visual management case study

You are using an outdated browser. Please upgrade your browser .

• Welcome to Two Experienced Consultants: Peter Maunder and Peter Kuttenkeuler
• Manufacturing
• Supply Chain and Distribution
• Small + Medium Enterprise
• Food and Agribusiness
• Private Equity and Fund Managers
• Lean Manufacturing
• Facility Layout
• Continuous Improvement
• Operational Excellence
• Industry 4.0
• Lean Leadership
• Supply Chain Management
• Problem Solving
• Practical 5S
• Accelerated Productivity Programme
• Lean Methodology
• Download Lean Articles
• Case Studies
• TXM Consulting FAQs
• TXM Training FAQs
• TXM Training
• TXM Television
• New Zealand

Case Studies: Visual Management Case Studies

Tasting the success of operational excellence: poppy’s chocolate.

Established with a passion for indulgent treats, Poppy's Chocolate has become synonymous with high-quality ingredients, …

Driving Cultural Change Through the Optimal Transfer of Information & Materials

SCD Remanufactured Vehicles contacted us to help drive cultural change in the business from taking order to delivery of …

Operations Optimization at ICO Bath Leads to Record Sales Growth

TXM North America were tasked to help ICO Bath optimize operations through the application of Lean Thinking. At a site v…

TXM Lean Case Study – CIVIQ Triples Output With Same Facility

CIVIQ produce high quality public use products for parks, sporting venues and all types of urban public use sapces. Empl…

TXM Lean Case Study – Ferguson Plarre Bakehouses

Ferguson Plarre baker creating one of their signature cakes. The Challenge Ferguson Plarre Bakehouses is a family owned …

TXM Lean Case Study – EGR North America

EGR Group called upon TXM's services to help drive revenue growth by reducing work in progress and driving lead time fro…

TXM Lean Case Study – DMG Mori China

The Challenge DMG Mori is one of the largest machine tools builders in the world. Like many manufacturers in China, DMG …

TXM Lean Case Study – Global Pneumatic Manufacturer

The Challenge Our client is a worldwide leader in automation technology, its Jinan plant located in north of China, incl…

TXM Lean Case Study – Business Process Optimisation

The Challenge Our client is a world-leading solution provider of steel belts and processing systems. Our client success …

TXM Lean Case Study – Managing Lean Office Processes with Colour Coding

We know how important visual management and colour coding are in our Lean Enterprise. Once implemented, it allows our te…

TXM Lean Case Study – Ferguson Plarre Bakehouses Interview

Ferguson Plarre is a major industrial bakery supplying quality cakes and pastries fresh daily to a chain of over 50 reta…

TXM Lean Case Study – Streamlining Accounting Processes

TXM worked with a Global Technology company to use Lean Business Process approaches to streamline end of month accountin…

TXM Lean Case Study – Lean Transformation at a Small Manufacturer

THE CHALLENGE Following the Post-Glover acquisition in 2009 half of the business was relocated to a new site. The resist…

It’s essential to keep transforming and improving your business to adapt to changing technology, customer demands, and industrial changes. Lean manufacturing is one of the best ways to achieve this –it streamlines and enhances business processes in all industries, including visual management. The possibilities of lean technologies are unlimited in every sector. Adopting lean principles enables companies to meet production capacities, standardise production (processes and products), minimise waste, lower lead times, and improve their working environment.

TXM Lean Solutions  is a pioneer lean technology solutions provider across Europe and North America with over 400 years of experience. We are ready to help you transform your business’ visual management.

Lean Technology in Visual Management

Lean technologies in visual management provide a means to communicate expectations, performance, standards, and challenges at a glance, thereby saving time. Visual management translates into sharing information, work standardisation and sharing, problem identification, and solving.

Visual management greatly benefits from lean principles:

• Saving time by reducing the time it takes to visualise and understand and work on information.
• Real-time updates through centralised management.
• Better team performance as accountability becomes higher.
• Quicker problem-solving using dynamic tools such as root cause analysis.
• Improved accountability as everyone’s role and responsibility are well-defined through standardised work procedures.

Some Selected Case Studies

TXM Lean Solutions has successfully worked with enterprises, enhancing their visual management, as shown in several  case studies . Below are a few of them:

• School Pix –Reduced Lead Times

TXM Lean Solutions transformed and streamlined School Pix’s operation through a colour coding system, the simplest form of visual management, allowing teams to identify what actions to take next easily. The company achieved their goal of having a 10-day turnaround in lead time.

• EGR Inc. –Enhance Teamwork and Accountability

Through visual management solutions from TXM, EGR Inc. was able to achieve better teamwork and more individual accountability while reducing lead times from 7-21 to 4 days.

• DMG Mori –Improved Shop Floor Productivity

Through visual management-oriented training and coaching, TXM transformed this tools manufacturer’s productivity through enhanced housekeeping, shop floor organisation, and better time management.

Lean Technology Is for You

The possibilities and benefits of lean technology are unlimited, provided you have the right partner. At  TXM Lean Solutions,  our goal is to provide solutions that will transform your business and give you the desired results.

• Explore the Platform
• Integrations
• Governance & Change Management
• Common Data Model
• Integrated Validation
• Data & Analytics
• Computer Vision
• Frontline Copilot®
• Automations
• Edge Connectivity
• Machine Connectivity
• Edge Devices
• Machine Kit
• Device Library
• Composable MES
• Digital Guidance
• Production Management
• Traceability and Compliance
• Digital Work Instructions
• Manufacturing Training Software
• Kitting Software
• Production Tracking Software
• Manufacturing Dashboards
• Inline Quality Inspection
• Non-Conformance Management
• Visual Quality Inspection
• Electronic Batch Records
• Device History Records
• Genealogy & Traceability
• Equipment Logbooks
• Industrial Products
• Consumer Products
• Luxury Goods
• Electronics
• Automotive & Specialty Vehicle
• Aerospace & Defense
• Food & Beverage
• Pharmaceutical Manufacturing
• Biotech Manufacturing
• Cell & Gene Therapy
• Medical Devices & Diagnostics
• High-Mix Discrete Assembly
• Additive Manufacturing
• Batch and Hybrid Batch
• Contract Manufacturing
• New Product Introduction (NPI)
• Case Studies
• Augmented Ops Podcast
• Augmented Lean
• 30-Day Free Trial
• Tulip University
• Knowledge Base
• Attend Operations Calling 2024
• Tulip Experience Center
• Trust Center
• Website Terms of Use
• Privacy Policy
• Terms of Service
• Support Policy
• Acceptable Use Policy

Lean Manufacturing

What is Visual Management? Definitions & Examples For Manufacturers

Jump to section

What is Visual Management?

Types of visual management, what’s the relationship between 5s and visual manufacturing, functions of visual management, benefits of visual management, share on social.

• Share on Twitter
• Share on LinkedIn

Visual management is a form of communication used to give a snapshot of manufacturing operations.

The goal of visual management is to translate shop floor processes and production statuses into easy-to-understand visual overviews.

Think of it as manufacturing’s scoreboard. With one glance, the whole team can get an understanding of a factory’s performance.

Visual management takes many forms. Let’s go over each in order to understand how it fits within lean methodology .

Visual Management Using Factory Layout

Visual management is often applied to factory layouts. Visual management tools like the FIFO lane help make workflows and cell design more intuitive. Assembly lines are organized in a manner to direct production flow from start to finish, with visual indicators placed at important points. This allows line operators to know which stage of production they are by the station they occupy.

Visual Management Using Tools and Parts

This form of visual control is done by incorporating Kaizen foams and shadow boards . Kaizen foams, similar to shadow boards, have outlines cut for each specific tool. This provides fast detection if a tool is missing or identifies where to place a tool once its use is done.

Visual Management Using Markings

Visual control of this nature employs the use of labels and markings throughout the shop floor. Most forms of labeling and markings of the shop floor is government regulated to ensure safety to shop floor operators. But labels and markings are key sign posts of what actions to take, where to locate a particular item, and what areas are restricted on a shop floor.

Visual Management Using Data Displays

This form of visual management deploys digital information displays across the shop floor to highlight KPIs. These forms of display are called Andons and dashboards. They broadcast real time analytics detailing shop floor performance.

5s (set, sort, shine, standardize, sustain) is a lean manufacturing principle for increasing order and efficiency in work environments. When combined with 5s, visual management can produce significantly better functioning work environments.

Process Transparency

Visual management of the production process amplifies process transparency. By increasing process transparency of the production process, the need of hierarchical communication between subordinate and supervisor is reduced. This loosens non-value add bottleneck activities such as asking repetitive questions and the like.

Visual tools can be used to habitually maintain correct procedures. By continuously interfacing with visual management, a manufacturer’s workforce is influenced into maintaining process standardization throughout the production cycle.

Job Facilitation

Deployment of visual aids improve cognitive and memory function when performing routine tasks. Use of visual clues such as shadow boards within the workspace reduces the need for non-value add actions like searching for tools.

On the Job Training

Visual management facilitates on the job training as information pertaining to the production process is readily available. This form of training is effective as it engages personnel into practical experience and is less work disruptive organizational practice.

When practiced regularly and consistently, visual management can greatly improve the efficiency of manufacturing operations. Some of the benefits include:

• Improved process efficiency
• Reduced waste (for all of the 8 wastes of lean )
• Safer workflows
• Inventory storage that matches production demands
• Higher team engagement

Visual management can provide a simple and yet effective solution to enhance information flow in many manufacturing shop floors. Easy access to production information not only maintains the integrity of production quality, but it can also be used to boost efficiency and aid in training.

Digitize your visual management tools with Tulip

See how a system of apps can enable continuous improvement with a free trial of Tulip.

• Leadership Development
• Operational Excellence
• Industry 4.0 – Management Digitalization
• Food & Bev
• Construction
• Manufacturing
• Heavy Industry
• The Manager's Journey
• Cross-platform tool
• Digital Gemba Walk
• Collaboration and Rituals
• Coaching and Improvement
• Knowledge Center - New
• All Features
• Industry 4.0 and 5.0

Case Studies

• Continuous Improvement
• Frontline Managers
• Key Behaviroral Indicators
• Management Skills
• Productivity
• Free Resources

TABLE OF CONTENT

Share this article, download a pdf version., subscribe to our newsletter, what is visual management + 15 tools to boost performance.

Downloaded on: September 4, 2024

• June 3, 2024

In a world where visual perception is paramount, the impact of images is indisputable. Stored in the brain's long-term memory, they reduce complexity, accelerate comprehension and enhance recall. With this in mind, it's easy to see why visual management has become so essential.

Visual control, or the art of making operational data accessible and comprehensible through graphic and physical representations, has a positive impact on efficiency, productivity and communication. In the manufacturing sector specifically, visual management tools are used alongside many continuous improvement methodologies for Lean, guaranteeing efficient, agile management and optimal operational performance .

This article tells you all about the benefits of this method, visual management examples, and best practices to implement it effectively within your organization.

Key takeways:

• Visual management tools provide immediate, clear insights into operational performance , helping teams stay informed and proactive.
• These tools facilitate better communication and collaboration within teams by making information easily accessible and understandable.
• By highlighting issues in real-time, visual management tools enable quicker identification and resolution of problems , reducing downtime and increasing efficiency.
• Visual management promotes the use of accurate and up-to-date data , supporting more informed decision-making processes.
• The consistent use of visual tools fosters a culture of continuous improvement , driving ongoing enhancements in productivity and quality.

In a hurry? Save this article as a PDF.

Tired of scrolling? Download a PDF version for easier offline reading and sharing with coworkers.

What is visual management?

Visual management (or “visual control”) is a dynamic management method that relies on visual cues to share information. These cues can include charts, graphs, signs, and any other display that visualizes workflow, performance and problems in real time. The main goal is to create a visual workplace. 

Why is this process so effective? Because it simplifies messages, clarifies complex data, and makes them more intuitive, decipherable at a glance. 

The origins of visual management

Humans have been using visual methods to simplify information and communication for centuries. However, visual management as such dates back to the 50s, during the development of the Toyota Production System. Indeed, the famous carmaker was one of the first to use visualization of production processes to facilitate understanding and communication between workers and managers.

Today, thanks to its proven effectiveness, visual management has become a fundamental element of many modern management methodologies , including Lean Management.

The main principles of visual control  

• Factual management: Decisions are based on precise visual statistical data, taking the guesswork out of the equation.
• Simplicity and clarity: Visual tools are easy to understand, with no need for further explanation.   
• Accessibility and transparency: Information is visible and accessible to everyone, from top management to frontline managers and operators.  
• Up-to-date information: Data and information displayed are kept up to date to reflect the current situation.  
• Engagement and accountability: Every employee can see the impact of his or her work on overall results, which fosters engagement and accountability.
• Continuous improvement : Instant visualization of inefficiencies and problems enables rapid and regular adjustments to processes.
• Standardization: Procedures and guidelines are standardized to ensure efficiency and consistency (all employees follow the same procedures).  
• Training: Visual elements facilitate hands-on learning by helping employees understand the work environment and what is expected of them. What they see is therefore more easily integrated, retained and applied.

The benefits of visual management

• Clarification, better understanding: Visual management goes much further than that. It offers a number of advantages that have a significant impact on the internal workings and performance of the organizations that use it.
• Efficient performance management: Performance is tracked in real time via dashboards and key metrics that are accessible to all, enabling rapid reaction in the event of deviations.  
• Faster problem resolution: With a visual management tool like a dashboard showing key performance indicators (KPIs) , problems are immediately visible. They can be reported by employees and then dealt with directly, preventing them from escalating.
• Informed decision-making: Based on current, accurate facts, managers quickly understand the issues at stake and are able to make better decisions.
• Better information sharing: The visual display of key information ensures that employees at all levels have access to the same data, including real time updates and changes . 
• Optimized communication: Visual elements simplify understanding and help overcome language or technical barriers. They make communication more formal and effective, and avoid ambiguity.
• Improved cohesion and teamwork: Full visibility of objectives, progress and responsibilities aligns employees with common goals, and fosters a transparent working environment . This strengthens cohesion, cooperation, trust and commitment.
• Efficient processes and workflows: Clearly visualizing production steps helps identify bottlenecks and eliminate waste , facilitating the improvement and streamlining of operations for greater workflow efficiency.
• Enhanced workplace organization and safety: The use of visual aids not only improves the organization of the workplace, but also makes it safer for people moving around in it.

15 Effective visual management tools

1. kanban boards.

Kanban boards represent the flow of work at different stages of a process. Their main goal is to balance demand with available capacity. They are accompanied by cards and columns to visualize and manage tasks (to do, in progress, completed, etc.).

Specific applications 

• Project management 
• Software development 
• Manufacturing production tracking
• IT support and operations 
• Marketing campaign planning and execution
• Improved productivity
• Better management of priorities
• Reduced lead times and bottlenecks
• Improved team collaboration 
• Simplicity and ease of use

2. Mind Mapping

Mind Mapping is a visual management tool that uses diagrams to organize words, ideas, tasks or issues around a central concept.  

• Brainstorming 
• Project planning
• Meeting management
• Problem solving
• Note-taking 
• Better understanding of information 
• Creativity and innovation 
• Better memorization 
• Versatility of use
• Improved communication

3. Design Thinking

Design Thinking is a method that focuses on the end-user. Its aim is to solve complex problems and generate innovative solutions through creativity and iteration.  

Specific applications  

• Development of new products and services 
• Business process improvement 
• Marketing and branding strategies 
• Services and customer experience 
• Technology and IT
• User-centric approach 
• Versatility
• Improved team collaboration  
• Complex problem solving 

4. Value Stream Mapping (VSM)

Value Stream Mapping (VSM) helps to visualize and understand all stages of a process. They show where waste occurs and identify opportunities for improving efficiency.

• Production process optimization 
• Lean integration 
• Employee training and engagement 
• New process design
• Supply chain management 
• Waste reduction 
• Optimization of production processes 
• Cost reduction
• Decision support 
• Better communication

Andon is a visual or audible warning system, much like traffic lights, used in manufacturing environments to signal problems in real time (quality defects, equipment breakdowns, etc.).  

• Detection and signaling of quality defects 
• Equipment failure monitoring 
• Inventory management 
• Workplace safety 
• Interdepartmental communication 
• Rapid problem detection and resolution 
• Improved product quality 
• Greater transparency 
• Employee empowerment  
• Support for continuous improvement 

6. Heijunka boards

Heijunka boards (Heijunka means "leveling" in Japanese) are used to balance workloads and optimize production. 

