Cognitive Interventions to Improve a Specific Cognitive Impairment for Adults With TBI (June 2013–October 2020)

Full Systematic Review Question

This systematic review addressed the question “What is the evidence for the effectiveness of cognitive processing, activity, and occupation-based interventions to improve participation for people with TBI and cognitive impairments?”

Current Theme Reported

The main theme of the studies included in this systematic review brief is cognitive intervention for which improvement in cognitive impairment is the primary outcome.

Clinical Scenario

Occupational performance deficits associated with cognitive impairment are common following traumatic brain injury (TBI; Dikmen et al., 2009; Temkin et al., 2009) and frequently prompts referral to occupational therapy services. Severity of occupational performance deficits following TBI are associated with both time since injury and injury severity (Novack et al., 2000). Across the range of mild to severe TBI the most frequently occurring cognitive impairments are in information processing speed, memory, and executive functions (Sigurdardottir et al., 2015). To address these problems, occupational therapy practitioners use two general approaches to help adults with TBI improve their functioning: 1) interventions that are designed to directly improve impaired cognitive domains in the presumption that doing so contributes to improved occupational performance (Cicerone et al., 2019); 2) interventions in which people with TBI receive strategy or task training to improve occupational performance (Dawson et al., 2013; Trevena-Peters et al., 2018). In this Systematic Review Brief, we summarize the evidence in support of interventions that are designed to directly improve cognitive impairments from studies that examine outcomes of repetitive cognitive exercise and/or strategy instruction related to specific cognitive domains. Of note, occupational therapy practitioners always pair interventions to remediate cognitive impairments with approaches that directly advance occupational performance (American Occupational Therapy Association, 2019).

Summary of Findings

Eleven articles were included in the review related to cognitive interventions to improve a specific cognitive impairment for adults with TBI (Table 1). Interventions were found to address specific cognitive impairment, multiple cognitive impairments, and cognitive–emotional symptoms associated with concussion. The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009).

Bottom Line for Occupational Therapy Practice

This systematic review provides evidence in support of individual, group, and computer- and virtual-reality-based (VR) intervention approaches to help adults with a range of injury severity associated with TBI to improve on measures of cognition, self-awareness, and quality of life. Evidence regarding the impact of the interventions described here on occupational performance is limited, and the use of domain-specific measures of cognitive information processing may not be adequate to indicate the adoption of such interventions by occupational therapy practitioners. Occupational therapy practitioners may consider combining such interventions with therapeutic approaches intended to translate improved cognition to improved occupational performance.

Self-awareness training using group-based (e.g., Goal Management Training, Short-Term Executive Plus training) or VR-based interventions have been found to improve self-awareness and executive functioning. For individuals with milder forms of TBI, problem-solving intervention, cognitive behavior therapy, or psychoeducation in combination with some forms of computer-based cognitive rehabilitation have been shown to reduce overall symptoms and to improve attention. VR alone or in combination with more traditional intervention may improve executive functions and predriving skills and may be superior to no treatment in improving memory, word fluency, and life satisfaction in patients across injury severities. There is evidence that long-duration engagement in cognitive computer training or T’ai χ is superior to no intervention in improving cognition and some aspects of physical functioning. The evidence to support the use of computer- or paper-and-pencil-based prospective memory training for individuals with moderate-to-severe TBI is low.