Neuropsychological rehabilitation and quality of life: A meta-analysis | Revista Iberoamericana de Psicología y Salud

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Facultat de Psicologia. Universitat de Barcelona. Passeig de la Vall d’Hebron, 171. 08035 Barcelona (Spain)." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Rehabilitación neuropsicológica y calidad de vida: una aproximación meta-analítica" ] ] "textoCompleto" => "IntroductionHealth-Related Quality of Life (HRQoL) is a wide concept, but there exists consensus on it being a subjective measure of physical, emotional, and psychological conditions (<a class="elsevierStyleCrossRef" href="#bib0095">Londos et al., 2008</a>). Some studies define HRQoL as an assessment of how a disease and its treatment affect a person's capability to develop everyday activities and play valuable roles in their own life (<a class="elsevierStyleCrossRef" href="#bib0025">Brissart, Leroy, & Debouverie, 2010</a>; <a class="elsevierStyleCrossRef" href="#bib0060">Fergusson et al., 2012</a>). Neuropsychological diseases, like any other diseases, affect the quality of life (QoL) of those who suffer from it (<a class="elsevierStyleCrossRef" href="#bib0110">Murell, 1999</a>). In spite of that, the HRQoL of the persons suffering from neuropsychological alterations has not been widely studied, and it is often claimed that rehabilitating treatments in neuropsychological diseases improve the patients’ quality of life without actually measuring HRQoL (<a class="elsevierStyleCrossRef" href="#bib0095">Londos et al., 2008</a>). Other works (<a class="elsevierStyleCrossRef" href="#bib0030">Cicerone, 2005</a>; <a class="elsevierStyleCrossRef" href="#bib0185">Wilde et al., 2010</a>) have recommended using HRQoL measures as outcome measures in order to grade the efficacy of neuropsychological rehabilitation in traumatic brain injury (TBI). Few works have studied the possible impact of neuropsychological interventions on the QoL of patients with cognitive alterations. There exist works on patients with epilepsy, TBI, multiple sclerosis, cardiovascular events, mild cognitive impairment, Alzheimer's disease, and persons on chemotherapy. The methodology used in those works includes pre- and post-treatment observational studies (<a class="elsevierStyleCrossRef" href="#bib0040">Cohen, Ylvisaker, Hamilton, Kemp, & Claiman, 2010</a>; <a class="elsevierStyleCrossRef" href="#bib0095">Londos et al., 2008</a>; <a class="elsevierStyleCrossRef" href="#bib0120">Rasquin et al., 2010</a>), case and control studies (<a class="elsevierStyleCrossRef" href="#bib0170">Svendsen &Teasdale, 2006</a>), and several clinical trials (<a class="elsevierStyleCrossRef" href="#bib0020">Brenk, Laun, & Haase, 2008</a>; <a class="elsevierStyleCrossRef" href="#bib0035">Clare et al., 2010</a>; <a class="elsevierStyleCrossRef" href="#bib0045">Davis, Massman, & Doody, 2001</a>; <a class="elsevierStyleCrossRef" href="#bib0050">Engelberts et al., 2002</a>; <a class="elsevierStyleCrossRef" href="#bib0070">Gehring et al., 2009</a>; <a class="elsevierStyleCrossRef" href="#bib0085">Hildebrand et al., 2007</a>; <a class="elsevierStyleCrossRef" href="#bib0090">Lincoln et al., 2002</a>; <a class="elsevierStyleCrossRef" href="#bib0165">Solari, Pucci, Forni, Mancardi, & Pozzilli, 2004</a>; <a class="elsevierStyleCrossRef" href="#bib0180">Voght et al., 2009</a>). Those studies present controversial results: whereas some find a positive effect of neuropsychological rehabilitation on QoL (<a class="elsevierStyleCrossRef" href="#bib0020">Brenk et al., 2008</a>; <a class="elsevierStyleCrossRef" href="#bib0035">Clare et al., 2010</a>; <a class="elsevierStyleCrossRef" href="#bib0040">Cohen et al., 2010</a>; <a class="elsevierStyleCrossRef" href="#bib0050">Engelberts et al., 2002</a>; <a class="elsevierStyleCrossRef" href="#bib0075">Glanz et al., 2010</a>; <a class="elsevierStyleCrossRef" href="#bib0105">Melchers, Maluck, Suhr, Scholten, & Lehmkuhl, 1999</a>; <a class="elsevierStyleCrossRef" href="#bib0170">Svendsen & Teasdale, 2006</a>), others do not (<a class="elsevierStyleCrossRef" href="#bib0045">Davis et al., 2001</a>). This positive effect on the patients’ quality of life is observable immediately after rehabilitation but is not persistent in follow-up evaluations (<a class="elsevierStyleCrossRef" href="#bib0165">Solan et al., 2004</a>). Other works find a positive effect of cognitive rehabilitation on some, but not all, QoL measures (<a class="elsevierStyleCrossRef" href="#bib0155">Seniow, Polanowska, Mandat, & Laudanski, 2003</a>; <a class="elsevierStyleCrossRef" href="#bib0160">Sitzer, Twamley, & Jeste, 2006</a>). These are understandable controversies given that most works use small samples of patients with different diseases, have different designs, apply neuropsychological interventions of a different nature, duration, intensity, and use diverse instruments to measure HRQoL.A previous work (<a class="elsevierStyleCrossRef" href="#bib0080">Guàrdia, Jarne, Urzúa, & Gudayol, 2012</a>) dealing with the impact of neuropsychological rehabilitation on QoL intended to approach this phenomenon by using meta-analysis techniques while bearing in mind their possible mediating effects in the analysis, as well as other substantive, methodological, and socio-demographic variables which may be affecting the results of the aforementioned works. That study yielded the following conclusions: the positive effect of the rehabilitating intervention is generally linked to an improvement in the patients’ quality of life. Likewise the use of retraining techniques (techniques intended to restore the lost cognitive function) seems to have a positive effect on HRQoL that is more intense than the effect of compensatory techniques (techniques designed to improve specific aspects of everyday life despite the specific cognitive loss experienced by the patient). That positive effect of cognitive rehabilitation on HRQoL tends to decrease as time goes by between the clinical intervention and the follow-up; and when analyzing the data as a whole, each study's sample size and design have a direct influence on the effect size of the QoL improvement. In fact, the above-mentioned work reanalyzes data from Spanish-speaking samples, and as the authors admit, most of the studies included in their study have a pre- post- simple design where the variable control mechanisms are minimal, and they tend to magnify the effect sizes of the phenomenon under study (<a class="elsevierStyleCrossRef" href="#bib0005">Ahn, Myers, & Jin, 2012</a>). Moreover the study purposefully excluded the works conducted with non-Spanish-speaking samples, and consequently, it involved relatively few works. On the date of its publication, there existed no other meta-analyses on the subject that allowed the authors to contrast their findings. Therefore their conclusions must be considered preliminary and they should be contrasted with results from non-Spanish-speaking samples, much more common in scientific literature.Thus, the goal of the present study is to conduct a meta-analysis of the effects of neuropsychological rehabilitation on the QoL of patients with neuropsychological alterations by using non-Spanish-speaking samples, according to the phases proposed by <a class="elsevierStyleCrossRef" href="#bib0015">Botella and Gambara (2006)</a>. In addition, we intend to compare our results to those of the individual works that approached this topic, and to the results of the meta-analysis by <a class="elsevierStyleCrossRef" href="#bib0080">Guàrdia et al. (2012)</a>. The differences between, for example, the sample sizes in works with Spanish-speaking samples and those with non-Spanish-speaking samples are so large in most cases that it is impossible to carry out one integrated study with all the papers, with Spanish- or non-Spanish-speaking samples, apart from the fact that the conditions of assistance and neurorehabilitating intervention are not comparable, either.MethodSearch of studiesTo be included in this meta-analysis, studies had to comply with the following inclusion criteria: a) they had to be original works focused on neuropsychological rehabilitation, that is, assessing the effect of a neurorehabilitation program; b) the studies had to have been published from 2001 to 2012 given that, prior to that period, there exist very few studies and they are much apart in time; c) they had to be indexed in Journal Citation Reports, PsycInfo, Pubmed, Scopus, SciELO, and Latindex; d) the papers had to include at least one psychometric standardized QoL measure; e) the study design had to be recognizable and undoubted in relation to the other variables set forth in this work; f) the studies had to be conducted on non-Spanish-speaking countries; g) the samples had to comprise adults only, samples of children and adolescents were excluded; and h) the studies had to include samples of subjects, case studies were excluded. We also excluded studies according to the following exclusion criteria: a) works where the concept of QoL was not operationalized empirically; and b) the methodological aspects were unclear, that is, neither the design type, nor the measures used, or the statistical contrasts were clearly identifiable. Complementing the above, we would like to specify that we conducted a search based on the Boolean criteria derived from the use of the following key words: Neuropsychological Neurorehabilitation, Clinical Trials, Estimation Clinical Effect Size, Quality of Life.Also, a manual search was conducted in some psychological or medical bibliographical sources (for example, reports by organizations of renowned prestige such as the World Health Organization or individual universities) hoping to find studies on the subject that had not been registered in the usual bibliographical databases. Studies listed in more than one of the aforementioned sources were not duplicated. This procedure yielded 71 studies within the period at hand. However, a detailed analysis of those led us to discard thirteen papers for using non-psychometric QoL measures, eighteen works for having sample sizes below 30 subjects, sixteen due to the impossibility to estimate the effect size for lack of some relevant data (e.g., sample sizes clearly identified or lack of a statistical contrast estimator), another three because, despite using psychometric registers, they did not use standardized criteria to evaluate QoL, yet four more because they were applied to samples of children or adolescents or were case studies (<a class="elsevierStyleCrossRef" href="#bib0155">Seniow et al., 2003</a>), and finally another one which was not obtained within the study period. Therefore, sixteen studies were eventually analyzed (marked with * in the reference section) with a combined total of 2,644 subjects. To validate the paper's selection process, the work was conducted by two independent researchers. The degree of fit was obtained with Cohen's kappa coefficient (k=.84), which, in accordance with <a class="elsevierStyleCrossRef" href="#bib0065">Fleis’ criteria (1981)</a>, implies a very high agreement.Coding of the variablesWe considered a series of variables relevant to the majority of studies selected according to the scheme used by <a class="elsevierStyleCrossRef" href="#bib0145">Sánchez-Meca, Rosa and Olivares (1999)</a>. They were classified as substantive, methodological, or extrinsic characteristics.We defined the following dependent variables in order to estimate the intervention's effect: a) mean effect size in QoL outcome measures; and b) mean effect size in neuropsychological outcome measures. Below is the list of substantive characteristics registered: a) disease etiology (samples exclusively from TBI, other etiologies (OE) such as Multiple Sclerosis or Alzheimer's Disease, or samples with mixed etiology (ME)); b) neuropsychological intervention (focused on retraining strategies or on compensatory techniques or mixed interventions); c) works with a treatment focused exclusively on neuropsychological interventions (% works); d) months between diagnosis of the illness and neuropsychological treatment; e) intensity of rehabilitation procedures (number of sessions); f) duration of the intervention (number of weeks); and g) ratio between number of sessions and duration in weeks. We selected the following socio-demographic characteristics: a) gender distribution through the studied samples (percentage of women); and b) mean age.Below is the list for methodological characteristics registered: a) type of study design (clinical trials, one-group designs, or pre- and post-treatment designs); b) measurement procedures for QoL outcomes (psychometric approaches such as the SF-36 or other valid instruments); c) sample size; and d) number of measurement waves.The extrinsic characteristics analyzed were exclusively the publishing year stratified in four-year periods between 2001 and 2012. In order to assess the