Content » Vol 39, Issue 6

Review article

Occurrence and measurement of transfer in cognitive rehabilitation: A critical review

OCCURRENCE AND MEASUREMENT OF TRANSFER IN COGNITIVE REHABILITATION: A CRITICAL REVIEW

Chantal A. V. Geusgens, MSc1,2, Ieke Winkens, MSc1,2, Caroline M. van Heugten1,2, 3, Jelle Jolles2 and Wim J. A. van den Heuvel1,4

From the 1Institute for Rehabilitation Research, Hoensbroek, 2Brain and Behavior Institute, Department of Psychiatry & Neuropsychology, University of Maastricht, Maastricht, 3Rehabilitation Centre De Hoogstraat, Utrecht and 4Netherlands School of Primary Care Research (CaRe), University of Maastricht, Maastricht, The Netherlands

OBJECTIVE: To investigate the occurrence of transfer of cognitive strategy training for persons with acquired brain injury, and to investigate the way in which transfer is measured.

METHODS: Electronic searches in PubMed, PsychINFO, EMBASE and CINAHL using combinations of search terms in the following categories: type of brain injury, transfer, type of disorder, type of intervention. A total of 39 papers was included in the review. The following aspects were judged: study design and participant characteristics, intervention characteristics and type of outcome measures used.

RESULTS: Transfer outcome measures could be classified into 3 groups: non-trained items, standardized daily tasks and daily life. Most studies reported at least one type of transfer; however, the methodological quality of the studies was low. Cognitive strategy training in the evaluated studies focused on 7 domains of functioning: information processing, problem solving/executive functioning, memory/attention, language, neglect, apraxia and daily activities.

CONCLUSION: Transfer of training effects of cognitive strategy training has been evaluated in a relatively small number of studies. Outcome measures used in these studies could be classified into 3 groups. Most studies reported the occurrence of transfer of training effects, although some serious remarks can be made concerning the methodological quality of the studies.

Key words: transfer, cognitive disorders, cerebrovascular accident, brain injuries, rehabilitation.

J Rehabil Med 2007; 39: 425–439

Correspondence address: Caroline van Heugten, Brain and Behavior Institute, Department of Psychiatry & Neuropsychology, Maastricht University, PO Box 616, NL-6200 MD Maastricht, The Netherlands. E-mail c.vanheugten@np.unimaas.nl

Introduction

The exact meaning of the terms “transfer” and “generalization” lacks consensus. It is, however, agreed that both terms relate to the way in which prior learning affects new learning. In the context of rehabilitation, transfer of treatment effects is of great importance. The aim of a rehabilitation programme is to restore patients to their greatest potential and maximum independence, hopefully resulting in independent functioning, the return to their own home and participation in society (1). To achieve this goal, transfer of training results is necessary. For patients to function as independently as possible at home, tasks that are taught in the rehabilitation setting should be transferred to the home setting. Moreover, therapists cannot possibly train a patient to handle all the difficulties and tasks he or she will encounter after discharge. Transfer of skills from trained to non-trained tasks is therefore of great importance to the clinical success of a therapy programme.

In recent years, strategy training has become a widely used treatment method in cognitive rehabilitation of patients with acquired brain injury (ABI). This type of therapy is based on the assumption that restoration of cognitive functions to their pre-injury structure and efficiency is not expected to occur and that rehabilitation should therefore concentrate on teaching compensatory strategies (1). Cognitive strategy training is aimed at teaching patients new, general ways to compensate for problems in everyday life, resulting from a cognitive impairment (2). Compensation can be achieved by teaching patients to use external as well as internal strategies and techniques to reach their goals in alternative ways. People with severe memory problems can, for example, use external memory aids, such as pagers or appointment books, to enable them to remember their daily schedules. In addition, people can be encouraged to use their residual, internal, skills more efficiently by applying rehearsal strategies or mnemonics (1).

In the recent literature on cognitive rehabilitation, it is often stated that the occurrence of transfer is expected in strategy training, as the training programme is not aimed at re-learning specific tasks, but at teaching patients new ways to handle problems resulting from an impairment (3). Patients are therefore expected to be able to use the strategies in new settings and while performing new tasks, despite the lasting presence of the cognitive deficits. Therefore cognitive strategy training is not expected to transfer to neuropsychological test results, since the aim of the training is not to improve the impairment itself. However, Cicerone et al. (4, 5) point out that relatively few studies have tried to evaluate the occurrence of transfer by directly evaluating the transfer of treatment effects to everyday situations or behaviours.

The objective of this paper is therefore to investigate the occurrence of transfer of cognitive strategy training to everyday situations and behaviours. First, educational psychology literature is reviewed to clarify the concept of “transfer”, as in rehabilitation research less attention has been paid to the definition. Secondly the paper discusses the results of a critical review of intervention studies evaluating transfer of cognitive strategy training. The paper attempts to answer the following questions: (i) How was transfer measured in these studies? and (ii) Does transfer occur? Finally, it reflects on the consequence of these results for clinical practice and makes suggestions for the design of future studies aimed at evaluating transfer of treatment effects.

Transfer

The term “transfer” is frequently used in spoken language and clinical practice. In addition, the term is commonly used in scientific research, in particular in contexts in which learning plays an important role, yet the exact meaning of this term lacks consensus. Nevertheless, it is agreed that “transfer” relates to the use of prior learning in new contexts, or, in other words, to the way in which prior learning affects new learning or performance (6–12).

Over the years, researchers have had difficulty demonstrating the occurrence of transfer. This is rather unfortunate as it has often been stated that it is essential to all situations in which learning is concerned and as transfer is said to be the main goal of all learning (6–8, 10). At the same time, it is also rather peculiar as transfer seems to occur frequently in everyday life, as it is by transfer of earlier experiences that people can function adequately in new situations, which are encountered almost every day (8).

Despite the lack of evidence of the occurrence of transfer, educational psychology has paid much attention to the question of how to promote transfer of learning. Based on literature, 6 prerequisites for the occurrence of transfer are:

• A person should know what transfer is and how it works (8, 13).

• A person should be aware of his own functioning before he or she will acknowledge that a strategy is needed to improve his functioning (14).

• A person should be able to judge when and where transfer can be applied (10, 15).

• General knowledge should be taught, as this type of knowledge is easier to transfer than specific knowledge (15).

• The connection between what is learned and the situation in which it is learned should be broken by practicing a strategy or skill while varying the practice situation as much as possible (8, 10, 15, 16).

• Transfer should be addressed during learning as it cannot be expected to occur automatically (8, 17).

We will now turn to the review of intervention studies evaluating transfer of cognitive strategy training.

Methods

A literature search was carried out in PubMed (1984 – April 2005), PsychINFO (1983 – April 2005), EMBASE (1989 – April 2005) and CINAHL (1982 – April 2005), using Silverplatter’s Webspirs retrieval software (18). Both controlled vocabulary words and free words in the article’s title, abstract or keywords were combined in the searches. Details of the search are shown in Appendix.

The first selection of papers was based on the title and the abstract. In some studies “transfer” was measured and discussed, but the term (or a synonym of it) was not mentioned in the title, abstract or keywords of the paper. As a result, these papers could not be retrieved from the databases. Therefore, the authors’ private libraries on cognitive rehabilitation were reviewed and papers that mentioned strategy training and transfer of training effects were selected.

In addition to these 2 search methods, the reference lists of all included studies were scanned to further identify eligible studies.

