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  • Guideline Summary
  • NGC:008842
  • 2011 Sept 13

Best evidence statement (BESt). Speech therapist directed use of computer assisted cognitive rehabilitation (CACR) for patients with acquired brain injury.

Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Speech therapist directed use of computer assisted cognitive rehabilitation (CACR) for patients with acquired brain injury. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2011 Sep 13. 6 p. [12 references]

View the original guideline documentation External Web Site Policy

This is the current release of the guideline.

Age Group

UMLS Concepts (what is this?)

SNOMEDCT_US
Adaptive and compensatory techniques (228594004), Biofeedback procedure (28150003), Biofeedback system (40432008), Biofeedback system (466651006), Brain damage (2470005), Brain damage (702632000), Cerebrovascular accident (230690007), Cognitive therapy (183383008), Cognitive therapy (228553007), Cognitive therapy (228557008), Cognitive therapy (304891004), Computer (706692004), Congenital arteriovenous malformation (234141001), Congenital arteriovenous malformation (24551003), Electroencephalogram (54550000), Encephalitis (45170000), Epilepsy (128613002), Epilepsy (313307000), Epilepsy (84757009), Errorless learning technique (228582008), Hydrocephalus (230745008), Magnetic resonance imaging (113091000), Magnetic resonance imaging (312250003), Magnetic resonance imaging unit (90003000), Malignant neoplasm of brain (428061005), Meningitis (7180009), Neoplasm of brain (126952004), Neuropsychological testing (307808008), Obstructive hydrocephalus (230746009), Rehabilitation therapy (52052004), Software (706687001), Speech therapy (5154007), Traumatic brain injury (127295002), Traumatic brain injury (275272006)

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a‒5b) are defined at the end of the "Major Recommendations" field.

It is recommended that pediatric patients with acquired brain injury use computer-assisted cognitive rehabilitation when directed by a speech-language pathologist to decrease impairment in:

  • Processing speed (Bangirana et al., 2009 [2b]; Kesler, Lacayo, & Jo, 2011 [4a])
  • Attention (Thornton & Carmody, 2008 [1b]; Cicerone et al., 2011 [1b]; Bangirana et al., 2009 [2b]; Thorell et al., 2009 [2b]; Kesler, Lacayo, & Jo, 2011 [4a]; Chen et al., 1997 [4b])
  • Working memory (Thorell et al., 2009 [2b]; Klingberg et al., 2005 [2b]; Kesler, Lacayo, & Jo, 2011 [4a]; Chen et al., 1997 [4b])
  • Inhibition (Thorell et al., 2009 [2b]; Klingberg et al., 2005 [2b])
  • Memory (Thornton & Carmody, 2008 [1b]; Cicerone et al., 2011 [1b]; Bangirana et al., 2009 [2b]; Dou et al., 2006 [2b]; Lloyd, Riley, & Powell, 2009 [2b]; Bergquist et al., 2009 [2b]; Sweeney et al., 2010 [2b]; Kesler, Lacayo, & Jo, 2011 [4a]; Chen et al., 1997 [4b])
  • Problem solving (Thornton & Carmody, 2008 [1b]; Klingberg et al., 2005 [2b]; Man et al., 2006 [2b]; Chen et al., 1997 [4b])

Definitions:

Table of Evidence Levels

Quality Level Definition
1a or 1b Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5a or 5b General review, expert opinion, case report, consensus report, or guideline
5 Local consensus

a = good quality study; b = lesser quality study

Note: See the original guideline document for further information about the dimensions used to judge the strength of the evidence.

Table of Recommendation Strength

Strength Definition
It is strongly recommended that…
It is strongly recommended that… not…
There is consensus that benefits clearly outweigh risks and burdens (or vice versa for negative recommendations).
It is recommended that…
It is recommended that… not…
There is consensus that benefits are closely balanced with risks and burdens.
There is insufficient evidence and a lack of consensus to make a recommendation…
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the body of evidence
  2. Safety/harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life

Clinical Algorithm(s)

None provided

Disease/Condition(s)

Sustained acquired brain injury (ABI), including:

  • Traumatic brain injury (TBI)
  • Brain tumor
  • Arteriovenous malformation (AVM)
  • Seizure disorder
  • Meningitis
  • Encephalitis
  • Cerebrovascular accident (CVA)
  • Hydrocephalus

