Zucchella, C., Capone, A., Codella, V., De Nunzio, A.M., Vecchione, C., Sandrini, G., . . . Bartolo, M. (2013). Cognitive rehabilitation for early post-surgery inpatients affected by primary brain tumor: A randomized, controlled trial. Journal of Neuro-Oncology, 114, 93-100. 

To evaluate the effectiveness of a cognitive rehabilitation program within two weeks of surgical resection for patients with primary brain tumors

Baseline neuropsychological assessments were performed within three days of admission to the inpatient rehabilitation unit and prior to treatment or control randomization. Treatment arm consisted of 16 one-hour individual sessions over a four week timeframe with content focused on time orientation, spatial orientation, visual attention, logical reasoning, memory recognition, and executive functions. Each session was therapist-guided with 45 minutes of computer-based exercises and 15 minutes of discussion about the exercises and how to apply the strategies to everyday life. In both arms of the study, patients received usual rehabilitation care with medication and physical therapies.

• N = 53    
• MEAN AGE: 58.7 years (treatment group), 52.7 years (control group)
• MALES: 56%, 47%, FEMALES: 44%, 53%
• KEY DISEASE CHARACTERISTICS: Two weeks post-neurosurgical primary brain tumor patients with no prior exposure to radiation or chemotherapy
• OTHER KEY SAMPLE CHARACTERISTICS: Inclusion criteria required cognitive deficits on a minimum of three neuropsych tests.

• SITE: Single site    
• SETTING TYPE: Inpatient    
• LOCATION: Neurological Mediterranean Institute

PHASE OF CARE: Active antitumor treatment

Randomized double-blind control trial with pre- and post-test assessments at baseline and four weeks after randomization

• Mini-Mental State Exam for global cognition
• Digit Span and Corsi’s test for verbal and spatial immediate memory span
• Rey auditory verbal learning test (RAVLT), immediate recall (IR) and delayed recall (DR), for verbal memory  
• Logical memory, IR and DR, for verbal memory
• Raven’s Coloured Progressive Matrices 47 for non-verbal reasoning
• Frontal assessment battery for frontal functionality
• Trials Making Test Parts A & B (TMT-A and TMT-B) for processing speed and complex attention
• Attentive Matrices for visual selective attention
• Rey-Osterrieth Complex Figure Copy Test for visuo-constructional abilities and verbal fluency
• Esame Neuropsicologico per l’Afasia for expressive and receptive language abilities

Within-group analyses found significant improvements (p < 0.05) on all neuropsychological tests for the treatment arm, while the control arm showed a non-significant trend towards improvement. Significant differences between groups were observed for improvements in visual attention and verbal memory (RAVLT-DR, Logical memory-IR and DR, TMT-A, TMT-B, Attentive matrices). There was no difference between groups in the socio-demographic, clinical characteristics, or baseline neuropsychological test scores. There was no difference between groups for number of subjects withdrawing from study due to medical conditions.

This inpatient cognitive rehabilitation program was developed for patients with a post-surgical primary brain tumor. Those receiving the intervention showed significant cognitive improvement in all domains, yet only visual attention and verbal memory performances were significantly different when compared to usual rehabilitation care. These results are limited by sample size, lack of additional longitudinal assessments to demonstrate sustained improvement, and program cost.

• Small sample (< 100)
• Findings not generalizable
• Intervention expensive, impractical, and needs training
• Subject withdrawals ≥ 10%
• Other limitations/explanation: Only one post-test assessment immediately following completion of intervention occurred, thus lacking demonstration of sustained cognitive improvement. Findings not generalizable due to cost of inpatient rehabilitation program, which would need adapting for use in outpatient settings.

Post-surgical cognitive interventions may be helpful in developing cognitive strategies for everyday function. Further study is warranted and intervention adaptation is necessary for outpatient settings.