Rehabilitation of Executive Functioning in Patients with Frontal Lobe Brain Damage with Goal Management Training

Abstract

Executive functioning deficits due to brain disease affecting frontal lobe functions cause significant real-life disability, yet solid evidence in support of executive functioning interventions is lacking. Goal Management Training (GMT), an executive functioning intervention that draws upon theories concerning goal processing and sustained attention, has received empirical support in studies of patients with traumatic brain injury, normal aging, and case studies. GMT promotes a mindful approach to complex real-life tasks that pose problems for patients with executive functioning deficits, with a main goal of periodically stopping ongoing behavior to monitor and adjust goals. In this controlled trial, an expanded version of GMT was compared to an alternative intervention, Brain Health Workshop that was matched to GMT on non-specific characteristics that can affect intervention outcome. Participants included 19 individuals in the chronic phase of recovery from brain disease (predominantly stroke) affecting frontal lobe function. Outcome data indicated specific effects of GMT on the Sustained Attention to Response Task as well as the Tower Test, a visuospatial problem-solving measure that reflected far transfer of training effects. There were no significant effects on self-report questionnaires, likely owing to the complexity of these measures in this heterogeneous patient sample. Overall, these data support the efficacy of GMT in the rehabilitation of executive functioning deficits.

Rehabilitation of Executive Functions in Patients with Chronic Acquired Brain Injury with Goal Management Training, External Cuing, and Emotional Regulation: A Randomized Controlled Trial

“…Other studies are single case-studies (Levine et al, 2000;Schweitzer et al, 2008;Metzler-Baddeley et al, 2010), or include small samples and are only partially randomized (Levine et al, 2011). Only two group-based GMT studies (Levine et al, 2011;Novakovic-Agopian et al, 2011) have reported follow-up analyses more than three months post-intervention, limiting the evidence for long-term effects.…”

“…Reviews recommend metacognitive strategy training including self-monitoring and self-regulation as practice standard following ED due to traumatic brain injury (TBI) (Cicerone et al, 2011;Kennedy et al, 2008). Promising results have been reported for interventions such as problem solving therapy (Rath, Simon, Langenbahn & Sherr, 2003;Miotto, Evans, de Lucia & Scaff, 2008;von Cramon, Matthes-von Cramon & Mai, 1991) and goal management training (GMT; e.g., Levine et al, 2011), incorporating self-instructions aimed at strengthening the individual's ability to interrupt and control ongoing behavior.…”

“…Habits or environmental triggers may oppose and displace higher-order goals, resulting in cue-dependent or distracted behavior, when the attention system is compromised (Fernandez-Duque, Baird & Posner, 2000;Levine et al, 2011). The capacity to allocate processing resources selectively to a particular stimulus (Blake, Heiser, Caywood, & Merzenich, 2006), presupposes an adequate level of arousal (Coull, 1995;Smith & Nutt, 1996).…”

“…Most theories describe EF as top-down controlled processes involved in the control and direction of self-regulatory cognition, emotion and behavior (Cicerone et al, 2006;Stuss, 2011). Current theories of cognitive EF bear close resemblance to dominant models of attention (Norman & Shallice, 1986;Posner & Petersen, 1990;2012) and working memory (Baddeley, 2010), placing attentional control at the cornerstone of the cognitive and anatomical infrastructure underlying EF (Chiesa, Calati & Serretti, 2011; Miyake et al, 2000).…”

“…Executive functions (EF) are required for independent, purposive, self-directed behavior and include processes of initiation, planning, purposive action, volition, inhibition, flexibility, as well as self-monitoring and self-regulation (Lezak, 1995;Stuss, 2011). A division between "cold" and "hot" components of EF has been suggested, with "cold" EF corresponding closely to cognitive and logical processes, and the "hot" aspects of EF involving regulation of emotion and motivation (Chan, Shum, Toulopoulou & Chen, 2008).…”