reliability of the proposed coding, we studied it on the sixteen selected studies and obtained an interclass correlation coefficient indicating high reliability in the coding (r=.88; p<.001).Some of the aforementioned variables required previously generating pertinent contingency tables from the original studies. In general, each variable's description was simple and the reconstruction of the table of observed frequencies involved manually calculating the application of a percentage to each sample size in order to obtain the observed frequency (e.g. the number of women treated versus placed in control groups in studies with group designs).Calculating the effect sizeFirstly, we obtained the estimate of the difference between standardized means for comparison studies between groups or in relation to the baseline measure and the standard difference between the pre- and post-treatment change scores in this type of tests. In some cases, we also reported percentages of improved subjects that were likewise used to estimate the effects of the intervention. In the latter cases, the Odds Ratio estimation was used as described by <a class="elsevierStyleCrossRef" href="#bib0140">Rücker, Schwarzer and Carpenter (2008)</a>. With all these results, we analyzed the 3×3 table generated by crossing the two main variables: the outcome measures in QoL (psychometric, qualitative, or mixed measures) and the type of treatment (retraining, compensation, or mixed). The data were then corresponded to each variable studied (effect size, sample size, years of diagnosis, etc.) for every possible combination. Therefore all the data tables from the studies were analyzed, and the odds ratio value was obtained for cases where the table presented a 2×2 order, later transformed to a correction value (r). For the remaining tables different from and larger than 3×3, the correlation values were estimated directly, which is usually the general indicator in meta-analysis works. All these analyses were conducted independently by two of the authors of the current paper, with completely matching estimates of the size effect and its corrections.Data analysisFirstly, r values were corrected by means of their variance to weigh them according to their sample sizes, since the p value related to the effect size is not independent from the sample size where it is estimated. This procedure was repeated following the scheme used by <a class="elsevierStyleCrossRef" href="#bib0130">Redondo, Sánchez-Meca and Garrido (2002)</a>, with the exception that, in that work, a fixed-effect model was used, and, in our case, we eventually opted for a random-effect model, given the high variability of the observed distributions of the effect sizes. All the analyses were conducted with the IBM-SPSS software, version 21.0, and some of the R software routines (<a class="elsevierStyleCrossRef" href="#bib0125">R Development Core Team, 2011</a>), more specifically, the Meta library (<a class="elsevierStyleCrossRef" href="#bib0150">Schwarzer, 2013</a>).ResultsDescription of the resultsFor the sixteen studies analyzed, the mean sample size was 165.25 (SD=11.08) and when combined, the studies yielded a mean age of 56.26 years (SD=9.13). The average time between the diagnosis of the disease and the onset of the cognitive rehabilitation program was 4.12 months (SD=1.11). The average number of sessions was 25 (SD=3.11) (range between 18 and 35). The average duration of the intervention from the onset of the program was 14 weeks (SD=1.94).Eleven (68.75%) of the studies used a clinical trial methodological strategy, two (12.5%) used case control, and the rest (3 studies) used a simple pre- and post-treatment design with repeated measures. In regard to measurement procedures, fifteen (93.75%) used strategies strictly based on psychometric-base questionnaires and/or scales (SF-36, WHOL, QoFS, etc.) to evaluate the outcome in QoL. No studies used qualitative evaluations by means of semi-structured interviews, and only one (6.25%) used both strategies. As for the publishing year, three studies were published between 2001 and 2003, three between 2004 and 2006, seven between 2007 and 2009, and three between 2010 and 2012. Two studies (12.5%) involved subjects with TBI (strokes caused by traffic and work accidents); eleven focused on individuals with other neuropsychological conditions, such as Multiple Sclerosis, Alzheimer's Disease, and Mild Cognitive Impairment, among others (68.65%). The rest of the studies (3) used subjects suffering from several pathologies. Finally, seven studies (43.75%) focused on retraining strategies, whereas two (12.5%) directed the treatment at compensation systems, and seven (43.75%) set forth mixed rehabilitation procedures (both retraining and compensation mechanisms).Finally, we would like to point out that the assessment of statistical and methodological quality (scale 1 to 7, 1 for a low evaluation, and 7 for and excellent evaluation)—conducted by four independent experts (coefficient of concordance of .94)—of the selected works yielded a mean of 5.77 (SD=0.91), which would indicate a not especially high methodological and statistical test in the complexity of the designs and statistical treatments set forth. These types of estimations are of little relevance, but they offer an approximate idea of the complexity of the strategies used and are frequent in studies on meta-analyses.Mean effect sizeAfter obtaining the effect sizes based on correlation, the observed global mean was r+=.38, which points at a highly significant effect (p<.001). These results are important because the obtained signification shows a high effect size. In order to establish better these results, the Binomial Effect Size Display (BESD) was applied (<a class="elsevierStyleCrossRef" href="#bib0135">Rosenthal & Rubin, 1982</a>; <a class="elsevierStyleCrossRef" href="#bib0175">Valera-Espín & Sánchez-Meca, 1997</a>). The BESD estimated values obtained for the treatment groups were of 60.28% and obviously of 39.72% for the failure. This high percentage warrants the significance of the results in the statistical and clinical domain. The analysis of the contingency tables indeed shows a clear tendency toward the use of intervention systems based on retraining by means of simple designs of pre- and post-test repeated measures. That is consistent with the data of previous meta-analyses conducted with English-speaking samples. As stated by <a class="elsevierStyleCrossRef" href="#bib0160">Sitzer et al. (2006)</a>, this would be expected in clinical trials applied in hospitals and is consistent with works similar to the present one, such as <a class="elsevierStyleCrossRef" href="#bib0030">Cicerone (2005)</a>.Moderating variablesThe initial analysis with the direct effect sizes show clear statistical significance (QT(15) = 97.42; p<.001), so we can assume the heterogeneity of the effect sizes derived from the different studies. Therefore, the need arises to evaluate the role of the different moderating variables identified in this study in order to search for reasonable explanations for that difference both in the boarding system and in the mechanisms of intervention. The mean effect size is good complementary information. Accordingly, the meta-analytical approach here presented may provide us with more thorough data than merely checking the published works, which is the usual methodology in scientific literature reviews.Therefore, the descriptive effect in favor of retraining strategies versus compensation strategies—discussed in the next section—must be clarified according to the role of the moderating variables we have determined, since it is reasonable that some of them may provide relevant information regarding the differences we found. The tables below show the statistical significance found for qualitative variables (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) and for quantitative variables (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Statistically significant data in both tables present a relatively clear scenario. First, regarding <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, we see that (QB(2)= 33.01; p<.05), so we can infer that this type of works use pre- and post-test designs with repeated measures without much of a doubt about that effect (r+=.62), as compared to those using clinical trials (r+=.22) or case control strategies (r+=11). In relation to the measurement procedures, the use of scales is the only significant source (r+=.88) and it allows us to infer that the scientific community widely agrees on this point and that both effects are important, given that R2=.371 (37.1% of explained variance), which should not be discarded. In fact, the effect of using psychometric scales for both pre- and post-test evaluations is decisive.Likewise, the papers published within the 2007–2009 period (r+=.31) show a tendency toward a somewhat higher average effect size (QB(3) = 32.41; p<.05), so it would be reasonable to think that over time the number of studies has increased, and the studies have become clearer with more significant effect sizes (18.1% of explained variance). In other words, in two years there has not only been a clear breakthrough in the number of studies published with non-Spanish-speaking samples.We would like to point out that the estimated effect is distributed asymmetrically among the studies using samples of patients with external or internal pathologies according to the definition above. External pathologies (r+=.10) were not statistically significant, but internal pathologies (r+=.47) were clearly significant instead (p<.01). The effect of samples with both pathologies has been discarded due to non-significance (r+=.07). Finally, the combined effect derived from retraining interventions was highly statistically significant (r+=.67; p<.01), as was the effect associated to the compensatory intervention (r+=.25; p<.05). Despite being statistically significant, they are far from the effect obtained by retraining interventions. Probably, that effect is partly due to the different tradition in the clinical studies applied to the one we discussed above, which focused on retraining as a choice of intervention in relatively simple designs. No associated effect to the mixed strategy was noted (r+=.039). In general, the explained variance was high (R2=.345 or 34.5% of the total) and statistically significant (QB(2) = 42.13; p<.05).If we focus on <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>, regression models show some effects to be highlighted. The percentage of works focusing solely on neuropsychological interventions (QR(8) = 3.228) was not significant. Instead, the months gone by from the diagnosis to the onset of the intervention (QR(5) = 7.931; p<.05), and the number of sessions (QR(12) = 9.271; p<.05) applied were significant. The duration of the intervention program was statistically significant (QR(12) = 8.222; p<.05), therefore it seems that longer rehabilitation programs bring more effect to the therapy results. Likewise, although there was no clear statistical significance (QR(12) = 7.121), a tendency can be established toward ratio significance between weekly sessions and the number of weeks of the program. This adds to the notion that a greater effect is obtained in programs involving more sessions during a longer period of time.The crucial data in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> are the results obtained with the data derived from the outcome in neuropsychological performance. The result is highly significant (QR(15) = 14.712; p<.01) for neuropsychological measures, exclusively. Thus, we can interpret that the studies analyzed show that cognitive rehabilitation programs are effective with an effect size that may be responsible for up to 38% of the explained variation, and, even more importantly, that effect is more intense when they are estimated by comparing the pre- and post- levels of these patients’ perceived QoL, up to 39% of the explained variation. There are no differences between one choice and the other, but it is important to highlight a certain tendency to improve neuropsychological values over strictly QoL measures.These comments need to be clarified, partially, by the role of the subject and the methodological variables included in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. There is, indeed, an evident bias in favor of women and younger patients. In the case of women, the effect is clear (QR(15) = 9.154; p<.05), and even more conclusive in the mean age of the groups treated (QR(15) = 17.992; p<.01). It should all be interpreted in the sense that the favorable effect in post-evaluations is more pronounced in the case of women and younger subjects (the coefficient of regression is negative, (β = −.392). Likewise, the effect attributed to the study of sample sizes and the number of measurements is also crucial. As regards the sample size, the results