Papers that were selected based on these 3 search methods were read by 1 of 3 reviewers (authors CvH, IW and CG). The following inclusion criteria were applied: (i) papers describe an intervention study; (ii) papers evaluate a cognitive strategy training. Cognitive strategy training was defined as a training that aims at teaching patients new ways to execute daily activities by using either internal or external strategies to compensate for cognitive impairments (19); (iii) participants are adults, clinically diagnosed as patients with ABI; (iv) outcome measures for transfer are used. Studies that evaluated transfer to new tasks as well as transfer to new situations were included. Studies that evaluated transfer of training effects to neuropsychological test results were not included in this review, as the aim of a strategy training is not to improve cognitive functioning, but to teach patients ways to function as independently as possible, despite the presence of the cognitive deficits; (v) papers are written in English. If uncertainty about compliance with the inclusion criteria still existed after the first reading, the paper was reread by 1 of the other 2 reviewers.

All included studies were judged on the following aspects, described in an adapted version of a rating list recommended by van Tulder et al. (20): study characteristics (design, number of participants, used type of outcome measures, used statistics), participant characteristics (age, time post-onset, type of injury) and intervention characteristics (intervention strategies used, duration of intervention, trainer characteristics).

Results

A total of 83 papers were read. After checking the inclusion criteria, 39 papers, describing 41 separate studies were included in the review. Forty-four papers that did not meet the inclusion criteria were excluded for the following reasons: papers did not describe intervention studies (18); studies did not use cognitive strategy training (18); studies did not use transfer outcome measures (10) and study participants were healthy adults (8).

Included papers were divided into 6 groups, based on the cognitive domains on which the intervention focused (information processing, problem solving skills/executive functioning, memory/attention, language, neglect, apraxia). A seventh group of studies consisted of interventions aimed at the training of daily activities, not specifically aimed at a single cognitive disorder.

Table I displays characteristics and methodological aspects of all included intervention studies on transfer in cognitive strategy training, divided into the 7 categories described above.

Table I. Study characteristics and outcome.

Paper

Design

n

Mean age (range)

Mean time post-onset (range)

Type of injury

Intervention strategies

Trainer characteristics

Duration of intervention

Type of transfer measured

Transfer demonstrated

Information processing

Dirette, 2002 (28)

Follow-up survey study

16

Intervention study: 21–56 years

Intervention study: 2–12 months

ABI

Chunking, pacing, verbalization

Not reported

Not reported

Daily life (self-report – questionnaire)

Yes, not statistically tested

Fasotti et al., 2000 (26)

Randomized clinical trail (TPM vs concentration training)

22

TPM group 26.1 years (18–45)

Concentration group 30.1 years (22–38)

TPM group 9.8 months (3–43)

Concentration group 8.3 months (3–20)

Closed head injury

TPM (awareness training, self-instruction)

Not reported

TPM group 1-h sessions, max 3 h/week for 2–3 weeks, mean 7.4 h total

Concentration group 30 min sessions each day, max 2–5 h/week for 3–4 weeks, mean 6.9 h total

1. Daily tasks (observation of used preventive and managing strategies)

2. Psychosocial well being (self-report – questionnaires)

1. TPM group uses significantly more managing strategies than concentration group; no between group effects in use of prevention strategies

2. No significant changes found

Problem solving/executive functioning

Cicerone & Wood, 1987 (29)

Single subject design

1

20 years

4 years

Closed head injury

Self-instruction, verbalization, training for transfer

Not reported

1-h sessions, 2 per week for 8 weeks, 16 h total

Daily life (report staff – rating scale)

Significant improvement on rating scale

Foxx et al., 1989 (32)

Non-randomized pre-test–post-test control group design

6

Experimental group 27.7 years (24–31)

Control group 28.7 years (26–31)

Experimental group 6.7 years (3–9)

Control group 9.3 years (7–12)

TBI

Generation of solutions to a specific problem

Not reported

Not reported

1. Different situation (interview)

2. Different situation (staged situations)

3. Non-trained tasks (different problems)

Experimental group improved more on all transfer measures than control group, not statistically tested

Levine et al., 2000 (30) (study 1)

Randomized clinical trial (GMT vs MST)

30

GMT group 29.0 years

MST group 30.8 years

GMT group 3.7 years (3–4)

MST group 3.8 years (3–4)

TBI

GMT

Not reported

GMT group 1 session, 4–6 h

MST group not reported

Daily tasks (paper and pencil tasks)

Significantly less errors and significantly more time needed in GMT group than in MST group in 2 of 3 tasks

Levine et al., 2000 (30) (study 2)

Single subject design

1

35 years

5 months

Meningo – Encephalitis

GMT

Not reported

5 sessions

1. Daily tasks (paper and pencil tasks)

2. Daily tasks (meal preparation)

3. Daily life (self-report – diary)

1. Yes, decreased errors on 2 of 3 tasks, not statistically tested

2. Significantly better performance

3. Yes, improved performance, not statistically tested)

Liu et al., 2002 (33)

Single subject design

3

62–78 years

13–15 days

Stroke

Self-regulation

Not reported

1 week

Daily tasks (non-standardized finding)

Yes in one case, not statistically tested

Table I contd.

Paper

Design

n

Mean age (range)

Mean time post-onset

Type of injury

Intervention strategies

Trainer characteristics

Duration of intervention

Type of transfer measured

Transfer demonstrated

Neistadt, 1994 (31)

Non-controlled pre-test–post-test design

23

Not reported

Not reported

Various

Saturational cueing Strategies (readying, imaging, focusing, executing, evaluating)

Occupational therapist

30-min sessions, 3 sessions per week for 5 weeks, 7.5 h total

Daily task (RKE-R: meal preparation test)

Significant improvement

Memory/attention

Boman et al., 2004 (34)

Non-controlled pre-test–post-test design

10

47.5 years (27–60)

17.7 months (9–40)

Various

Various strategies (e.g. use of external and internal compensatory strategies)

Not reported

1-h sessions, 3 sessions per week for 3 weeks, 9 h total

1. Daily tasks (AMPS)

2. Daily life (self-report – EBIQ)

1. No significant improvements

2. No significant improvements

Cicerone, 2002 (27)

Pre-test–post-test matched group design

8

Treatment group 31.0 years

Control group 34.8 years

Treatment group 8.3 months

Control group 7.0 months

Mild traumatic brain injury

Psycho-education, verbal mediation, rehearsal, anticipation of task demands, self-pacing strategies

Not reported

1-h sessions, 1 session per week for 11–27 weeks

Daily life (self-report – Attention Rating and Monitoring Scale)

Treatment group reported significantly less problems than control group

Doornheim & de Haan, 1998 (36)

Randomized clinical trail (memory strategy training vs drill and practice)

12

Strategy group 51.3 years

Drill and practice group 51.7 years

Not reported

Stroke

Mnemonics (association and organization)

Not reported

Strategy group 2 sessions per week, for 4 weeks

Drill and practice group 2 sessions per week, for 4 weeks

Daily life (self-report – memory questionnaire)

No significant between group differences

Fleming at al., 2005 (23)

Single subject design

3

19–52 years

2–12 months

Various

Self-awareness training, use of organizational device, use of cueing device, organizational strategies, training for transfer

Occupational therapist

1–2 h a week, for 8 weeks

Daily life:

1. Prospective memory failure (self-report CAPM)

2. Use of organizational device (number of dairy entries)

3. Community integration (self-report SPRS)

1. Varying results, not statistically tested

2. Improvement in all cases, not statistically tested

3. Improvement in two cases, not statistically tested

Kaschel et al., 2002

(22)

Randomized clinical trail (imagery training vs pragmatic memory training)

21

Imagery group 36.6 years (21– 55)

Pragmatic training group 41.9 years (27–55)

Imagery group 60 months (6–301)

Pragmatic training group 65 months (1–80)

Various

Imagery group: imagery-based mnemonics strategy, training for transfer

Pragmatic group: various standard internal and external memory strategies

Not reported

Imagery group 3 session per week, for 10 weeks

Pragmatic training group 3 session per week, for 10 weeks

Daily life (self-report and report relatives – memory questionnaire)

Imagery group relatives report significantly less memory problems than pragmatic group relatives, no significant change in self-report patients

Kime et al., 1996 (24)

Single subject design

1

24 years

1.5 years

Status epilepticus following TBI

Multidisciplinary milieu approach, using mnemonics, organizational devices, cueing devices and training for transfer

Multidisciplinary rehabilitation team

17 weeks

Daily life: use of organizational devices (e.g. checking dairy after cueing, number of dairy entries)

Significant improvements on all transfer measures

Milders et al., 1998 (37)

Pre-test–post-test matched group design, multiple baseline (TBI patients vs healthy controls)

26

39.0 years (24–57)

4.6 years (1.9–8.1)

Closed head injury

Mnemonics in name learning

Not reported

1–1.5-h sessions during 4 months, 8 sessions in total

Non-trained items:

1. Name learning test

2. Name-occupation-town learning test

3. Famous faces naming test

1. No significant between group differences

2. Patient group improves significantly more than control group

3. Patient group improves significantly more than control group

Wade & Troy, 2001 (35)

Single subject design

5

10–51 years

13 months– 15 years

Various

External memory aid (mobile phone providing memory prompts)

Not reported

12 weeks

Daily life: self-reports on remembering to carry out 5 target tasks

Yes, improvement on self-initiated behaviours in all cases, not statistically tested

Language

Hinckley et al., 2001 (38)

Pre-test–post-test control group design; randomized intervention groups and non-randomized baseline group

(context based vs skill based vs baseline)

17

Context group 51.6 years (24–63)

Skill group 50.3 years (34–63)

Baseline group 59.6 years (52–70)

Context group 26.8 months (6–58)

Skill group 26.8 months (4–102)

Baseline group 49.6 months (21–82)

Stroke

Context group: practice of compensatory strategies during role play of a specific task (e.g. use of contextual cues, self-generated cues, problem solving strategies)

Skill group: training accuracy and speed in picture and word naming (e.g. use of semantic and phonemic cues)

Baseline group: traditional therapy

Clinicians, trained to perform the interventions

Context group mean 11.7 sessions in total, mean 275 min in total

Skill group mean 11.8 sessions in total, mean 195 min in total

Daily tasks

1. Ordering articles from catalogue (written version)

2. Communication activities of daily living test (CADL)

3. Daily life (report caregivers – communication effectiveness questionnaire)

1. Yes, skill group improves more than context group not statistically tested

2. Yes, skill group improves more than context group, not statistically tested

3. Yes, skill group improves more than context group, not statistically tested

Hopper & Holland, 1998 (39)

Single subject design

2

39–62 years

21–53 months

Stroke

Use of w-questions to describe emergency situations

Speech and language therapist

45-min sessions, 4–5 sessions per week, max of 10 sessions total

Non-trained items

Yes, in one case, the other case shows limited transfer, not statistically tested

Table I contd.

Paper

Design

n

Mean age (range)

Mean time post-onset

Type of injury

Intervention strategies

Trainer characteristics

Duration of intervention

Type of transfer measured

Transfer demonstrated

Jacobs, 2001 (40)

Non-controlled pre-test–post-test design

5

44–79 years

19–198 months

ABI

Linguistic specific treatment: strategies to use correct grammatical structure in communication

Not reported

15–60 session in total

Daily task: rating of language samples by

1. Researcher: rating of communicative informativeness and efficiency

2. Naive listener: rating of effectiveness, informativeness, grammaticality and listening comfort

1. Significant improvement on efficiency

2. No significant improvements

Maneta et al., 2001

(41)

Single subject design

1

84 years

5 years

Stroke

1. Lip-reading (patient)

2. Communication strategies (spouse)

Speech and language therapist

Not reported

1. Non-trained items (auditory input test)

2. Daily life communication with spouse; language comprehension

1. No significant improvement

2. Significantly more correct responses, reduction in number and length of communication breakdowns. No significant improvement in language comprehension

Nitzberg Lott & Friedman, 1999 (42)

Single subject multiple baseline design

1

67 years

4 months

Stroke

Tactile-kinaesthetic strategy to improve letter-by-letter reading

Not reported

1-h sessions, 3 sessions per week, 81 sessions in total

1. Non-trained items (letters, words, non-words)

2. Daily life (self-report and report spouse – questionnaire)

Both types of transfer were demonstrated, not statistically tested

Robson et al., 1998 (43)

Single subject design

1

57 years

24 months

Stroke

Use of syllabic structure and first phoneme as a self-cueing naming strategy

Not reported

20-min sessions during 6 months, 40 sessions in total

1. Non-trained items (written picture naming)

2. Daily life (spontaneous speech – non standardized finding)

1. Significant improvement

2. Yes, not statistically tested

Robson et al., 1998 (44)

Single subject design

1

77 years

18 months

Stroke

Use of writing as communication strategy, training for transfer

Authors

45-min sessions, 59 sessions in total

1. Non-trained items (written picture naming)

2. Daily tasks (use of strategy in answering standardized questions)

3. Daily life (use of strategy in conversation – non standardized finding)

1. Significant improvement, only after specific transfer therapy

2. Significant improvement only after specific transfer therapy

3. Yes, only after specific training of functional use of the therapy, not statistically tested

Robson et al., 2001 (25) (study 1)

Single subject design

6

49–86 years

27.5 months (8–53)

Stroke

Use of writing as a communication strategy

Authors

45–60-min sessions, 12 sessions in total

1. Non-trained items (written picture naming)

2. Daily tasks (message assessment)

3. Daily life (use in conversation – non standardized finding)

1. No significant improvement

2. No significant improvements except for one participant

3. No improvement, not statistically tested

Robson et al., 2001 (25) (study 2)

Single subject design

3

49–86 years

24 months (16–38)

Stroke

Use of writing as a communication strategy, combined with message therapy

Authors

45–60-min sessions, 18 sessions in total

1. Non-trained items (picture naming)

2. Daily tasks (message assessment)

3. Daily life (use in conversation – non standardized finding

1. No significant improvements

2. Significant improvement in one subject on application of trained words, no improvement on non-trained words

3. Yes, improvement in all subjects, not statistically tested

Richards et al., 2002

(45)

Single subject design

3

44–71 years

2–2.5 years

Stroke

Priming of right-hemisphere intention mechanisms by movements of non-dominant hand

Not reported

45-min sessions, 30 sessions in total

1. Non-trained items (naming test)

2. Daily life (staff observation – non standardized finding)

1. Yes, in one case, not statistically tested

2. Yes, in one case staff notes strategy use in everyday situations and improvements in functional communication, not statistically tested

Table I contd.