• High-volume production 
• Lean production 
• Maintenance management
• Event management  
• Automotive assembly
• Reduced production fluctuations 
• Improved operational efficiency  
• Reduce excess inventory 
• Improved quality 
• Flexible response to customer demand 

7. Poka-Yoke

Poka-Yoke (meaning "error-prevention" in Japanese) refers to mechanisms or techniques designed to prevent human errors before they occur in production processes. 

• Assembly of consumer products
• Production line verification systems
• Error prevention in the healthcare sector
• Logistics and inventory management
• Financial services
• Reduction of errors 
• Increased productivity 
• Cost reduction 
• Enhanced safety  

8. Pareto diagrams and decision trees

Pareto diagrams are statistical analysis tools that help identify the most important causes of a problem. They are based on the principle that 80% of problems are often due to 20% of causes. 

Decision trees are also diagrams, but are used to make decisions based on different variables. 

Together, these powerful tools help prioritize problems and facilitate decision-making. 

• Quality management (Pareto)
• Inventory management (Pareto)
• Cost optimization (Pareto)
• Risk management decision-making (Decision trees)
• Investment strategies (Decision trees)
• Software development (Decision trees)
• Efficient prioritization (Pareto)
• Continuous improvement (Pareto)
• Clear visualization (Pareto)
• Simplified decision-making (Decision trees)
• Risk management (Decision trees)
• Flexibility (Decision trees)

9. UTrakk dashboards  

UTrakk dashboards offer real-time visualization of key performance indicators and other critical data to help managers monitor, analyze, and improve operations. 

• Industrial production tracking and management
• Operation management
• Project management
• Equipment maintenance and management
• Performance monitoring
• Improved visibility on data and KPIs
• Informed decision-making 
• Quick problem resolution 
• Real-time performance monitoring 
• Personalization

10. Visual signage  

Visual signals used to guide, inform or warn users in a work environment (lines on the shop floor, signs, badges, labels, panels, etc.). 

• Workplace safety (industrial, manufacturing, construction)
• Traffic management (warehouses, logistics centers) 
• Public health signage
• Wayfinding in public spaces 
• Signage for specific areas 
• Enhanced safety 
• Increased operational efficiency 
• Regulatory compliance 
• Accessibility 
• Enhanced user experience 

11. Graphics and posters

This type of visual medium is used to communicate important information, guidelines or data.

• Data and performance display 
• Internal corporate communication 
• Promotion and marketing 
• Orientation and navigation 
• Exhibitions and presentations 
• Improved communication  
• Increased engagement and recall
• Effective dissemination of information 
• Flexibility of use 
• Cost-effective 

12. Samples and prototypes

These preliminary versions provide a physical visualization of a product or project under development, facilitating testing, evaluation and understanding of the final product. 

• Product development 
• Research and development 
• Marketing and market research 
• Quality standards control  
• Usability and market testing
• Improved design 
• Risk reduction 
• Functionality validation 
• Cost optimization 
• Production optimization

13. Operation sheets

These detailed documents provide precise instructions on how to carry out specific tasks. They generally contain information on procedures to be followed, safety standards, equipment to be used, and critical process steps.

• Process standardization
• Quality management 
• Maintenance operations 
• Construction or installation instructions 
• Description of protocols
• Reduced errors 
• Operational efficiency 
• Continuous improvement
• Enhanced safety

14. One Point Lessons (OPL)

One Point Lessons are short training sessions or instruction sheets designed to impart concise, targeted knowledge or instructions on a specific key point or skill. 

• On-the-job training
• Maintenance and repair 
• Introduction of new equipment 
• Targeted learning 
• Time efficiency 
• Ease of implementation and versatility 
• Performance enhancement 
• Continuous improvement 

15. UTrakk Knowledge Center

UTrakk Knowledge Center centralizes and organizes an organization's essential information and resources. It gives employees easy access to important documents, guides, policies, and procedures.

• Production management
• Industrial maintenance
• New employee integration 
• Training and development
• Centralized access to information and resources 
• Improved compliance
• Autonomy and empowerment
• Enhanced team collaboration

Bonus tool: Visual management boards

Visual management boards are visual controls used within an organization to display key information about processes, progress, and performance in a visually engaging and easily understandable manner.

They are extremely useful because they provide immediate visual feedback to all team members about what’s happening within a department or across the organization. 

Here are some visual management boards examples:

• Safety metrics board
• Production status board
• Project status board
• KPI dashboard
• Maintenance schedule board
• Employee performance board
• Inventory management board
• Six Sigma board

Each visual management board can be customized to fit specific operational needs or environments.

Tips for implementing visual management in your organization

Assess needs and existing processes.

Start with a thorough assessment of current processes to identify areas where visual management could bring about significant improvements. Look for bottlenecks, inefficiencies, and opportunities to create a more transparent, clear and easy-to-navigate work environment. 

Involve teams from the outset

For your visual implementation to work (including over the long term), your employees' buy-in is crucial. Engage them from the outset by taking their needs into account and soliciting their suggestions for process improvement. This will not only encourage the adoption of new practices, but also ensure their application and ongoing integration into the corporate culture, thanks to the active support of the teams.

Train staff for the principles of visual management

Involving a team also means ensuring that every employee understands how to use the visual controls and supports you want to put in place. To this end, organize regular training sessions to teach the principles and importance of visual management. 

Roll out new initiatives progressively

As with any change, start small. Introduce new types of visual management gradually, to give employees time to adapt. Start with pilot improvement projects or specific departments before rolling out the practices to the whole organization.

Use tools designed to meet your objectives

As you've seen, there are many visual tools. Instead of trying them all, select visual management ideas that specifically meet your company's needs, even if it means adding to them later.  

Monitor and adjust systems as necessary

Analyze the impact of your visual indicators by collecting feedback and measuring performance against defined objectives . You can then adjust practices if necessary, based on the results.

Embrace visual management to drive performance efficiently

Visual management can schematize, explain and clarify, but it's more than that. More than simply improving visibility via a set of tools or techniques, this method is a powerful strategic lever for improving operations management, safety and organizational efficiency . 

It's a management philosophy that also works on a human level, improving communication and transparency within teams, enabling every employee to clearly understand processes, objectives and responsibilities. 

Integrating visual management into your organization means making the choice to create a more open, collaborative and inclusive working environment, with the key to far superior performance.

FAQ on visual management

What are visual management tools.

Visual management tools are systems and methods used to display critical information in an easily understandable visual format. They help teams monitor performance, identify issues, and streamline processes, enhancing overall productivity and efficiency.

How do visual management tools improve team performance?

Visual management tools improve team performance by providing clear and immediate visibility into key performance metrics. They facilitate quick decision-making, enhance communication, and ensure everyone is aligned with the team's goals and objectives.

What are some examples of visual management tools?

Examples of visual management tools include Kanban boards, performance dashboards, Gemba walks, and visual indicators such as color-coded charts and graphs. These tools help teams track progress, identify bottlenecks, and maintain focus on priorities.

Why is visual management important in manufacturing?

Visual management is crucial in manufacturing because it provides real-time insights into production processes. It helps identify inefficiencies, reduce waste, and ensure consistent product quality. Visual tools support a proactive approach to problem-solving and continuous improvement.

Can visual management tools be integrated with digital technologies?

Yes, visual management tools can be integrated with digital technologies such as IoT sensors, data analytics platforms, and software applications. This integration enhances data accuracy, allows for real-time updates, and provides a comprehensive view of performance metrics, enabling more effective management.

Ready to optimize your workplace performance with a visual factory?

Use the power of visual management to transform production, engage employees, and boost performance. Proaction International's experts offer tailored support and step-by-step guidance to help you implement these tools and techniques.

Adeline de Oliveira

Writer and editorial manager for about 15 years, Adeline is passionate about human behavior and communication dynamics. At Proaction International, she covers topics ranging from Industry 5.0 to operational excellence, with a focus on leadership development. This expertise enables her to offer insights and advice on employee engagement and continuous improvement of managerial skills.

Déli-Porc Develops an Agile, Digitalized Culture Focused on Optimization

Kefor maximizes its performance by optimizing manager skills, le goupe maurice: motivate and retain talents by focusing on the leadership development of managers.

© 2023 Proaction International Inc. All rights reserved. Terms of Use | Privacy Notice | Cookie Notice

Creating Visual Management

Whilst many organisations have recognised the wide-ranging benefits of becoming lean, very few companies truly understand exactly what it entails, resulting in the omission of critical lean elements. By contrast, authentic lean enterprises have commitment at all levels of the organisation, generating a top-to-bottom desire for improvement - and it is often said that ‘the lean workplace is the visual workplace’. In this context, Visual Management provides a mechanism that depicts the current situation within an organisation, allowing anyone to understand that situation and take consequent action. This case study focuses on how Visual Management can be implemented across multiple sites.

The Challenge

The UK, the client – HSS Hire – wanted a standard approach to visual standards (5S) and visual management (performance boards) across all 300 UK branches.

The Results

• Design – Pilot – Deploy’, the approach taken for distribution, engineering and sales functions.
• Mobile 5S shadow boards designed and built, creates shop floor flexibility.
• Visual Management and daily huddle meetings established; enables everyone to be kept informed.

Professional, efficient, and versatile with excellent communication and engagement skills, Chris is a strong project leader and manager who can be as effective on the shop floor as he can in the board room. I look forward to working with him again in the future. General Manager - Unipart

Designing Visual Management

Contact me today +44 (0)7970 137351

Related case studies.

Implementing 5S

Book a consultancy call.

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nulla sit amet vehicula neque. Phasellus luctus maximus rutrum. Lorem ipsum dolor sit amet.

Academia.edu no longer supports Internet Explorer.

To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to  upgrade your browser .

Enter the email address you signed up with and we'll email you a reset link.

• We're Hiring!
• Help Center

Visual management in industrial construction: a case study

Related Papers

Patricia Tzortzopoulos Fazenda

26th Annual Conference of the International Group for Lean Construction

Daniela D Viana

Journal of Management in Engineering

Patricia Tzortzopoulos , Lauri Koskela

Construction Innovation

Zeeshan Aziz

Purpose The purpose of this paper is to explore the benefits of visual management (VM) systems in transportation construction projects in England. Design/methodology/approach Following a comprehensive literature review, the benefits of VM were investigated through action and case study research executed within two construction projects in England. Findings The main findings are: VM can contribute to increased self-management, better team coordination, better promises or an increasing plan percent complete, easier control for the management and improved workplace conditions in the transportation sector. It is important for the management to obtain the engagement of their workforce for VM through increased participation and show the actual benefits. However, managerial monitoring and control on the systems should not be underestimated. Originality/value The transportation sector in England has been systematically deploying Lean construction techniques in its operations for a while. On...

J. Inf. Technol. Constr.

Lean construction and construction automation are two of the important efforts to improve the performance of the construction industry. However, apart from a small number of scholarly articles and implementation prototypes, the lean and digital construction movements seem to be largely running independent of each other. This paper aims at exploring those connections between Visual Management (VM), a fundamental information management strategy in lean construction, and emerging technologies, demonstrating the synergy between the two concepts over potential implementation scenarios and establishing their conceptual connections in construction. Consequently, the hypothesis of the paper is there is a significant synergy between emerging technologies (construction automation) and visual/sensory information management strategies (Visual Management) in lean construction. The hypothesis is explored by (i) discussing how emerging technologies can support conventional VM tools and techniques ...

Patricia Tzortzopoulos

Lean construction has recently gained momentum in England’s highways construction supply chain. The literature indicates that the current view to Visual Management (VM) within those lean implementations is limited to some VM tools. This paper explores the condition of VM, which is a fundamental sensory information management strategy in the lean production system, in the highways sector in England. VM in construction is a scarcely researched topic, particularly outside the building construction context. The existing VM research focuses generally on the application of a specific VM tool rather than the VM strategy itself. The paper identifies the current VM condition with its realization means (VM tools), drivers, barriers and future implementation opportunities in England’s highways construction supply chain through five case studies and a focus group research effort. The main findings are; (a) the current implementation of VM, particularly on English highways construction fields, i...

Procedia Economics and Finance

Petra Bosch-Sijtsema

20th Annual Conference of the International Group for Lean Construction

Loading Preview

Sorry, preview is currently unavailable. You can download the paper by clicking the button above.

RELATED PAPERS

Marinna Pivatto

Engineering, Construction and Architectural Management

Sustainability

Ana Reinbold

ali zouiter

Daniela D Viana , Patricia Tzortzopoulos

28th Annual Conference of the International Group for Lean Construction (IGLC) - Berkeley, California, USA - 2020

Sergio A Migowski

Marcus Ormerod

Louise Rönnqvist

Markus Wallmyr

Applied Sciences

Regina Leite

Revista de Gestão e Secretariado

José Salvador da Motta Reis

Giancarlo Nota

ASCE's Journal of Computing in Civil Engineering

Yong K Cho , Reza Akhavian

Nashwan Dawood

2010 14th International Conference Information Visualisation

Terrence Fernando

Thomas Olofsson

Proceedings of the …

Bruno Mota , Lauri Koskela , José P. Barros Neto

Audrey Schultz

•   We're Hiring!
•   Help Center
• Find new research papers in:
• Health Sciences
• Earth Sciences
• Cognitive Science
• Mathematics
• Computer Science
• Academia ©2024

The Lean Post / Articles / Visual Management – the Good, the Bad, and the Ugly

Problem Solving

Visual Management – the Good, the Bad, and the Ugly

By John Shook

June 20, 2012

Visualization is a good thing. We all know that. And many of us in the Lean Community practice it, to greater or lesser degrees of effectiveness. Among other benefits, making visible such things (see examples below) as pace or quality of work makes it easier to solve problems and sustain gains. To quote Dr. Thoralf Sundt of Mayo Clinic, "If I can see it, I can fix it."

Visualization is a good thing. We all know that. And many of us in the Lean Community practice it, to greater or lesser degrees of effectiveness. Among other benefits, making visible such things (see examples below) as pace or quality of work makes it easier to solve problems and sustain gains . To quote Dr. Thoralf Sundt of Mayo Clinic, “If I can see it, I can fix it.”  The reverse must also be true – it’s hard to fix what you can’t see. This past month I ran across three examples of visualization – good, bad, and ugly – to share with you.

The first case involved a young woman doing a quality check at the end of an assembly line of electromechanical components. For two years she had been collecting the same quality information. Performing a series of checks, she would confirm that all connectors were firmly attached, components all assembled and in working order. As she found problems, she recorded them into a computer database, which was then compiled into a larger database. The database was reviewed, analyzed, and results fed back to the production group and others.

There was no direct connection between the workers making the errors and the inspector finding the errors, and the information that was eventually shared followed a long and irregular time line. Management began looking at the situation because of a perceived “lack of motivation” in the workers and inspectors. As plant management explored various means of increasing worker engagement and motivation, a quality engineer noticed the disconnect between the workers and feedback on their performance . Problems that could have been fixed right away took days and weeks to even surface, and the time required for errors to be corrected could take much longer. The engineer wanted to fix his technical problem.

It was the woman doing the inspecting who made the suggestion. “How about,” she offered, “instead of me just entering the error information into a database, I tick off each example as they occur on this unused white board?” She found it easy to simply make a quick note of each problem on the board, and to enter it later into the database.

What happened next was unplanned. The production line leader started noticing what she was doing. He was a little nervous, seeing the performance – the mistakes – of his team members displayed for all to see. The next suggestion was his. “How about,” he offered, “if I bring my team over to take a look at the board at the end of each day, so we can see how we are doing?”

What happened next was interesting. As the inspector and the workers looked at her board together, they started to talk about it. Turned out, one of the workers who had been committing many of the mistakes mentioned that he had always had a problem with one of the connectors. The two ends of the connector were very small, his hands weren’t, and the space he had to work in was very tight. A recurring problem had been uncovered, its cause identified, and the engineer was delighted as he knew he could make the situation better with a relatively easy engineering adjustment. Other problems that got raised were often even easier to remedy, often right on the spot.

What motivates?

What happened next was even more interesting. As the inspector and workers got to know each other better, instead of waiting until the end of the shift, they started stopping by during their lunch break. They could see how they had done so far in the shift. Before long, the inspector and the team were engaged in a day-long exchange of how production was proceeding. Importantly, workers were  struggling less while producing more and the inspector’s very role in the process had changed dramatically. Management had sought to improve motivation and they did. But not at all in the way they had expected. Turned out that what was needed to increase motivation among the employees was more effective support in helping them be successful and engaged in their work.

