NeuroRehabilitation 32 (2013) 359368 DOI:10.

3233/NRE-130856 IOS Press

359

Review Article

Effect of computer-based cognitive rehabilitation (CBCR) for people with stroke: A systematic review and meta-analysis
Yu-Jin Chaa and Hee Kima,b,
a Department b Department

of Occupational Therapy, Semyung University, Jecheon, Republic of Korea of Occupational Therapy, Graduate School of Yonsei University, Wonju, Republic of Korea

Abstract. OBJECTIVE: We conducted a systematic review and meta-analysis to identify the effect of computer-based cognitive rehabilitation (CBCR) on improving cognitive functions in patients with stroke. METHODS: Researchers performed a literature search using computerized databases such as the Cochrane Database, EBSCO (CINAHL), PsycINFO, PubMed and Web of Science. The following keywords were used: stroke, computer-based, cognitive rehabilitation, and others. The methodological quality was evaluated. Statistical heterogeneity and standardized mean difference were used to compute the overall effect size and that of subgroups. Also publication bias of the selected studies was analysed. RESULTS: Twelve studies met the inclusion criteria including a total of 461 stroke survivors. Among studies, six RCT studies were rated as high methodological quality. Overall effect size was medium 0.54, and the 95 % condence interval was 0.330.74. The effect sizes of acute and chronic phase of stroke were both 0.54. They can be interpreted as medium effect size and were statistically signicant. The statistical heterogeneity and publication bias were not signicant. CONCLUSION: The present study provides evidence that CBCR is effective on improving cognitive function after stroke. We recommend conducting meta-analysis on subgroups of CBCR programs in further studies. Keywords: Cognitive, computer, meta-analysis, review, stroke, systematic, therapy

1. Introduction Cognitive rehabilitation (CR) is a mechanism that can compensate for an impaired nervous system by systematic treatment that can cause functional changes through the reinforcement, promotion and relearning of previously learned or new patterns to enhance cognitive function [1, 43]. CR after a stroke, in particular, is a process of alleviating ones cognitive impairment by maintaining specic
Address for correspondence: Hee Kim, Department of Physical Medicine and Rehabilitation, Wonju City Medical Center, Kaewoondong 437, Wonju, Kangwon-do, Republic of Korea. Tel.: +81 33 760 4712; Fax.: +82 33 761 5121; E-mail: jenna0214@yahoo.co.kr.

component skills, learning compensation techniques, or completely replacing the behaviour, which helps one to readapt to ones environment. As a result, patients with stroke can experience improvements in occupational performance, perform meaningful activities and increase their independence in activities of daily living [6, 34]. One of the approaches to improve cognitive functions is compensatory approach which changes the patients environment, habit or routine, and strategies to compensate for impairments or inefciencies [34]. Using planners, alarms and pill cases are examples of compensatory treatment for cognitively impaired people. In remedial approaches, paper and pencil, telephones,