Paper

Design

n

Mean age (range)

Mean time post-onset

Type of injury

Intervention strategies

Trainer characteristics

Duration of intervention

Type of transfer measured

Transfer demonstrated

Wambaugh & Martinez, 2000 (46)

Single subject multiple baseline design

1

38 years

6.6 years

Stroke

Rate and rhythm control by hand tapping to improve sound production

Authors

1-h sessions, 3 sessions per week, 20 sessions in total

Non-trained items (4 different types of words: same as trained, different stress pattern, different length, s-blend)

Yes, transfer to all types of words was demonstrated, not statistically tested

Neglect

Antonucci at al., 1995 (47)

Randomized clinical trial (immediate vs delayed training)*

20

Immediate training 67.7 years

Delayed training 70.2 years

Immediate training 75.3 days

Delayed training

83.3 days

Stroke

Scanning strategy

Not reported

Immediate training 1-h sessions, 5 times per week for 8 weeks, 40 h total

Delayed training 1-h sessions, 3 times a week for 8 weeks, 24 h total

Daily tasks (semi-structured scale for the functional evaluation of extrapersonal neglect)

Both groups improve significantly on transfer tasks after training

Bailey et al., 2002 (48)

Single subject design

7

60–85 years

13–46 days

Stroke

Scanning and cueing strategies (including lighthouse strategy) (5 subjects), left-limb activation strategy (2 subjects)

Not reported

Scanning and cueing group 1-h sessions, min. of 10 sessions in total

Left-limb activation group 1-h sessions, min. of 10 sessions in total

Daily life (self-report, non-standardized finding)

Yes, one subject in scanning group and both subjects in LLA group, not statistically tested

Gouvier, et al., 1987 (49)

Single subject design

5

36–67 years

Start training for all subjects within 2 months post-stroke

Stroke

Scanning strategy, using anchor cues

Not reported

Not reported

Daily tasks (copying an address, wheelchair obstacle course)

Mixed findings, related to mental status of the cases, not statistically tested

Hanlon et al., 1992

(50)

Single subject multiple baseline design

1

69 years

6 months

Stroke

Scanning and cueing, visuospatial analysis and perceptuomotor integration

Multidisciplinary rehabilitation team

Two treatment intervals of 5 weeks each

Daily tasks (ADL tasks – standardized observations)

Yes, not statistically tested

Niemeier et al., 2001 (51)

Non-randomized pre-test–post-test control group design (strategy training vs care as usual)

19

No significant between- group differences found; mean or range not reported

No significant between- group differences found; mean or range not reported

Various

Visual imagery scanning strategy: lighthouse strategy

Multidisciplinary rehabilitation team

Strategy training group 30-min sessions, 3 sessions in total

1. Daily life (staff rating on FIM)

2. Daily task (route-finding)

1. Strategy group improved significantly more on 2 subscales than control group

2. Strategy group performed significantly better than control group

Pizzamiglio et al., 1992 (52)

Non-controlled pre-test–post-test design

13

63.1 years (58–74)

8.7 months (3–35)

Stroke

Scanning strategy

Not reported

5 sessions per week for 8 weeks, 40 sessions in total

Daily tasks (semi-structured scale for the functional evaluation of extrapersonal neglect)

Significant improvement

Pizzamiglio et al., 2004 (53)

Simple randomized pre-test–post-test design (strategy training vs strategy training including optokinetic stimulation)*

22

Scanning, no optokinetic stimulation 64.4 years (56–73)

Scanning, optokinetic stimulation

62.7 years (46–79)

1–4 months

Stroke

Scanning strategy vs scanning strategy and optokinetic stimulation

Not reported

Scanning group 1-h sessions, 5 sessions per week, 30 sessions in total

Scanning and optokinetic stimulation group 1-h sessions, 5 sessions per week, 30 sessions in total

Daily tasks:

1. Test of personal neglect

2. Semi-structured scale for the functional evaluation of extrapersonal neglect

1. No significant improvements in both groups, no between-group differences

2. Both groups improve significantly, no significant between-group differences

Webster et al., 2001 (54)

Case-control study (computer assisted training (CAT) vs usual care)

40

Experimental group 59.5 years

Control group 60.2 years

Experimental group 173.3 days

Control group 159.8 days

Stroke

CAT: scanning strategy, self-instruction

Not reported

CAT 45-min sessions, 12–20 sessions in total

1. Hospital incident reports (number of incidents)

2. Daily task (wheelchair obstacle course)

1. CAT group had significantly less incidents than usual care group

2. CAT group performed significantly better than usual care group

Apraxia

Goldenberg & Hagman, 1998 (55)

Non-controlled pre-test–post-test design

15

55.7 years

6.1 weeks

Stroke

Training of details (inferring function of an object from its structure)

Occupational therapist

20–40-min sessions, 5 days per week, for 3 weeks plus training during the daily morning routine on each working day

Daily tasks (observations of errors)

No statistically significant improvements on non-trained tasks

Table I contd.

Paper

Design

n

Mean age (range)

Mean time post-onset

Type of injury

Intervention strategies

Trainer characteristics

Duration of intervention

Type of transfer measured

Transfer demonstrated

Goldenberg et al., 2001 (56)

Non-controlled pre-test–post-test design; subjects are also evaluated as single cases

6

58.7 years (31–68)

18.7 months (6–60)

Stroke

Exploration training (inferring function of an object from its structure)

Occupational therapist

1-h sessions, 6 sessions per treatment interval, 4 treatment intervals in total

Daily tasks (observations of amount of assistance needed and errors made)

No statistically significant improvements on non-trained tasks

Geusgens et al., 2006 (21)

Randomized clinical trial

(strategy training vs usual care)

113

Strategy training group 67.6 years (47–93)

Usual care group 63.3 years (38–88)

Strategy training group 100.2 days (19–393)

Usual care group 102.9 days (26–418)

Stroke

Strategies such as using pictures and verbalization, focused on initiation/orientation, execution, control/correction

Occupational therapist

Strategy training group 8 weeks, mean 25 sessions in total, mean 15 h in total

Control group 8 weeks, mean 27 sessions in total, mean 19 h in total

Daily tasks (observation of level of independent functioning)

Strategy training group improves significantly more on non-trained tasks than usual care group

Daily activities

Gorman et al., 2003 (57)

Case study

2

31 years (both)

2 – 18 months

Various

ISAAC, assistive technology device: initiated prompting, procedural memory, logging of use

Rehabilitation therapists

No report on duration of initial training, use of ISAAC for 11–12 months

Daily life:

1. Performance of daily tasks

2. FIM rating

Yes, both types of transfer demonstrated in both patients, not statistically tested

Liu et al., 2004 (58)

Randomized clinical trial (MI vs FR)

46

MI group 71.0 years

FR group 72.7 years

MI group 12.3 days;

FR group 15.4 days

Stroke

MI of daily tasks

Occupational therapist

MI group 1-h sessions, 5 per week, for 3 weeks, 15 sessions in total

FR group 1-h sessions, 5 per week, for 3 weeks, 15 sessions in total

Daily tasks (observation of level of independent functioning)

MI group performed significantly better on non-trained tasks than functional retraining group

O’Reilly et al., 1990 (59)

Case study

4

18–37 years

1–8 years

TBI

Checklist training to teach home accident prevention skills

Author

50-min sessions, 5 sessions per week, 17–34 sessions in total

Daily task (identification of potential hazards in a non-trained room)

Yes, two cases made large improvements on the transfer task, two cases made small improvements; not statistically tested

*Authors claim to have conducted a randomized controlled trial, in our opinion the study design was pseudo-randomized, as randomization was not conducted as is customary; group assignment took place based on patients’ bed numbers and order of admission, respectively.

s-blend: word starting with “s” followed by two other consonants; FR: functional retraining; TBI: traumatic brain injury; ABI: acquired brain injury; TPM: time pressure management; MI: mental imagery; FIM: functional independence measure; MST: motor skill training; GMT: goal management training; CAT: computer assisted training; RKE-R: rabideau kitchen evaluation-revised; LLA: left limb activation; AMPS: assessment of motor and process skills; EBIQ: European brain injury questionnaire; CAPM: comprehensive assessment of prospective memory; SPRS: Sydney psychosocial reintegration scale.