we obtained (QR(15) = 12.543; p<.01) show that the effect size is higher and clearer with large samples. It is also important to note that the effect of the duration of the follow-ups (measurement waves) is also clearly significant (QR(15) = 16.211; p<.01). The negative value of the coefficient of regression (β = −.399) would show that, as the follow-up duration increases, the effect size decreases. The reduction of post- effects is clear, as they seem to dilute over time. Both variables are essential given the variation percentages they explain: 29% and 33% respectively. Finally, in order to evaluate the possible bias of publication, we estimated the Egger test (<a class="elsevierStyleCrossRef" href="#bib0055">Egger, Smith, Schneider, & Minder, 1997</a>), which was non-significant (p=.86). Therefore it was unnecessary to include information of the Funnel plot.DiscussionThe results allow us to draw several conclusions. Firstly, it is important to highlight that the number of papers with non-Spanish-speaking samples analyzed (16) was lower than the number of papers with Spanish-speaking samples (21) reported on <a class="elsevierStyleCrossRef" href="#bib0080">Guàrdia et al. (2012)</a>, since the publications in non-Spanish-speaking countries vastly outnumber any others. The reason may lie in the fact that this type of works commonly use clinical samples, and intervention times are glaringly longer in Spanish-speaking healthcares than in non-Spanish-speaking ones. Additionally, in the Spanish-speaking world, it is somewhat more common to use Quality of Life measurements as indicators of effect associated to the neurorehabilitation program. The tradition in the Spanish-speaking neuropsychological approach is somewhat longer than in the non-Spanish-speaking one.Furthermore, we must note the existence of a positive effect of neuropsychological rehabilitation techniques on QoL. We can thus state that the different neuropsychological intervention therapies improve the patients’ quality of life, with a moderate effect size. However, that effect tends to decrease over time. As time goes by after the neuropsychological intervention applied, the patient's quality of life tends to diminish, which suggests that the therapy's positive effect on the variable is not permanent. In addition, the rehabilitation's effect on QoL is very much influenced by several moderating variables, both quantitative and qualitative. As for the effect of the substantive variables, we must note that the type of therapy applied seems to influence the phenomenon under study, so that those works where the neuropsychological intervention was based on the use of retraining techniques are the ones showing the greatest improvements in their patients’ quality of life, whereas those using compensatory treatment strategies yield more modest results. However, that fact can be due, at least partly, to the slightly higher number of participants in that sub-sample than in other intervention groups, which is hardly surprising when we consider that those techniques have a greater tradition in neuropsychological intervention. For that reason, this fact could be biasing the results, thus yielding a greater effect size than other interventions. Other substantive variables interfering with the neuropsychological rehabilitation's effect on QoL are all those related to the intensity and the duration of the interventions. If we increase the weeks of duration of the intervention, the number of sessions of the intervention, and the relationship between the number of sessions and the duration of the intervention in weeks, then the effects on QoL increase, too. Nevertheless, those variables must be understood within the patients’ clinical context, since they are often determined by the conditions of the health services. The neuropsychological deficit's etiology is another substantive variable seeming to influence the effects of rehabilitation on QoL. Accordingly, neuropsychological interventions do not seem to bear a positive effect on QoL in persons who suffered from traumatic brain injury, but instead they do on patients with cognitive alterations due to other etiologies. The patients’ age also had an important mediating effect. Younger persons seem to obtain greater increases in their QoL after rehabilitation.With regard to the method's variables, the works using a clinical trial classic methodology obtained greater increases in QoL after clinical interventions than the studies using a pre-test post-test methodology and the case and control studies, since in the latter the rehabilitation bore no significant effect on QoL. However, most of the studies included in the present meta-analysis used the clinical trial methodology, for which reason the number of patients included in this sub-sample is much larger than in the other two, which could bias the statistical effects found in this work. As for the extrinsic variables, the year of publication influences the effect size of post-intervention QoL. Accordingly, it is highest in the group of papers published between 2007 and 2009. Yet again, the number of works published in this period is higher than in the other periods studied, with a greater accumulated sample size, which entails a possible bias effect on the estimated effect size.When comparing the results of the present works to those of Spanish-speaking samples (<a class="elsevierStyleCrossRef" href="#bib0080">Guàrdia et al., 2012</a>), we must highlight the following conclusions. Both present important differences as regards the results obtained. The present paper has a higher total sample size than the Spanish-speaking samples and comprises originals with a higher average number of participants. Likewise, among the studies included in this meta-analysis, there are more of them using a clinical trial methodology and, in general, from the methodological point of view, i.e., the originals included in this meta-analysis have a higher methodological quality than those included in <a class="elsevierStyleCrossRef" href="#bib0080">Guàrdia et al. (2012)</a>. Important differences also exist between them regarding several substantive variables that have an important mediating effect on QoL. Therefore, in the present work, the duration and the intensity of neuropsychological interventions were higher than in <a class="elsevierStyleCrossRef" href="#bib0080">Guàrdia et al. (2012)</a>. The patients’ average age in this study is lower than in the study with Spanish-speaking samples, and the time elapsed between the onset of the disease and the administration of neuropsychological treatment is shorter in this paper than in <a class="elsevierStyleCrossRef" href="#bib0080">Guàrdia et al. (2012)</a>. Likewise, important differences exist between both meta-analyses regarding the type of treatment administered. In both works, a significant proportion of the patients were treated using only retraining techniques, but in the study with Spanish-speaking samples, a great number of patients were treated only with compensatory techniques, and very few were treated with a combination of both techniques. In contrast, in the present study, the opposite tendency was observed. More patients were treated with a combination of techniques than with compensatory strategies only.Even more significant are the differences between both studies as regards substantive variables such as the patients’ age, the time elapsed between the onset of the disease and the treatment, or its intensity. We must point out that such variables usually affect the neuropsychological treatment's outcome (<a class="elsevierStyleCrossRef" href="#bib0115">Niemeier, Kreutzer, Marwitz, Gary, & Ketchum, 2011</a>), for which reason it might also be expected that they should have a direct effect on the patients’ quality of life. Despite all these differences, the general conclusions of the present work agree with those of <a class="elsevierStyleCrossRef" href="#bib0080">Guàrdia et al. (2012)</a>. In both cases, we can conclude that neuropsychological rehabilitation has a positive effect on HRQoL, with a moderate effect size. However, as the follow-up time goes by, the effects of neuropsychological rehabilitation tend to diminish and even disappear. Therefore, both studies also agree on this change seemingly not being permanent. The fact that the central conclusion of both meta-analyses agrees on substantive variables is important, given that it favors the idea that our interpretation of the data is correct and, therefore, our conclusions are accurate. Our study presents an important limitation, which is that it was not possible to analyze the mediating effect of such variables as the severity of the pathology or the patient's socio-economic context. These are variables which, as is known, influence the outcome of the neuropsychological rehabilitation (<a class="elsevierStyleCrossRef" href="#bib0010">Arango, 2012</a>), they could affect QoL, and they are indeed part of that construct (<a class="elsevierStyleCrossRef" href="#bib0100">Mayo, Moriello, Asano, Van der Spuy, & Finch, 2011</a>). This is because the works considered here have not involved analyzable data in relation to those variables. Leaving aside the latter consideration, the consonance between the results obtained in both populations allow us to guarantee a clear line in the effects found, as well as serious limitations in the effect's perdurability.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres528398" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec548646" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres528397" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec548647" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Method" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Search of studies" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Coding of the variables" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Calculating the effect size" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Data analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Description of the results" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Mean effect size" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Moderating variables" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflicts of interest" ] 9 => array:2 [ "identificador" => "xack180141" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-02-02" "fechaAceptado" => "2014-07-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec548646" "palabras" => array:4 [ 0 => "Neuropsychological rehabilitation" 1 => "Quality of life" 2 => "Cognitive deficit" 3 => "Meta-analysis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec548647" "palabras" => array:4 [ 0 => "Rehabilitación neuropsicológica" 1 => "Calidad de vida" 2 => "Déficits cognitivos" 3 => "Meta-análisis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The purpose of this study was to conduct a meta-analysis on the effects of neuropsychological rehabilitation procedures on the quality of life in non-Spanish-speaking individuals with some cognitive deficit. Sixteen studies published during the 2001–2012 period which yielded relevant information regarding the sample sizes used, the types of statistical contrasts, the evaluation instruments or pathologies among others, were analyzed. We carried out study following the usual estimation procedures, based on the definition of the effect size and the scrutiny of their relationship with relevant variables (e.g., sample sizes, type of population), or methodological variables (e.g., type of research or sampling design). The data analysis shows a statistically significant effect (r+=.38; p<.001) in all the variables associated with the characteristics of the intervention (duration, type of intervention, gender, year of publication and, more importantly, quality of life and neuropsychological outcomes). As a general conclusion, we were able to determine that Quality of Life (QoL) can improve, under certain conditions, through neuropsychological rehabilitation, but this change is not permanent." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El propósito de este estudio fue generar un meta-análisis sobre los efectos de la rehabilitación neuropsicológica en la dimensión Calidad de Vida en muestras de no hispano-hablantes, con algún déficit cognitivo. Se analizaron dieciséis estudios publicados durante el período 2001–2012, que mostraron información relevante con respecto a los tamaños de muestra utilizados, los tipos de contrastes estadísticos, los instrumentos de evaluación o diagnóstico, entre otros. Se realizó el estudio siguiendo los procedimientos de estimación habituales, sobre la base de la definición del tamaño del efecto y el análisis de su relación con las variables relevantes (tamaños de muestra, tipo de población, etc.), o variables metodológicas (tipo de investigación o diseño de la muestra, etc.) El análisis de los datos muestra un efecto estadísticamente significativo (r+=.38, p<.001) en todas las variables asociadas a las características de la intervención (duración, tipo de intervención, género, año de publicación y, más importante, la calidad de vida y los resultados neuropsicológicos). Como conclusión general, la dimensión calidad de vida (QoL) puede mejorar, bajo ciertas condiciones, a través de la rehabilitación neuropsicológica, pero este cambio no es permanente." ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "Note. k = Numberof studies for each category; r+j = mean of the correlation coefficient; Qb = statistical signification test; R2 determination coefficient." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Moderating variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">kj \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">r+j \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">QB \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">R2 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Method variables \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.01<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.371 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Study design</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Clinical trials \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.22<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">One group design \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pre-Post-test desig \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.62<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Measurement procedures</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Psychometric approach \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.88<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other psychometric \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Extrinsic variables \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.41<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.181 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Year of publication</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">2001–2003 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">2004–2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">2007–2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.31<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">2010–2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Substantive variables \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.13<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.345 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Disease etiology</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Traumatic Brain Injury (TBI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other Etiologies (OE) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.47<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mixed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Neuropsychological intervention</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Retraining \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.67<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Compensatory \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.25<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mixed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.039 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab850825.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "p<.05" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "**" "nota" => "p<.01" ] ] ] "descripcion" => array:1 [ "en" => "Results of the variance analyses for the qualitative moderating variables." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "Note. k = number of studies; B = is the non-standardized regression coefficient; Qr = statistical signification test for each regression coefficient; R2 = the determination coefficient." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Moderating variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">kj \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">B \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">QR(df) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">R2 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Substantive variables</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mean effect size in neuropsychological outcome measures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.399 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.712(15)<a class="elsevierStyleCrossRef" href="#tblfn0020">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Works with treatment focused exclusively on neuropsychological interventions (% works) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.219 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.228(8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Months between illness diagnosis and neuropsychological treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.121 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.931<a class="elsevierStyleCrossRef" href="#tblfn0015">*</a>(5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Intensity of rehabilitation procedures (Number of sessions) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.299 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.271<a class="elsevierStyleCrossRef" href="#tblfn0015">*</a>(12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Intervention's duration (Number of weeks) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.218 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.222<a class="elsevierStyleCrossRef" href="#tblfn0015">*</a>(12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ratio between number of sessions by duration in weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.232 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.121(12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Subject variables</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Gender (% of women in the samples) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.077 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.154<a class="elsevierStyleCrossRef" href="#tblfn0015">*</a>(15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">-.392 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.992<a class="elsevierStyleCrossRef" href="#tblfn0020">**</a>(15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.39 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Method variables</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Sample size \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.278 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.543<a class="elsevierStyleCrossRef" href="#tblfn0020">**</a>(15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.29 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Number of measurement waves \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">-.399 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.211<a class="elsevierStyleCrossRef" href="#tblfn0020">**</a>(15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.33 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab850824.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "*" "nota" => "p<.05" ] 1 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "**" "nota" => "p<.01" ] ] ] "descripcion" => array:1 [ "en" => "Results of the weighted simple regression analyses for the quantitative moderating variables." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:37 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "Ahn et al., 2012" "referencia" => array:1 [ 0 => array:2 [ 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Von Steinbuechel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.apmr.2010.06.033" "Revista" => array:6 [ "tituloSerie" => "Archives of Physical Medicine and Rehabilitation" "fecha" => "2010" "volumen" => "91" "paginaInicial" => "1650" "paginaFinal" => "1660" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21044708" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack180141" "titulo" => "Acknowledgements" "texto" => "This research was made possible by the PSI2010-21214-C02-01 project and was carried out by members of the Generalitat de Catalunya's SGR 388 Consolidated Research Group." "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21712069/0000000600000001/v1_201507010000/S2171206915700025/v1_201507010000/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/21712069/0000000600000001/v1_201507010000/S2171206915700025/v1_201507010000/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2171206915700025?idApp=UINPBA00004N"]

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Neuropsychological rehabilitation and quality of life: A meta-analysis

Rehabilitación neuropsicológica y calidad de vida: una aproximación meta-analítica

Joan Guàrdia-Olmosa,

Corresponding author

jguardia@ub.edu

Corresponding author: Departament de Metodologia de les Ciències del Comportament. Facultat de Psicologia. Universitat de Barcelona. Passeig de la Vall d’Hebron, 171. 08035 Barcelona (Spain).

, Maribel Peró-Cebolleroa, Esteve Gudayol-Ferréb

a Department of Methodology for Behavioral Sciences, School of Psychology, University of Barcelona, Research Institute of Brain, Cognition and Behavior (IR3C), Barcelona, Spain

b School of Psychology, Universidad Michoacana de San Nicolás de Hidalgo de Morelia, Morelia, MICH, Mexico

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Health-Related Quality of Life &#40;HRQoL&#41; is a wide concept&#44; but there exists consensus on it being a subjective measure of physical&#44; emotional&#44; and psychological conditions &#40;<a class="elsevierStyleCrossRef" href="#bib0095">Londos et al&#46;&#44; 2008</a>&#41;&#46; Some studies define HRQoL as an assessment of how a disease and its treatment affect a person&#39;s capability to develop everyday activities and play valuable roles in their own life &#40;<a class="elsevierStyleCrossRef" href="#bib0025">Brissart&#44; Leroy&#44; &#38; Debouverie&#44; 2010</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0060">Fergusson et al&#46;&#44; 2012</a>&#41;&#46; Neuropsychological diseases&#44; like any other diseases&#44; affect the quality of life &#40;QoL&#41; of those who suffer from it &#40;<a class="elsevierStyleCrossRef" href="#bib0110">Murell&#44; 1999</a>&#41;&#46; In spite of that&#44; the HRQoL of the persons suffering from neuropsychological alterations has not been widely studied&#44; and it is often claimed that rehabilitating treatments in neuropsychological diseases improve the patients&#8217; quality of life without actually measuring HRQoL &#40;<a class="elsevierStyleCrossRef" href="#bib0095">Londos et al&#46;&#44; 2008</a>&#41;&#46; Other works &#40;<a class="elsevierStyleCrossRef" href="#bib0030">Cicerone&#44; 2005</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0185">Wilde et al&#46;&#44; 2010</a>&#41; have recommended using HRQoL measures as outcome measures in order to grade the efficacy of neuropsychological rehabilitation in traumatic brain injury &#40;TBI&#41;&#46; Few works have studied the possible impact of neuropsychological interventions on the QoL of patients with cognitive alterations&#46; There exist works on patients with epilepsy&#44; TBI&#44; multiple sclerosis&#44; cardiovascular events&#44; mild cognitive impairment&#44; Alzheimer&#39;s disease&#44; and persons on chemotherapy&#46; The methodology used in those works includes pre- and post-treatment observational studies &#40;<a class="elsevierStyleCrossRef" href="#bib0040">Cohen&#44; Ylvisaker&#44; Hamilton&#44; Kemp&#44; &#38; Claiman&#44; 2010</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0095">Londos et al&#46;&#44; 2008</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0120">Rasquin et al&#46;&#44; 2010</a>&#41;&#44; case and control studies &#40;<a class="elsevierStyleCrossRef" href="#bib0170">Svendsen &#38;Teasdale&#44; 2006</a>&#41;&#44; and several clinical trials &#40;<a class="elsevierStyleCrossRef" href="#bib0020">Brenk&#44; Laun&#44; &#38; Haase&#44; 2008</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0035">Clare et al&#46;&#44; 2010</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0045">Davis&#44; Massman&#44; &#38; Doody&#44; 2001</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0050">Engelberts et al&#46;&#44; 2002</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0070">Gehring et al&#46;&#44; 2009</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0085">Hildebrand et al&#46;&#44; 2007</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0090">Lincoln et al&#46;&#44; 2002</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0165">Solari&#44; Pucci&#44; Forni&#44; Mancardi&#44; &#38; Pozzilli&#44; 2004</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0180">Voght et al&#46;&#44; 2009</a>&#41;&#46; Those studies present controversial results&#58; whereas