The second case involved a production analysis board (PAB) that seemed, on the surface, to be working well. The production plan was laid out on an hourly plan versus actual basis. Ample space was allocated on the board for employees to capture their problems, ideas, remarks. But, a couple of things didn’t look right and a conversation with the team leader revealed that the board wasn’t working well. A deeper conversation and a little observation showed why.

All rework is bad – rework of worker engagement is worst of all.

The first problem in this case was one that is all too common. Management had asked the workers to write down the problems they encountered in the course of performing their daily work. A noble effort on the part of well-intentioned managers. The problem was what happened next, which was … nothing. There is little more demoralizing to a workforce than to gear them up to engage their minds only to miss-shift and find yourself going in reverse. The workers had no difficulty finding problems to capture on the dry erase PAB. The difficulty came when management failed to respond to them effectively. The list got longer. That was bad. Then, the list got shorter. But, that wasn’t good – it got shorter not because management responded by clearing off the items; the list shortened because the workers stopped reporting. A waste of time, they said.  

Next time management tries to engage these workers, they will find the workers – who were convinced they had been scammed again – to be more skeptical than ever.

What to say if you want to create waste and hide problems: “Produce as much as you can.”

The next problem in this example could be discerned from a close look at the plan versus actual – P/A – numbers on the board. The plan numbers showed no change from day to day, just steady plan to produce 240 units per shift, further broken down into 30 per hour. Okay, maybe that’s all right. Then, the actual numbers – records of actual production – were all over the map. That was interesting and could point toward any number of problems – identifying those is the very purpose of the P/A board. But, exploring just a little further, it turned out that the plan numbers weren’t real at all. Due to various product issues, the truth was that there was zero expectation of producing 240 units per shift. Actual hourly output ranged from 10 to 40, daily from 120 to 240, with one instance of 260. The explanation? “Well, we are having a lot of engineering changes, so we can’t meet our demand, but the target is still 240.” So, I queried, “How many do you actually expect to produce today – how many do you want to make?” The reply, “Well, we don’t know how many we can make but we want to make as many as we can …”

It is critical to provide unambiguous expectations – targets. “Today, we need to produce 240 units, 30 per hour. ” Not 239. Not 241. 240. The unambiguous target makes problem solving easier – “We only produced 230 of the targeted 240 units – exactly where did the missing ten units go?” We can pursue the cause-effect relationship between the missing 10 units and the various factors that cause them. As we improve our skills, we can tighten the management response time (instilling the all-important sense of urgency) to hourly and even less. The point here is that without a clear target, it is difficult to do PDCA . There is no PDCA without the P – that is precisely what “plan versus actual” is all about. The number that I, as leader, write in the P space represents the number that I am – no kidding – asking the team to produce. Problem solving is the challenge that I am asking them to accept in order to meet the target. (There is a role for “stretch goals,” but that is a different discussion.) Instructions such as “Produce as many as you can” create a dynamic of ambiguity, encourage excuses, and lead directly to those incessant cycles of firefighting that we wish to avoid.

See PAB explanation on pages 110-111 in Kaizen Express

For an interesting example of ugly visualization, check out this blog post .

This example reminds me of “lean offices” that shadow board every item on every cubicle desk, even while the flow of work remains murky, problems out of sight, and the way forward completely invisible.

Making visible normal from abnormal, arranging the physical environment to represent the way we want to work, and ensuring that our way of thinking about work is embodied in the way we configure our physical environment are methods to help us tap into natural human motivations. Random visualization will yield random results and unintended consequences. The countermeasure is to make sure each visual artifact has a clear and specific purpose, defined owners and users, along with rules and a cadence of usage. LEI’s Dave Logozzo recommends these three simple questions to make sure your visual boards are useful and can deliver the intended consequence:

• What is the purpose?
• Who is it for?
• How often do you use and/or respond to indications of abnormality – what is your PDCA pulse ?

Far better than shadow boards (nothing against shadow boards – I love them!) that make sure no one walks off with our staplers, let’s focus on this: arrange the flow of work so that problems are highlighted as they arise, enabling and encouraging individuals and teams to tackle them right away. Visualization which supports that is visualizaton I can support.

John Shook Chairman and CEO Lean Enterprise Institute, Inc. [email protected]

PS: Another example of visual management can be found right here at LEI. Since moving into our new offices in March, we are redoubling efforts to make our work as visible as possible. We invested in white boards of various kinds, white board paneling (metal, so it is also magnetic), a smart board, and painted many of our walls with white board paint.  When you visit us, you will be able to see our annual work plan – objectives, activities, timeline – on a 3×4 meter wall.

What we do here is office work and neither the work volume requirements nor the quality performance indicators are as crisp as on the operations examples above, but we’re endeavoring to make them as crisp as appropriate. Since we plan to offer more workshops in our new training room (as I write this, David Verble is teaching a workshop on Change Agent Skills and in July Mike Rother and team will lead a three-day Improvement Kata workshop), I hope you will find an occasion to visit us soon and give us your feedback and improvement ideas for our visual office. You can tell us if we are good, bad, or ugly.

Written by:

About John Shook

John Shook learned about lean management while working for Toyota for 11 years in Japan and the U.S., helping it transfer production, engineering, and management systems from Japan to NUMMI and other operations around the world. While at Toyota’s headquarters, he became the company’s first American kacho (manager) in Japan.…

Leave a Comment Cancel reply

Your email address will not be published. Required fields are marked *

Save my name, email, and website in this browser for the next time I comment.

Revolutionizing Logistics: DHL eCommerce’s Journey Applying Lean Thinking to Automation  

Podcast by Matthew Savas

Transforming Corporate Culture: Bestbath’s Approach to Scaling Problem-Solving Capability

Teaching Lean Thinking to Kids: A Conversation with Alan Goodman 

Podcast by Alan Goodman and Matthew Savas

Related books

A3 Getting Started Guide

by Lean Enterprise Institute

The Power of Process – A Story of Innovative Lean Process Development

by Eric Ethington and Matt Zayko

Related events

September 26, 2024 | Redmond, WA or Morgantown, PA

Building a Lean Operating and Management System 

October 02, 2024 | In-Person (Oakland University in Rochester, MI) OR Coach-Led Online

Managing to Learn

Explore topics.

Subscribe to get the very best of lean thinking delivered right to your inbox

Privacy overview.

• > Everyday Examples of Visual Management

Everyday Examples of Visual Management

Posted by Matt Banna

May 8, 2018 9:46:52 AM

Visual management falls into six categories based on the purpose.

To Share Information With Others

This is the most basic application of visual management. Think of an Open/Closed sign on a business. You know right away whether to come on in. A simple bulletin board with tacked up notices is another example. Perhaps the most widely used approach is color coding. Everyone knows that green means go, yellow means use caution, and red means stop. Because the meaning of these colors is so widely understood, they are used well beyond traffic lights. I’ve seen dozens of spreadsheets with on track projects, happy clients, and approved projects all in green. It works because it's like a language that everyone can understand immediately.

To Communicate Standards

There’s an exercise used by many Lean teachers in which participants are given very specific instructions on how to draw a pig. Everyone has the same instructions, so the pigs should all look alike, right? Nope. Even given detailed text descriptions, people interpret the steps differently, and no standard is achieved. You’ll get far more consistent results by showing them what the final pig looks like. Images can be used in all sorts of ways to make sure that everyone understands what it looks like when the standard is achieved whether the standard is related to a product, an organized workspace , a correctly completed form, or almost anything else.

To Enforce the Standards

Sometimes visual management can be used to make it more difficult to ignore the standard than to comply. Templates for Word and PowerPoint documents are examples of this type of visual management. We notice this a lot in databases. For example, you might have a drop-down select field for “State,” rather than a text field so that you don’t end up with hundreds of states because Texas, Tx, and TX are all represented.

To Bring Attention to Irregularities

This is one you probably see a lot. Your phone flashes at you when the battery is low. There’s a light on your dashboard when your car is running too hot. Your fridge probably has a light that lets you know when the water filter needs to be replaced. The stop light flashes red when there’s something wrong with the system. There are non-electronic examples as well. If you have a peg board in your garage with a hook for every tool and an outline of that tool’s shape drawing on the board, you know right away when someone didn’t put your hammer away.

To React to Irregularities When They Occur

Of course, we believe that when irregularities occur, the right course of action is to figure out the root cause and solve the problem, but sometimes a “Caution, Wet Floor,” sign really comes in handy. Detour signs for road work, monitors for patient vital signs, and the buttons that have replaced andon cords on many factory floors are all examples.

To Stop Irregularities from Occurring in the First Place

The sign that says, “You must be this tall to ride this ride,” posted at the start of the line, prevents folks that are too small getting booted after a long wait. In theory, the gadget at the airport gate that shows the maximum size of overhead luggage should prevent oversized bags from making it onto the plane. (Here’s an excellent example of how visual management tools are only useful if they are used by employees.) I have a blender that won’t blend unless the arrow on the lid is properly aligned with the indicator on the handle to prevent accidents. The same is true for my bottle of Tylenol that won’t open unless the arrows are aligned, something a toddler is unlikely able to do. These are all examples of visual cues used to prevent problems.

Visual management is somewhat of a business buzzword these days, but it shouldn’t be implemented just for the sake of it. When you consider incorporating visualization, whether it be in improvement management software , or physically in the workspace, think about what you are trying to communicate or achieve and which of the categories of visual management can be of help.

Topics: Continuous Improvement Software , Visual Management

Add a Comment

Subscribe via email, recent posts.

Why KaiNexus

• Collaboration
• Standardization
• Customer Success Manager
• Lean Strategy
• Solutions Engineering
• Customer Marketing
• Configuration
• Continuous Enhancements
• Employee Driven
• Leader Driven
• Strategy Development
• Process Driven
• Daily Huddles
• Idea Generation
• Standard Work
• Visual Management
• Advanced ROI
• Notifications
• Universal Badges
• Case Studies
• Education Videos

Copyright © 2024 Privacy Policy

• Certification
• Case Studies
• 5S Consulting Services
• Facility Visual Management Project (FVM)
• Signs and Posters
• Pragati – Business Performance Improvement Project
• Performance White Boards
• Business Strategy Building Session

What is Visual Management?

• Post author By Strategy_Access_1
• Post date September 9, 2023
• No Comments on What is Visual Management?

In today’s rapidly evolving corporate landscape, organizations are continually seeking innovative approaches to enhance quality, safety, and productivity. Visual management has emerged as a transformative solution, and Visualmitra, at the forefront of this movement, is revolutionizing work culture. In this blog, we will delve into what visual management is and how it serves as a catalyst for improving various aspects of operations, particularly in manufacturing and corporate settings.

Visual management is a comprehensive approach that leverages visual cues and tools to streamline operations, enhance communication, and drive continuous improvement. At its core, visual management aims to make critical information readily available and easy to understand for everyone within an organization.

Visualmitra, a leading expert in visual management solutions, embodies this concept, offering innovative techniques and technologies to transform workplaces. Here’s how Visualmitra defines visual management:

“Visual management is a dynamic system that utilizes visual aids, such as charts, graphs, boards, signs, and color-coded displays, to communicate vital information, facilitate problem-solving, and create a shared understanding of goals and performance across all levels of an organization.”

Inspiring a Culture of Excellence

Visualmitra understands that the power of visual management extends beyond mere aesthetics; it inspires a culture of excellence within an organization. Here’s how visual management serves as a catalyst for this cultural transformation:

Clarity and Transparency Visual management makes complex data and processes accessible to everyone, fostering transparency. When employees can easily grasp the current state of operations, they are more likely to contribute to improvements.

Engagement and Ownership By involving employees in visual management practices, they become active participants in their work environment. This engagement instills a sense of ownership and accountability, driving them to take pride in their contributions.

Problem-Solving and Continuous Improvement Visual management highlights areas that require attention or improvement. When issues are visually represented, teams can collaboratively identify solutions and implement changes swiftly, driving a culture of continuous improvement.

Standardization Visual management supports the establishment of standardized processes, reducing variability and ensuring consistency. This standardization leads to improved quality and efficiency.

Data-Driven Decision-Making Visual management relies on real-time data representation. Teams can make informed decisions based on current performance data, leading to better choices and more efficient problem-solving.

Quality, Safety, and Productivity

Visualmitra’s expertise lies in harnessing visual management to significantly enhance quality, safety, and productivity in various operational settings, including manufacturing and corporate environments.

Quality Visual management ensures that employees adhere to standardized processes, reducing errors and defects. By making quality-related information visible, it becomes easier to identify and address quality issues promptly, resulting in higher product and service quality.

Safety Safety is paramount in any workplace. Visual management helps create a safer environment by highlighting safety protocols, procedures, and potential hazards. It increases safety awareness and empowers employees to take preventive actions, reducing accidents and injuries.

Productivity Visual management optimizes workflow by eliminating bottlenecks, reducing downtime, and enhancing resource allocation. It enables teams to monitor progress in real-time, leading to increased productivity and efficiency.

Visual management, as championed by VisualMitra , is not merely a visual enhancement but a powerful catalyst for inspiring a culture of excellence. Through clarity, engagement, and data-driven decision-making, visual management transforms work culture while significantly enhancing quality, safety, and productivity. In an ever-evolving business landscape, adopting visual management is not just a choice; it’s a strategic imperative to stay competitive and drive success. Visualmitra continues to lead the way in this transformative journey, empowering organizations to achieve operational excellence through the art of visual management.

• Tags visual management

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Save my name, email, and website in this browser for the next time I comment.

Enquire now

Enquire Now

Ready to get started.

IEEE Account

• Change Username/Password
• Update Address

Purchase Details

• Payment Options
• Order History
• View Purchased Documents

Profile Information

• Communications Preferences
• Profession and Education
• Technical Interests
• US & Canada: +1 800 678 4333
• Worldwide: +1 732 981 0060
• Contact & Support
• About IEEE Xplore
• Accessibility
• Terms of Use
• Nondiscrimination Policy
• Privacy & Opting Out of Cookies

A not-for-profit organization, IEEE is the world's largest technical professional organization dedicated to advancing technology for the benefit of humanity. © Copyright 2024 IEEE - All rights reserved. Use of this web site signifies your agreement to the terms and conditions.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

How Visual Management for Continuous Improvement Might Guide and Affect Hospital Staff: A Case Study

Affiliation.

• 1 Medical Management Centre, Karolinska Institutet, Stockholm, Sweden (Drs Ulhassan, von Thiele Schwarz, Sandahl, and Thor); Department of Psychology (Dr von Thiele Schwarz) and Stress Research Institute (Dr Westerlund), Stockholm University, Stockholm, Sweden; and the Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden (Dr Thor).
• PMID: 26426324
• DOI: 10.1097/QMH.0000000000000073

Visual management (VM) tools such as whiteboards, often employed in Lean thinking applications, are intended to be helpful in improving work processes in different industries including health care. It remains unclear, however, how VM is actually applied in health care Lean interventions and how it might influence the clinical staff. We therefore examined how Lean-inspired VM using whiteboards for continuous improvement efforts related to the hospital staff's work and collaboration. Within a case study design, we combined semistructured interviews, nonparticipant observations, and photography on 2 cardiology wards. The fate of VM differed between the 2 wards; in one, it was well received by the staff and enhanced continuous improvement efforts, whereas in the other ward, it was not perceived to fit in the work flow or to make enough sense in order to be sustained. Visual management may enable the staff and managers to allow communication across time and facilitate teamwork by enabling the inclusion of team members who are not present simultaneously; however, its adoption and value seem contingent on finding a good fit with the local context. A combination of continuous improvement and VM may be helpful in keeping the staff engaged in the change process in the long run.