1053-8135/13/$27.50 2013 IOS Press and the authors. All rights reserved

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computers, etc. are used to train, practice and stimulate ones impaired cognitive functions into recovery [41]. Among them, computer-based cognitive rehabilitation (CBCR) has been proven to be effective since the early 1980 s in treating the cognitive impairments of elderly and other patients with brain injury, dementia or schizophrenia [17, 29, 30, 42]. Conducting CBCR, patients use a computer as an intervention tool to provide feedback to patient responses and reaction speed via input devices like a keyboard or joystick and monitor the results of tasks through output device like computer screen [18, 46]. One of the advantages of CBCR is the costeffectiveness of providing individualized treatments based on each patients neuropsychological patterns to continuously and repeatedly stimulate impaired cognitive areas. CBCR is an effective means to broaden hospital-based into home-based treatment. Specially, internet and mobile CR systems will be an emerging eld in the future, which are expected to make ubiquitous care without any boundary on time or place possible [3, 7, 12, 15, 19, 35, 49]. CBCR has many other advantages, such as helping practitioners effectively manage their treatment sessions and objectively measure patient performance; and providing convenience to patients [50]. Recently, studies on CBCR are active on memory, organization and planning, and time management showing results of improvements in patients response time, attention and verbal memory and decrease in psychiatric negative symptoms immediately after training [5, 8, 16]. However, controversies on the most effective period of treatment phase exist among previous studies. Robey [36] reported that language rehabilitation in the acute phase is most effective to patients with aphasia after stroke. Yet, Rohling [37] failed to conclude the different effects between acute and chronic phase because of insufcient sample. Despite the explosive increase in use of CBCR since 1980 s and advantages, studies of the efciency of CBCR among patients with stroke disagree with each other and comprehensive and objective results are lacking [42]. In addition, previous CR studies were not able to nd a signicant different effect of acute and chronic phase of stroke on the result of CR treatments. Thus, there is an urgent need to verify whether the efciency of CBCR is sufcient, using comprehensive and objective methods. Evidence-based practice has recently attracted attention as a new paradigm that suggests not only that medical practice should be consulted on the basis of

scientic evidence, but also provides ways to attain systematic, scientic medical knowledge, provide medical education and determine reasonable healthcare policies [21, 27, 45]. In order to achieve evidence-based practice, meta-analysis is frequently used to synthesize diverse study results. Meta-analysis is a research method that can integrate previous study results to draw a strong conclusion that is more objective and reliable than a single study [45]. The purpose of this study is to conduct a systematic review and meta-analysis on CBCR participants who have had a stroke in order to identify CBCRs effectiveness for cognitive improvement. The result is expected to provide clinicians with evidence that CBCR is an appropriate method for treating the cognitive impairments of patients who have had a stroke. 2. Methods 2.1. Study selection and data collection Two reviewers (Y.J. and H.) independently selected studies that met the predetermined inclusion criteria and reached an agreement on selecting studies after discussion for the disagreeing ones. Studies selected for this systematic review and meta-analysis were CBCRrelated studies on stroke patients and were published between January 1980 and February 2012. Literature for the systematic review and metaanalysis was found through computerized databases such as the Cochrane Database, EBSCO (CINAHL), PsycINFO, PubMed and Web of Science. A secondary search, which involved manually searching the literature for reference to previous studies, was performed. The following keywords were used: computer, cognitive rehabilitation, stroke, etc. Inclusion criteria for studies were as follows. First of all, study participants were to be adults diagnosed as having had a stroke; second, the intervention should be a CBCR program; nally, the outcome variable was to be classied as a cognitive function assessed by validated, standardized evaluation tools. A total of 107 related studies were found, but 95 were excluded because of insufcient data, leaving twelve studies that met all of the criteria (Fig. 1). 2.2. Methodological quality The methodological qualities of the selected seven RCTs were independently evaluated using the Jadad scale by the researchers (Y.J. and H.). The Jadad scale

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Computed effect sizes can be visually depicted as a forest plot, which is a visual aid that helps view at a glance the value of studies calculated effect sizes and condence interval. Later, we evaluated the publication bias that can come up during the analysis process through funnel plots and Eggers regression intercept test. 2.4. Publication bias Publication bias refers to the distortion of the results of a meta-analysis that can come up when more studies with positive results are identied compared to those with negative results during the literature search. Since most journal editors prefer positive results that are statistically signicant, published research is more likely to be distorted to the positive side [39]. In order to test the publication bias of the analysed studies, a funnel plot and Eggers regression intercept test were employed; the value of was 0.05. The funnel plot visually presents the standard error on the y-axis and the effect size on the x-axis. If publication bias exists, the points on the funnel plot will be asymmetrical. An Eggers regression intercept test with a p-value of above 0.05 is interpreted as indicating no publication bias [14].

