no significant differ-
ence in ESs for intervention studies (experimental groups)
that contained a control group vs. intervention studies that did
not contain a control group, for average age of the patients in
control and intervention studies (paediatric vs. adult) or type
of intervention (computerized vs. not-computerized). There
was no significant correlation between ES and the ratio of
males-to-females in the sample or for the year of publication
in control and intervention studies.
Post-hoc correlation analyses investigating the relationship
between dependent variables in the control and intervention
conditions and ESs did not reveal any significant relationship
(p40.05) between the ESs and the number of dependent
variables in either the control or the experimental conditions.
Figure 3. Forest plot of ESs in intervention group studies. Additional post-hoc correlation analyses show that there was
no significant correlation (p40.05) between sample sizes
and ESs for intervention (experiment) group studies, but that
there was a significant correlation (p50.05) between sample
sizes and ESs for control group studies. There were no other
significant covariate/ES correlations.

Discussion
This meta-analytic review investigated differences in studies
examining the influence of memory rehabilitation interven-
tions for individuals who suffered brain damage as a result
of TBI or stroke. One goal of this meta-analysis was to
supplement the work published by Cicerone et al. [10, 17] and
Rohling et al. [8]. The Cicerone et al. [10, 17] study did not
quantitatively evaluate ESs; the Rohling et al. [8] study had a
relatively small sample size for memory studies. The present
study also examined more covariates than the Rohling et al.
[8] meta-analysis. The results obtained in this investigation
Figure 4. Funnel plot for intervention studies.
for the intervention group show a significant moderate effect
(r ¼ 0.51) of the interventions which could not be attributed
69.31% indicates that there was somewhat less heterogeneity to the passage of time. However, the control analyses show
than the control conditions where I2 ¼ 82.25%. These statis- a smaller, but also significant and moderate effect (r ¼ 0.31)
tics should be considered more reliable for the intervention for recovery without a treatment intervention. This pattern of
analysis (k ¼ 26) according to sample size criteria in Higgins results replicated the ES relationship found in Rohling et al.
et al. [24]. [8]. In both studies, there was a small ES that could not be
The Begg’s test statistics computed on these data showed the result of spontaneous natural recovery, which suggested
that dissemination bias was present in the sample of studies that the interventions used in the examined studies were
used for the analysis. The intervention analysis funnel plot responsible for the treatment effect. Unlike Rohling et al. [8],
(Figure 4) is an additional indication of the presence of the present analysis found that the difference in ESs between
dissemination bias in intervention studies. This shows that, control and intervention conditions was significant. This
similar to published control studies, published intervention shows that, overall, the memory rehabilitation strategies
studies have inflated ESs and may be over-estimating the produced the desired effect. The confidence intervals
effect of recovery due to rehabilitation. computed around the ESs in the control groups indicated
Two of the study covariates predicted the ESs. The 95% that the average ES was significantly greater than zero;
confidence intervals computed on the ESs in the intervention this suggests that significant spontaneous improvement in
DOI: 10.3109/02699052.2014.934921 Efficacy of memory rehabilitation therapy 1615

memory occurs after brain injury and stroke. The fact that The present study investigated only memory. It is,
some amount of the ES in the experimental treatment therefore, possible that additional meta-analyses of attention,
condition cannot be attributed to the passage of time suggests visual spatial and language also may reveal efficacy in
that therapeutic intervention may accelerate this those domains as well. Limitations of the current study are
improvement. primarily due to a lack of available information in the
The heterogeneity of ESs in these studies could be published studies examined. For example, it was generally
accounted for partially by a few moderating variables. impossible to describe exactly what the authors had provided
Analyses show that studies of stroke recovery produced relative to treatment intervention. Furthermore, there was
significantly larger ESs than were apparent in studies of TBI generally no discussion of the locus of the neurological insult
recovery or mixed injury recovery. This ES difference in any of the studies. The average level of education for the
occurred across intervention and control group studies, participants was seldom discussed.
which suggests that stroke patients experienced more The present paper suggests that the ESs in studies of stroke
change in their functional status over time and were more survivors are larger than those obtained in studies of TBI.
responsive to treatment. This finding is inconsistent with Future studies should provide more rigorous statistical
published research [25, 26]. Persons with TBI are typically investigations as to why cognitive rehabilitation of memory
younger than stroke patients and, thus, typically have better produces a larger effect in stroke patients. For instance, neuro-
prognosis for recovery than stroke patients. Individuals with imaging of brain areas associated with memory in TBI
TBI are more frequently discharged from in-patient facilities and stroke patients should be documented before and after
and make larger gains in treatment [27]. Their actual recovery, treatment, as should a standardized qualitative account of the
however, may last a lifetime [28, 29]. The larger ESs for injury profile. Most of the studies examined provided vague
stroke studies reported here may be directly related to the descriptions and classifications of stroke or TBI damage
particular behavioural and medical treatment approaches in their sample. Many times the only information about
implemented with the stroke samples in the studies examined; participants’ TBI variability was a GCS range. Even this
for example, the use of pharmaceutical treatments [16] to information was impossible to code across studies, as some
stop haemorrhaging quickly and preventative measures that investigators did not use GCS to define severity and some
decreased the level of brain damage when the person had used it in combination with other variables like neuro-
the stroke [27]. imaging and post-traumatic amnesia. Demographic data such
Studies addressing working memory produced signifi- as hemispheric location of injury and cognitive deficits of
cantly larger effect sizes relative to studies that involved participants were rarely available. The results from the
rehabilitation of other types of memory problems. These present analysis demonstrate hopeful statistical findings for
results suggest that cognitive rehabilitation therapy may be individuals recovering from TBI and stroke. The available
most effective when applied to stroke rehabilitation and memory rehabilitation treatments appear to be effective;
when the goal of the therapy is to improve working memory additionally, to a lesser degree, memory also recovers without
functions. The fact that significant improvement in memory rehabilitation over time.
occurred in the control condition suggests the need for
baseline evaluations immediately for individuals who suffered Declaration of interest
brain damage as a result of TBI or stroke.
The authors report no conflicts of interest. The authors alone
The results are also interesting regarding which covariates
are responsible for the content and writing of the paper.
did not predict the ESs. The Beggs’s test suggests that ESs in
the selected studies may be over-estimated. Other character-
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