PubMed Disclaimer

Similar articles

• Antecedents and characteristics of lean thinking implementation in a Swedish hospital: a case study. Ulhassan W, Sandahl C, Westerlund H, Henriksson P, Bennermo M, von Thiele Schwarz U, Thor J. Ulhassan W, et al. Qual Manag Health Care. 2013 Jan-Mar;22(1):48-61. doi: 10.1097/QMH.0b013e31827dec5a. Qual Manag Health Care. 2013. PMID: 23271593
• Effects of organizational context on Lean implementation in five hospital systems. Harrison MI, Paez K, Carman KL, Stephens J, Smeeding L, Devers KJ, Garfinkel S. Harrison MI, et al. Health Care Manage Rev. 2016 Apr-Jun;41(2):127-44. doi: 10.1097/HMR.0000000000000049. Health Care Manage Rev. 2016. PMID: 25539057
• Implementing large-scale quality improvement: lessons from The Productive Ward: Releasing Time to Care. Morrow E, Robert G, Maben J, Griffiths P. Morrow E, et al. Int J Health Care Qual Assur. 2012;25(4):237-53. doi: 10.1108/09526861211221464. Int J Health Care Qual Assur. 2012. PMID: 22755479
• Quality initiatives: lean approach to improving performance and efficiency in a radiology department. Kruskal JB, Reedy A, Pascal L, Rosen MP, Boiselle PM. Kruskal JB, et al. Radiographics. 2012 Mar-Apr;32(2):573-87. doi: 10.1148/rg.322115128. Epub 2012 Feb 8. Radiographics. 2012. PMID: 22323617 Review.
• Lean Thinking for Primary Care. Anderson JB, Marstiller H, Shah K. Anderson JB, et al. Prim Care. 2019 Dec;46(4):515-527. doi: 10.1016/j.pop.2019.07.009. Epub 2019 Aug 1. Prim Care. 2019. PMID: 31655748 Review.
• Improving the standardisation, timeliness and efficiency of the occupational therapy admission process in an older adult inpatient service. Ige JJ, Hunt DF, Mitchell A, Eaton E, Walker A, Fearn R, Kirkham L, Staples A, Giles A, Wilson B. Ige JJ, et al. BMJ Open Qual. 2023 Dec 14;12(4):e002514. doi: 10.1136/bmjoq-2023-002514. BMJ Open Qual. 2023. PMID: 38097284 Free PMC article.
• The voluntary medical male circumcision Site Capacity and Productivity Assessment Tool (SCPT): An innovative visual management tool to optimize site service delivery. Njeuhmeli E, Tchuenche M, Opuni M, Stegman P, Hamilton M, Forsythe S, Nhaduco F, Zita F, Gaspar N, Come J. Njeuhmeli E, et al. PLOS Glob Public Health. 2022 Jan 28;2(1):e0000126. doi: 10.1371/journal.pgph.0000126. eCollection 2022. PLOS Glob Public Health. 2022. PMID: 36962141 Free PMC article.
• The impact of lean management on frontline healthcare professionals: a scoping review of the literature. Mahmoud Z, Angelé-Halgand N, Churruca K, Ellis LA, Braithwaite J. Mahmoud Z, et al. BMC Health Serv Res. 2021 Apr 26;21(1):383. doi: 10.1186/s12913-021-06344-0. BMC Health Serv Res. 2021. PMID: 33902552 Free PMC article. Review.
• Using kaizen to improve employee well-being: Results from two organizational intervention studies. von Thiele Schwarz U, Nielsen KM, Stenfors-Hayes T, Hasson H. von Thiele Schwarz U, et al. Hum Relat. 2017 Aug;70(8):966-993. doi: 10.1177/0018726716677071. Epub 2016 Dec 1. Hum Relat. 2017. PMID: 28736455 Free PMC article.

Publication types

• Search in MeSH

LinkOut - more resources

Full text sources.

• Ingenta plc
• Ovid Technologies, Inc.
• Wolters Kluwer

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Peer-reviewed

Research Article

Purtscher’s and Purtscher-like retinopathy etiology, features, management, and outcomes: A summative systematic review of 168 cases

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Ophthalmology, Hamad Medical Corporation, Doha, Qatar

Roles Formal analysis, Methodology, Writing – original draft, Writing – review & editing

Affiliation Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt

Roles Data curation, Formal analysis, Investigation, Methodology, Project administration

Roles Software, Validation, Visualization, Writing – original draft

Affiliation Gavin Herbert Eye Institute, University of California, Irvine, Irvine, California, United States of America

Roles Conceptualization, Data curation, Investigation, Project administration

Affiliation Department of Ophthalmology, Islamic Hospital, Amman, Jordan

Roles Investigation, Methodology, Project administration, Resources

Affiliation Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN, United States of America

Roles Data curation, Formal analysis, Visualization, Writing – original draft

Affiliation Department of Ophthalmology, National University Hospital, Singapore, Singapore

Roles Formal analysis, Investigation, Methodology, Project administration

Affiliation College of Medicine, Qatar University, Doha, Qatar

Roles Project administration, Resources, Software, Writing – original draft

Affiliation Department of Ophthalmology, MedStar Georgetown University Hospital, Washington, D.C., United States of America

Roles Conceptualization, Supervision, Validation, Writing – review & editing

Affiliations Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States of America, Department of Ophthalmology, Faculty of Medicine, Cairo University, Cairo, Egypt

• Hashem Abu Serhan, 
• Mohammad T. Abuawwad, 
• Mohammad J. J. Taha, 
• Amr K. Hassan, 
• Luai Abu-Ismail, 
• Mohammad Delsoz, 
• Hamzeh M. Alrawashdeh, 
• Hamad A. Alkorbi, 
• Obadah Moushmoush, 
• Ayman G. Elnahry

• Published: September 6, 2024
• https://doi.org/10.1371/journal.pone.0306473
• Reader Comments

To describe Purtscher’s and Purtscher-like retinopathy clinical features, etiologies, management options, and visual outcomes.

Our protocol was registered on PROSPERO [registration number: CRD42023406843 ]. Seven online databases were searched: PubMed, Scopus, Medline, ScienceDirect, CENTRAL, clinicaltrials.gov, and Google Scholar. Original articles were included if they reported at least one subject diagnosed with Purtscher’s or Purtscher-like retinopathy. The primary outcome is to describe the clinical features of Purtscher and Purtscher-like retinopathies, including etiologies, results of related investigations, management lines, and visual outcomes. All analyses were conducted with the use of Statistical Package for Social Sciences (SPSS) version 27 (IBM SPSS Corp, SPSS Statistics ver. 26, USA) and Cochrane’s RevMan software. The methodological quality of included studies was assessed using the NIH quality assessment tools.

A total of 114 articles were included, describing 168 cases of Purtscher’s and Purtscher-like retinopathy. Patients were evenly distributed between males (50.89%) and females (49.11%). Average age of patients was 34.62 years old. Trauma was the leading cause of retinopathy, being reported in 39.88% of our patients, followed by systemic lupus erythematosus (SLE) (13.1%) and acute pancreatitis (11.9%). Bilateral symptoms were reported in 57.7% of patients with centrally blurred vision being the most complained symptom (OS: 34.32% and OD: 18%). 75% of patients elicited bilateral retinal findings. Cotton-wool spots were of highest prevalence (58%). Purtscher flecken was seen in 53% of patients. Macular edema was seen in 13% of patients. Overall, patients had a favorable prognosis (53%).

Purtscher’s and Purtscher-like retinopathies are rare sight-threatening retinopathies that develop most commonly following trauma or other systemic diseases as SLE and acute pancreatitis. Little data is available regarding these conditions, and available data is of low quality. Patients develop bilateral disease in approximately 50% of cases, and several retinal findings are observed, with no specific tendency. Most observed signs are cotton-wool spots in around 55% of patients and Purtscher flecken in 51% of patients. Patients spontaneously recovered, although data is not conclusive. No clear prognostic value of etiological factors is identified, and further research is required in this regard.

Citation: Serhan HA, Abuawwad MT, Taha MJJ, Hassan AK, Abu-Ismail L, Delsoz M, et al. (2024) Purtscher’s and Purtscher-like retinopathy etiology, features, management, and outcomes: A summative systematic review of 168 cases. PLoS ONE 19(9): e0306473. https://doi.org/10.1371/journal.pone.0306473

Editor: Kai Januschowski, Mount Saint Peter Eye Clinic, University of Tuebingen, GERMANY

Received: March 1, 2024; Accepted: June 18, 2024; Published: September 6, 2024

Copyright: © 2024 Serhan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

First described in 1910 by Otmar Purtscher, Purtscher’s retinopathy is a form of traumatic retinal angiopathy. It is brought about by occlusive microvasculopathy which may be associated with intraretinal hemorrhages, and often presents with sudden regression of visual acuity, bilaterally, within two days of trauma. A few potential pathological mechanisms resulting in Purtscher’s retinopathy were described in literature, all of which suggest that the most likely cause of the flecken is a precapillary arteriolar occlusion due to an embolus. Some these mechanisms include raised intracranial pressure and extravasation of lymph, raised intrathoracic pressure and venous dilatation, and vasculitis due to free fatty acids [ 1 ]. Retinas affected by Purtscher’s retinopathy often elicit Purtscher flecken (areas of retinal whitening), retinal hemorrhages, and cotton-wool spots [ 2 – 4 ]. Purtscher-like retinopathy is a similar retinopathy that is not related to traumatic origin but rather develops in the setting of pancreatitis, kidney disease, malignancy, hemolytic uremic syndrome (HUS), autoimmune diseases (e.g. Systemic lupus erythematosus (SLE)), and several other systemic and infectious illnesses including the novel COVID-19 [ 5 ]. The incidence of Purtscher-like retinopathy has been linked to multiorgan failure or advanced disease, leading to fatality [ 6 ].

Diagnosis of Purtscher-like retinopathy is often done clinically. A history of etiological factors in association with clinical signs can be sufficient to diagnose patients. Purtscher flecken seen on fundoscopy are considered pathognomic, although not seen in 50% of patients, however; other findings like cotton-wool spots and intraretinal hemorrhages can also aid in diagnosis [ 2 , 5 , 7 ]. The main hypothesis for the pathophysiology of Purtscher-like retinopathy is an occlusion of peripapillary terminal arterioles. This occlusion occurs due to a sequence of inflammation, leukoembolization, endothelial damage, activation of complement C5, and C5a predisposition of leukocytes (granulocytes) aggregation [ 1 , 8 ]. Around 60% of cases of this condition are bilateral [ 6 ]. The incidence of Purtscher’s retinopathy is not clear, as some reports have estimated the annual incidence of Purtscher’s and Purtscher-like retinopathies to be approximately 0.24 individuals per million, while others assumed the incidence to be higher since this condition could often be asymptomatic [ 5 ].

Overall, cases of Purtscher’s and Purtscher-like retinopathy are managed conservatively, with marked visual improvement spontaneously occurring. Nevertheless, some literature suggests that patients benefit from intravenous methylprednisolone pulse, suggesting it helps restore microvasculature and inhibit granulocyte aggregation. Otherwise, symptomatic treatment has been used, such as anti-vascular endothelial growth factor for cases with macular edema, steroids, and immunosuppressive therapy for autoimmune disease-related cases [ 9 – 12 ]. In this systematic review of the literature, we attempt to explore clinical features, causes, cross-correlations, management and prognostic factors in Purtscher’s and Purtscher-like retinopathy.

This systematic review was conducted as per the recommendation of the PRISMA checklist for systematic reviews and meta-analyses ( S1 Checklist ). Our protocol was registered on PROSPERO prospectively [registration number: CRD42023406843 ]. This study adhered to the tenets of the Declaration of Helsinki. Given that our study did not involve human subjects, an institutional review board (IRB) approval was not required. On June 14, 2023, seven online databases were searched: PubMed, Scopus, Medline, ScienceDirect, Cochrane Central Register of Controlled Trials (CENTRAL), clinicaltrials.gov, and Google Scholar.

The search query was built following the PICO framework: participants were patients diagnosed with Purtscher’s or Purtscher-like retinopathy, and no restrictions applied on the interventions, comparators, and describing clinical features, etiologies, management options, and visual outcomes. In addition, no restrictions were applied depending on language, publication date, or study design. The primary outcome is to describe the clinical features of Purtscher and Purtscher-like retinopathies, including etiologies, results of related investigations, management lines, and visual outcomes. Secondary outcome included provide prognostic factors for Purtscher or Purtscher-like retinopathies related to the underlying etiology.

The search including the following keywords ((Purtscher[tiab] OR Purtscher-like[tiab] OR Pseudo-Purtscher) AND retinopath*[tiab]. The search criteria were modified as per the searched database. In addition, an updated manual search was performed to avoid missing any potentially related studies.

Eligibility criteria

Original research articles were included if they reported at least one subject diagnosed with Purtscher’s or Purtscher-like retinopathy. In the meantime, studies were excluded if they met at least one of the following criteria: (1) articles not reporting the target population, (2) non-original research (i.e., reviews, commentaries, guidelines, editorials, correspondence, and letters to editors), (3) unavailable full texts, (4) abstract-only papers with no published full texts, (5) duplicated studies, and (6) studies with unextractable data.

Selection of studies

Retrieved articles from electronic databases were imported in Endnote Software for duplicate removal. Then, citations were exported an Excel Sheet for screening. Screening was performed on two steps: title/abstract and full text screening. Two sets of two reviewers each [LAI and MD; HAA and OM] carried out the screening process, where the titles, abstracts, and full texts of all records were screened simultaneously by two reviewers. Differences between reviewers were solved by a thorough discussion, and when necessary, the senior authors [HAS and AGE] were consulted to give a final decision in unsolved disputes.

Data extraction

Two reviewers [HAS and AGE] developed the data extraction sheet with the use of Microsoft Excel. The extraction sheet included three parts: baseline characteristics, main outcomes, and secondary outcomes. The first part included references’ information (i.e., author name, year of publication, study design, and sample size [number of patients and eyes]) and patients’ characteristics (i.e., intervention and comparison groups, type of retinopathy, age, and gender). The second part included data related to Purtscher’s or Purtscher-like retinopathy, such as the etiology, symptoms, signs, and management lines. The third part was related to the quality assessment and risk of bias of the include articles. Two sets of two reviewers each [LAI and MD; HAA and OM] extracted relevant data from finally included articles. Finally, two senior authors checked the accuracy of extracted data before the analysis [HAS and AGE].

Risk of bias assessment

The methodological quality of included studies was assessed using the National Institute of Health (NIH) quality assessment tools ( https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools ) for each respective study design included. The NIH tool assesses the included of studies at the level of several domains: research question, study population, sample size justification, inclusion and exclusion criteria prespecified and applied uniformly, case and control definitions, random selection of study participants, exposure assessed prior to outcome measurement, exposure measures and assessment, blinding of exposure assessors and statistical analysis. Each of these domains is given a final decision of no information or good (>7), fair (4–7), or poor (<4). Finally, each study is given a final evaluation based on the evaluation reported in all domains. The quality assessment was performed by two sets of two reviewers, where each article was assessed by [LAI and MD; HAA and OM]. Any differences between reviewers were solved by discussion, and the senior authors [HAS and AGE] were consulted to give a final decision regarding any unsolved disputes.

Data synthesis and analysis

All analyses were conducted per-protocol ( CRD42023406843 ) according to assessed patients with the use of Statistical Package for Social Sciences (SPSS) version 27 (IBM SPSS Corp, SPSS Statistics ver. 26, USA) and Cochrane’s RevMan software. We performed descriptive analysis presenting the categorical variables as percentages and frequencies while numerical variables as a mean and standard. The significance of the data was assessed using a categorical Chi-square test. All statistical tests were conducted with a 95% confidence interval and a 5% error margin. A p-value of less than 0.05 was considered statistically significant.

Characteristics of the included studies

Our initial search concluded 1084 articles. Filtration was done according to the inclusion criteria, yielding 114 papers after the final stage. Fig 1 describes the filtration process according to the PRISMA guidelines. Included articles described 168 cases of Purtscher’s or Purtscher-like retinopathy with ages ranging from 2–75 years, with an average of 34.62 years. Of patients, 49.11% were female, and cases were reported from countries all over the world. Table 1 includes a summery for all included articles.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0306473.g001

https://doi.org/10.1371/journal.pone.0306473.t001

Causes of Purtscher’s & Purtscher-like retinopathy

The causative co-morbidity of retinopathy for each patient in our review was recorded. About 80.37% had clear causative co-morbidity, with trauma being the leading cause. Head/face trauma and other site trauma were the leading causes of retinopathy in 22.62% and 17.26% of included subjects respectively. Other causes had little prevalence, except for SLE (13.1%) and acute pancreatitis (11.9%), which had a relatively higher occurrence. Table 2 summarizes the prevalence of each causative co-morbidity in our review.

https://doi.org/10.1371/journal.pone.0306473.t002

Diagnostic tests used for investigation

Patients were diagnosed by several methods, and reported diagnostic tests were aggregated in Table 3 . Most patients were subjected to multiple diagnostic tests to assess different parts of the eye. In general, four tests were mostly acquired, namely fluorescence angiography (61.9%), fundus photography (55.95%), slit lamp (55.36%), and optical coherence tomography (OCT) (41.07%).

https://doi.org/10.1371/journal.pone.0306473.t003

Relationship between cause of retinopathy and visual prognosis

The relationship between causes of retinopathy and the prognosis for affected eyes has been assessed using Chi-square analysis. Prognosis for each eye was either explicitly stated or acquired from final best corrected visual acuity (BCVA) changes during the follow-up period. We defined good prognosis as any improvement in the final BCVA, while poor prognosis as worsening of final BCVA compared to presentation. Unfortunately, no significant correlation was observed between cause of retinopathy and the extent of effect. Table 4 shows the relationship as described in cases.

https://doi.org/10.1371/journal.pone.0306473.t004

In patients, BCVA before and after treatment was used as an indicator for visual improvement/regression. Overall, patient showed great variety in terms of presentation BCVA, both OD and OS, however; after treatment, the trend was towards 0 logMAR BCVA, which corresponds to normal vision.

