Executive dysfunction in chronic brain-injured patients: Assessment in outpatient rehabilitation

The 20-item dysexecutive questionnaire after severe traumatic brain injury: Distribution of the total score and its significance

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01437683..

Exploring the Multidimensional Participation of Adults Living in the Community in the Chronic Phase following Acquired Brain Injury

This exploratory study aimed to examine multiple aspects of the participation of adults in the chronic phase following acquired brain injury (ABI), considering different disability levels. Our study included 25 adults ≥6 months after ABI (predominantly stroke), living at home, without severe cognitive decline. Primary measures included the Canadian Occupational Performance Measure (subjective participation) and the Mayo-Portland Adaptability Inventory-4 Participation Index (objective participation). The results indicated subjective participation problems in all of the International Classification of Functioning, Disability and Health participation domains. In addition, objective participation was reported as most limited in the areas of leisure and recreational activities, residence, and employment. Both subjective and objective participation profiles varied according to the disability level except for the social and leisure areas, which were found to be similar across all subgroups. However, only partial compatibility was found between the subjective and objective participation aspects. To conclude, our findings indicated that chronic ABI survivors report a variety of subjective and objective participation concerns that varied according to their disability levels. Moreover, the incongruity between the participation aspects suggests that the level of limitation may not necessarily correspond to the importance of a particular participation area. This highlights the need for comprehensive assessments to determine unique individual participation profiles in order to facilitate client-centered interventions supporting the rehabilitation of community-dwelling ABI survivors.

A Performance-Based Teleintervention for Adults in the Chronic Stage after Acquired Brain Injury: An Exploratory Pilot Randomized Controlled Crossover Study

This pilot study aimed to investigate the initial effect of a remotely delivered performance-based client-centered intervention on activity performance and participation among adults in the chronic phase after acquired brain injury (ABI). Sixteen participants living at home with little to no assistance in basic daily activities were allocated into intervention or waitlist control groups. Assessments were conducted at the baseline, after the 3-month intervention/wait period, and at a 3-month follow-up. The primary outcomes were activity performance using the Canadian Occupational Performance Measure (COPM) and the Performance Quality Rating Scale (PQRS) and participation using the Mayo-Portland Adaptability Inventory-4 (MPAI-4). The intervention included weekly videoconferencing sessions using the Cognitive Orientation to Daily Occupational Performance approach (tele-CO-OP). The participants identified five functional goals, of which three were directly addressed. Wilcoxon signed-ranks test results showed no significant improvements in the control group at the end of the 3-month wait period. Pooled data from both groups showed significant improvements in COPM scores for trained and untrained goals following the intervention. Significant improvements were also found in the PQRS and MPAI-4 scores. Improvements were partially maintained at follow-up. Our preliminary results suggest that tele-CO-OP may positively impact the lives of adults after ABI who are coping with long-term disability.

Relationships between neuropsychological impairments and functional outcome eight years after severe traumatic brain injury: Results from the PariS-TBI study

BACKGROUND/OBJECTIVES

The objective was to assess the relationships between neuropsychological impairments, functional outcome and life satisfaction in a longitudinal study of patients after a severe traumatic brain injury (TBI) (PariS-TBI study).

PATIENTS

Out of 243 survivors, 86 were evaluated 8 years post-injury. They did not significantly differ from patients lost-to-follow up except for the latter being more frequently students or unemployed before the injury.

METHODS

Outcome measures included the Glasgow Outcome Scale-Extended (GOS-E), a functional independence questionnaire, employment, mood, fatigue and satisfaction with life. Neuropsychological outcome was assessed by two ways: performance-based outcome measures, using neuropsychological tests and patient and relative-based measures.

RESULTS

Neuropsychological measures were not significantly related to initial injury severity nor to gender, but were significantly related to age and education. After statistical correction for multiple comparisons, cognitive testing and cognitive questionnaires were significantly correlated with most outcome measures. By contrast, satisfaction with life was only related with patient-rated questionnaires. A regression analysis showed that the Trail-Making-Test-A was the best predictor of functional outcome, in addition to education duration.

CONCLUSIONS

Cognitive measures, particularly slowed information processing speed, were significant indicators of functional outcome at a long-term post-injury, beyond and above demographics or injury severity measures.