Fig. 1. Flow diagram of search strategy.

has proved to be the simplest and most objective scale to evaluate RCT. It consists of ve items, each worth a point, for a perfect score of ve. RCTs were classied as low quality if the total score is 2 or below and high quality if it is 3 or above [22]. 2.3. Data synthesis and statistical analysis Data from eligible studies were summarized independently by two reviewers. Statistical heterogeneity, effect size and publication bias of the selected studies were analysed using Comprehensive Meta-Analysis v. 2.0 (Biostat, Englewood, NJ, USA). The statistical heterogeneity means that the degree of variation of inconsistency in the results of individual studies is statistically different. To identify it, Cochrans Q test was conducted as a signicance test. In this case, if the p-value of Q is less than 0.1, the heterogeneity between groups can be interpreted as signicant [38]. This study conducted a statistical heterogeneity test on the data before estimating the integrated effect size, compared the results of several models and analysed the cumulative effect size on the estimated size integration. Quantitative meta-analysis is a process of calculating and integrating effect size. An effect size is an equivalent scale that can be used to compare the effects of different interventions when comparing or synthesizing many studies [33]. Also additional meta-analyses were conducted on the subgroups (acute, chronic) of CBCR. The effect sizes of 0.2, 0.5 and 0.8 are interpreted as small, medium and large, respectively [10].

3. Results The general characteristics of the twelve summarized studies are as follows. All of the studies were published in English between 1988 and 2011. They used CBCR programs for patients with stroke and evaluated the effect with standard evaluation tools. Summarized studies are seven RCTs and one of each case series, single group pre-post, matched group comparison, independent group post-test only and single case experimental. The total number of participants was 461, and their onsets of stroke were acute in six studies and chronic in other six. For the CBCR program, each study used simulator-based training, Psion organiser, CogRehab, GX-video capture system, 2D Virtual Reality computer program, VTI driving simulator, RehaCom, Wiener Determinationsgerat, UCB s.a. and RoboMemo. Treatment sessions and periods varied among studies from ten to sixty minute-sessions and three to six week-periods. In order to evaluate the cognitive functions of the participants, three of the studies used the MiniMental State Examination, two of the studies used the

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Wechsler Adult Intelligence Scale and all used the Test Ride for Investing, the Mass Transit Railway, the Neuropsychological Test Battery, the Rivermead Behavioural Memory Test, Reading Performance and the Testing Battery for Attention Performance. Other evaluation tools used are listed on Table 1. As for evaluating the cognitive subgroups, eight of the studies included attention and four respective studies included memory and overall cognitive functions. Else, thinking operations, executive functions, and orientation were evaluated respectively (Table 1).

4. Discussion CBCR is increasingly used in rehabilitation settings recently because of its numerous advantages. Even though the effects of CBCR to stroke population is obscure and has not yet been synchronized. Thus, there is an urgent need to verify whether the efciency of CBCR is sufcient, using comprehensive and objective methods. Reecting this circumstance, this study synthesized and discussed the effect of CBCR on improving cognitive functions in patients with stroke by conducting a systematic review and meta-analysis. As a result of this study, the effect size of CBCR to cognitive function of stroke patients was 0.54, which could be classied as medium. The effect size of strength training to improve upper-limb function of stroke patients being 0.21, augmented exercise therapy to reduce ADL dependence being 0.13 and constraintinduced movement therapy to enhance arm motor function being 0.44 show that small to medium effect size in rehabilitation for patients with stroke is clinically meaningful [11, 20, 25]. As a result of this study, the effect size of acute and chronic phase of stroke were both 0.54 suggesting that the effect was not different according to the phase of patients. Rohling [37] reported that patients with brain injury within 1-year yielded a signicant moderate effect of 0.43, whereas others with onset over 1-year yielded a small effect of 0.15. The reasons of different effect size between the study of Rohling [37] and ours is considered to be the different subject group and therapeutic approach. On the funnel plot to identify publication bias of the selected studies, all eight values were distributed in the section and showed symmetric funnel shape centering around the synthesized effect size and Eggers regression intercept showed a p-value higher than 0.05. Thus, the studies included in this meta-analysis can be considered to have minimum publication bias [20, 32]. This means that CBCR to enhance cognitive function of patients with stroke has proved effective. Practitioners are encouraged to use validated CBCR tools to enhance cognitive functions such as attention, memory, thinking operations and executive functions with stroke patients. In a prior meta-analysis on the effect of CR to patients with brain injuries including stroke and traumatic brain injury (TBI), a small effect size of 0.30 was presented [37]. Another meta-analysis on cognitive remediation for patients with schizophrenia showed an effect size of 0.41, which is classied as medium. The studies in this analysis included both computerized and