Eye symptoms reported by patients

Tables 5 – 8 summarize our findings regarding presenting symptoms, signs and finding in the retinas of patients. Regarding symptoms, they were centered around loss of vision, weather central or peripheral, blurring or sudden, without reports of pain. Of patients, 97 (57.7%) reported bilateral symptoms. The most reported symptom was OS centrally blurred vision at 34.32%, while OD central vision blurring was reported in approximately 18% of patients. Other symptoms were reported especially OD, including floaters, scotomas, ptosis, and color vision affection ( Table 5 ) .

https://doi.org/10.1371/journal.pone.0306473.t005

https://doi.org/10.1371/journal.pone.0306473.t006

https://doi.org/10.1371/journal.pone.0306473.t007

https://doi.org/10.1371/journal.pone.0306473.t008

Eye signs reported in patients

Table 6 summarizes signs observed in patients. Bilaterality was noted in about 75% of patients, which is significantly higher than reported symptoms. Cotton-wool spots were of highest prevalence, as they were reported OD in 56.8% of patients and OS in 58% of patients. Following, retinal whitening was seen in approximately 53% patients OD and 50% patients OS, then retinal hemorrhages was reported in around 50% of patients OD and OS. Several other signs were observed to a lesser extent.

Correlation between observed signs and visual prognosis

In order to assess findings of prognostic visual value, Chi-square analysis was conducted. Interestingly Purtscher flecken (p<0.01), Cotton-wool spots (p<0.01), and optic nerve swelling (p<0.01) were associated with unknown or good visual prognosis ( Table 7 ). No specific clinical finding was found to be associated with poor visual prognosis. However, data were insufficient to provide clear prognostic value of observed signs due to high missing data from the primary included studies.

Types of retinal complications

Retinal complications were also recorded in patients. Most notably, macular edema was seen in 13% of patients. It is important to note that a wide range of retinal complications has been observed in patients. Table 8 contains a summary for the prevalence of complications among patients.

Treatment options utilized

Patients were managed according to their condition. In our review, treatments fell into six major categories, the most used of which was conservative management (60.7%). Systemic and topical corticosteroids in different doses were administered to 16.1% of included subjects. Combined anti-VEGF and laser therapy injections were used in 7.1%, and remaining modalities were acquired in small groups making 5% or less of patients ( Table 9 ).

https://doi.org/10.1371/journal.pone.0306473.t009

Purtscher’s and Purtscher-like retinopathy are sight threatening retinal conditions that manifest in relation to trauma or co-morbidity, respectively [ 2 ]. In this review, we attempt at a cross-comparison between published cases, in order to explore common factors in incidence, clinical picture, and prognosis. It is important to note that relatively low number cases are available in literature, as per our search, only 114 cases are available across all major medical research databases. Also, many published cases are of low quality. However, this review is the largest review discussing this rare entity.

The average age of included subjects is 34.62 years, which is consistent with similar cohorts in literature [ 5 , 125 ]. However, our age group had a wide range, including patients as young as 2 years old, and as old as 75. Subjects were almost evenly distributed between males (50.89%) and females (49.11%). In this regard, literature suggests that males are subjected to head trauma or traumatic brain injuries at higher rates than females, reaching 40% more likelihood [ 126 , 127 ]. On the contrary, acute pancreatitis, being the most reported co-morbidity with Purtscher-like retinopathy, is equally distributed between both sexes [ 128 ]. Of note, is the fact that epidemiological data for Purtscher’s and Purtshcer-like retinopathies is not sufficiently aggregated nor classified, making the identification of specific age/sex group as a risk group difficult.

In our review, only 80.37% of cases had clear related co-morbidity reported, which could hinder the full understanding of related causality. Nevertheless, of reported reasons, 67 (39.88%) patients reported a history of recent trauma, the majority of whom had head or facial trauma. This is reasonable, since the definition of Purtscher’s retinopathy includes the traumatic causality [ 2 , 5 ]. As to Purtscher-like retinopathy, the most reported co-morbidity was SLE (13.1%) followed by acute pancreatitis (11.9%). Only one systematic review is available to compare these results, namely Miguel et al., and the findings in our study do not concede, as it reports acute pancreatitis to be the most reported co-morbidity [ 5 ]. However, our review has a much larger sample size, which gives more confidence in our findings. Both SLE and acute pancreatitis are associated with altered hemostasis, pre-disposing patients to retinal microangiopathy [ 46 , 125 ]. But each of these diseases affects a different age group, as SLE is often manifested in younger individuals, i.e. second to third decade of life, while pancreatitis develops in older adults within their fifth to sixth decades [ 129 , 130 ]. Thus, the connection between SLE and Purtscher’s retinopathy agrees with the findings regarding average age of patients affected. We conducted a chi-square analysis to assess the link between the predisposing co-morbidity and prognosis, with insignificant results due to poor available information. It was suggested in Miguel et al. study that male gender and etiological factors (acute pancreatitis and trauma) are of important prognostic value, but these findings are lacking in statistical power, in addition to being biased since most cases in the study are trauma or acute pancreatitis in the first place [ 5 ].

Information about the clinical picture in Purtscher’s and Purtscher-like retinopathies has been also recorded. Bilateral symptoms were reported in 97 (57.7%) patients, but upon examination, 75% of patients had bilateral findings. In the Miguel et al. study, bilaterality was reported in 14/68 (20.95%) cases [ 5 ]. Another study investigating Purtscher-like retinopathy in SLE patients reported bilaterality in 15/17 (88.2%) patients, however; this could be related to the nature of SLE, being a systemic multi-system disease [ 125 ].

Symptoms and signs did not have any tendency towards right or left eye and were evenly distributed. Patients complained mostly of centrally blurring of vision (OS: 34.32%, OD: 18%), however; these percentages suggest a high heterogenicity in symptoms presented.

Regarding signs, patients mostly had cotton-wool spots and retinal whitening. Retinal whitenings, known as Purtscher flecken are important features of Purtscher’s as the name implies [ 2 ]. Some literature considered that the presence of Purtscher flecken and cotton-wool spots along with etiological factors as a suitable diagnostic criterion for Purtscher’s and Purtscher-like retinopathies, which is questionable since Purtscher flecken were present in 50–53% of our patients only, and in 63.23% of patients in the Miguel et al. study [ 5 , 125 ]. These findings manifest due to retinal artery occlusion by emboli of various origins and natures [ 2 ]. Retinal whitening manifests due to occlusion to the proximal retinal artery, while cotton-wool spots develop due to distal artery occlusion with small emboli [ 1 ]. Since distal arteries are of smaller diameter, smaller emboli are needed to exert effect, thus; cotton-wool spots are more likely to develop, which is what our data suggests. Retinal complications were specifically assessed, and were very diverse, making the most common complication macular edema which was seen in 13% of patients.

Overall, patients had a favorable prognosis (53%), which was also reported in an article by Schmidt and Otto on prognosis in Purtscher’s patients [ 131 ]. Although some complications are expected at a higher frequency as a result of the etiology of Purtshcer’s retinopathy, namely, trauma; No specific clinical finding was found to be associated with poor visual prognosis. Trauma-related complications as retinal detachment or vitreous hemorrhage were reported in a minority of patients (2.96% and 4.73%, respectively). This diversity of retinal complications can be attributed to the broad etiological base by which retinopathy develops, and our findings suggest the certain findings might have a significant prognostic value. Although about a third of reviewed articles did not provide clear prognostic description, we found that Purtscher flecken, cotton-wool spots, and optic nerve swelling might correlate to better improvement and favorable prognosis (p<0.01). However, the findings Schmidt and Otto suggest otherwise, as their work finds Purtscher flecken to correspond with worse prognosis. In addition, depending on case reports and series to provide strong evidence of the prognostic value couldn’t be conclusive.

Treatment of Purtshcer’s and Purtscher-like retinopathy are rather limited, especially with its ambiguous pathology. Generally speaking, each case should be individually assessed and managed, nevertheless; certain clinical features could help guide physicians. Since most patients were managed conservatively (60.7%), the primary clinical presentation is often indicative of no further complication, hence; no further intervention would be needed. In cases where complications develop, each complication calls for a suitable treatment modality. In our cohort, according to presentation and complications, modalities as corticosteroid-based management (16.1%), and combined anti-VEGF & laser therapy (7.1%) were used. A systematic review conducted by Xia et al. investigated the efficacy of Purtscher’s treatments on 139 eyes of 88 patients. In their study, glucocorticoids were used the most, in 63.29% of eyes, and conservative observation was used in 43.17% [ 132 ]. This suggests that management of Purtscher’s retinopathy patients can show great variety. In the Xia et al. study, patients showed improved vision across all groups, and no significant differences between treatment modalities was found. Moreover; similar to our observation, the quality of available evidence in this regard is rather poor, and no conclusive statements can be made [ 132 ]. A direct link between etiology-complication-treatment cannot be drawn from available information, moreover; treatment of Purtscher’s and Purtscher-like retinopathies often tend to the underlying systemic disease (e.g. SLE or Pancreatitis), making a specific management criterion tailored to Purtshcer’s or Purtscher-like retinopathy difficult to develop. Future research in this regard could assist in developing treatment guidelines for Purtscher’s and Purtscher-like retinopathies.

Limitations to this study can be summarized in the scarcity of available data, as well as the low quality of most cases reported. Future research in this topic should consider this limitation, as by overcoming them, a robust diagnostic criterion for Purtscher’s and Purtscher-like retinopathies can be developed. In addition, the nature of case reports and series may introduce bias and limit the generalizability of our findings raising questionable associations and prognostic values. Moreover, future research should pay attention to establishing a conventional treatment modality for these conditions, and to recognizing prognostic factors in order to prevent visual deterioration and loss.

Supporting information

S1 checklist. prisma checklist..

https://doi.org/10.1371/journal.pone.0306473.s001

Acknowledgments

Open Access funding provided by the Qatar National Library.

• View Article
• Google Scholar
• 2. Tripathy K, Patel BC. Purtscher Retinopathy. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2023, StatPearls Publishing LLC.; 2023.
• PubMed/NCBI
• 127. Faul M, Coronado V. Chapter 1—Epidemiology of traumatic brain injury. In: Grafman J, Salazar AM, editors. Handbook of Clinical Neurology. 127: Elsevier; 2015. p. 3–13.
• 129. Gapp J, Tariq A, Chandra S. Acute Pancreatitis. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2023, StatPearls Publishing LLC.; 2023.

• Systematic Review
• Open access
• Published: 04 September 2024

The effect of computerized cognitive training and transcranial direct current stimulation on working memory among post-stroke individuals: a systematic review with meta-analysis and meta-regression

• Csaba Kazinczi 1 , 2 ,
• Krisztián Kocsis 8 ,
• Katalin Boross 3 ,
• Mihály Racsmány 4 , 9 , 10 ,
• Péter Klivényi 1 ,
• László Vécsei 1 , 5 &
• Anita Must 6 , 7  

BMC Neurology volume  24 , Article number:  314 ( 2024 ) Cite this article

Metrics details

Working memory (WM) impairment is a common phenomenon after stroke; however, its management in rehabilitation is less researched. This systematic review and meta-analysis aimed to provide a quantitative synthesis of the impact of computerised cognitive training (CCT) and transcranial direct current stimulation (tDCS) on WM span in post-stroke individuals.

The literature search in PubMed, Embase, Scopus, and Cochrane Library focused on randomized controlled trials testing the effect of CCT and tDCS on treated stroke patients as compared to untreated controls. Neuropsychological instruments such as Digit Span Forward/Backward and Visual Span Forward Tests defined the outcome of WM span. After extracting study characteristics and quality assessment using the Cochrane Risk of Bias Tool, we conducted a meta-analysis and meta-regression using standardised mean differences.

The search yielded 4142 articles, nine of which ( N  = 461) fulfilled the inclusion criteria. In the case of CCT, we found significant improvement in Digit Span Backward Test (Z = 2.65, P  = 0.008; 95% CI [0.10, 0.67]) and Visual Span Forward Test performance (Z = 3.05, P  = 0.002; 95% CI [0.15, 0.69]), while for tDCS, we could not find a sufficient number of studies for the analysis. Furthermore, no significant moderating factor was found in the meta-regression.

Conclusions

In conclusion, CCT appears to be a suitable choice to enhance WM span performance after stroke. However, further research is needed to investigate the effect of tDCS due to the limited number of studies.

Trial registration

The meta-analysis was conducted according to PRISMA (Preferred Reporting of Systematic Reviews and Meta-Analyses) standards with a PROSPERO registration protocol (ID: CRD42023387182).

Peer Review reports

Cognitive dysfunction after a stroke is a common phenomenon that affects a significant proportion of patients, impacting their quality of life [ 1 ]. Cognitive dysfunction typically influences language and memory domains, frequently working memory (WM) [ 2 ]. WM is responsible for processing information ‘online’ and executing goal-directed behaviour, playing a crucial role in daily activities [ 3 ]. According to theoretical considerations, one of the subdomains related to WM is the central executive (CE), which is responsible for executive functions (EF), such as updating, shifting, and inhibition [ 4 ]. Information to be processed is temporarily stored in the phonological loop (verbal modality) and the visuospatial sketchpad (visual modality). Additionally, the episodic buffer integrates diverse information in WM and is linked to long-term memory [ 4 , 5 , 6 ]. According to Lugtmeijer and colleagues (2021), differentiation can be made not only in terms of modality but also of WM load. WM load can be categorised into two segments: low-load WM tasks, typically demanding short-term memory processes, and high-load WM tasks, which more specifically require demanding EFs and other cognitive functions (e.g., inhibition, attention, and interference control) [ 7 ].

Various neuropsychological tests are available to assess WM functions based on load and modality. Since post-stroke cognitive dysfunction impacts WM, it is essential to consider the types of assessments with low cognitive load while being well-suited for clinical practice. In clinical settings, WM measures are often associated with specific subtests of the Wechsler Adult Intelligence Scale (WAIS), such as span tasks [ 8 , 9 , 10 ], which mainly measure the capacity/span of WM [ 11 ]. A relevant approach for assessing WM span involves using the Digit Span Forward test (low-load, verbal modality) and the Visual Span Forward/Corsi Block Tapping Task (low-load, visual modality) [ 12 ]. Additionally, the Digit Span Backward test is widely used in clinical settings and is considered a high-load task requiring EFs. However, compared to other high-load WM tasks (e.g., N-back, Stroop tasks), it involves significantly less cognitive load and is not recommended to be used interchangeably with other high-load measures of WM [ 13 ]. This perspective is supported by an EEG correlates study by Scharinger and colleagues (2017), which suggests that, for instance, the high-load ‘N-back’ task places notably higher demands on WM processing and cognitive control than complex span tasks. This finding has been confirmed by other research in the last decades [ 14 , 15 , 16 ], showing the difference between WM span tasks and other, more complex WM measurement procedures. In our study, we define a test as having a low cognitive load if it requires minimal additional processing beyond the primary task. Although tasks like the digit span test may be challenging for patients with WM deficits, these tests are more appropriate for minimising cognitive demands than complex WM tasks (e.g., N-back). Hence, span tasks are suitable for measuring WM capacity/span without significant additional cognitive load while minimising the burden on patients and reducing the measurement of other cognitive functions.

Despite the high prevalence of cognitive impairment after a stroke, studies focusing on WM span represent a smaller proportion of the growing body of this research area [ 2 , 17 ]. Including such studies would be highly recommended, as the integrity of the WM span is essential for other complex WM-related cognitive functions. Consequently, the targeting of these domains raises further questions, and choosing the appropriate cognitive training tools within cognitive rehabilitation presents an additional challenge for professionals.