some find a positive effect of neuropsychological rehabilitation on QoL &#40;<a class="elsevierStyleCrossRef" href="#bib0020">Brenk et al&#46;&#44; 2008</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0035">Clare et al&#46;&#44; 2010</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0040">Cohen et al&#46;&#44; 2010</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0050">Engelberts et al&#46;&#44; 2002</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0075">Glanz et al&#46;&#44; 2010</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0105">Melchers&#44; Maluck&#44; Suhr&#44; Scholten&#44; &#38; Lehmkuhl&#44; 1999</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0170">Svendsen &#38; Teasdale&#44; 2006</a>&#41;&#44; others do not &#40;<a class="elsevierStyleCrossRef" href="#bib0045">Davis et al&#46;&#44; 2001</a>&#41;&#46; This positive effect on the patients&#8217; quality of life is observable immediately after rehabilitation but is not persistent in follow-up evaluations &#40;<a class="elsevierStyleCrossRef" href="#bib0165">Solan et al&#46;&#44; 2004</a>&#41;&#46; Other works find a positive effect of cognitive rehabilitation on some&#44; but not all&#44; QoL measures &#40;<a class="elsevierStyleCrossRef" href="#bib0155">Seniow&#44; Polanowska&#44; Mandat&#44; &#38; Laudanski&#44; 2003</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0160">Sitzer&#44; Twamley&#44; &#38; Jeste&#44; 2006</a>&#41;&#46; These are understandable controversies given that most works use small samples of patients with different diseases&#44; have different designs&#44; apply neuropsychological interventions of a different nature&#44; duration&#44; intensity&#44; and use diverse instruments to measure HRQoL&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A previous work &#40;<a class="elsevierStyleCrossRef" href="#bib0080">Gu&#224;rdia&#44; Jarne&#44; Urz&#250;a&#44; &#38; Gudayol&#44; 2012</a>&#41; dealing with the impact of neuropsychological rehabilitation on QoL intended to approach this phenomenon by using meta-analysis techniques while bearing in mind their possible mediating effects in the analysis&#44; as well as other substantive&#44; methodological&#44; and socio-demographic variables which may be affecting the results of the aforementioned works&#46; That study yielded the following conclusions&#58; the positive effect of the rehabilitating intervention is generally linked to an improvement in the patients&#8217; quality of life&#46; Likewise the use of retraining techniques &#40;techniques intended to restore the lost cognitive function&#41; seems to have a positive effect on HRQoL that is more intense than the effect of compensatory techniques &#40;techniques designed to improve specific aspects of everyday life despite the specific cognitive loss experienced by the patient&#41;&#46; That positive effect of cognitive rehabilitation on HRQoL tends to decrease as time goes by between the clinical intervention and the follow-up&#59; and when analyzing the data as a whole&#44; each study&#39;s sample size and design have a direct influence on the effect size of the QoL improvement&#46; In fact&#44; the above-mentioned work reanalyzes data from Spanish-speaking samples&#44; and as the authors admit&#44; most of the studies included in their study have a pre- post- simple design where the variable control mechanisms are minimal&#44; and they tend to magnify the effect sizes of the phenomenon under study &#40;<a class="elsevierStyleCrossRef" href="#bib0005">Ahn&#44; Myers&#44; &#38; Jin&#44; 2012</a>&#41;&#46; Moreover the study purposefully excluded the works conducted with non-Spanish-speaking samples&#44; and consequently&#44; it involved relatively few works&#46; On the date of its publication&#44; there existed no other meta-analyses on the subject that allowed the authors to contrast their findings&#46; Therefore their conclusions must be considered preliminary and they should be contrasted with results from non-Spanish-speaking samples&#44; much more common in scientific literature&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Thus&#44; the goal of the present study is to conduct a meta-analysis of the effects of neuropsychological rehabilitation on the QoL of patients with neuropsychological alterations by using non-Spanish-speaking samples&#44; according to the phases proposed by <a class="elsevierStyleCrossRef" href="#bib0015">Botella and Gambara &#40;2006&#41;</a>&#46; In addition&#44; we intend to compare our results to those of the individual works that approached this topic&#44; and to the results of the meta-analysis by <a class="elsevierStyleCrossRef" href="#bib0080">Gu&#224;rdia et al&#46; &#40;2012&#41;</a>&#46; The differences between&#44; for example&#44; the sample sizes in works with Spanish-speaking samples and those with non-Spanish-speaking samples are so large in most cases that it is impossible to carry out one integrated study with all the papers&#44; with Spanish- or non-Spanish-speaking samples&#44; apart from the fact that the conditions of assistance and neurorehabilitating intervention are not comparable&#44; either&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Method</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Search of studies</span><p id="par0020" class="elsevierStylePara elsevierViewall">To be included in this meta-analysis&#44; studies had to comply with the following inclusion criteria&#58; a&#41; they had to be original works focused on neuropsychological rehabilitation&#44; that is&#44; assessing the effect of a neurorehabilitation program&#59; b&#41; the studies had to have been published from 2001 to 2012 given that&#44; prior to that period&#44; there exist very few studies and they are much apart in time&#59; c&#41; they had to be indexed in Journal Citation Reports&#44; PsycInfo&#44; Pubmed&#44; Scopus&#44; SciELO&#44; and Latindex&#59; d&#41; the papers had to include at least one psychometric standardized QoL measure&#59; e&#41; the study design had to be recognizable and undoubted in relation to the other variables set forth in this work&#59; f&#41; the studies had to be conducted on non-Spanish-speaking countries&#59; g&#41; the samples had to comprise adults only&#44; samples of children and adolescents were excluded&#59; and h&#41; the studies had to include samples of subjects&#44; case studies were excluded&#46; We also excluded studies according to the following exclusion criteria&#58; a&#41; works where the concept of QoL was not operationalized empirically&#59; and b&#41; the methodological aspects were unclear&#44; that is&#44; neither the design type&#44; nor the measures used&#44; or the statistical contrasts were clearly identifiable&#46; Complementing the above&#44; we would like to specify that we conducted a search based on the Boolean criteria derived from the use of the following key words&#58; Neuropsychological Neurorehabilitation&#44; Clinical Trials&#44; Estimation Clinical Effect Size&#44; Quality of Life&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Also&#44; a manual search was conducted in some psychological or medical bibliographical sources &#40;for example&#44; reports by organizations of renowned prestige such as the World Health Organization or individual universities&#41; hoping to find studies on the subject that had not been registered in the usual bibliographical databases&#46; Studies listed in more than one of the aforementioned sources were not duplicated&#46; This procedure yielded 71 studies within the period at hand&#46; However&#44; a detailed analysis of those led us to discard thirteen papers for using non-psychometric QoL measures&#44; eighteen works for having sample sizes below 30 subjects&#44; sixteen due to the impossibility to estimate the effect size for lack of some relevant data &#40;e&#46;g&#46;&#44; sample sizes clearly identified or lack of a statistical contrast estimator&#41;&#44; another three because&#44; despite using psychometric registers&#44; they did not use standardized criteria to evaluate QoL&#44; yet four more because they were applied to samples of children or adolescents or were case studies &#40;<a class="elsevierStyleCrossRef" href="#bib0155">Seniow et al&#46;&#44; 2003</a>&#41;&#44; and finally another one which was not obtained within the study period&#46; Therefore&#44; sixteen studies were eventually analyzed &#40;marked with &#42; in the reference section&#41; with a combined total of 2&#44;644 subjects&#46; To validate the paper&#39;s selection process&#44; the work was conducted by two independent researchers&#46; The degree of fit was obtained with Cohen&#39;s kappa coefficient &#40;<span class="elsevierStyleItalic">k</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;84&#41;&#44; which&#44; in accordance with <a class="elsevierStyleCrossRef" href="#bib0065">Fleis&#8217; criteria &#40;1981&#41;</a>&#44; implies a very high agreement&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Coding of the variables</span><p id="par0030" class="elsevierStylePara elsevierViewall">We considered a series of variables relevant to the majority of studies selected according to the scheme used by <a class="elsevierStyleCrossRef" href="#bib0145">S&#225;nchez-Meca&#44; Rosa and Olivares &#40;1999&#41;</a>&#46; They were classified as substantive&#44; methodological&#44; or extrinsic characteristics&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We defined the following dependent variables in order to estimate the intervention&#39;s effect&#58; a&#41; mean effect size in QoL outcome measures&#59; and b&#41; mean effect size in neuropsychological outcome measures&#46; Below is the list of substantive characteristics registered&#58; a&#41; disease etiology &#40;samples exclusively from TBI&#44; other etiologies &#40;OE&#41; such as Multiple Sclerosis or Alzheimer&#39;s Disease&#44; or samples with mixed etiology &#40;ME&#41;&#41;&#59; b&#41; neuropsychological intervention &#40;focused on retraining strategies or on compensatory techniques or mixed interventions&#41;&#59; c&#41; works with a treatment focused exclusively on neuropsychological interventions &#40;&#37; works&#41;&#59; d&#41; months between diagnosis of the illness and neuropsychological treatment&#59; e&#41; intensity of rehabilitation procedures &#40;number of sessions&#41;&#59; f&#41; duration of the intervention &#40;number of weeks&#41;&#59; and g&#41; ratio between number of sessions and duration in weeks&#46; We selected the following <span class="elsevierStyleItalic">socio-demographic characteristics&#58;</span> a&#41; gender distribution through the studied samples &#40;percentage of women&#41;&#59; and b&#41; mean age&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Below is the list for methodological characteristics registered&#58; a&#41; type of study design &#40;clinical trials&#44; one-group designs&#44; or pre- and post-treatment designs&#41;&#59; b&#41; measurement procedures for QoL outcomes &#40;psychometric approaches such as the SF-36 or other valid instruments&#41;&#59; c&#41; sample size&#59; and d&#41; number of measurement waves&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The extrinsic characteristics analyzed were exclusively the publishing year stratified in four-year periods between 2001 and 2012&#46; In order to assess the reliability of the proposed coding&#44; we studied it on the sixteen selected studies and obtained an interclass correlation coefficient indicating high reliability in the coding &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;88&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Some of the aforementioned variables required previously generating pertinent contingency tables from the original studies&#46; In general&#44; each variable&#39;s description was simple and the reconstruction of the table of observed frequencies involved manually calculating the application of a percentage to each sample size in order to obtain the observed frequency &#40;e&#46;g&#46; the number of women treated versus placed in control groups in studies with group designs&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Calculating the effect size</span><p id="par0055" class="elsevierStylePara elsevierViewall">Firstly&#44; we obtained the estimate of the difference between standardized means for comparison studies between groups or in relation to the baseline measure and the standard difference between the pre- and post-treatment change scores in this type of tests&#46; In some cases&#44; we also reported percentages of improved subjects that were likewise used to estimate the effects of the intervention&#46; In the latter cases&#44; the Odds <span class="elsevierStyleItalic">Ratio</span> estimation was used as described by <a class="elsevierStyleCrossRef" href="#bib0140">R&#252;cker&#44; Schwarzer and Carpenter &#40;2008&#41;</a>&#46; With all these results&#44; we analyzed the 3&#215;3 table