Impaired self-awareness after traumatic brain injury: a systematic review. Part 1: Assessment, clinical aspects and recovery

BACKGROUND

Impaired self-awareness (ISA) has frequently been found to be both frequent and deleterious in patients with moderate to severe traumatic brain injury (TBI).

OBJECTIVES

The present paper is the first of a two-part systematic review of ISA after traumatic brain injury (TBI), focusing on assessment methods, clinical aspects and recovery.

METHODS

Following the PRISMA guidelines, 95 articles meeting the inclusion criteria were included.

RESULTS

ISA occurs in 30% to 50% of patients with moderate to severe TBI, although it tends to improve with time. There is no one single gold-standard measure of ISA. Self-proxy discrepancy scores, with scales such as the Patient Competency Rating Scale or the Awareness Questionnaire, or a structured interview such as the Self Awareness of Deficits Interview, are the most frequently used assessment methods, with adequate psychometric properties. Scores on these different scales correlate only moderately with each other, which suggests that they may address different aspects of self-awareness. ISA mainly concerns cognitive and behavioral problems rather than physical or sensory impairments and may concern different areas of functioning, such as anticipatory, emergent or meta-cognitive awareness.

CONCLUSION

ISA is a complex and multifaceted issue that should be systematically assessed in rehabilitation settings using a range of relatively well-validated tools. The consequences and predictors of ISA after TBI will be addressed in a companion paper.

Long-term cognitive disability after traumatic brain injury: Contribution of the DEX relative questionnaires

Executive functions are high-level cognitive processes commonly impaired after severe traumatic brain injury (sTBI), which may be associated with persistent anosognosia. The dysexecutive questionnaire (DEX) was designed to assess different domains of executive functioning in daily life. Two versions of the DEX exist (DEX-S completed by the patient, DEX-O completed by a relative) to compare cognitive complaints and patient's awareness. This work was aimed at studying the relevance of DEX-O for assessing daily-life limitations, the persistence of anosognosia and its association with global disability (GOSE) and magnetic resonance imaging (MRI) markers of brain alterations. Sixty-three patients (and relatives) were included within 63.4 months (±20.7) after sTBI. DEX-S and DEX-O scores were significantly positively correlated. We obtained significant correlations between DEX-S and episodic memory and phasic alert but not with executive assessment, GOSE and diffusion MRI markers. DEX-O was significantly correlated with executive function, episodic memory, attention (phasic alert sustained and divided attention), with the GOSE and the volume of the body of the corpus callosum (MRI marker). Anosognosia score (DEX-O minus DEX-S) correlated with mean diffusivity measure. These results highlight the clinical interest of DEX-O in assessing long-term disability.

The influence of computer-based cognitive flexibility training on subjective cognitive well-being after stroke: A multi-center randomized controlled trial

Background

Stroke can result in cognitive complaints that can have a large impact on quality of life long after its occurrence. A number of computer-based training programs have been developed with the aim to improve cognitive functioning. Most studies investigating their efficacy used only objective outcome measures, whereas a reduction of subjective cognitive complaints may be equally important for improving quality of life. A few studies used subjective outcome measures but were inconclusive, partly due to methodological shortcomings such as lack of proper active and passive control groups.

Objective

The aim of the current study was to investigate whether computer-based cognitive flexibility training can improve subjective cognitive functioning and quality of life after stroke.

Methods

We performed a randomized controlled double blind trial (RCT). Adults (30–80 years old) who had a stroke 3 months to 5 years ago, were randomly assigned to either an intervention group (n = 38), an active control group (i.e., mock training; n = 35), or a waiting list control group (n = 24). The intervention and mock training consisted of 58 half-hour sessions within 12 weeks. The primary subjective outcome measures were cognitive functioning (Cognitive Failure Questionnaire), executive functioning (Dysexecutive Functioning Questionnaire), quality of life (Short Form Health Survey), instrumental activities of daily living (IADL; Lawton & Brody IADL scale), and participation in society (Utrecht Scale for Evaluation of Rehabilitation-Participation). Secondary subjective outcome measures were recovery after stroke, depressive symptoms (Hospital Anxiety Depression Scale—depression subscale), fatigue (Checklist Individual Strength—Fatigue subscale), and subjective cognitive improvement (exit list). Finally, a proxy of the participant rated the training effects in subjective cognitive functioning, subjective executive functioning, and IADL.