Over the past few decades, a wide array of cognitive rehabilitation (CR) tools has emerged, encompassing conventional techniques (e.g., paper/pencil exercises), non-invasive brain stimulation (e.g., transcranial magnetic stimulation or transcranial direct current stimulation (tDCS)), and computer-assisted cognitive rehabilitation (CACR), such as computerised cognitive training programs (CCT). Other restorative interventions (e.g., aerobic exercises, pharmacological and educational interventions) are also available [ 18 , 19 , 20 , 21 ]. An essential aspect of CR is the accessibility and usability of the chosen rehabilitation method. In this regard, CCTs and tDCS are appropriate and popular choices in post-stroke CR, given their low resource intensity, cost-effectiveness and high level of technical support compared to other methods (e.g. TMS). Furthermore, they can be applied in combination to increase their effectiveness [ 22 , 23 ].

CCT and tDCS exert distinct effects on modulating cognitive function. CCTs offer training possibilities for post-stroke CR and have the potential to facilitate restorative training for cognitive functions by stimulating various cognitive domains, positively influencing patient motivation [ 24 ]. As a result, we can expect significant improvement in the domain related to the trained task (near transfer effect), albeit some tasks also involve improvement in non-trained domains (far transfer effect) [ 25 ]. Thus, WM improvements can be achieved through targeted and non-targeted CCTs. Various CCTs are currently available, and the choice depends on the preferences and expertise of the training professional. In recent years, recommendations have emerged regarding which CCTs could suit various neurological diseases; for instance, based on Maggio and colleagues’ (2023) research, ERICA and Lumosity can offer appropriate options for post-stroke WM training. In terms of post-stroke CR research, Zhao and colleagues (2021) conclude that computer-assisted training has no significant effect on WM; however, these results are not specific to the WM span. Other studies have found a transfer effect for WM-specific measures, but these have not focused on the WM span either [ 26 ].

Conversely, tDCS is a non-invasive neuromodulation technique that utilises direct current to influence sodium-calcium channels and N-methyl-D-aspartate receptors, resulting in alterations to the resting membrane potential [ 27 ]. Consequently, a specific cognitive function can be improved through increased neural responsiveness in related brain areas during facilitation; however, this outcome is not universally observed. Various parameters, such as dosing, intensity, and duration, can result in reversing effects if they are prolonged or not appropriately calibrated. Therefore, it is crucial for specialists to carefully adjust these parameters to ensure optimal outcomes [ 28 ]. Studies on WM training primarily focus on the prefrontal and dorsolateral prefrontal cortex (DLPFC); recent research has also emphasised the importance of a broader frontoparietal network [ 29 , 30 , 31 , 32 , 33 ]. The effectiveness of tDCS stimulation is influenced by various settings, such as stimulation strength or location. Neurological conditions such as stroke can modify normal responses in neuronal activity, necessitating consideration in the training approach for practitioners [ 34 , 35 , 36 ]. The use of tDCS alonein post-stroke WM research is less pronounced; tDCS is usually utilised in combination with CCT. Hence, the effect is challenging to interpret.

This systematic review and meta-analysis aims to understand the effects of two widely-used and cost-effective CR procedures, CCTs and tDCS, on WM span in post-stroke individuals. The mechanisms of these techniques are different and partly unclear, with the potential for improving specific aspects of WM yet to be explored. Our study focused on comparing RCTs, deliberately excluding combined applications of these techniques. We specifically targeted the assessment of WM span, comparing tests used in clinical practice, such as the Digit Span Forward, Digit Span Backward, and Visual Span Tests, as outcome measures. This analysis represents one of the first attempts to explore the effects of these rehabilitation techniques on WM span in post-stroke individuals, providing insights into their potential efficacy and mechanisms of action.

The present meta-analysis aimed at synthesising the results of controlled studies on the rehabilitation effects of CCT and tDCS on WM span in post-stroke individuals. The meta-analysis was conducted according to PRISMA (Preferred Reporting of Systematic Reviews and Meta-Analyses) standards with a PROSPERO registration protocol (ID: CRD42023387182) [ 37 ]. The review protocol and data used in the analysis are available from the authors (for the PRISMA 2020 Checklist, see Supplementary Materials).

Eligibility criteria

According to the PICOS model, the inclusion/exclusion criteria are presented in Table  1 .

Outcome measures of working memory span

In the selection of outcome measures, we aimed to select WM measures that (a) are relevant and commonly used in clinical practice, (b) measure WM span/capacity with the lowest possible additional cognitive load, and (c) measure either verbal or visual modalities (detailed justification for these criteria can be found in the Background section). Based on theoretical considerations and previous research, the following instruments meet these criteria:

Short-term verbal recall - digit span forward test (DSTF)

The task requires the subject to recall sequences of numbers of different lengths in the order in which the examiner tells them. The capacity usually ranges from 3 to 9 units, during which no manipulation of the spoken information is required. The most widely used neuropsychological test procedure for this purpose is the Digit Span Test, part of the Wechsler Intelligence Test [ 38 ].

Working memory - digit span backward test (DSTB)

A procedure for testing WM in which the subject is asked to recall a series of numbers of different lengths in reverse order. The task involves retaining and manipulating acquired information and integrating CE and short-term memory capacity. The most widely used neuropsychological testing procedure for this purpose is the Digit Span Backward Test as a part of the Wechsler Intelligence Test [ 38 ].

Visual working memory – visual span test/corsi block tapping task (VSTF)

Visual WM (visuospatial sketchpad) is usually measured using the Visual Span Test or Corsi Block Tapping Task. In this test, the subject is shown several sequences of a growing number of visual elements in a specified order (e.g., blocks up to 9), which they must reproduce in the same series [ 39 ].

Search strategy

Two authors (Cs.K. and K.B.) performed systematic searches in PubMed, Scopus, Cochrane Library and Embase databases, complemented by a manual search of studies between 15/12/2022 and 10/01/2023. The search strategy applied an extended combination of keywords related to the PICOS, with particular focus on WM and related measures (‘working memory’ or ‘executive functions’ or ‘cognition’ or ‘memory’ or ‘digit span’ or ‘short-term memory’ or ‘visual span’ or ‘spatial span’ or ‘Corsi block tapping task’) and (‘tdcs’ or ‘transcranial direct current stimulation’ or ‘cognitive training’ or ‘computer-based cognitive training’ or ‘computer-assisted cognitive training’ or ‘cct’ or ‘computerised cognitive training’ or ‘computerised cognitive training’) and (‘stroke’ or ‘post-stroke’ or ‘patients after stroke’ or ‘post-stroke patients’). Two authors (Cs.K. and K.B.) independently created the database and screened titles and abstracts for inclusion criteria. We identified further potential studies by reviewing references related to the topic.

Study selection

Two authors (Cs.K. and K.B.) independently reviewed which articles were to be included in the analysis. After building the databases, the collected references were imported into the Endnote 20.3 (Clarivate) reference management program. The process was then carried out as follows: (1) duplicates were first automatically and then manually deleted; (2) the titles were filtered manually, deleting articles containing terms that did not meet the PICOS criteria (e.g., traumatic brain injury, Parkinson’s disease, transcranial magnetic stimulation); (3) the abstracts were filtered according to the same rule; (4) the full texts of the remaining articles were reviewed; (5) if it was not possible to collect at least five relevant studies for an intervention, the meta-analysis would not be carried out. The final decisions regarding the inclusion and exclusion of studies were compared between the two reviewers. The references of the included records were automatically and manually screened, with the task divided between the two reviewers. The interrater agreement between the two reviewers was assessed using Cohen’s kappa statistic. Cohen’s Kappa was calculated for the initial search, resulting in a value of 0.71, indicating substantial agreement. However, the combination of the neuropsychological tests and interventions we investigated may result in rare events within the selected population; we calculated the Prevalence-Adjusted and Bias-Adjusted Kappa (PABAK) to provide a more accurate measure of agreement. The PABAK was calculated for both the abstract and full-text screening phases based on the work of Mackinnon (2000) [ 40 ]. Based on the results, the agreement between the two reviewers was adequate (Abstract: Cohen’s Kappa = 0.75, PABAK = 0.79; Full-text: Cohen’s Kappa = 0.77, PABAK = 0.82). Any discrepancies were resolved by discussion. We used the flowchart adopted by PRISMA to illustrate the selection process visually (Fig.  1 ).

Risk and bias assessment

The methodological quality of each article included was independently and critically assessed by two authors (Cs.K. and K.K.) using Version 2 of the Cochrane Risk of Bias Tool (RoB2), which allowed the analysis of six domains: (1) randomisation process (2) deviation from intended interventions, (3) missing outcome data, (4) measurement of the outcome, (5) selection of the reported result, (6) overall bias [ 41 ]. Each domain was classified as ‘low’, ‘high’ or ‘some concerns’.

Data extraction

Only data containing the appropriate population, interventions, comparisons, outcome variables, and research design were extracted by two authors (K.Cs. and K.B). Post-intervention means, standard deviations, medians and IQR were collected during data extraction. Descriptive information included: author and year, number of subjects, mean age, sex distribution, type of stroke, time after stroke, type of intervention, duration of intervention (minutes/sessions), type of control and primary outcomes. Stimulation location, dose, electrode size, and current density were listed for tDCS studies. Where two or more groups of interventions were included in the same study, they were interpreted separately according to the recommendations of the Cochrane Handbook [ 41 ]; furthermore, in the case of more than one control group (e.g. active control vs. waiting list control), we interpreted active controls. Discrepancies identified during cross-checking were resolved through discussions. In the case of Wentink and colleagues (2016), this involved converting median and interquartile range values (IQR) into means and standard deviations (SD) for subsequent statistical calculations.

Statistical analysis and meta-regression

The meta-analysis used Review Manager Software Desktop and Web (RevMan, version 5.4). Post-intervention means, standard deviations (Mean ± SD) and variances were collected from each selected study as post-intervention data for the outcome in the experimental and control groups. In the case of non-normal data, a transformation was performed into mean and ± SD, using the given medians and IQR values based on previous methodological recommendations [ 42 , 43 ]. For heterogeneity, I 2 and P-values were determined and considered significant if P  < 0.10 or I 2  > 50%. Values for I 2 are expressed as a percentage, with suggested values of 25% (low), 50% (moderate), and 75% (high) used to categorise levels of heterogeneity [ 44 ]. The analysis converted means and standard deviations to standardised mean differences (SMD) with a 95% confidence interval (CI). A random-effects model was used in every case since the collected studies showed moderate variability from the viewpoint of intervention and measurement type [ 45 ]. We assessed each study’s effect on the overall effect size to test sensitivity, and removed studies individually responsible for heterogeneity [ 46 ]. Based on previous methodological considerations, we classified effect sizes into 0.2 (small), 0.5 (medium) and 0.8 (large) categories [ 47 ]. The indication of statistical significance was set at P  < 0.05. In the analysis performed, heterogeneity is expected to emerge, presumably between-study differences that may appear in the studies regarding training time and mean age. To explore this, we planned to run a meta-regression for the following continuous variables: age (AGE), number of interventions (NO. OF SESSIONS), and time per intervention (DURATION), using a random-effects model with the Restricted Maximum Likelihood (REML) method in the Jamovi project (Package for R, 2018, Jamovi project, Version 0.9). The random effects model accounts for variability within and between studies by including random effects, thus accommodating heterogeneity among study results. To accurately estimate the variance components of this model, we employed REML, which is particularly suited for this purpose as it provides less biased estimates of the between-study variance (τ²) by focusing on the likelihood of the residuals after accounting for the fixed effects. According to recent studies [ 48 ], REML reduces bias in estimating variance components and improves the accuracy of heterogeneity assessment, making it a preferred method in meta-analysis. This approach ensures robust and precise heterogeneity estimation, thereby enhancing the reliability of our meta-regression findings.

Search results

Initially, 4118 articles were identified from the electronic databases (PubMed: 609; Scopus: 1036; Embase: 929; Cochrane Library: 1544), with 24 additional publications identified during manual search, resulting in 4142 articles in total. This was followed by excluding duplicates, manual filtering, and screening of titles and abstracts, narrowing the preliminary extensive database to 53 publications. Subsequently, further 44 studies were filtered out as they were not in English (3), not performed on purely stroke population (10), not RCTs (9), did not include the previously defined outcome variables or did not meet the inclusion criteria (18), or tDCS was used in combination with CCT (4) (Fig.  1 ). Finally, nine articles were included in the study, all of which used CCT solely [ 19 , 43 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ] and no study could be selected for tDCS intervention to apply a meta-analysis (Fig.  1 ).

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram of study selection

Results of risk and bias assessment

Four selected articles were classified as ‘low-risk’, five as ‘some concern’, and none as ‘high risk’. Concerning the randomisation and allocation, we could not entirely assess the process used in one case [ 19 ]. In four cases, several factors raised questions about randomisation or allocation In the other cases, the studies met this requirement [ 19 , 49 , 54 – 55 ]. Furthermore, in three studies, the choice of measurement instruments was not clearly justified [ 19 , 50 , 55 ]. The studies targeted global cognition in several cases. Thus, we could not identify an apparent risk factor for WM-related measurements we chose in our analysis. The details of the methodological quality assessment are shown in Fig.  2 .

Results of risk and bias assessment according to the cochrane risk of bias tool

Study characteristics

The articles were published between 2007 and 2022. A total of 461 (Intervention: 234 Control: 227) subjects were included in CCT studies. The countries involved were China (1), Italy (2), Korea (2), Netherlands (2), Sweden (1), and Taiwan (1). The studies showed a wide range of sample sizes, mean ages, and sex distributions, focusing on various stroke types and cognitive impairments. Sample sizes across studies varied, with intervention groups ranging from 9 to 50 (Mean: 25) participants and control groups from 9 to 57 (Mean: 26) participants. The range of age spanned from 43.9 to 67.5 years (Mean: 59.0), with a mixed distribution of males and females (M/F ratio: 1.31:1). In the selected studies, we found a mixture of primarily ischemic stroke (IS) and intracerebral haemorrhage (ICH) (5 studies) and vascular cognitive impairment (VCI) (1 study), while in three cases, data on medical background/condition/aetiology was not included. The average time post-stroke among participants ranged from 3 months to 28.3 months (Mean: 13.8). The studies included five different types of control conditions. These control conditions were utilised as follows: “Other restorative intervention” was employed in 4 studies, “Conventional Cognitive Rehabilitation” was used in 2 studies, “Conventional CR and Other Restorative Intervention” was applied in 1 study, “Waiting List Control” was used in 1 study, and “Passive Control” was employed once. The primary aims across these studies were to improve various cognitive functions such as “general cognitive functions” were the primary aim in 5 studies, “memory and attention” was the focus in 1 study, “executive functions” was targeted in one 1 study, “cognitive flexibility” was the primary aim in 1 study, and “working memory” was the focus in 1 study (for study characteristics, see Table  2 ).

Intervention characteristics

We found six different CCTs (Cogpack, RehaCom, Erica, Lumosity, RoboMemo, BrainGymmer) and, in one case, results from an unknown, non-standardized rehabilitation program. The CCTs were generally used either alone or in addition to traditional enhancement program, with a duration of 20 to 60 min across sessions ranging from 10 to 58. Lumosity ( www.lumosity.com ) and RehaCom ( www.hasomed.de/en/products/rehacom/ ), software were the most commonly used for the selected studies, offering 30 modules depending on the specified functions. Furthermore, Cogpack ( www.markersoftware.com ) offers 64 tasks, such as visual-motor integration, learning, memory, attention and EF. Cogpack is widely used in clinical settings as the functions can flexibly adapt to individual needs. RehaCom offers more than 30 training modules to improve memory, attention, executive functions and visuospatial skills. It is often used in neurorehabilitation for patients with neurocognitive impairment following stroke or traumatic brain injury. RehaCom allows the difficulty of the tasks to be adjusted in real-time based on the patient’s performance, thus providing personalised cognitive training. Erica ( www.erica.giunti.it ), has customizable modifications for five cognitive domains; the program is primarily known for its user-friendly interface and ability to create customised cognitive training plans. Lumosity includes over 50 training exercises to improve memory, attention, problem-solving, and mental flexibility. It is available via a web browser and mobile platform; hence, patients can easily integrate cognitive training into their daily routine. RoboMemo ( www.cogmed.com ). includes visuospatial and auditory WM tasks that target specific areas of cognitive functioning. Previous studies have shown that RoboMemo can significantly improve WM capacity. BrainGymmer ( www.braingymmer.com ) includes a variety of cognitive tasks to improve attention, inhibitory control, cognitive flexibility and WM. It offers a wide range of motivational tasks with a user-friendly design. BrainGymmer also provides feedback and progress monitoring.