Guideline Category

Assessment of Therapeutic Effectiveness

Rehabilitation

Treatment

Clinical Specialty

Family Practice

Neurology

Pediatrics

Speech-Language Pathology

Intended Users

Advanced Practice Nurses

Nurses

Physician Assistants

Physicians

Speech-Language Pathologists

Guideline Objective(s)

To evaluate, among pediatric patients with acquired brain injury, if speech therapist directed use of computer-assisted cognitive rehabilitation (CACR) in addition to traditional rehabilitative cognitive-linguistic speech therapy versus traditional rehabilitative cognitive-linguistic speech therapy alone decreases impairment and improve functional independence

Target Population

Inclusion: Pediatric patients (ages 3 to 21 years) that have sustained acquired brain injury (ABI), including traumatic brain injury (TBI), brain tumor, arteriovenous malformation (AVM), seizure disorder, meningitis, encephalitis, cerebrovascular accident (CVA), and hydrocephalus

Exclusion: Patients with neurological impairments that are hereditary; patients with psychological diagnosis prior to injury; patients with severe visuospatial deficits which impact their ability to complete tasks on a computer screen

Interventions and Practices Considered

  1. Computer-assisted cognitive rehabilitation
    • Captain's Log cognitive training software
    • Lumos Labs, Incorporated software
    • RoboMemo software (Cogmed)
    • The Bracy Process Approach
  2. Traditional rehabilitative cognitive-linguistic speech therapy
    • Errorless learning
    • Compensatory strategies
    • Personal instruction
  3. Other methods of confirming results
    • Neuropsychological measures (e.g., Mayo-Portland Adaptability Inventory-4)
    • Functional magnetic resonance imaging
    • Electroencephalogram biofeedback

Major Outcomes Considered

  • Changes in processing speed
  • Changes in attention level
  • Changes in working memory and overall memory
  • Changes in inhibition
  • Changes in problem solving

Methods Used to Collect/Select the Evidence

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Date range: 1995-April 2011

Keywords: brain/head injury, neurological injury, acquired/traumatic brain injury, brain tumor, stroke, CVA, speech therapy/pathology, computer, computer assisted cognitive rehabilitation, cognitive rehab/rehabilitation, child/children

Databases: CINAHL, Ovid, Medline, PubMed, Cochrane Library, Scopus, EBSCO, ASHA, PsycINFO, ERIC, Google Scholar, National Guideline Clearinghouse (www.guideline.gov External Web Site Policy)

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level Definition
1a or 1b Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5a or 5b General review, expert opinion, case report, consensus report, or guideline
5 Local consensus

a = good quality study; b = lesser quality study

Note: See the original guideline document for further information about the dimensions used to judge the strength of the evidence.

Methods Used to Analyze the Evidence

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength Definition
It is strongly recommended that…
It is strongly recommended that… not…
There is consensus that benefits clearly outweigh risks and burdens (or vice versa for negative recommendations).
It is recommended that…
It is recommended that… not…
There is consensus that benefits are closely balanced with risks and burdens.
There is insufficient evidence and a lack of consensus to make a recommendation…
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the body of evidence
  2. Safety/harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

This Best Evidence Statement has been reviewed against quality criteria by 2 independent reviewers from the Cincinnati Children's Hospital Medical Center (CCHMC) Evidence Collaboration.

References Supporting the Recommendations

Bangirana P, Giordani B, John CC, Page C, Opoka RO, Boivin MJ. Immediate neuropsychological and behavioral benefits of computerized cognitive rehabilitation in Ugandan pediatric cerebral malaria survivors. J Dev Behav Pediatr. 2009 Aug;30(4):310-8. PubMed External Web Site Policy

Bergquist T, Gehl C, Mandrekar J, Lepore S, Hanna S, Osten A, Beaulieu W. The effect of internet-based cognitive rehabilitation in persons with memory impairments after severe traumatic brain injury. Brain Inj. 2009 Sep;23(10):790-9. PubMed External Web Site Policy

Chen SH, Thomas JD, Glueckauf RL, Bracy OL. The effectiveness of computer-assisted cognitive rehabilitation for persons with traumatic brain injury. Brain Inj. 1997 Mar;11(3):197-209. PubMed External Web Site Policy

Cicerone KD, Langenbahn DM, Braden C, Malec JF, Kalmar K, Fraas M, Felicetti T, Laatsch L, Harley JP, Bergquist T, Azulay J, Cantor J, Ashman T. Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008. Arch Phys Med Rehabil. 2011 Apr;92(4):519-30. PubMed External Web Site Policy