Results and conclusions

All groups improved on the two measures of subjective cognitive functioning and subjective executive functioning, but not on the other measures. These cognitive and executive improvements remained stable 4 weeks after training completion. However, the intervention group did not improve more than the two control groups. This suggests that improvement was due to training-unspecific effects. The proxies did not report any improvements. We, therefore, conclude that the computer-based cognitive flexibility training did not improve subjective cognitive functioning or quality of life after stroke.

Do Old Errors Always Lead to New Truths? A Randomized Controlled Trial of Errorless Goal Management Training in Brain-Injured Patients

Both errorless learning (EL) and Goal Management Training (GMT) have been shown effective cognitive rehabilitation methods aimed at optimizing the performance on everyday skills after brain injury. We examine whether a combination of EL and GMT is superior to traditional GMT for training complex daily tasks in brain-injured patients with executive dysfunction. This was an assessor-blinded randomized controlled trial conducted in 67 patients with executive impairments due to brain injury of non-progressive nature (minimal post-onset time: 3 months), referred for outpatient rehabilitation. Individually selected everyday tasks were trained using 8 sessions of an experimental combination of EL and GMT or via conventional GMT, which follows a trial-and-error approach. Primary outcome measure was everyday task performance assessed after treatment compared to baseline. Goal attainment scaling, rated by both trainers and patients, was used as secondary outcome measure. EL-GMT improved everyday task performance significantly more than conventional GMT (adjusted difference 15.43, 95% confidence interval [CI] [4.52, 26.35]; Cohen's d=0.74). Goal attainment, as scored by the trainers, was significantly higher after EL-GMT compared to conventional GMT (mean difference 7.34, 95% CI [2.99, 11.68]; Cohen's d=0.87). The patients' goal attainment scores did not differ between the two treatment arms (mean difference 3.51, 95% CI [-1.41, 8.44]). Our study is the first to show that preventing the occurrence of errors during executive strategy training enhances the acquisition of everyday activities. A combined EL-GMT intervention is a valuable contribution to cognitive rehabilitation in clinical practice.

Temporal dysfunction in traumatic brain injury patients: primary or secondary impairment?

Adequate temporal abilities are required for most daily activities. Traumatic brain injury (TBI) patients often present with cognitive dysfunctions, but few studies have investigated temporal impairments associated with TBI. The aim of the present work is to review the existing literature on temporal abilities in TBI patients. Particular attention is given to the involvement of higher cognitive processes in temporal processing in order to determine if any temporal dysfunction observed in TBI patients is due to the disruption of an internal clock or to the dysfunction of general cognitive processes. The results showed that temporal dysfunctions in TBI patients are related to the deficits in cognitive functions involved in temporal processing rather than to a specific impairment of the internal clock. In fact, temporal dysfunctions are observed when the length of temporal intervals exceeds the working memory span or when the temporal tasks require high cognitive functions to be performed. The consistent higher temporal variability observed in TBI patients is a sign of impaired frontally mediated cognitive functions involved in time perception.

Sensitivity, specificity and predictive value of the BADS to anterior executive dysfunction

In this study we investigated the validity of the BADS subtests to adequately discriminate anterior lesions (AL) from posterior lesions (PL). Therefore, we compared the performances of 30 AL patients, 22 PL patients and 29 healthy controls (HC) on the BADS subtests. Seven standard executive test variables were also examined. Our multiple comparisons showed that the BADS Zoo Map-Part 1 was not indicative for AL, whereas Rule Shifting, Action Programme, Key Search, Zoo Map-total score, and BADS-total score were found to be sensitive to AL. More importantly, the Modified Six Element Test (MSET), and the Zoo Map-Part 2 were highly specific for AL. In both BADS subtests AL patients performed significantly worse than either the PL or the HC groups, whereas no significant differences on the same variables were found between PL and HC individuals. Further logistic regression analysis revealed that the BADSMSET was the best predictor for distinguishing AL from PL patients, correctly classifying 78.8% of the patients. These results suggest that the BADSMSET is an accurate screening tool for the detection of anterior pathology. Poor performance on this BADS subtest is a significant indicator of executive dysfunctioning after anterior brain damage.