Outcome characteristics

As for neuropsychological tests, all of the selected studies included at least one measure of DSTF, DSTB and VSTF, in addition to the following tests to measure cognitive function: Trail-Making Test (TMT), Stroop Test, Mental Rotation, Visual Continuous Performance Test (VCPT); Auditory Controlled Continuous Performance Test (ACCPT), Boston Naming Test (BNT), Mini-Mental State Examination (MMSE), Phonemic Verbal Fluency (PVF); Raven’s Coloured Progressive Matrices (RAV); Rey Auditory Verbal Learning Test Immediate (RAVLI); Rey Auditory Verbal Learning Test Late (RAVLL); Semantic Verbal Fluency (SVF); Token Test (TT); Symbol Digit Modalities Test (SDMT), Wisconsin Card Sorting Test (WCST), N-back, Flanker Task, Paced Auditory Serial Addition Test (PASAT), RUFF 2&7, Verbal Learning Test (VeLT), Visual Learning Test (ViLT). Regarding the rehabilitation effect, significant improvement in cognitive functions was found in 8 cases (88%) in CCT studies.

Meta-analysis outcomes

Since the evaluation methods were inconsistent, the standard mean difference method was chosen for analysis. Furthermore, we applied the random-effects model due to the variability of study parameters. Short-term recall (DSTF) was analysed in eight studies involving CCT ( n  = 384). Heterogeneity was moderate ( P  = 0.05; I2 = 50%), and the meta-analysis showed no significant improvement compared to the control group (Z = 1.95; P  = 0.05) (SMD = 0.30, 95%CI = 0.06 to 0.46, I 2  = 50%). According to the funnel plot analysis, we identified asymmetry: the sensitivity analysis results indicated that two studies (Bo et al., 2019; Westerberg, 2007) have contributed to heterogeneity. After removing these studies, heterogeneity was reduced considerably; however, still no significant difference occurred ( P  = 0.54, I 2  = 0%) (SMD = 0.08, 95% CI = -0.15 to 0.32; Z = 0.70; P  = 0.49).

Four CCTs ( n  = 193) were analysed with WM (DSTB) as an outcome, in the case of which the analysis showed significant improvement compared to the control group, with low heterogeneity ( P  = 0.93; I2 = 0%) (SMD = 0.39, 95% CI = 0.10 to 0.67; Z = 2.65, P  = 0.008).

For visuospatial span (VSTF), we found seven studies using a CCT intervention ( n  = 323). The CCT intervention showed no significant difference, with moderate heterogeneity ( P  = 0.12; I 2  = 40%) (SMD = 0.22, 95%CI = -0.01 to 0.44; Z = 1,90, P  = 0.06). Based on funnel plot analysis, one research was responsible for moderately strong heterogeneity for CCT (Wentink, 2016). After removing this study, the heterogeneity dropped to zero, and we observed a significant effect compared to the control group (Z = 3.14; P  = 0.002) (SMD = 0.43, 95%CI = 0.16 to 0.69, I 2  = 0%) (Figs.  3 , 4 and 5 ; Table  2 , 3 ).

Effect of CCT on short-term recall measured by digit span forward test (DSTF) compared to controls

Effect of CCT on WM measured by digit span backward test (DSTB) compared to controls

Effect of CCT on visuospatial WM measured by visual span forward test (VSTF) compared to controls

Meta-regression outcomes

In the meta-regression model, the following variables which may cause significant variability for CCT and tDCS interventions were included : ’age’, ’time intervention (mins)’ and ’number of intervention sessions’. Based on the meta-regression results, no significant moderating effect of any variable was found on neuropsychological test results (Supplementary Table 1 ).

In this study, we examined the effectiveness of CCT and tDCS on WM span, utilising measures including the Digit Span Forward Test, Digit Span Backward Test, and Visual Span Forward Test in individuals post-stroke. The results of our meta-analysis indicate a significant effect of CCT on WM span measured by DSTB and VSTF. However, not enough tDCS studies were available to be included in the analysis. In light of these findings, several points warrant discussion, including the implications of post-stroke CR, the mechanisms underlying the observed effects, and possibilities for future research.

Firstly, the observed improvements in DSTB and VSTF due to CCT interventions highlight the potential of CCT in enhancing WM span after a stroke. These findings align with previous literature suggesting that targeted CCTs can improve general cognitive function. However, it supplements the findings of Van de Ven and colleagues (2016), who found that CCT can be effective on DSTB, but not in VSTF and contradicts the conclusions of Zhao and colleagues (2021), who reported that computer-assisted programs in post-stroke cognitive rehabilitation do not improve WM function. The efficacy of CCT in improving WM can be attributed to several mechanisms; CCT tasks are designed to target specific cognitive processes, such as attention, processing speed, and executive functions, which are known to contribute to WM performance [ 56 ]. Through repeated practice and feedback, individuals may develop more efficient cognitive strategies and neural networks supporting WM function [ 57 ]. Accordingly, there is no clear evidence that WM tasks, in general, cannot be effectively improved in post-stroke patients. Nevertheless, it is essential to note that in the study of Zhao and colleagues (2021), the subdomain of WM was not specified, as in our case.

Secondly, the heterogeneity of the studies included in our analysis was relatively high. Consequently, interpreting the results should consider variations in study design, participant characteristics, intervention protocols, and outcome measures. For example, Cho and colleagues (2015), Yoo and colleagues (2015), and Ho and colleagues (2022) used a rigorous RCT design, while Bo and colleagues (2019) used a single-blind RCT framework. There were also some differences in control, as Van de Ven and colleagues (2017) used a wait-list control where participants received a delayed intervention. In contrast, Westerberg and colleagues (2007) used a passive control group design in which the control group had no other additional treatment. Tarantino and colleagues (2021) used traditional cognitive rehabilitation and other therapeutic interventions as controls. Participant characteristics also differed between studies; participants ranged in age from 43.9 to 64.6 years. The time since stroke also varied, with some studies recruiting participants within 3–6 months after stroke (e.g. Cho et al., 2015) and others recruiting participants within a longer period after stroke, such as 28.3 months, as in the study by Van de Ven and colleagues (2017). These differences between age and time since stroke can significantly affect the outcomes of interventions; for example, a study by Knoflach and colleagues (2012) found that younger stroke patients tend to have better rehabilitation outcomes than older patients [ 58 ]. This highlights the importance of considering patient demographics and stroke chronology when evaluating the effectiveness of rehabilitation interventions.

Regarding rehabilitation programmes, there was considerable heterogeneity in the intervention protocols used in the studies. For example, Yoo and colleagues (2015) used the RehaCom software for 30 min per session five times a week for five weeks. In contrast, Cho and colleagues (2015) used a six-week training protocol with two 30-minute sessions per week. Bo and colleagues (2019) combined physical activity and cognitive training in structured 12-week-long, 50-60-minute sessions three times a week. Different intervention protocols may result in variations in the intensity and duration of CCTs, which are vital components for neuroplasticity [ 59 ]. Furthermore, studies have shown that higher intensity and longer duration of CCTs are associated with better outcomes in improving cognitive function; however, the individual abilities of patients should be taken into account to avoid unnecessary strain [ 60 ].

The neuropsychological tests used to assess additional cognitive functions also varied widely; however, the measures we selected were available in all test sets. This may be significant because different studies may have targeted different cognitive functions. For example, Yoo and colleagues (2015) and Cho and colleagues (2015) used digit span tasks (both forward and backward) and visual range tests to assess WM. Bo and colleagues (2019) used a broader range of cognitive tests, including the Trail Making Test Part B, the Stroop Test, the DSFT, and mental rotation tasks to assess cognitive flexibility and selective attention. Considering these differences in measurement may be crucial in post-stroke research, as they may significantly affect the comparability and interpretation of results. Different neuropsychological testing procedures may focus on different aspects of cognitive function, which may lead to differences in reported results. Standardisation of outcome measures in post-stroke cognitive rehabilitation research would ensure consistency and reliability in assessing the effectiveness of interventions; furthermore, despite heterogeneity, we found measurable effects on our selected neuropsychological tests, demonstrating the robustness and potential efficacy of interventions in different settings.

In summary, based on the broader literature, heterogeneity determinants such as study design, participant characteristics, intervention protocols, and variation in outcome measures can significantly impact the results and their interpretation. Likewise, the type and intensity of cognitive training may also affect the results. However, despite the significant heterogeneity, we found measurable effects on our selected neuropsychological tests, indicating the robustness and potential effectiveness of the interventions. Yet, the variables examined in the meta-regression (e.g. age, duration, no. of sessions) did not prove to be significant factors.

Our results can also be interpreted through Baddeley’s WM model, according to which WM consists of several components: the phonological loop, the spatial-visual sketchpad, the episodic buffer and the CE. The improvements observed in DSBT suggest improvements in the phonological loop and CE, as this task involves verbal WM and complex information manipulation. Similarly, the improvements observed in VSFT indicate an improvement in the spatial-visual sketchpad. The lack of improvement seen in DSFT, primarily related to the phonological loop, suggests that training programs are more effective in improving tasks requiring more complex cognitive processing than simple memory tasks. However, this phenomenon can be explained by the research of Donolato and colleagues (2017), who found significant differences between forward and backward versions of verbal WM tasks, as the backward version typically represents a higher cognitive load for the participants in their study. However, no such differences between forward and backward recall tasks were found for the spatial-visual sketchpad in healthy individuals [ 61 ], suggesting no significant difference in CE load for the visual modality, but there is for the verbal modality. These results indicate that CCT can effectively target and enhance specific elements of WM, particularly those involving more complex manipulation of information.

The question emerges whether targeted cognitive training designed to improve WM could yield significant effects on general cognitive function. More specifically, CCT interventions may promote neuroplasticity and facilitate the recruitment of neural networks associated with near or far transfer effects [ 62 ]. Our study specifically collected WM span measures with the lowest possible cognitive load to illustrate the training potential of low-load WM processes. Notably, the possible far transfer effects observed in our study suggest that improvements in trained tasks may generalise to untrained tasks, underscoring the potential for broader functional gains following CCT interventions. Additionally, our meta-analysis revealed improvements in verbal and visual WM tasks following CCT, suggesting that training effects may generalise across different modalities. Furthermore, the mechanisms underlying the observed improvements in WM span following CCT interventions merit consideration. Neuroimaging studies have implicated a network of brain regions, including the prefrontal cortex and parietal cortex, in WM processes [ 29 ]. Future research employing neuroimaging techniques could provide detailed insights into the neural mechanisms mediating the effects of CCT on WM span in post-stroke individuals.

Moreover, although our study looked strictly separately at the effects of tDCS and CCT in post-stroke patients, in many cases, these interventions are used together. Hence, the potential synergistic effects of combining CCT with other rehabilitation modalities warrant investigation. Previous studies have suggested that multimodal interventions combining cognitive training with non-invasive brain stimulation techniques, such as tDCS, may yield enhanced cognitive outcomes compared to single-modality interventions [ 63 , 64 ]. By targeting complementary neural mechanisms, multimodal interventions can potentially maximise neuroplasticity [ 63 ]. Recent studies have shown that combining tDCS and CCT can improve WM outcomes in people with neuropsychiatric disorders [ 65 ]. For instance, tDCS can modulate cortical excitability and improve neuroplasticity, thereby potentially enhancing the effects of cognitive training [ 66 ]. In healthy populations, the synergistic effects of tDCS and CCT have been investigated with promising results [ 67 ]. For example, Andrews and colleagues (2011) found that combining anodal tDCS and WM training led to significant improvements in performance compared to sham stimulation [ 68 ]. Similarly, a study by Martin and colleagues (2014) reported enhanced learning rates and retention of trained tasks when tDCS was used alongside CCT. Future research would benefit from exploring the long-term effects of combined tDCS and CCT interventions and should investigate optimal stimulation parameters, including electrode placement, current intensity and session duration. In addition, understanding individual differences in response to these interventions, such as baseline cognitive abilities, may help to develop tailored treatment strategies [ 69 ].

Furthermore, the choice of outcome measures in assessing WM span and methodological considerations regarding measurement procedures are pivotal to understanding CR interventions’ impact on WM function. While DSTB and VSTF are commonly utilised in clinical practice, they represent only a subset of the multifaceted cognitive processes within the WM domain. Future studies could benefit from employing a broader range of WM tasks, encompassing verbal and visuospatial span measures and tasks assessing executive functions such as updating, shifting, and inhibition [ 4 ]. Research often leans towards employing WM tasks with higher loads, such as N-back, Stroop, and Flanker tasks. Additionally, current research commonly utilises ‘N-back’ tasks as indicators, raising questions about the role of the CE in short-term verbal recall and visual WM. Using DSTB test results as indicators, we measured a different function than ‘N-back’ tasks, with complex WM being necessary for both but not equivalent between the two [ 13 ]. While DSTB may emphasise capacity, ‘N-back’ tasks place greater emphasis on specific CE functions, mainly updating. This underscores the impact of CCT on WM function, even without specific training modules.

In contrast to the positive effects observed for CCT, our meta-analysis did not find sufficient evidence to support the efficacy of tDCS in improving WM in post-stroke individuals. This finding is still surprising, given the growing interest in tDCS as a potential intervention for CR [ 66 ]. However, it is essential to note that the tDCS literature in post-stroke populations is relatively limited, and studies vary widely regarding stimulation protocols, outcome measures, and participant characteristics. Most of the tDCS research uses it as an adjunctive neuromodulation tool, and there are few available randomized controlled trials of its inedependent use. Furthermore, the variability in stimulation parameters, such as electrode placement, current intensity, duration, and place of stimulation, influence treatment outcomes [ 70 , 71 ]. Individual differences in neuroplasticity, lesion location, and stroke severity may have influenced responsiveness to tDCS [ 72 ]. Future research should aim to elucidate the specific effects of tDCS on WM span in stroke survivors, considering factors such as stimulation parameters, target brain regions, and individual differences in response to stimulation.

Some further general limitations indicate that the current results should be treated cautiously. First, for CCT, the high variability and unclear focus in research settings make it difficult to interpret the results specifically for WM capacity. To address and reduce heterogeneity, future research should consider certain methodological improvements: (1) Establishing standardized protocols for cognitive training interventions, including the duration, frequency, and type of training. (2) Adopting a core set of standardized cognitive assessments widely accepted and validated in stroke rehabilitation research may improve the consistency of outcome measurements. (3) Providing comprehensive details about participant demographics, stroke severity, and time since stroke may help contextualize the findings and enable better comparisons between studies. (4) Conducting long-term follow-up assessments to evaluate the sustainability of cognitive improvements may provide insights into the long-term efficacy of interventions. (5) Further exploring the synergistic effects of combining cognitive training with other rehabilitation modalities, such as tDCS or physical exercise, can shed light on the added benefit of complex intervention in post-stroke cognitive rehabilitation. Following the above suggestions would not only improve the quality of research, but may also allow for more accurate comparisons across studies. Finally, for future practical considerations, there are several factors to consider regarding post-stroke rehabilitation; for instance, the optimal utilisation of financial and personnel resources in the rehabilitation procedure could enhance the benefits of CCT or tDCS.

In conclusion, our results indicate that CCT interventions are promising in enhancing WM span in post-stroke individuals, as demonstrated by improvements in DSTB and VSTF. However, there remains a need for further investigation into the specific impact of tDCS on WM span in this population. Additionally, future research should delve into the underlying neural mechanisms driving these observed effects and explore the potential synergies between cognitive training and non-invasive brain stimulation interventions. With a more advanced understanding in this field, researchers can guide the development of targeted and efficient rehabilitation strategies to improve cognitive outcomes and enhance the quality of life of post-stroke individuals. Furthermore, our research also points out that the number of RCTs for post-stroke rehabilitation is still low, and there is even less focus on specific studies of WM.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

• Working memory

Transcranial Direct Current Stimulation

Computerized cognitive training

Executive functions

Central executive

Digit Span Forward Test

Digit Span Backward Test

Visual Span Forward Test

Randomized Controlled Trial

Dorsolateral Prefrontal Cortex

Cognitive Rehabilitation

Computer-Assisted Cognitive Rehabilitation

Jaracz K, Kozubski W. Quality of life in stroke patients. Acta Neurol Scand. 2003;107:324–9.

Article   CAS   PubMed   Google Scholar  

Lugtmeijer S, Lammers NA, de Haan EH, de Leeuw F-E, Kessels RP. Post-stroke working memory dysfunction: a meta-analysis and systematic review. Neuropsychol Rev. 2021;31:202–19.