Methods

Study design. Most studies had single subject designs (n = 20). Other designs that were used are randomized clinical trial designs (n = 8), non-controlled pre-test–post-test designs (n = 6) and non-randomized group designs (n = 6), of which 3 studies used matched groups. In one study, 2 randomized intervention groups and one non-randomized control group were used.

The sample sizes of the studies generally ranged from one to 46 participants, although most studies had a sample size of less than 15 participants (n = 28). Only one larger study was found, in which 113 subjects participated (21).

Participant characteristics. The mean age of the participants reported in the studies falls into a broad range (20–84 years), which can be attributed to the different types of injuries on which the studies focused. Most studies focused on patients after stroke (n = 24). Overall, participants in these studies were older than 50 years. In contrast, patients with traumatic brain injury formed a much younger group, with a mean age under 40 years. The time post-onset at the start of the therapy also had a broad range. It varied from 14 days to 25 years. Time post-onset also had large variations within studies itself, for example ranging from one month to 25 years in a randomized clinical trial (22).

Intervention characteristics. Most studies (n = 23) did not report trainer characteristics. Studies that did mention who performed the intervention, reported varying disciplines, such as occupational therapists, speech and language therapists and rehabilitation therapists. In 3 studies the entire rehabilitation team was reported to be involved with the cognitive training, whereas in 5 studies the training was reported to be conducted by the authors of the papers. The duration of the intervention ranged from one week to 6 months. Studies reported 1–5 training sessions per week. In most studies, training sessions lasted 30–60 minutes.

Three papers explicitly reported that during the intervention, “training for transfer” was used (23–25). In addition, 3 papers reported that during training, attention was paid to the enlargement of the patient’s awareness of his own deficits (23, 26, 27), which is an important prerequisite for the occurrence of transfer (14). All other studies did not report using techniques to promote transfer.

The various intervention types can best be described based on the cognitive domains on which the intervention focused.

Information processing. Two studies were found describing strategies aimed at information processing. One study used strategies aimed at self-instruction by verbalization and at chunking and pacing the amount of information that had to be processed (28). Strategies used in the other study were aimed at reducing the load on information processing capacity by generating a plan of action before the performance of a task and by verbalization of the action plan during task performance (26).

Problem solving/executive functioning. Six studies were found describing strategies aimed at problem solving and executive functioning. In all studies self-regulation or self-instruction was used, aimed at either generating and adapting a plan of action before and during the performance of a task (29–31) or generating solutions to a specific problem (32, 33). In most studies, overt verbalization of the action plan was a key feature at the start of the training, generally fading into internalized speech.

Memory/attention. Eight studies were found describing strategies aimed at memory and attention. Three different strategies could be identified:

• Self-awareness training: information on the cognitive skills and on problems related to these skills is provided. Patients are helped to recognize the ways in which these problems affect their own situations (23, 27).

• External compensatory strategies: aimed at teaching patients to use a variety of external memory and planning aids, ranging from notebooks to cueing devices, such as pagers and mobile phones (22–24, 34, 35).

• Internal compensatory strategies: aimed at teaching patients internal strategies to facilitate memory function, mostly using mnemonics associating new information with old information and structuring and organizing new information (22, 24, 27, 34, 36, 37).

Most studies used a combination of these strategies.

Language. Eleven studies were found describing strategies aimed at language deficits (25, 38–46). In these studies, a large variety of strategies was used. However, 3 types of strategies that were used in more than one study could be identified. Strategies used in the other studies are summarized in Table I.

• Linguistic strategies: aimed at improving the grammatical structure of spoken language, hereby increasing the informativeness of the message (39, 40).

• External compensatory strategies: aimed at teaching patients and/or partners to use written instead of spoken language (25, 41, 44).

• Internal compensatory strategies: aimed at teaching patients to use self-cueing strategies such as tactile-kinaesthetic information to improve letter-by-letter reading or deriving a word from its first phoneme (38, 42, 43).

Neglect. Nine studies were found describing strategies aimed at visuo-spatial or perceptual neglect. In all studies one or a combination of the following strategies was used:

• Scanning strategies: aimed at teaching the patients to move their heads all the way from left to right. This strategy was used in all 9 neglect studies (47–54), sometimes combined with one of the following strategies:

• Self-instruction: patients verbalize the command to turn their heads all the way to the left and move them all the way to the right.

• Mental imagery: patients are taught to imagine their eyes are a lighthouse, scanning the sea all the way from left to right.

• Cueing strategies: aimed at guiding the patient's attention to an anchor cue on the left of the visual field (48–50). Patients are instructed to start scanning from the anchor cue. In one study, this strategy was internalized by teaching the patient to turn his head until the tip of his chin was in line with the top of his left shoulder and to move his head until the tip of his chin was in line with the top of his right shoulder (51).

Apraxia. Three studies were found describing strategies aimed at apraxia. Two strategies were aimed at teaching patients to infer the function of an object from its structure (55, 56). The other study was aimed at teaching strategies such as verbalization and the use of pictures to improve the internal concept of a task, the execution of a task, or the control over a task. One of these 3 interventions was chosen, depending on the type of problems a patient was experiencing (21).

Daily activities. Three studies were found describing strategies specifically aimed at improving the performance of daily activities (57–59). No overall strategies could be identified as the studies used widely differing interventions, namely checklist training, the use of an assistive technology device and the use of mental imagery of daily tasks.

Measurement of transfer

A variety of outcome measures was used to asses transfer. All outcome measures could be classified in one of the following 3 outcome types:

• Non-trained items (n = 11): transfer of treatment is measured by assessing performance on items similar to the items that were used during training.

• Daily tasks (n = 23): transfer of treatment is measured by using standardized observations of a simulated performance of daily tasks in a laboratory environment.

• Daily life (n = 21): transfer to daily life situations is measured. In this type of transfer measurement, 3 different perspectives can be distinguished:

• Patients (self-reports): the patient judges his or her own functioning. Outcome measures are questionnaires (focused on quality of life, the use of compensatory strategies or experienced problems due to the cognitive deficit), diary entries and non-standardized remarks.

• Caregivers: people living with the patient judge the patient's functioning. Outcome measures are questionnaires focused on experienced problems due to the cognitive deficit and non-standardized remarks based on coincidental observations.

• Staff: members of the rehabilitation team judge the patient's functioning. Outcome measures are standardized rating scales and non-standardized remarks based on coincidental observations.

Most studies used a combination of these 3 outcome types.

Outcome

At least one type of transfer was demonstrated in 36 of the 41 evaluated studies. However, in 15 of these studies, the transfer effect was not statistically tested. As was mentioned before, most studies evaluated more than one type of transfer. Table II displays the data, arranged in the 3 types of transfer.