generated by crossing the two main variables&#58; the outcome measures in QoL &#40;psychometric&#44; qualitative&#44; or mixed measures&#41; and the type of treatment &#40;retraining&#44; compensation&#44; or mixed&#41;&#46; The data were then corresponded to each variable studied &#40;effect size&#44; sample size&#44; years of diagnosis&#44; etc&#46;&#41; for every possible combination&#46; Therefore all the data tables from the studies were analyzed&#44; and the odds <span class="elsevierStyleItalic">ratio</span> value was obtained for cases where the table presented a 2&#215;2 order&#44; later transformed to a correction value &#40;<span class="elsevierStyleItalic">r</span>&#41;&#46; For the remaining tables different from and larger than 3&#215;3&#44; the correlation values were estimated directly&#44; which is usually the general indicator in meta-analysis works&#46; All these analyses were conducted independently by two of the authors of the current paper&#44; with completely matching estimates of the size effect and its corrections&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Data analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">Firstly&#44; <span class="elsevierStyleItalic">r</span> values were corrected by means of their variance to weigh them according to their sample sizes&#44; since the p value related to the effect size is not independent from the sample size where it is estimated&#46; This procedure was repeated following the scheme used by <a class="elsevierStyleCrossRef" href="#bib0130">Redondo&#44; S&#225;nchez-Meca and Garrido &#40;2002&#41;</a>&#44; with the exception that&#44; in that work&#44; a fixed-effect model was used&#44; and&#44; in our case&#44; we eventually opted for a random-effect model&#44; given the high variability of the observed distributions of the effect sizes&#46; All the analyses were conducted with the IBM-SPSS software&#44; version 21&#46;0&#44; and some of the R software routines &#40;<a class="elsevierStyleCrossRef" href="#bib0125">R Development Core Team&#44; 2011</a>&#41;&#44; more specifically&#44; the Meta library &#40;<a class="elsevierStyleCrossRef" href="#bib0150">Schwarzer&#44; 2013</a>&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Description of the results</span><p id="par0065" class="elsevierStylePara elsevierViewall">For the sixteen studies analyzed&#44; the mean sample size was 165&#46;25 &#40;<span class="elsevierStyleItalic">SD</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#46;08&#41; and when combined&#44; the studies yielded a mean age of 56&#46;26 years &#40;<span class="elsevierStyleItalic">SD</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#46;13&#41;&#46; The average time between the diagnosis of the disease and the onset of the cognitive rehabilitation program was 4&#46;12 months &#40;<span class="elsevierStyleItalic">SD</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;11&#41;&#46; The average number of sessions was 25 &#40;<span class="elsevierStyleItalic">SD</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;11&#41; &#40;range between 18 and 35&#41;&#46; The average duration of the intervention from the onset of the program was 14 weeks &#40;<span class="elsevierStyleItalic">SD</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;94&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Eleven &#40;68&#46;75&#37;&#41; of the studies used a clinical trial methodological strategy&#44; two &#40;12&#46;5&#37;&#41; used case control&#44; and the rest &#40;3 studies&#41; used a simple pre- and post-treatment design with repeated measures&#46; In regard to measurement procedures&#44; fifteen &#40;93&#46;75&#37;&#41; used strategies strictly based on psychometric-base questionnaires and&#47;or scales &#40;SF-36&#44; WHOL&#44; QoFS&#44; etc&#46;&#41; to evaluate the outcome in QoL&#46; No studies used qualitative evaluations by means of semi-structured interviews&#44; and only one &#40;6&#46;25&#37;&#41; used both strategies&#46; As for the publishing year&#44; three studies were published between 2001 and 2003&#44; three between 2004 and 2006&#44; seven between 2007 and 2009&#44; and three between 2010 and 2012&#46; Two studies &#40;12&#46;5&#37;&#41; involved subjects with TBI &#40;strokes caused by traffic and work accidents&#41;&#59; eleven focused on individuals with other neuropsychological conditions&#44; such as Multiple Sclerosis&#44; Alzheimer&#39;s Disease&#44; and Mild Cognitive Impairment&#44; among others &#40;68&#46;65&#37;&#41;&#46; The rest of the studies &#40;3&#41; used subjects suffering from several pathologies&#46; Finally&#44; seven studies &#40;43&#46;75&#37;&#41; focused on retraining strategies&#44; whereas two &#40;12&#46;5&#37;&#41; directed the treatment at compensation systems&#44; and seven &#40;43&#46;75&#37;&#41; set forth mixed rehabilitation procedures &#40;both retraining and compensation mechanisms&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Finally&#44; we would like to point out that the assessment of statistical and methodological quality &#40;scale 1 to 7&#44; 1 for a low evaluation&#44; and 7 for and excellent evaluation&#41;&#8212;conducted by four independent experts &#40;coefficient of concordance of &#46;94&#41;&#8212;of the selected works yielded a mean of 5&#46;77 &#40;<span class="elsevierStyleItalic">SD</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;91&#41;&#44; which would indicate a not especially high methodological and statistical test in the complexity of the designs and statistical treatments set forth&#46; These types of estimations are of little relevance&#44; but they offer an approximate idea of the complexity of the strategies used and are frequent in studies on meta-analyses&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Mean effect size</span><p id="par0080" class="elsevierStylePara elsevierViewall">After obtaining the effect sizes based on correlation&#44; the observed global mean was <span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;38&#44; which points at a highly significant effect &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; These results are important because the obtained signification shows a high effect size&#46; In order to establish better these results&#44; the Binomial Effect Size Display &#40;BESD&#41; was applied &#40;<a class="elsevierStyleCrossRef" href="#bib0135">Rosenthal &#38; Rubin&#44; 1982</a>&#59; <a class="elsevierStyleCrossRef" href="#bib0175">Valera-Esp&#237;n &#38; S&#225;nchez-Meca&#44; 1997</a>&#41;&#46; The BESD estimated values obtained for the treatment groups were of 60&#46;28&#37; and obviously of 39&#46;72&#37; for the failure&#46; This high percentage warrants the significance of the results in the statistical and clinical domain&#46; The analysis of the contingency tables indeed shows a clear tendency toward the use of intervention systems based on retraining by means of simple designs of pre- and post-test repeated measures&#46; That is consistent with the data of previous meta-analyses conducted with English-speaking samples&#46; As stated by <a class="elsevierStyleCrossRef" href="#bib0160">Sitzer et al&#46; &#40;2006&#41;</a>&#44; this would be expected in clinical trials applied in hospitals and is consistent with works similar to the present one&#44; such as <a class="elsevierStyleCrossRef" href="#bib0030">Cicerone &#40;2005&#41;</a>&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Moderating variables</span><p id="par0085" class="elsevierStylePara elsevierViewall">The initial analysis with the direct effect sizes show clear statistical significance &#40;<span class="elsevierStyleItalic">Q</span><span class="elsevierStyleInf">T&#40;15&#41;</span> &#61; 97&#46;42&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; so we can assume the heterogeneity of the effect sizes derived from the different studies&#46; Therefore&#44; the need arises to evaluate the role of the different moderating variables identified in this study in order to search for reasonable explanations for that difference both in the boarding system and in the mechanisms of intervention&#46; The mean effect size is good complementary information&#46; Accordingly&#44; the meta-analytical approach here presented may provide us with more thorough data than merely checking the published works&#44; which is the usual methodology in scientific literature reviews&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Therefore&#44; the descriptive effect in favor of retraining strategies versus compensation strategies&#8212;discussed in the next section&#8212;must be clarified according to the role of the moderating variables we have determined&#44; since it is reasonable that some of them may provide relevant information regarding the differences we found&#46; The tables below show the statistical significance found for qualitative variables &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; and for quantitative variables &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Statistically significant data in both tables present a relatively clear scenario&#46; First&#44; regarding <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; we see that <span class="elsevierStyleSmallCaps">&#40;</span><span class="elsevierStyleItalic"><span class="elsevierStyleSmallCaps">Q</span></span><span class="elsevierStyleInf">B</span><span class="elsevierStyleSmallCaps">&#40;2&#41;</span>&#61; 33&#46;01&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#44; so we can infer that this type of works use pre- and post-test designs with repeated measures without much of a doubt about that effect &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;62&#41;&#44; as compared to those using clinical trials &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;22&#41; or case control strategies &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41;&#46; In relation to the measurement procedures&#44; the use of scales is the only significant source &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;88&#41; and it allows us to infer that the scientific community widely agrees on this point and that both effects are important&#44; given that <span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;371 &#40;37&#46;1&#37; of explained variance&#41;&#44; which should not be discarded&#46; In fact&#44; the effect of using psychometric scales for both pre- and post-test evaluations is decisive&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Likewise&#44; the papers published within the 2007&#8211;2009 period &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;31&#41; show a tendency toward a somewhat higher average effect size &#40;<span class="elsevierStyleItalic">Q</span><span class="elsevierStyleInf">B</span>&#40;<span class="elsevierStyleInf">3</span>&#41; &#61; 32&#46;41&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#44; so it would be reasonable to think that over time the number of studies has increased&#44; and the studies have become clearer with more significant effect sizes &#40;18&#46;1&#37; of explained variance&#41;&#46; In other words&#44; in two years there has not only been a clear breakthrough in the number of studies published with non-Spanish-speaking samples&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">We would like to point out that the estimated effect is distributed asymmetrically among the studies using samples of patients with external or internal pathologies according to the definition above&#46; External pathologies &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;10&#41; were not statistically significant&#44; but internal pathologies &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;47&#41; were clearly significant instead &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46; The effect of samples with both pathologies has been discarded due to non-significance &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;07&#41;&#46; Finally&#44; the combined effect derived from retraining interventions was highly statistically significant &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;67&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#44; as was the effect associated to the compensatory intervention &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;25&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46; Despite being statistically significant&#44; they are far from the effect obtained by retraining interventions&#46; Probably&#44; that effect is partly due to the different tradition in the clinical studies applied to the one we discussed above&#44; which focused on retraining as a choice of intervention in relatively simple designs&#46; No associated effect to the mixed strategy was noted &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;039&#41;&#46; In general&#44; the explained variance was high &#40;<span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;345 or 34&#46;5&#37; of