Article   PubMed   Google Scholar  

Jung M, Matsumoto T, Tani J. Goal-directed behavior under variational predictive coding: dynamic organization of visual attention and working memory. 2019 IEEERSJ int. Conf. Intell. Robots Syst. IROS, IEEE; 2019:1040–7.

Kim NY, Wittenberg E, Nam CS. Behavioral and neural correlates of executive function: interplay between inhibition and updating processes. Front Neurosci. 2017;11:378.

Article   PubMed   PubMed Central   Google Scholar  

Baddeley A. The episodic buffer: a new component of working memory? Trends Cogn Sci. 2000;4:417–23.

Cowan N. What are the differences between long-term, short-term, and working memory? Prog Brain Res. 2008;169:323–38.

Wei H, Zhou R. High working memory load impairs selective attention: EEG signatures. Psychophysiology. 2020;57:e13643.

Camara WJ, Nathan JS, Puente AE. Psychological test usage: implications in professional psychology. Prof Psychol Res Pract. 2000;31:141.

Article   Google Scholar  

Rabin LA, Barr WB, Burton LA. Assessment practices of clinical neuropsychologists in the United States and Canada: a survey of INS, NAN, and APA Division 40 members. Arch Clin Neuropsychol. 2005;20:33–65.

Shelton JT, Elliott EM, Hill BD, Calamia MR, Gouvier WD. A comparison of laboratory and clinical working memory tests and their prediction of fluid intelligence. Intelligence. 2009;37:283–93.

Chai WJ, Abd Hamid AI, Abdullah JM. Working memory from the psychological and neurosciences perspectives: a review. Front Psychol. 2018;9:401.

Wilde NJ, Strauss E, Tulsky DS. Memory span on the Wechsler Scales. J Clin Exp Neuropsychol. 2004;26:539–49.

Redick TS, Lindsey DRB. Complex span and n-back measures of working memory: a meta-analysis. Psychon Bull Rev. 2013;20:1102–13.

Jaeggi SM, Buschkuehl M, Perrig WJ, Meier B. The concurrent validity of the N -back task as a working memory measure. Memory. 2010;18:394–412.

Kane MJ, Conway AR, Miura TK, Colflesh GJ. Working memory, attention control, and the N-back task: a question of construct validity. J Exp Psychol Learn Mem Cogn. 2007;33:615.

Miller KM, Price CC, Okun MS, Montijo H, Bowers D. Is the n-back task a valid neuropsychological measure for assessing working memory? Arch Clin Neuropsychol. 2009;24:711–7.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Draaisma LR, Wessel MJ, Hummel FC. Neurotechnologies as tools for cognitive rehabilitation in stroke patients. Expert Rev Neurother. 2020;20:1249–61.

Bornheim S, Croisier J-L, Maquet P, Kaux J-F. Transcranial direct current stimulation associated with physical-therapy in acute stroke patients-A randomized, triple blind, sham-controlled study. Brain Stimulat. 2020;13:329–36.

Cho H-Y, Kim K-T, Jung J-H. Effects of computer assisted cognitive rehabilitation on brain wave, memory and attention of stroke patients: a randomized control trial. J Phys Ther Sci. 2015;27:1029–32.

Draaisma LR, Wessel MJ, Hummel FC. Non-invasive brain stimulation to enhance cognitive rehabilitation after stroke. Neurosci Lett. 2020;719:133678.

Zhao Q, Wang X, Wang T, Dmytriw AA, Zhang X, Yang K, et al. Cognitive rehabilitation interventions after stroke: protocol for a systematic review and meta-analysis of randomized controlled trials. Syst Rev. 2021;10:66.

Antal A, Paulus W. Investigating neuroplastic changes in the Human Brain Induced by Transcranial Direct (tDCS) and Alternating Current (tACS) stimulation methods. Clin EEG Neurosci. 2012;43:175–175.

Zhang H, Huntley J, Bhome R, Holmes B, Cahill J, Gould RL et al. Effect of computerised cognitive training on cognitive outcomes in mild cognitive impairment: a systematic review and meta-analysis. BMJ Open 2019;9.

Maggio MG, De Bartolo D, Calabrò RS, Ciancarelli I, Cerasa A, Tonin P, et al. Computer-assisted cognitive rehabilitation in neurological patients: state-of-art and future perspectives. Front Neurol. 2023;14:1255319.

Sala G, Aksayli ND, Tatlidil KS, Tatsumi T, Gondo Y, Gobet F. Near and far transfer in cognitive training: a second-order meta-analysis. Collabra Psychol 2019;5.

Van de Ven RM, Murre JM, Veltman DJ, Schmand BA. Computer-based cognitive training for executive functions after stroke: a systematic review. Front Hum Neurosci. 2016;10:150.

PubMed   PubMed Central   Google Scholar  

Lefaucheur J-P, Antal A, Ayache SS, Benninger DH, Brunelin J, Cogiamanian F, et al. Evidence-based guidelines on the therapeutic use of transcranial direct current stimulation (tDCS). Clin Neurophysiol. 2017;128:56–92.

Bikson M, Grossman P, Thomas C, Zannou AL, Jiang J, Adnan T, et al. Safety of transcranial direct current stimulation: evidence based update 2016. Brain Stimulat. 2016;9:641–61.

Darki F, Klingberg T. The role of fronto-parietal and fronto-striatal networks in the development of working memory: a longitudinal study. Cereb Cortex. 2015;25:1587–95.

Funahashi S. Working memory in the prefrontal cortex. Brain Sci. 2017;7:49.

Harding IH, Yücel M, Harrison BJ, Pantelis C, Breakspear M. Effective connectivity within the frontoparietal control network differentiates cognitive control and working memory. NeuroImage. 2015;106:144–53.

Lara AH, Wallis JD. The role of prefrontal cortex in working memory: a mini review. Front Syst Neurosci. 2015;9:173.

Thompson TW, Waskom ML, Gabrieli JD. Intensive working memory training produces functional changes in large-scale frontoparietal networks. J Cogn Neurosci. 2016;28:575–88.

Jia W, Kamen Y, Pivonkova H, Káradóttir RT. Neuronal activity-dependent myelin repair after stroke. Neurosci Lett. 2019;703:139–44.

Wang Y, Liu G, Hong D, Chen F, Ji X, Cao G. White matter injury in ischemic stroke. Prog Neurobiol. 2016;141:45–60.

Zhao Y, Zhang X, Chen X, Wei Y. Neuronal injuries in cerebral infarction and ischemic stroke: from mechanisms to treatment (review). Int J Mol Med. 2021;49:15.

Network E. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement.[online][cit. 2020-09-23] 2020.

Wechsler D. The measurement of adult intelligence 1944.

Corsi PM. Human memory and the medial temporal region of the brain. PhD Thesis. ProQuest Information & Learning, 1973.

Mackinnon A. A spreadsheet for the calculation of comprehensive statistics for the assessment of diagnostic tests and inter-rater agreement. Comput Biol Med. 2000;30:127–34.

Cumpston M, Li T, Page MJ, Chandler J, Welch VA, Higgins JP et al. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. Cochrane Database Syst Rev. 2019;2019.

Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014;14:1–13.

Wentink MM, Berger MaM, de Kloet AJ, Meesters J, Band GPH, Wolterbeek R, et al. The effects of an 8-week computer-based brain training programme on cognitive functioning, QoL and self-efficacy after stroke. Neuropsychol Rehabil. 2016;26:847–65.

Huedo-Medina TB, Sánchez-Meca J, Marín-Martínez F, Botella J. Assessing heterogeneity in meta-analysis: Q statistic or I^2 index? Psychol Methods. 2006;11:193.

DerSimonian R, Kacker R. Random-effects model for meta-analysis of clinical trials: an update. Contemp Clin Trials. 2007;28:105–14.

Lee YH. An overview of meta-analysis for clinicians. Korean J Intern Med. 2018;33:277.

Kinney AR, Eakman AM, Graham JE. Novel effect size interpretation guidelines and an evaluation of statistical power in rehabilitation research. Arch Phys Med Rehabil. 2020;101:2219–26.

Tanriver-Ayder E, Faes C, Van De Casteele T, McCann SK, Macleod MR. Comparison of commonly used methods in random effects meta-analysis: application to preclinical data in drug discovery research. BMJ Open Sci 2021;5.

Bo W, Lei M, Tao S, Jie LT, Qian L, Lin FQ, et al. Effects of combined intervention of physical exercise and cognitive training on cognitive function in stroke survivors with vascular cognitive impairment: a randomized controlled trial. Clin Rehabil. 2019;33:54–63.

De Luca R, Leonardi S, Spadaro L, Russo M, Aragona B, Torrisi M, et al. Improving cognitive function in patients with stroke: can computerized training be the future? J Stroke Cerebrovasc Dis. 2018;27:1055–60.

Ho H-Y, Chen M-D, Tsai C-C, Chen H-M. Effects of computerized cognitive training on cognitive function, activity, and participation in individuals with stroke: a randomized controlled trial. NeuroRehabilitation. 2022;51:79–89.

Tarantino V, Burgio F, Toffano R, Rigon E, Meneghello F, Weis L, et al. Efficacy of a training on executive functions in potentiating rehabilitation effects in stroke patients. Brain Sci. 2021;11:1002.

Van De Ven RM, Buitenweg JI, Schmand B, Veltman DJ, Aaronson JA, Nijboer TC, et al. Brain training improves recovery after stroke but waiting list improves equally: a multicenter randomized controlled trial of a computer-based cognitive flexibility training. PLoS ONE. 2017;12:e0172993.

Westerberg H, Jacobaeus H, Hirvikoski T, Clevberger P, Östensson M-L, Bartfai A, et al. Computerized working memory training after stroke–A pilot study. Brain Inj. 2007;21:21–9.

Yoo C, Yong M, Chung J, Yang Y. Effect of computerized cognitive rehabilitation program on cognitive function and activities of living in stroke patients. J Phys Ther Sci. 2015;27:2487–9.

Olesen PJ, Westerberg H, Klingberg T. Increased prefrontal and parietal activity after training of working memory. Nat Neurosci. 2004;7:75–9.

Klingberg T. Training and plasticity of working memory. Trends Cogn Sci. 2010;14:317–24.

Knoflach M, Matosevic B, Rücker M, Furtner M, Mair A, Wille G, et al. Functional recovery after ischemic stroke—A matter of age: data from the Austrian Stroke Unit Registry. Neurology. 2012;78:279–85.

Shinaver C, Entwistle PC. Computerized cognitive training based upon neuroplasticity. In: Dewan NA, Luo JS, Lorenzi NM, editors. Ment. Health Pract. Digit. World. Cham: Springer International Publishing; 2015. pp. 81–122.

Chapter   Google Scholar  

Peeters G, Black IL, Gomersall SR, Fritschi J, Sweeney A, Guedes De Oliveira Y, et al. Behaviour Change techniques in Computerized Cognitive Training for cognitively healthy older adults: a systematic review. Neuropsychol Rev. 2023;33:238–54.

Donolato E, Giofrè D, Mammarella IC. Differences in verbal and visuospatial forward and backward order recall: a review of the literature. Front Psychol. 2017;8:219220.

Sala G, Aksayli ND, Tatlidil KS, Tatsumi T, Gondo Y, Gobet F. Near and far transfer in cognitive training: a second-order meta-analysis. Collabra Psychol. 2019;5:18.

Martin DM, Liu R, Alonzo A, Green M, Loo CK. Use of transcranial direct current stimulation (tDCS) to enhance cognitive training: effect of timing of stimulation. Exp Brain Res. 2014;232:3345–51.

Yuan-Wen LIU, Zhong-Hua C, Jing LUO, Ming-Yu YIN, Li-Li LI, Yu-De Y et al. Explore combined use of transcranial direct current stimulation and cognitive training on executive function after stroke. J Rehabil Med 2021;53.

Burton CZ, Garnett EO, Capellari E, Chang S-E, Tso IF, Hampstead BM, et al. Combined cognitive training and transcranial direct current stimulation in neuropsychiatric disorders: a systematic review and meta-analysis. Biol Psychiatry Cogn Neurosci Neuroimaging. 2023;8:151–61.

PubMed   Google Scholar  

Miniussi C, Cappa SF, Cohen LG, Floel A, Fregni F, Nitsche MA, et al. Efficacy of repetitive transcranial magnetic stimulation/transcranial direct current stimulation in cognitive neurorehabilitation. Brain Stimulat. 2008;1:326–36.

Hill AT, Fitzgerald PB, Hoy KE. Effects of anodal transcranial direct current stimulation on working memory: a systematic review and meta-analysis of findings from healthy and neuropsychiatric populations. Brain Stimulat. 2016;9:197–208.

Andrews SC, Hoy KE, Enticott PG, Daskalakis ZJ, Fitzgerald PB. Improving working memory: the effect of combining cognitive activity and anodal transcranial direct current stimulation to the left dorsolateral prefrontal cortex. Brain Stimulat. 2011;4:84–9.

Katz B, Jones MR, Shah P, Buschkuehl M, Jaeggi SM. Individual Differences in Cognitive Training Research. In: Strobach T, Karbach J, editors. Cogn. Train. Cham: Springer International Publishing; 2021. pp. 107–23.

Woods AJ, Antal A, Bikson M, Boggio PS, Brunoni AR, Celnik P, et al. A technical guide to tDCS, and related non-invasive brain stimulation tools. Clin Neurophysiol. 2016;127:1031–48.

Nitsche MA, Boggio PS, Fregni F, Pascual-Leone A. Treatment of depression with transcranial direct current stimulation (tDCS): a review. Exp Neurol. 2009;219:14–9.

Stagg CJ, Bachtiar V, O’Shea J, Allman C, Bosnell RA, Kischka U, et al. Cortical activation changes underlying stimulation-induced behavioural gains in chronic stroke. Brain. 2012;135:276–84.

Download references

Acknowledgements

We sincerely thank Virag Szolcsak and Judit Szigeti F. Ph.D., who helped with English proofreading.

Open access funding provided by University of Szeged.

Author information

Authors and affiliations.

Department of Neurology, University of Szeged, 6, Semmelweis Street, Szeged, 6725, Hungary

Csaba Kazinczi, Péter Klivényi & László Vécsei

Department of Clinical Psychology, Semmelweis University, 25, Üllői Street, Budapest, 1091, Hungary

Csaba Kazinczi

Department of Neurology, St. Borbala Hospital, 77, Dózsa György Street, Tatabánya, 2900, Hungary

Katalin Boross

University of Szeged, Institute of Psychology, 2, Egyetem Street, Szeged, 6722, Hungary

Mihály Racsmány

HUN-REN-SZTE Neuroscience Research Group, University of Szeged, 2, Szikra Street, Szeged, 6725, Hungary

László Vécsei

WCG Clinical Endpoint Solutions, Princeton, NJ, USA

Department of Psychiatry, Whanganui District Health Board, Whanganui, New Zealand

Department of Radiology, University of Szeged, 2, Semmelweis Street, Szeged, 6725, Hungary

Krisztián Kocsis

Institute of Cognitive Neuroscience and Psychology, HUN-REN Research Centre for Natural Sciences, 2, Magyar Tudósok Boulevard, Budapest, 1117, Hungary

Cognitive Medicine Research Group, Competence Centre for Neurocybernetics of the Life Sciences Cluster, Centre of Excellence for Interdisciplinary Research, Development and Innovation, University of Szeged, 13, Dugonics Square, Szeged, 6720, Hungary

You can also search for this author in PubMed   Google Scholar

Contributions

C. K.: Conceptualization, Data Curation, Formal Analysis and Writing (original draft); K. K.: Data Curation and Formal Analysis; K.B.: Data Curation; R.M.: Conceptualization and Supervision; P.K.: Supervision; L.V.: Supervision; A.M.: Conceptualization and Supervision. All authors reviewed the manuscript.

Corresponding author

Correspondence to Csaba Kazinczi .

Ethics declarations

Ethical approval and consent to participate.

This article contains no studies with human participants or animals performed by any authors.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Kazinczi, C., Kocsis, K., Boross, K. et al. The effect of computerized cognitive training and transcranial direct current stimulation on working memory among post-stroke individuals: a systematic review with meta-analysis and meta-regression. BMC Neurol 24 , 314 (2024). https://doi.org/10.1186/s12883-024-03813-x

Download citation

Received : 05 May 2024

Accepted : 20 August 2024

Published : 04 September 2024

DOI : https://doi.org/10.1186/s12883-024-03813-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Computer-based
• Cognitive training
• Systematic review

BMC Neurology

ISSN: 1471-2377

• General enquiries: [email protected]