Dou ZL, Man DW, Ou HN, Zheng JL, Tam SF. Computerized errorless learning-based memory rehabilitation for Chinese patients with brain injury: a preliminary quasi-experimental clinical design study. Brain Inj. 2006 Mar;20(3):219-25. PubMed External Web Site Policy

Kesler SR, Lacayo NJ, Jo B. A pilot study of an online cognitive rehabilitation program for executive function skills in children with cancer-related brain injury. Brain Inj. 2011;25(1):101-12. PubMed External Web Site Policy

Klingberg T, Fernell E, Olesen PJ, Johnson M, Gustafsson P, Dahlstrom K, Gillberg CG, Forssberg H, Westerberg H. Computerized training of working memory in children with ADHD--a randomized, controlled trial. J Am Acad Child Adolesc Psychiatry. 2005 Feb;44(2):177-86. PubMed External Web Site Policy

Lloyd J, Riley GA, Powell TE. Errorless learning of novel routes through a virtual town in people with acquired brain injury. Neuropsychol Rehabil. 2009 Jan;19(1):98-109. PubMed External Web Site Policy

Man DW, Soong WY, Tam SF, Hui-Chan CW. Self-efficacy outcomes of people with brain injury in cognitive skill training using different types of trainer-trainee interaction. Brain Inj. 2006;20(9):959-70. [55 references] PubMed External Web Site Policy

Sweeney S, Kersel D, Morris RG, Manly T, Evans JJ. The sensitivity of a virtual reality task to planning and prospective memory impairments: group differences and the efficacy of periodic alerts on performance. Neuropsychol Rehabil. 2010 Apr;20(2):239-63. PubMed External Web Site Policy

Thorell LB, Lindqvist S, Bergman Nutley S, Bohlin G, Klingberg T. Training and transfer effects of executive functions in preschool children. Dev Sci. 2009 Jan;12(1):106-13. PubMed External Web Site Policy

Thornton KE, Carmody DP. Efficacy of traumatic brain injury rehabilitation: interventions of QEEG-guided biofeedback, computers, strategies, and medications. Appl Psychophysiol Biofeedback. 2008 Jun;33(2):101-24. [87 references] PubMed External Web Site Policy

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Potential Benefits

Decreased impairment and improved functional independence

Potential Harms

Not stated

Qualifying Statements

This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Description of Implementation Strategy

Applicability Issues

  • Proper education and training of computer-assisted cognitive rehabilitation for staff involved in the care of patients with acquired brain injury.
  • Appropriate documentation tools are required to monitor use of Computer Assisted Cognitive Rehabilitation (CACR) during treatment and/or during home program.
  • A valid and reliable outcome measure is needed to measure functional independence.

Implementation Tools

Audit Criteria/Indicators

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

IOM Care Need

Getting Better

Living with Illness

IOM Domain

Effectiveness

Bibliographic Source(s)

Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Speech therapist directed use of computer assisted cognitive rehabilitation (CACR) for patients with acquired brain injury. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2011 Sep 13. 6 p. [12 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2011 Sept 13

Guideline Developer(s)

Cincinnati Children's Hospital Medical Center - Hospital/Medical Center

Source(s) of Funding

Cincinnati Children's Hospital Medical Center

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Group/Team Leader: Katherine Baker, MA, CCC-SLP, Division of Speech Pathology, Outpatient Neurorehabilitation Team (ONRT)

Support personnel: Mary Ellen Meier, MS, RN, CPN Evidence-Based Practice Mentor, Center for Professional Excellence/Research and Evidence-Based Practice; Patti Besuner, MS, RN, CPN Evidence-Based Practice Mentor, Center for Professional Excellence/Research and Evidence-Based Practice

Financial Disclosures/Conflicts of Interest

Conflicts of interest were declared for each team member and no financial conflicts of interest were found.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site External Web Site Policy.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Availability of Companion Documents

The following are available:

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

In addition, suggested process or outcome measures are available in the original guideline document External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on March 28, 2012.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of Cincinnati Children's Hospital Medical Center (CCHMC) External Web Site Policy Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

  • Copies may be provided to anyone involved in the organization's process for developing and implementing evidence based care
  • Hyperlinks to the CCHMC website may be placed on the organization's website
  • The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents
  • Copies may be provided to patients and the clinicians who manage their care

Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.

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