Who benefits from treatment for executive dysfunction after brain injury? Negative effects of emotion recognition deficits

Deficits in emotion recognition, a crucial aspect of social cognition, are common after serious brain injury, as are executive deficits. Since social cognition and executive function are considered to be separate constructs, our first aim was to examine the presence of emotion recognition problems in brain injury patients with dysexecutive problems. We studied 65 brain injury patients of mixed aetiology participating in a randomised controlled trial evaluating the effects of a multifaceted treatment for executive dysfunction (Spikman, Boelen, Lamberts, Brouwer, & Fasotti, 2010 ) and 84 matched controls with a test for emotion recognition. Results showed that, in patients with acquired brain injury exhibiting executive deficits, emotion recognition deficits are also present. Male patients are more impaired than female patients, irrespective of aetiology. Our second aim was to investigate whether emotion recognition problems negatively predict the results of the treatment programme. Pre-treatment emotion recognition performance significantly predicted resumption of roles in daily life (Role Resumption List; RRL) and performance on an ecologically valid test for everyday executive functioning (Executive Secretarial Task; EST) post-treatment and, in addition, interfered negatively with treatment condition. Moreover, worse pre-treatment emotion recognition skills affect the learning of compensatory strategies for executive dysfunction negatively, whereas pre-treatment dysexecutive deficits do not.

A randomized controlled trial on errorless learning in goal management training: study rationale and protocol

Background

Many brain-injured patients referred for outpatient rehabilitation have executive deficits, notably difficulties with planning, problem-solving and goal directed behaviour. Goal Management Training (GMT) has proven to be an efficacious cognitive treatment for these problems. GMT entails learning and applying an algorithm, in which daily tasks are subdivided into multiple steps. Main aim of the present study is to examine whether using an errorless learning approach (preventing the occurrence of errors during the acquisition phase of learning) contributes to the efficacy of Goal Management Training in the performance of complex daily tasks.

Methods/Design

The study is a double blind randomized controlled trial, in which the efficacy of Goal Management Training with an errorless learning approach will be compared with conventional Goal Management Training, based on trial and error learning. In both conditions 32 patients with acquired brain injury of mixed etiology will be examined. Main outcome measure will be the performance on two individually chosen everyday-tasks before and after treatment, using a standardized observation scale and goal attainment scaling.

Discussion

This is the first study that introduces errorless learning in Goal Management Training. It is expected that the GMT-errorless learning approach will improve the execution of complex daily tasks in brain-injured patients with executive deficits. The study can contribute to a better treatment of executive deficits in cognitive rehabilitation.

Trial registration

(Dutch Trial Register): http://NTR3567

Goal Management Training for rehabilitation of executive functions: a systematic review of effectiveness in patients with acquired brain injury

PURPOSE

To determine if Goal Management Training (GMT) is effective for the rehabilitation of executive functions following brain injury when administered alone or in combination with other interventions.

METHOD

Systematic review, with quality appraisal specific to executive functions research and calculation of effect sizes.

RESULTS

Twelve studies were included. Four studies were "Proof-of-principle" studies, testing the potential effectiveness of GMT and eight were rehabilitation studies. Effectiveness was greater when GMT was combined with other interventions. The most effective interventions appeared to be those combing GMT with: Problem Solving Therapy; personal goal setting; external cueing or prompting apply GMT to the current task; personal homework to increase patients' commitment and training intensity; ecological and daily life training activities rather than paper-and-pencil, office-type tasks. Level of support for GMT was higher for studies measuring outcome in terms of increases in participation in everyday activities rather than on measures of executive impairment.

CONCLUSION

Comprehensive rehabilitation programs incorporating GMT, but integrating other approaches, are effective in executive function rehabilitation following brain injury in adults. There is insufficient evidence to support use of GMT as a stand-alone intervention.

Telerehabilitation for addressing executive dysfunction after traumatic brain injury

PRIMARY OBJECTIVE

To investigate the feasibility of implementing the Cognitive Orientation to daily Occupational Performance approach (CO-OP) in a telerehabilitation format and to examine its impact on community integration and executive dysfunction for adults with traumatic brain injury (TBI).

RESEARCH DESIGN

A pilot series of three case studies with 3-month follow-up was conducted.