Table II. Number of studies that evaluated and demonstrated the 3 types of transfer.

Type of transfer

Total number of studies (transfer demonstrated)

Transfer demonstrated – statistically tested

Transfer demonstrated – not statistically tested

Non-trained items

11 (8)

3

5

Daily tasks

23 (19)

15

4

Daily life

22 (18)

6

12

A total of 39 papers, describing 41 studies was included in this review; several studies evaluated more than one type of transfer.

In a relatively large number of studies, transfer to daily life was evaluated (n = 22). This type of transfer was demonstrated in 18 of the 22 studies. However, transfer effects were not statistically tested in 12 of the 18 studies that demonstrated transfer to daily life.

Transfer to daily tasks was the most often evaluated type of transfer. Twenty-three studies evaluated this type of transfer and it was demonstrated in 19 of these studies. Fifteen of these studies did statistically test the positive research findings; 4 did not.

Transfer to non-trained items was demonstrated in 8 studies, 3 of which used statistical testing.

Only 12 evaluations of all types of transfer combined did not demonstrate transfer. Ten of these negative findings were statistically corroborated, 2 were not. No similarities could be identified in the studies reporting negative findings.

Discussion

A literature search was performed in order to inventory studies evaluating transfer effects of cognitive strategy training. A total of 41 relevant studies were identified. This is a small number of studies, compared with the large number on cognitive rehabilitation that was reviewed by Cicerone et al. (4, 5). Many different strategies and many different outcome measures were used in the studies. However, most strategies could be classified as the classical intervention strategies used in cognitive rehabilitation (60). Outcome measures could be classified in 3 groups: non-trained items, daily tasks and daily life. The studies we evaluated include the cognitive domains that were also identified in Cicerone et al.’s review (4, 5). In addition, a seventh group of studies was identified, consisting of strategies aimed at the training of daily activities, not specifically at a single cognitive disorder. In accordance with Cicerone et al. (4, 5), we found relatively large numbers of studies evaluating transfer of training effects in the domains of neglect, memory and language, compared with the other domains. This reflects the fact that the domains of neglect, memory and language are, in general, studied more often than other cognitive domains.

Limitations of the review

We acknowledge that we could have missed articles that did measure “transfer” if the term was not mentioned in the abstract or keywords of the paper. We therefore reviewed an independent sample of articles that were included in the updated review of Cicerone et al. (5) containing all recently published studies on cognitive rehabilitation. Our sample consisted of 15% of the studies that were included in the updated review; that is, 13 of the 87 studies that were included by Cicerone et al. (5). Studies were selected from each category in proportion to the number of studies Cicerone et al. included in the different categories they distinguished. Of these 13 studies, 3 turned out to be included in our review and 2 studies were retrieved by our search strategy, but were not included in our review as they did not meet with our inclusion criteria. Seven studies could be excluded, based on our exclusion criteria. Thus, the conclusion of this sample is that we missed one out of 13 studies. In our opinion, this is an acceptable result.

Limitations of the evaluated studies

Methodological issues. Many studies used single subject designs or had a small sample size. Furthermore, it should be noted that many positive results were not statistically tested. This was especially the case in studies that evaluated transfer to daily life. In 6 studies the demonstration of transfer to daily life was based on coincidental observations of people living with the patient, or on coincidental remarks the patient made. In these studies, identifying transfer to daily life was not formulated as an aim of the study beforehand, and therefore it was not measured in a standardized way.

Choice of outcome measures. A type of transfer we excluded from this review is transfer to neuropsychological tests, measuring transfer effects of cognitive strategy training to cognitive functions. The aim of strategy training is not to improve cognitive functioning, but to teach patients ways to function as independently as possible, despite the presence of the cognitive deficits. Therefore, little change in cognitive deficits is expected in cognitive strategy training (2). However, the 13 studies we included in our review did evaluate transfer effects of strategy training to neuropsychological test results in addition to one of the other types of transfer we distinguished (22, 23, 26, 27, 29, 31, 34, 36, 47, 48, 50–52). Eleven studies did report transfer to neuropsychological test results. Two of these studies did report that their findings are surprising, since cognitive functioning was not expected to improve (23, 26). Two other studies distinguished between neuropsychological tests in which the trained strategy could not be used vs tests in which the strategy could be used, because the components of the test reflected the focus of the training (22, 29). In this way, the fact that in most neuropsychological tests subjects are not allowed to use the strategies they learned to use is annulled.

Evaluation of the effectiveness of a rehabilitation programme should be attuned to the results that are to be expected of this programme. When evaluating the effectiveness of a rehabilitation programme, the study ideally should be aimed at assessing transfer to daily life, as teaching patients to function as independently as possible in their own home and in society is considered to be the primary goal of rehabilitation practice (1, 61). Unfortunately, it seems to be difficult to evaluate this type of transfer in a standardized way. Most studies we identified measuring transfer to daily life, made use of self-reports of the patients by analysing questionnaires, diary entries and coincidental remarks the patient made. The standardization of the latter 2 methods can obviously be doubted. However, one can also argue about the reliability of a self-report questionnaire completed by a patient with ABI (62). There appears to be a lack of reliable, standardized instruments to measure this type of transfer, making it difficult to evaluate the effectiveness of a rehabilitation programme.

Although, of course, demonstrating transfer to daily life is the best way to prove the clinical effectiveness of a rehabilitation programme, demonstrating transfer to (simulated) daily tasks, performed in standardized laboratory settings can be seen at “the next best thing”. We identified 23 studies evaluating this type of transfer, 15 of which demonstrated it statistically.

General conclusions

Transfer of training effects of cognitive strategy training has been evaluated in a relatively small number of studies. Outcome measures used in these studies could be classified into 3 groups: non-trained items, daily tasks and daily life. Most studies reported positive results with regard to the occurrence of transfer of training effects, although some serious concerns may be raised about the methodological quality of the studies.

Recommendations for future research

To be able to evaluate the effectiveness of cognitive strategy training, more studies are needed that are specifically designed for measuring transfer effects. In accordance, a workshop organized by the National Center for Medical Rehabilitation Research in the USA recommends that more attention should be paid to the investigation of transfer of rehabilitation programmes; particularly to transfer of functionally important tasks in meaningful task environments (63).

While designing a study to measure transfer effects of cognitive strategy training, 2 important factors should be taken into account. First, before starting the study, measuring transfer should be set as the primary aim of the study, hence making sure that transfer effects can be measured and statistically tested in a standardized way. Secondly, outcome measures should be chosen carefully, taking into account what the aim of the therapy is and whether reliable, standardized instruments exist to evaluate this aim. Studies aimed at evaluating transfer should use measures of activities as their primary outcome, demonstrating whether or not the strategy actually reduces limitations on activities, thus measuring transfer effects to daily tasks. In the studies we included in our review, this type of transfer was assessed by using standardized observations of a simulated performance of daily tasks in a laboratory environment. However, standardized observations of the simulated performance of daily tasks can also be made in daily settings, for example by observing a participant who performs a specific task in his own home environment. This outcome measure provides more information on the participant’s functioning in daily settings, although, of course, it is not an exact reflection of the participant’s performance in everyday life.

In addition, studies investigating whether and in what way transfer itself can be trained could provide valuable information for clinical practice. The prerequisites for the occurrence of transfer derived from educational psychology that were described in the introduction of this paper, could be considered to be a good starting point for answering this question.