3.1. Data quality The methodological qualities of seven RCTs are presented in the Table 2. Six studies (i.e., Jadad 3) [2, 4, 13, 23, 31, 48] but one (i.e., Jadad 2) [26] have high quality (Table 2).

3.2. Effect size of CBCR in patients with stroke With a mean Cochrans Q of 3.69 (df = 7, p = 0.81), the data on the effectiveness of CBCR in improving cognitive functions of stroke patients had no significant heterogeneity (p > 0.1). Thus, to synthesize the results of the studies, the xed-effects model was appropriate. The overall effect size of CBCR in patients with stroke was 0.54 (95% CI [0.33, 0.74]) which can be interpreted as a medium effect size. As a result of the meta-analysis, the calculated effect size showed a positive (+) value. This means the experimental group had a higher value than the control group, and the difference was statistically signicant (p < 0.05) (Fig. 2). The effect size of acute and chronic phase of stroke were 0.54 (95% CI [0.28, 0.80]), 0.54 (95% CI [0.21, 0.86]). It can be interpreted as a medium effect size and it was statistically signicant (p < 0.05) (Fig. 3).

3.3. Publication bias On the analysed funnel plot, all eight values were distributed in the triangular section and showed a symmetric funnel shape centering around the summarized effect size (0.54) (Fig. 4). Eggers regression intercept suggests no signicant publication bias, with a p-value higher than 0.05 (Table 3).

Table 1 Characteristics of studies included in systematic review and meta-analysis Type of stroke Method Simulator-based training Attention process training IVA-CPT, CFQ Attention MMSE Overall duration measure domain Intervention Outcome Cognitive Result

Author and

Design

Participants

year

Akinwuntan 2005 [2]

RCT

Barker-Collo 2009 [4]

RCT

60 min. 3/wk 15 sessions for 5 wk 60 min. 30 hours for 4 wk

Signicant difference in road sign recognition test between groups APT is a viable and effective means of improving attention decits

Devos 2009 [13]

RCT

n = 83 (Exp : Con = 42 : 41) Ischemic, Mean age: 54 yr Onset: 69 hemorrhage weeks (acute phase) n = 78 (Exp : Con = 38 : 40) Ischemic, Mean age: 69 yr Onset: intracerebral 13.5 hours (acute phase) hemorrhage, subarachnoid hemorrhage n = 73 (ST : CT = 37 : 36) Ischemic infarct, Mean age: 54 yr Onset: 69 hemorrhagic weeks (acute phase) infarct Simulator-based training 60 min. 3/wk 15 sessions for 5 wk CARA MMSE Attention Overall

Giles 1989 [16] 30 min 5/wk 40 sessions for 8 wk

Case series

n = 1 Age: 25 yr Onset: 4 mo (acute phase)

Hemorrhage

Psion Organiser1)

WAIS, RTMT

Overall Memory Attention

Y.-J. Cha and H. Kim / Effect of CBCR for people with stroke

Kang 2009 [23]

RCT

n = 16 (Exp : Con = 8 : 8) Mean age: 61 yr Onset: 61 days (acute phase)

Infarction, hemorrhage

CAMSHIFT algorithm, PSS CogRehab2)

30 min 3/wk12 MMSE sessions for 5wk

Overall

Kizony 2004 [24]