METHODS AND PROCEDURES

Three adults (all males, >10 years post-TBI) and their significant others were recruited. The CO-OP intervention, a meta-cognitive approach, was delivered through videoconferencing via Internet to train three of five participant-identified goals. Two goals were not trained to allow examination of transfer. Outcome measures included the Canadian Occupational Performance Measure, the Mayo-Portland Adaptability Inventory-4 Participation Index, and the Dysexecutive Questionnaire. Descriptive statistical analysis was used.

MAIN OUTCOMES AND RESULTS

The CO-OP approach administered in a telerehabilitation format was found to be feasible. All participants indicated self-reported improvement in both trained and untrained goals. Trends toward fewer symptoms of executive dysfunction and greater community integration were demonstrated. All participants expressed satisfaction with the Internet delivery method.

CONCLUSIONS

Telerehabilitation shows promise as a way to deliver the CO-OP approach and may help promote community integration of individuals living with TBI. Further study is warranted.

Time discrimination in traumatic brain injury patients

Time management skills are required for most daily activities. Traumatic brain injury (TBI) patients often present with cognitive dysfunction, but few studies have investigated temporal impairment. The aim of the present study was to assess temporal abilities in TBI patients using a time discrimination task. Twenty-seven TBI patients (ages = 18-60 years) and 27 controls (ages = 20-60 years) were asked to discriminate between two time intervals presented sequentially. The standard intervals were 500 ms or 1,300 ms long followed by a comparison stimulus that was 25% shorter or longer than the standard one. Participants were also asked to perform two tasks to assess attention, speed-of-processing (the Stroop task), and working memory (the n-back task) abilities. The TBI patients were less accurate than the controls on the time discrimination task and showed greater time-order error effects. In fact, TBI patients pressed the "short" key more times when the standard time interval was 500 ms and the "long" key more times when the standard interval was 1,300 ms. Significant correlations were found between time discrimination, working memory, and speed of processing in both TBI and controls when the standard time interval was 1,300 ms. Attention appeared to be involved in different ways in the two groups. Working memory and speed of processing were involved in time processing only in TBI patients when the standard time interval was 500 ms. These data lend additional support to the notion that two different systems are responsible for elaborating time durations shorter or longer than a second.

Practice of contemporary dance improves cognitive flexibility in aging

As society ages and frequency of dementia increases exponentially, counteracting cognitive aging decline is a challenging issue for countries of the developed world. Previous studies have suggested that physical fitness based on cardiovascular and strength training helps to improve attentional control in normal aging. However, how motor activity based on motor-skill learning can also benefit attentional control with age has been hitherto a neglected issue. This study examined the impact of contemporary dance (CD) improvisation on attentional control of older adults, as compared to two other motor training programs, fall prevention and Tai Chi Chuan. Participants performed setting, suppressing, and switching attention tasks before and after 5.7-month training in either CD or fall prevention or Tai Chi Chuan. Results indicated that CD improved switching but not setting or suppressing attention. In contrast, neither fall prevention nor Tai Chi Chuan showed any effect. We suggest that CD improvisation works as a training for change, inducing plasticity in flexible attention.

Effects of a multifaceted treatment program for executive dysfunction after acquired brain injury on indications of executive functioning in daily life

A multicenter randomized control trial (RCT) was conducted to evaluate the effects of a treatment for dysexecutive problems after acquired brain injury (ABI) on daily life functioning. Seventy-five ABI patients were randomly allocated to either the experimental treatment, multifaceted strategy training for executive dysfunction, or a control treatment, computerized cognitive function training. Assessment took place before, directly after, and 6 months post-treatment. The primary outcome measure, the Role Resumption List (RRL), and two other follow-up measures, the Treatment Goal Attainment (TGA) and the Executive Secretarial Task (EST), were indications of daily life executive functioning. The experimental group improved significantly more over time than the controls on the RRL and attained significantly higher scores on the TGA and EST. We conclude that our treatment has resulted in significant improvements of executive functioning in daily life, lasting at least 6 months post-treatment. Although control patients' satisfaction and subjective well-being were at the same level, the experimental group had better abilities to set and accomplish realistic goals, to plan, initiate, and regulate a series of real-life tasks, and to resume previous roles with respect to work, social relations, leisure activities, and mobility.