the total&#41; and statistically significant &#40;<span class="elsevierStyleItalic">Q</span><span class="elsevierStyleInf">B&#40;2&#41;</span> &#61; 42&#46;13&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">If we focus on <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#44; regression models show some effects to be highlighted&#46; The percentage of works focusing solely on neuropsychological interventions <span class="elsevierStyleSmallCaps">&#40;</span><span class="elsevierStyleItalic"><span class="elsevierStyleSmallCaps">Q</span></span><span class="elsevierStyleInf">R<span class="elsevierStyleSmallCaps">&#40;8&#41;</span></span> &#61; 3&#46;228&#41; was not significant&#46; Instead&#44; the months gone by from the diagnosis to the onset of the intervention <span class="elsevierStyleSmallCaps">&#40;</span><span class="elsevierStyleItalic"><span class="elsevierStyleSmallCaps">Q</span></span><span class="elsevierStyleInf">R<span class="elsevierStyleSmallCaps">&#40;5&#41;</span></span> &#61; 7&#46;931&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#44; and the number of sessions <span class="elsevierStyleSmallCaps">&#40;</span><span class="elsevierStyleItalic"><span class="elsevierStyleSmallCaps">Q</span></span><span class="elsevierStyleInf">R<span class="elsevierStyleSmallCaps">&#40;12&#41;</span></span> &#61; 9&#46;271&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41; applied were significant&#46; The duration of the intervention program was statistically significant <span class="elsevierStyleSmallCaps">&#40;</span><span class="elsevierStyleItalic"><span class="elsevierStyleSmallCaps">Q</span></span><span class="elsevierStyleInf">R<span class="elsevierStyleSmallCaps">&#40;12&#41;</span></span> &#61; 8&#46;222&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#44; therefore it seems that longer rehabilitation programs bring more effect to the therapy results&#46; Likewise&#44; although there was no clear statistical significance &#40;<span class="elsevierStyleItalic"><span class="elsevierStyleSmallCaps">Q</span></span><span class="elsevierStyleInf">R<span class="elsevierStyleSmallCaps">&#40;12&#41;</span></span> &#61; 7&#46;121&#41;&#44; a tendency can be established toward ratio significance between weekly sessions and the number of weeks of the program&#46; This adds to the notion that a greater effect is obtained in programs involving more sessions during a longer period of time&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The crucial data in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> are the results obtained with the data derived from the outcome in neuropsychological performance&#46; The result is highly significant <span class="elsevierStyleSmallCaps">&#40;</span><span class="elsevierStyleItalic"><span class="elsevierStyleSmallCaps">Q</span></span><span class="elsevierStyleInf">R<span class="elsevierStyleSmallCaps">&#40;15&#41;</span></span> &#61; 14&#46;712&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; for neuropsychological measures&#44; exclusively&#46; Thus&#44; we can interpret that the studies analyzed show that cognitive rehabilitation programs are effective with an effect size that may be responsible for up to 38&#37; of the explained variation&#44; and&#44; even more importantly&#44; that effect is more intense when they are estimated by comparing the pre- and post- levels of these patients&#8217; perceived QoL&#44; up to 39&#37; of the explained variation&#46; There are no differences between one choice and the other&#44; but it is important to highlight a certain tendency to improve neuropsychological values over strictly QoL measures&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">These comments need to be clarified&#44; partially&#44; by the role of the subject and the methodological variables included in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; There is&#44; indeed&#44; an evident bias in favor of women and younger patients&#46; In the case of women&#44; the effect is clear &#40;<span class="elsevierStyleItalic">Q</span><span class="elsevierStyleInf">R&#40;15&#41;</span> &#61; 9&#46;154&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#44; and even more conclusive in the mean age of the groups treated <span class="elsevierStyleSmallCaps">&#40;</span><span class="elsevierStyleItalic"><span class="elsevierStyleSmallCaps">Q</span></span><span class="elsevierStyleInf">R<span class="elsevierStyleSmallCaps">&#40;15&#41;</span></span> &#61; 17&#46;992&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46; It should all be interpreted in the sense that the favorable effect in post-evaluations is more pronounced in the case of women and younger subjects &#40;the coefficient of regression is negative&#44; &#40;&#946; &#61; &#8722;&#46;392&#41;&#46; Likewise&#44; the effect attributed to the study of sample sizes and the number of measurements is also crucial&#46; As regards the sample size&#44; the results we obtained <span class="elsevierStyleSmallCaps">&#40;</span><span class="elsevierStyleItalic"><span class="elsevierStyleSmallCaps">Q</span></span><span class="elsevierStyleInf">R<span class="elsevierStyleSmallCaps">&#40;15&#41;</span></span> &#61; 12&#46;543&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; show that the effect size is higher and clearer with large samples&#46; It is also important to note that the effect of the duration of the follow-ups &#40;measurement waves&#41; is also clearly significant &#40;<span class="elsevierStyleItalic"><span class="elsevierStyleSmallCaps">Q</span></span><span class="elsevierStyleInf">R&#40;15&#41;</span> &#61; 16&#46;211&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46; The negative value of the coefficient of regression &#40;&#946; &#61; &#8722;&#46;399&#41; would show that&#44; as the follow-up duration increases&#44; the effect size decreases&#46; The reduction of post- effects is clear&#44; as they seem to dilute over time&#46; Both variables are essential given the variation percentages they explain&#58; 29&#37; and 33&#37; respectively&#46; Finally&#44; in order to evaluate the possible bias of publication&#44; we estimated the Egger test &#40;<a class="elsevierStyleCrossRef" href="#bib0055">Egger&#44; Smith&#44; Schneider&#44; &#38; Minder&#44; 1997</a>&#41;&#44; which was non-significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;86&#41;&#46; Therefore it was unnecessary to include information of the Funnel plot&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">The results allow us to draw several conclusions&#46; Firstly&#44; it is important to highlight that the number of papers with non-Spanish-speaking samples analyzed &#40;16&#41; was lower than the number of papers with Spanish-speaking samples &#40;21&#41; reported on <a class="elsevierStyleCrossRef" href="#bib0080">Gu&#224;rdia et al&#46; &#40;2012&#41;</a>&#44; since the publications in non-Spanish-speaking countries vastly outnumber any others&#46; The reason may lie in the fact that this type of works commonly use clinical samples&#44; and intervention times are glaringly longer in Spanish-speaking healthcares than in non-Spanish-speaking ones&#46; Additionally&#44; in the Spanish-speaking world&#44; it is somewhat more common to use Quality of Life measurements as indicators of effect associated to the neurorehabilitation program&#46; The tradition in the Spanish-speaking neuropsychological approach is somewhat longer than in the non-Spanish-speaking one&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Furthermore&#44; we must note the existence of a positive effect of neuropsychological rehabilitation techniques on QoL&#46; We can thus state that the different neuropsychological intervention therapies improve the patients&#8217; quality of life&#44; with a moderate effect size&#46; However&#44; that effect tends to decrease over time&#46; As time goes by after the neuropsychological intervention applied&#44; the patient&#39;s quality of life tends to diminish&#44; which suggests that the therapy&#39;s positive effect on the variable is not permanent&#46; In addition&#44; the rehabilitation&#39;s effect on QoL is very much influenced by several moderating variables&#44; both quantitative and qualitative&#46; As for the effect of the substantive variables&#44; we must note that the type of therapy applied seems to influence the phenomenon under study&#44; so that those works where the neuropsychological intervention was based on the use of retraining techniques are the ones showing the greatest improvements in their patients&#8217; quality of life&#44; whereas those using compensatory treatment strategies yield more modest results&#46; However&#44; that fact can be due&#44; at least partly&#44; to the slightly higher number of participants in that sub-sample than in other intervention groups&#44; which is hardly surprising when we consider that those techniques have a greater tradition in neuropsychological intervention&#46; For that reason&#44; this fact could be biasing the results&#44; thus yielding a greater effect size than other interventions&#46; Other substantive variables interfering with the neuropsychological rehabilitation&#39;s effect on QoL are all those related to the intensity and the duration of the interventions&#46; If we increase the weeks of duration of the intervention&#44; the number of sessions of the intervention&#44; and the relationship between the number of sessions and the duration of the intervention in weeks&#44; then the effects on QoL increase&#44; too&#46; Nevertheless&#44; those variables must be understood within the patients&#8217; clinical context&#44; since they are often determined by the conditions of the health services&#46; The neuropsychological deficit&#39;s etiology is another substantive variable seeming to influence the effects of rehabilitation on QoL&#46; Accordingly&#44; neuropsychological interventions do not seem to bear a positive effect on QoL in persons who suffered from traumatic brain injury&#44; but instead they <span class="elsevierStyleItalic">do</span> on patients with cognitive alterations due to other etiologies&#46; The patients&#8217; age also had an important mediating effect&#46; Younger persons seem to obtain greater increases in their QoL after rehabilitation&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">With regard to the method&#39;s variables&#44; the works using a clinical trial classic methodology obtained greater increases in QoL after clinical interventions than the studies using a pre-test post-test methodology and the case and control studies&#44; since in the latter the rehabilitation bore no significant effect on QoL&#46; However&#44; most of the studies included in the present meta-analysis used the clinical trial methodology&#44; for which reason the number of patients included in this sub-sample is much larger than in the other two&#44; which could bias the statistical effects found in this work&#46; As for the extrinsic variables&#44; the year of publication influences the effect size of post-intervention QoL&#46; Accordingly&#44; it is highest in the group of papers published between 2007 and 2009&#46; Yet again&#44; the number of works published in this period is higher than in the other periods studied&#44; with a greater accumulated sample size&#44; which entails a possible bias effect on the estimated effect size&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">When comparing the results of the present works to those of Spanish-speaking samples &#40;<a class="elsevierStyleCrossRef" href="#bib0080">Gu&#224;rdia et al&#46;&#44; 2012</a>&#41;&#44; we must highlight the following conclusions&#46; Both present important differences as regards the results obtained&#46; The present paper has a higher total sample size than the Spanish-speaking samples and comprises originals with a higher average number of participants&#46; Likewise&#44; among the studies included in this meta-analysis&#44; there are more of them using a clinical trial methodology and&#44; in general&#44; from the methodological point of view&#44; i&#46;e&#46;&#44; the originals included in this meta-analysis have a higher methodological quality than those included in <a class="elsevierStyleCrossRef" href="#bib0080">Gu&#224;rdia et al&#46; &#40;2012&#41;</a>&#46; Important differences also exist between them regarding several substantive variables that have an important mediating effect on QoL&#46; Therefore&#44; in the present work&#44; the duration and the intensity of neuropsychological interventions were higher than in <a class="elsevierStyleCrossRef" href="#bib0080">Gu&#224;rdia et al&#46; &#40;2012&#41;</a>&#46; The patients&#8217; average age in this study is lower than in the study with Spanish-speaking samples&#44; and the time elapsed between the onset of the disease and the administration of neuropsychological treatment is shorter in this paper than in <a class="elsevierStyleCrossRef" href="#bib0080">Gu&#224;rdia et al&#46; &#40;2012&#41;</a>&#46; Likewise&#44; important differences exist between both meta-analyses regarding the type of treatment administered&#46; In both works&#44; a significant proportion of the patients were treated using only retraining techniques&#44; but in the study with Spanish-speaking samples&#44; a great number of patients were treated only with compensatory techniques&#44; and very few were treated with a combination of both techniques&#46; In contrast&#44; in the present study&#44; the opposite tendency was observed&#46; More patients were treated with a combination of techniques than with compensatory strategies only&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Even more significant are the differences between both studies as regards substantive variables such as the patients&#8217; age&#44; the time elapsed between the onset of the disease and the treatment&#44; or its intensity&#46; We must point out that such variables usually affect the neuropsychological treatment&#39;s outcome &#40;<a class="elsevierStyleCrossRef" href="#bib0115">Niemeier&#44; Kreutzer&#44; Marwitz&#44; Gary&#44; &#38; Ketchum&#44; 2011</a>&#41;&#44; for which reason it might also be expected that they should have a direct effect on the patients&#8217; quality of life&#46; Despite all these differences&#44; the general conclusions of the present work agree with those of <a class="elsevierStyleCrossRef" href="#bib0080">Gu&#224;rdia et al&#46; &#40;2012&#41;</a>&#46; In both cases&#44; we can conclude that neuropsychological rehabilitation has a positive effect on HRQoL&#44; with a moderate effect size&#46; However&#44; as the follow-up time goes by&#44; the effects of neuropsychological rehabilitation tend to diminish and even disappear&#46; Therefore&#44; both studies also agree on this change seemingly not being permanent&#46; The fact that the central conclusion of both meta-analyses agrees on substantive variables is important&#44; given that it favors the idea that our interpretation of the data is correct and&#44; therefore&#44; our conclusions are accurate&#46; Our study presents an important limitation&#44; which is that it was not possible to analyze the mediating effect of such variables as the severity of the pathology or the patient&#39;s socio-economic context&#46; These are variables which&#44; as is known&#44; influence the outcome of the neuropsychological rehabilitation &#40;<a class="elsevierStyleCrossRef" href="#bib0010">Arango&#44; 2012</a>&#41;&#44; they could affect QoL&#44; and they are indeed part of that construct &#40;<a class="elsevierStyleCrossRef" href="#bib0100">Mayo&#44; Moriello&#44; Asano&#44; Van der Spuy&#44; &#38; Finch&#44; 2011</a>&#41;&#46; This is because the works considered here have not involved analyzable data in relation to those variables&#46; Leaving aside the latter consideration&#44; the consonance between the results obtained in both populations allow us to guarantee a clear line in the effects found&#44; as well as serious limitations in the effect&#39;s perdurability&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            1 => "Quality of life"
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            3 => "Meta-analysis"
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            0 => "Rehabilitaci&#243;n neuropsicol&#243;gica"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The purpose of this study was to conduct a meta-analysis on the effects of neuropsychological rehabilitation procedures on the quality of life in non-Spanish-speaking individuals with some cognitive deficit&#46; Sixteen studies published during the 2001&#8211;2012 period which yielded relevant information regarding the sample sizes used&#44; the types of statistical contrasts&#44; the evaluation instruments or pathologies among others&#44; were analyzed&#46; We carried out study following the usual estimation procedures&#44; based on the definition of the effect size and the scrutiny of their relationship with relevant variables &#40;e&#46;g&#46;&#44; sample sizes&#44; type of population&#41;&#44; or methodological variables &#40;e&#46;g&#46;&#44; type of research or sampling design&#41;&#46; The data analysis shows a statistically significant effect &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;38&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; in all the variables associated with the characteristics of the intervention &#40;duration&#44; type of intervention&#44; gender&#44; year of publication and&#44; more importantly&#44; quality of life and neuropsychological outcomes&#41;&#46; As a general conclusion&#44; we were able to determine that Quality of Life &#40;QoL&#41; can improve&#44; under certain conditions&#44; through neuropsychological rehabilitation&#44; but this change is not permanent&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El prop&#243;sito de este estudio fue generar un meta-an&#225;lisis sobre los efectos de la rehabilitaci&#243;n neuropsicol&#243;gica en la dimensi&#243;n Calidad de Vida en muestras de no hispano-hablantes&#44; con alg&#250;n d&#233;ficit cognitivo&#46; Se analizaron diecis&#233;is estudios publicados durante el per&#237;odo 2001&#8211;2012&#44; que mostraron informaci&#243;n relevante con respecto a los tama&#241;os de muestra utilizados&#44; los tipos de contrastes estad&#237;sticos&#44; los instrumentos de evaluaci&#243;n o diagn&#243;stico&#44; entre otros&#46; Se realiz&#243; el estudio siguiendo los procedimientos de estimaci&#243;n habituales&#44; sobre la base de la definici&#243;n del tama&#241;o del efecto y el an&#225;lisis de su relaci&#243;n con las variables relevantes &#40;tama&#241;os de muestra&#44; tipo de poblaci&#243;n&#44; etc&#46;&#41;&#44; o variables metodol&#243;gicas &#40;tipo de investigaci&#243;n o dise&#241;o de la muestra&#44; etc&#46;&#41; El an&#225;lisis de los datos muestra un efecto estad&#237;sticamente significativo &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf">&#43;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;38&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; en todas las variables asociadas a las caracter&#237;sticas de la intervenci&#243;n &#40;duraci&#243;n&#44; tipo de intervenci&#243;n&#44; g&#233;nero&#44; a&#241;o de publicaci&#243;n y&#44; m&#225;s importante&#44; la calidad de vida y los resultados neuropsicol&#243;gicos&#41;&#46; Como conclusi&#243;n general&#44; la dimensi&#243;n calidad de vida &#40;QoL&#41; puede mejorar&#44; bajo ciertas condiciones&#44; a trav&#233;s de la rehabilitaci&#243;n neuropsicol&#243;gica&#44; pero este cambio no es permanente&#46;</p></span>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;22<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>One group design&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pre-Post-test desig&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;62<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Measurement procedures</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Psychometric approach&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;88<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other psychometric&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Extrinsic variables</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;41<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;181&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Year of publication</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2001&#8211;2003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2004&#8211;2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2007&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;31<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2010&#8211;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Substantive variables</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;13<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;345&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Disease etiology</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Traumatic Brain Injury &#40;TBI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other Etiologies &#40;OE&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;47<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Neuropsychological intervention</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Retraining&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;67<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Compensatory&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;25<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;039&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Moderating variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">k</span><span class="elsevierStyleInf">j</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Q</span><span class="elsevierStyleInf">R</span>&#40;df&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">R<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Substantive variables</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean effect size in neuropsychological outcome measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;399&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;712&#40;15&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Works with treatment focused exclusively on neuropsychological interventions &#40;&#37; works&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;219&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;228&#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Months between illness diagnosis and neuropsychological treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;931<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intensity of rehabilitation procedures &#40;Number of sessions&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;299&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;271<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intervention&#39;s duration &#40;Number of weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="center" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;218&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;222<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ratio between number of sessions by duration in weeks&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 21712069
Original language: English

DOI:10.1016/S2171-2069(15)70002-5

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	1	0	1
2024 October	32	2	34
2024 September	36	2	38
2024 August	29	4	33
2024 July	35	6	41
2024 June	28	5	33
2024 May	31	2	33
2024 April	21	3	24
2024 March	46	1	47
2024 February	33	7	40
2024 January	25	4	29
2023 December	22	5	27
2023 November	39	6	45
2023 October	81	19	100
2023 September	30	3	33
2023 August	12	3	15
2023 July	13	3	16
2023 June	16	4	20
2023 May	15	3	18
2023 April	44	1	45
2023 March	26	2	28
2023 February	27	8	35
2023 January	27	2	29
2022 December	25	4	29
2022 November	27	9	36
2022 October	34	11	45
2022 September	33	31	64
2022 August	28	6	34
2022 July	26	6	32
2022 June	39	10	49
2022 May	36	10	46
2022 April	37	16	53
2022 March	63	12	75
2022 February	37	8	45
2022 January	30	7	37
2021 December	41	16	57
2021 November	17	8	25
2021 October	12	10	22
2021 September	10	7	17
2021 August	11	5	16
2021 July	13	7	20
2021 June	12	8	20
2021 May	9	5	14
2021 April	24	28	52
2021 March	12	4	16
2021 February	8	12	20
2021 January	12	11	23
2020 December	10	6	16
2020 November	16	7	23
2020 October	8	7	15
2020 September	12	7	19
2020 August	11	10	21
2020 July	7	8	15
2020 June	7	4	11
2020 May	13	7	20
2020 April	9	3	12
2020 March	19	1	20
2020 February	9	8	17
2020 January	7	0	7
2019 December	11	10	21
2019 November	8	4	12
2019 October	12	2	14
2019 September	11	6	17
2019 August	11	2	13
2019 July	9	7	16
2019 June	20	13	33
2019 May	58	45	103
2019 April	22	18	40
2019 March	8	1	9
2019 February	13	8	21
2019 January	5	5	10
2018 December	5	3	8
2018 November	5	3	8
2018 October	6	10	16
2018 September	4	3	7
2018 August	19	1	20
2018 July	6	0	6
2018 June	2	2	4
2018 May	6	4	10
2018 April	1	2	3
2018 March	2	0	2
2018 February	3	0	3
2018 January	10	1	11
2017 December	6	1	7
2017 November	6	0	6
2017 October	15	2	17
2017 September	5	1	6
2017 August	6	0	6
2017 July	14	3	17
2017 June	8	4	12
2017 May	10	5	15
2017 April	12	2	14
2017 March	17	8	25
2017 February	16	2	18
2017 January	9	4	13
2016 December	18	4	22
2016 November	30	5	35
2016 October	35	5	40
2016 September	25	2	27
2016 August	20	6	26
2016 July	28	11	39
2016 June	45	19	64
2016 May	48	15	63
2016 April	33	28	61
2016 March	38	11	49
2016 February	34	29	63
2016 January	34	14	48
2015 December	29	17	46
2015 November	38	15	53
2015 October	51	29	80
2015 September	38	12	50
2015 August	36	17	53
2015 July	20	16	36
2015 June	39	24	63
2015 May	39	19	58
2015 April	48	14	62
2015 March	39	19	58
2015 February	28	15	43
2015 January	55	64	119

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