Single-group pre-post

n = 13 Mean age: 66 yr Onset: Unknown 11 mo (chronic phase)

GX- video capture 34 min Each of system3) the 3 virtual environments

SCT, MSCT, CMT, LOTCA, BADS

The effects were primarily seen in anticipation and perception of road signs, visual behaviour and communication, quality of trafc participation and turning left Average or near-average intelligence and retained or mildly impaired reasoning skills Improvement of visual perception implying no signicant cognitive dysfunction The results revealed some moderate relationships between several cognitive abilities and VR performance 2D Virtual Reality 45 min10 sessions for 4 wk MTR Attention, Memory, Thinking operations, Executivefunctions Orientation Improvements in MTR skills, orientation skill

Lam 2006 [26] RCT

n = 58 Unknown (2DVR : VM : Con = 20 : 16 : 22) Mean age: 71.3 yr Onset: 4.1 yr (chronic phase)

(continued)

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Table 1 (Continued) Type of stroke Method VTI driving simulator4) Simulator driving 20 km, on-road driving, 25 km TMTB, Digit Symbol, WCST Attention, Executive functions duration measure domain Intervention Outcome Cognitive Result

Author and

Design

Participants

year

Lundqvist 2000 [28]

Matched group comparison

n = 30 (Exp : Con = 15 : 15) Infarction, Mean age: 68 yr Onset: 8.6 hemorrhage mo (chronic phase)

M odden 2011 [31] 30 min 15 sessions TAP RP for 3wk

RCT

Unknown

RehaCom5)

Attention

Decreased cognitive and attentional processing were suggested to be associated with an overall speed impairment The alertness test did not differ between groups

Sturm 1991 [44] 10 items 5/wk150 SCT, WAIS, sessions for 3wk IST

Vascular, inammatory, traumatic Unknown UCB s.a.7) 40 min 4/wk 24 SMQ RMT sessions for 6wk 40 min 5/wk for 5wk NTB

Wiener Determinations gerat6)

Attention, Overall

Towle 1988 [47] Hemorrhages, infarctions RoboMemo8) from Cogmed Cognitive Medical Systems AB

Memory

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Westerberg 2007 [48]

n = 45 (RT : CT : OT = 15 : 15 : 15) Mean age: 50.9 yr Onset: 14.3 mo (chronic phase) Independent n = 35 (LHD-early : LHDgroups post-test late : RHD-late = 13 : 14 : 8) only Mean age: 54 yr Onset: 20.1 mo (chronic phase) Single case n = 11 Mean age: 66.4 yr experimental Onset: 26.2 weeks (acute phase) RCT n = 18 (Exp : Con = 9 : 9) Mean age: 54 yr Onset: 20.1 mo (chronic phase)

Attention, Memory

The results showed signicant training effects for a number of attention Signicant improvement was seen on the immediate recall task The reduction of cognitive problems was signicant

2DVR: 2D Virtual Reality group; BADS: Behavioral Assessment of Dysexecutive Syndrome; BIT: Behavioural Inattention Test; CARA: Center for Fitness to Drive Evaluation and Car Adaptations; CFQ: Cognitive Failures Questionnaire; CMT: Contextual Memory Test; Con: control; CT : cognitive training; CT: compensatory therapy; Exp: experimental; IVA-CPT: Integrated Visual Auditory Continuous Performance Test; IST: Intelligence Structure Test; LHD: left hemisphere damage; LOTCA: Lowenstein Occupational Therapy Cognitive Assessment; MMSE: Mini-Mental State Examination; MTR: Mass Transit Railway; MSCT: Mesulam Symbol Cancellation Test; NTB: Neuropsychological Test Battery; OT: occupational therapy; RBMT: Rivermead Behavioural Memory Test; RCT: randomized controlled trial; RHD: right hemisphere damage; RMF: Recognition Memory Test; RP: Reading performance; RTMT: Reitan Trail-Making Test; SCT: Star cancellation test; ST: simulator-based training; TAP: Testing Battery for Attention Performance; TRIP: Test Ride for Investing Practical tness to drive; VM: video-modelling group; SDSA: Stroke Driver Screening Assessment; SMQ: Subjective Memory Questionnaire; TMTB: Trail Making B; WCST: Wisconsin Card Sorting Test; WAIS: Wechsler Adult Intelligence Scale. 1) Psion Ltd., UK, 2) Psychological Software Service, USA, 3) Gesturetek Health, UK, 4) FERSI, Swedish, 5) HASOMED GmbH, Germany, 6) Schuhfried Company, Austria, 7) Burden Neurological Institute, UK, 8) Stockholm, Sweden.