In clinical practice several of these prerequisites for the occurrence of transfer are already being applied. Three of these recommendations were actively used in the studies we described. Firstly, 3 studies explicitly described that during training attention was paid to the enlargement of the patient’s awareness of his own deficits (23, 26, 27). This is an important prerequisite for the occurrence of transfer, as someone must acknowledge that there is a need to adapt his behaviour (14).

Next, it was stated that general knowledge is, by definition, easier to transfer than specific knowledge (15). This distinction corresponds to the distinction between strategy training and task specific training. Strategy training is said to be more generally applicable than task-specific training (3). All studies included in this review evaluated transfer effects of cognitive strategy training.

Lastly, a small number of studies specifically used “training for transfer” (23, 24, 44), corresponding with the statement that transfer does not occur automatically and that it takes place during learning, not afterwards (8, 17). However, 3 recommendations of educational psychology do not reappear in the strategies that were described in the papers. Possibly, they have been used during training, but were not described in the papers.

The aim of this paper was to investigate the occurrence of transfer of cognitive strategy training for patients with ABI. We hope that, by means of this paper, clinical practitioners as well as researchers working in rehabilitation settings become more aware of the importance of transfer for the clinical success of a rehabilitation programme, and of the way in which transfer of training effects should be evaluated. We are certain that this awareness will make a vast difference while applying and studying rehabilitation practice.

Acknowledgements

This research was supported by The Netherlands Organisation of Health Research and Development, Rehabilitation Research programme (grant no. 14350009) and the Institute of Rehabilitation Research.

References

1. Wilson BA. Compensating for cognitive deficits following brain injury. Neuropsychol Rev 2000; 10: 233–243.

2. Fasotti l, Kovacs F. Slow information processing and the use of compensatory strategies. In: Chamberlain MA, editor. Traumatic brain injury rehabilitation: services, treatments and outcomes. London: Chapman & Hall; 1995.

3. Ben-Yishay Y, Diller L. Cognitive remediation in traumatic brain injury: Update and issues. Arch Phys Med Rehabil 1993; 74: 204–213.

4. Cicerone KD, Dahlberg C, Kalmar K, Langenbahn DM, Malec JF, Bergquist TF, et al. Evidence-based cognitive rehabilitation: recommendations for clinical practice. Arch Phys Med Rehabil 2000; 81: 1596–1615.

5. Cicerone KD, Dahlberg C, Malec JF, Langenbahn DM, Felicetti T, Kneipp S, et al. Evidence-based cognitive rehabilitation: Updated review of the literature from 1998 through 2002. Arch Phys Med Rehabil 2005; 86: 1681–1692.

6. Singley MK, Anderson JR, editors. The transfer of cognitive skill. Cambridge: Harvard University Press; 1989.

7. Marini A, Genereux R. The challenge of teaching for transfer. In: McKeough A, Lupart J, Marini A, editors. Teaching for transfer: fostering generalization in learning. Mahwah: Lawrence Erlbaum Assocoates; 1995, p. 1–20.

8. Haskell RE, editor. Transfer of learning: cognition, instruction, and reasoning. San Diego: Academic Press; 2001.

9. Annett J. Motor skills. In: Mackintosh NJ, Colman AM, editors. Learning and skills. London: Longman; 1995, p. 56–75.

10. Byrnes JP, editor. Cognitive development and learning in instructional contexts. Boston: Allyn and Bacon; 1996.

11. Gagne ED, Walker Yekovich C, Yekovich FR, editors. The cognitive psychology of school learning. New York: HarperCollins College Publishers; 1993.

12. Cormier SM, Hagman JD. Introduction. In: Cormier SM, Hagman JD, editors. Transfer of learning. Contemporary research and applications. San Diego: Academic Press; 1987, p. 1–8.

13. Campione JC, Shapiro AM, Brown AL. Forms of transfer in a community of learners: Flexible learning and understanding. In: McKeough A, Lupart J, Marini A, editors. Teaching for transfer: fostering generalization in learning. Mahwah: Lawrence Erlbaum Associates; 1995, p. 35–68.

14. Crosson B, Barco PP, Velozo CA, Bolesta MM, Cooper PV, Werts D, et al. Awareness and compensation in postacute head injury rehabilitation. J Head Trauma Rehabil 1989; 4: 46–54.

15. Salomon G, Perkins DN. Rocky roads to transfer: rethinking mechanisms of a neglected phenomenon. Educ Psychol 1989; 24: 113–142.

16. Pinnington LL, Ward CD. Learning and skill acquisition. In: Greenwood RJ, Barnes MP, McMillan TM, Ward CD, editors. Handbook of neuropsychological rehabilitation. Hove: Psychology Press; 2003.

17. Perkins DN, Salomon G. Teaching for transfer. Educational Leadership 1988; 46: 22–32.

18. OvidTechnologies. Silverplatter’s information retrieval system for the world wide web. In. 5.1 edn. Sandy, Utah: Ovid Technologies; 2005.

19. Berg IJ, editor. Memory rehabilitation for closed-head injured patients. Amsterdam: Vrije Universiteit; 1993.

20. van Tulder MW, Assendelft WJJ, Koes BW, Bouter LM. Method guidelines for systematic reviews in the Cochrane collaboration Back review group for spinal disorders. Spine 1997; 22: 2323–2330.

21. Geusgens C, van Heugten C, Donkervoort M, van den Ende E, Jolles J, van den Heuvel W. Transfer of training effects in stroke patients with apraxia: an exploratory study. Neuropsychol Rehabil 2006; 16 :213–229.

22. Kaschel R, Della Sala S, Cantagallo A, Fahlbock A, Laaksonen R, Kazen M. Imagery mnemonics for the rehabilitation of memory: a randomized group controlled trial. Neuropsychol Rehabil 2002; 12: 127–153.

23. Fleming JM, Shum D, Strong J, Lightbody S. Prospective memory rehabilitation for adults with traumatic brain injury: a compensatory training programme. Brain Inj 2005; 19: 1–10.

24. Kime SK, Lamb DG, Wilson BA. Use of comprehensive programme of external cueing to enhance procedural memory in a patient with dense amnesia. Brain Inj 1996; 10: 17–25.

25. Robson J, Marshall J, Chiat S, Pring T. Enhancing communication in jargon aphasia: A small group study of written therapy. Int J Language Commun Dis 2001; 36: 471–488.

26. Fasotti L, Kovacs F, Eling PATM, Brouwer WH. Time pressure management as a compensatory strategy training after closed head injury. Neuropsychol Rehabil 2000; 10: 47–65.

27. Cicerone KD. Remediation of “’working attention”’ in mild traumatic brain injury. Brain Inj 2002; 16: 185–195.

28. Dirette D. The use of cognitive strategies by adults with acquired brain injuries: Results of a two-year post-treatment survey. J Cognitive Rehabil 2002; 20: 6–10.

29. Cicerone KD, Wood JC. Planning disorder after closed head injury: a case study. Arch Phys Med Rehabil 1987; 68: 111–115.

30. Levine B, Robertson IH, Clare L, Carter G, Hong J, Wilson BA, et al. Rehabilitation of executive functioning: an experimental- clinical validation of goal management training. J Int Neuropsychol Soc 2000; 6: 299–312.

31. Neistadt ME. A meal preparation treatment protocol for adults with brain injury. Am J Occup Ther 1994; 48: 431–438.

32. Foxx RM, Martella RC, Marchand-Martella NE. The acquisition, maintenance, and generalization of problem-solving skills by closed head-injured adults. Behav Ther 1989; 20: 61–76.

