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of the multifaceted nature of memory dysfunction and
limited economic resources (9).
While a number of comprehensive reviews have
explored best-practice recommendations for cognitive
impairment following acquired brain injury (10, 11),
only a minority of studies included in these reviews
were conducted in stroke-only samples. Consequently,
the long-held view that MSG training is the treatment
of choice in rehabilitating memory has been largely
speculative post-stroke and appears to have been ba-
sed on an absence of evidence, rather than evidence
of absence for the effectiveness of CCT (5). The aim
of this study was to compare the effectiveness of CCT
and MSG training in community dwelling survivors of
stroke in achieving individualized, functional memory
goals. A further aim was to explore the effect of training
on secondary measures of objective, neuropsycholo-
gical memory tasks and subjective memory ratings. In
addressing these aims, we intended to maintain ecolo-
gical validity by evaluating the interventions as they
are clinically implemented (rather than transforming
them to be experimentally matched with each other on
characteristics such as group vs individual format), with
the goal of facilitating clinical translation. We hypothe-
sized that intervention participants (i.e. CCT and MSG)
would show greater improvement in performance on
outcome measures than waitlist control participants
(WC). Given the proposed mechanism of action of each
approach, we also hypothesized participants in the CCT
group would show greater improvement on neuropsy-
chological tests of memory, while participants in the
MSG would show greater improvement on functional
measures of memory and strategy use.
MATERIAL AND METHODS
Trial design and participants
This study was a parallel, 3-group, single-blind randomized
controlled trial with outcomes assessed up to 3 months following
randomization. Initial power analysis for a 3 × 3 multivariate
analysis of variance (MANOVA) was conducted using G*power
(v3). Analysis indicated that 52 participants would be necessary
to detect a medium effect size (f = 0.35) (12) with power of 0.80
and alpha of 0.05. With an anticipated attrition rate of 20%, a total
sample size of 65 participants was indicated. Community dwelling
survivors of stroke were recruited through advertising in local
newspapers, community clinician referrals and the Australian
Stroke Clinical Registry between January 2015 and January 2017
(AuSCR) (13). Responding individuals completed a telephone
screen to check whether the eligibility criteria were met.
Inclusion criteria were: history of stroke confirmed by
neurological examination and brain imaging at least 3 months
previously, and self or close other (i.e. relative) reported eve-
ryday memory complaints. Exclusion criteria were: (i) physical
impairment preventing access to intervention, (ii) inadequate
computer proficiency limiting computer use, (iii) severe cog-
nitive or communication deficits (secondary to aphasia or
www.medicaljournals.se/jrm
English as a second language) impacting engagement and (iv)
history of other neurological or psychiatric condition impacting
cognition. Exclusion criteria were determined on the basis of
clinical judgment, aided by review of available medical records
by a researcher trained in the study protocol . In cases where
eligibility was unclear, consultation occurred with DW and
RS who are both experienced clinical neuropsychologists and
researchers. Participants were not compensated financially for
their time, but were provided the intervention free of charge.
Ethical approval to conduct the study was granted by re-
levant ethics committees and the project was registered with
the Australian New Zealand Clinical Trials Registry (ACTRN
12616001056482). The data that support the findings of this
study are available from the corresponding author on request.
Baseline measures
At baseline, all participants completed measures of cognitive
functioning, computer proficiency, and everyday functioning.
Neuropsychological measures included the Test of Premorbid
Functioning (TOPF) (14) to estimate premorbid intelligence and
the Montreal Cognitive Assessment (MoCA) (15) to provide a
gross measure of general cognitive functioning. The short form
of the Computer Proficiency Questionnaire (CPQ) (16) was used
to assess computer proficiency, while the Nottingham Extended
Activities of Daily Living scale (NEADL) (17) was used as a
measure of daily living functional independence.
Primary outcome measure
Attainment of personal, memory-specific rehabilitation goals was
assessed using Goal Attainment Scaling (GAS) (18). GAS was
selected as the primary outcome measure due to its flexibility
in managing heterogeneous outcomes and ability to explore
functionally meaningful change; which arguably represents the
fundamental goal of rehabilitation, irrespective of theoretical ap-
proach (19). Goals were developed collaboratively with partici-
pants using SMART principles (Specific, Measurable, Attainable,
Realistic, Timely) according to established guidelines for clinical
use (20). Participants were encouraged to set 2 memory-specific
goals with a trained researcher. The scoring method originally
proposed by Kiresuk & Sherman (18) was adopted due to its
established sensitivity to change in rehabilitation outcomes fol-
lowing stroke (21). Accordingly, a standard 5-point scale (–2;
a lot less than expected, 0; at expectation, +2; a lot more than
expected) was employed. In line with current recommendations
for use (20), baseline achievement was set at –1 to allow for
deterioration, unless there was no clinically conceivable worse
outcome, in which case baseline performance was set at –2. Raw
achievement scores were aggregated across memory goals and
converted to a standardized T-score (20). All goals were set with
participants prior to randomization to minimize bias. Common
participant goals are presented below in Table I.
Secondary outcome measures
Neuropsychological Measures of Memory. The Rey Auditory
Verbal Learning Task (RAVLT) (22) and the Brief Visuospatial
Memory Test-Revised (BVMT-R) (23) were used to measure
verbal and visual learning and memory, respectively. Total
words recalled over learning trials (total learning), and number
of items spontaneously recalled following a 30-min delay (de-
layed recall) were examined. All raw scores were converted to
standardized z-scores using age- and education-based normative
data to enhance clinical translation (22, 23). The Royal Prince