Y.-J. Cha and H. Kim / Effect of CBCR for people with stroke Table 2 Methodological quality of the RCTs Author Akinwuntan Barker-Collo Devos Kang Lam M odden Westerberg Randomization 1 1 1 1 1 1 1 Appropriateness of randomization 1 0 1 1 1 1 1 Double-blinding 1 0 0 1 0 1 0 Appropriateness of double-blinding 1 0 0 1 0 1 0 Withdrawals and drop-outs 1 1 1 1 0 1 1

365

Total (out of 5) 5 3 3 5 2 5 4

Coding: 1 = yes; 0 = no/not mentioned/insufcient detail; 1 = inappropriate method.

Fig. 2. Forest plot of CBCR in patients with stroke.

Fig. 3. Subgroup meta-analysis of acute (A) and chronic phase (B).

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Fig. 4. Funnel plot for publication bias. Table 3 Eggers regression intercept test Intercept Standard error 95% lower limit (two-tailed) 95% upper limit (two-tailed) t-value d.f. P-value (1-tailed) P-value (2-tailed) 0.71 1.06 3.32 1.89 0.66 6.00 0.26 0.52

non-computerized training to see the difference in the effect size on cognitive performance [30]. The overall effect size of cognitive training for improving the cognitive functions of patients with Alzheimers disease was 0.50, classied as medium [40]. Other reviews of patients with TBI reported an effect size of 0.44 for computer intervention studies on improving an assessment on memory and attention [46]. Therefore, the effect size of cognitive training for schizophrenia, Alzheimers disease and traumatic brain injury is 0.300.50. Results presented above show that the effect of CBCR on patients with stroke calculated in this study is bigger than in previous studies. The reason is considered to be related to CBCR continuously providing individualized treatments based on each patients neuropsychological pattern and repeatedly stimulating impaired cognitive areas. Also by using CBCR, practitioners have access to various ways to control the levels of tasks and patients can check their own error without the presence of a professional since constant feedback is presented, automatically [9, 19]. Our study has several limitations. First, only small numbers of high-quality studies are available on CBCR

in stroke patients and thus the studies included in this meta-analysis limit the generalizability of the results of this study. Second, although we provided subgroup analyses results, they are limited to a specic subgroup and the effect size results on other cognitive subgroups such as memory, thinking operations, executive functions, and orientation are absent. Third, small number of studies on CBCR reecting various characteristics of stroke patients limited our study on suggesting the effect size of CBCR according to ones pre-stroke computeracy, severity of stroke and age. Future studies based on this studys results should include more RCTs to more accurately assess CBCRs effectiveness in improving the cognitive functions of patients with stroke. Also subgroup meta-analysis should be carried out to nd the inuence of individual cognitive domain of CBCR; this is expected to be a good reference in developing more effectual CBCR programs.

5. Conclusion This study conducted a systematic review and metaanalysis of the results of twelve selected studies to identify the effect of CBCR on the improvement of cognitive functions in patients with stroke. Since the results showed a medium effect size and no statistical heterogeneity or publication bias, CBCR has been shown to be effective in improving cognitive functions. Based on this study, practitioners working in cognitive rehabilitation-related areas can feel condent that they have sufcient evidence to use CBCR in treating patients who have suffered one or more strokes.

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