33. Liu KPY, Chan CCH, Lee TMC, Li LSW, Hui-Chan CWY. Self-regulatory learning and generalization for people with brain injury. Brain Inj 2002; 16: 817–824.

34. Boman I, Lindstedt M, Hemmingsson H, Bartfai A. Cognitive training in home environment. Brain Inj 2004; 18: 985–995.

35. Wade TK, Troy JC. Mobile phones as a new memory aid: a preliminary investigation using case studies. Brain Inj 2001; 15: 305–320.

36. Doornhein K, de Haan EHF. Cognitive training for memory deficits in stroke patients. Neuropsychol Rehabil 1998; 8: 393–400.

37. Milders M, Deelman B, Berg I. Rehabilitation of memory for people’s names. Memory 1998; 6: 21–36.

38. Hinckley JJ, Patterson JP, Carr TH. Differential effects of context- and skill-based treatment approaches: preliminary findings. Aphasiology 2001; 15: 463–476.

39. Hopper T, Holland A. Situation-specific training for adults with aphasia: an example. Aphasiology 1998; 12: 933–944.

40. Jacobs BJ. Social validity of changes in informativeness and efficiency of aphasic discourse following linguistic specific treatment (LTS). Brain Lang 2001; 78: 115–127.

41. Maneta A, Marshall J, Lindsay J. Direct and indirect therapy for word sound deafness. Int J Lang Commun Disord 2001; 36: 91–106.

42. Nitzberg Lott S, Friedman RB. Can treatment for pure alexia improve letter-by-letter reading speed without sacrificing accuracy. Brain Lang 1999; 67: 188–201.

43. Robson J, Marshall J, Pring T, Chiat S. Phonological naming therapy in jargon aphasia: positive but paradoxal effects. J Int Neuropsychol Soc 1998; 4: 675–686.

44. Robson J, Pring T, Marshall J, Morrison S, Chiat S. Written communication in undifferentiated jargon aphasia: a therapy study. Int J Lang Commun Disord 1998; 33: 305–328.

45. Richards K, Singletary F, Gonzalez Rothi LJ, Koehler S, Crosson B. Activation of intentional mechanisms through utilization of nonsymbolic movements in aphasia rehabilitation. J Rehabil Res Dev 2002; 38: 445–454.

46. Wambaugh JL, Martinez AL. Effects of rate and rhythm control treatment on consonant production accuracy in apraxia of speech. Aphasiology 2000; 14: 851–871.

47. Antonucci G, Guariglia C, Judica A, Magnotti L, Paolucci S, Pizzamiglio L, et al. Effectiveness of neglect rehabilitation in a randomized group study. J Clin Exp Neuropsychol 1995; 17: 383–389.

48. Bailey MJ, Riddoch MJ, Crome P. Treatment of visual neglect in elderly patients with stroke: a single-subject series using either a scanning and cueing strategy or a left-limb strategy. Phys Ther 2002; 82: 782–797.

49. Gouvier WD, Bua BG, Blanton PD, Urey JR. Behavioral changes following visual scanning training: observations of five cases. Int J Clin Neuropsychol 1987; 9: 74–80.

50. Hanlon RE, Dobkin BH, Hadler B, Ramirez S, Cheska Y. Neurorehabilitation following right thalamic infarct: effects of cognitive retraining on functional performance. J Clin Exp Neuropsychol 1992; 14: 433–447.

51. Niemeier JP, Cifu DX, Kishore R. The lighthouse strategy: improving the functional status of patients with unilateral neglect after stroke and brain injury using a visual imagery intervention. Top Stroke Rehabil 2001; 8: 10–18.

52. Pizzamiglio L, Antonucci G, Judica A, Razzano C, Zoccolotti P. Cognitive rehabilitation of the hemineglect disorder in patients with unilateral right brain damage. J Clin Exp Neuropsychol 1992; 14: 901–923.

53. Pizzamiglio L, Fasotti L, Jehkonen M, Antonucci G, Magnotti L, Boelen D, et al. The use of optokinetic stimulation in rehabilitation of the hemineglect disorder. Cortex 2004; 40: 441–450.

54. Webster JS, McFarland PT, Rapport LJ, Morrill B, Roades LA, Abadee PS. Computer-assisted training for improving wheelchair mobility in unilateral neglact patients. Arch Phys Med Rehabil 2001; 82: 769–775.

55. Goldenberg G, Hagmann S. Therapy of activities of daily living in patients with apraxia. Neuropsychol Rehabil 1998; 8: 123–141.

56. Goldenberg G, Daumuller M, Hagmann S. Assessment and therapy of complex activities of daily living in apraxie. Neuropsychol Rehabil 2001; 11: 147–169.

57. Gorman P, Dayle R, Hood C, Rumrell L. Effectiveness of the ISAAC cognitive prosthetic system for improving rehabilitation outcomes with neurofunctional impairment. NeuroRehabilitation 2003; 18: 57–67.

58. Liu KP, Chan CC, Lee TM, Hui-Chan CW. Mental imagery for promoting relearning for people after stroke: a randomized controlled trial. Arch Phys Med Rehabil 2004; 85: 1403–1408.

59. O’Reilly MF, Green G, Braunling-McMorrow D. Self-administered written prompts to teach home accident prevention skills to adults with brain injuries. J Appl Behav Anal 1990; 24: 431–446.

60. Wilson BA, editor. Neuropsychological rehabilitation: Theory and practice. Lisse: Swets & Zeitlinger; 2003.

61. Carney N, Chesnut RM, Maynard H, Mann NC, Patterson P, Helfand M. Effect of cognitive rehabilitation on outcomes for persons with traumatic brain injury: a systematic review. J Head Trauma Rehabil 1999; 14: 277–307.

62. Lezak MD, editor. Neuropsychological Assessment. 3 edn. New York: Oxford University Press; 2004.

63. Fuhrer MJ, Keith RA. Facilitating patient learning during medical rehabilitation. Am J Phys Med Rehabil 1998; 77: 557–561.

APPENDIX. Details of literature search.

Category

Terms

Controlled vocabulary words (combinations of these terms)

Type of brain injury

Brain injury TBI, cerebrovascular accident, CVA, brain contusion, brain concussion

Transfer

Transfer (psychology), transfer (learning), generalization (psychology), generalization (learning), learning, transferability, learning environment – clinical, activities of daily living

Type of disorder

Neurobehavioral manifestations, cognitive impairment, cognitive defect, cognition disorders, cognition (OMAHA)

Type of intervention

Rehabilitation, cognitive rehabilitation, neuropsychological rehabilitation, rehabilitation - community based, home rehabilitation, education

Free text words (combinations of these terms and in combination with controlled vocabulary words)

Type of brain injury

“traumatic brain injury”, stroke, contusion, CVA, “cerebro vascular accident”

Transfer

Transfer, generalisation, generalization, “environmental validity”, “environmental valid”, “activities of daily living”, ADL

Type of disorder

“Cognit* disorder”, “cognitive impairment”

Type of intervention

Rehabilitation, remediation, compensation, strategy, “compensatory strategy”, “compensation training”, “compensatory training”, “strategy training”, “cognitive training”, “cognitive retraining”, “cognitive rehabilitation”, “cognitive remediation”, “remediation strategy”

TBI: traumatic brain injury; CVA: cerebrovascular accident; ADL: activities of daily living.

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