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

Abstract

Methods: Seventy patients with a verified ABI and executive dysfunction were randomly allocated to GMT (n = 33) or a psycho-educative active control condition, Brain Health Workshop (BHW) (n = 37). In addition, all participants received external cueing by text messages. Neuropsychological tests and self-reported questionnaires of executive functioning were administered pre-intervention, immediately after intervention, and at 6 months followup. Assessors were blinded to group allocation.Results: Questionnaire measures indicated significant improvement of everyday executive functioning in the GMT group, with effects lasting at least 6 months post-treatment. Both groups improved on the majority of the applied neuropsychological tests. However, improved performance on tests demanding executive attention was most prominent in the GMT group. Conclusions:The results indicate that GMT combined with external cueing is an effective metacognitive strategy training method, ameliorating executive dysfunction in daily life for patients with chronic ABI. The strongest effects were seen on self-report measures of executive functions 6 months post-treatment, suggesting that strategies learned in GMT were applied and consolidated in everyday life after the end of training. Furthermore, these findingsshow that executive dysfunction can be improved years after the ABI. INTRODUCTIONExecutive 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).Thus, EF is an umbrella term for a set of interrelated capacities resulting from activity in anatomically and functionally independent, but interconnected networks subserved by widespread brain regions, the prefrontal cortex playing a central role (Stuss & Alexander, 2007).Executive dysfunction (ED) is common following acquired brain injury (ABI) (Stuss & Levine, 2002;Novakovic-Agopian et al, 2011), and may disrupt the ability to effectively use intact functions or compensatory strategies, undermine efficient self-management (Lewis, Babbage & Leathem, 2011), hamper the rehabilitation process (Robertson & Murre, 1999), and is also associated with long-term negative psychosocial and vocational outcome (Draper & Ponsford, 2008; Ylvisaker & Feeney, 2000). Thus, techniques for reducing ED might significantly impact functional outcome (Manly & Murphy, 2012).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 & Shalli...

Incorporation of a working memory strategy in GMT to facilitate serial-order behaviour in brain-injured patients

“…On the contrary, GMT seems to be more effective when it is combined with attentional and problem-solving strategies (Cantor et al, 2014;Chen et al, 2011;Miotto, Evans, Souza de Lucia, & Scaff, 2009;Novakovic-Agopian et al, 2011;Spikman et al, 2010;van Hooren et al, 2007). Recent studies, combining GMT with errorless learning techniques (Bertens, Kessels, Fiorenzato, Boelen, & Fasotti, 2015) or external cueing (Tornås et al, 2016) have confirmed this.…”

A Randomized Controlled Trial of Assisted Intention Monitoring for the Rehabilitation of Executive Impairments Following Acquired Brain Injury

“…The relatively brief two-session goal management training adopted here (in comparison with the 14 or more hours of face-to-face GMT training typically reported 16 ) might be considered insufficient for many with ABI. Future evaluation of clinical effectiveness, should consider a more extended and tailored period of strategy and self-regulation training 16,17,22 and inclusion in the intervention of additional components that enhance likelihood of transfer of strategies 16,22,[41][42][43] .…”

“…A recent trial 22 found GMT incorporating text message reminders resulted in gains on self-report and neuropsychological measures, although the independent contribution of cueing was not evaluated. Previous trials have used questionnaires or neuropsychological tests rather than real-world behavioural measures to evaluate outcome.…”

Can an external device create and trigger intention in a patient with a severe brain injury?

“…This training was proven to be efficient in the maintenance and realisation of intention in patients with mild to moderate cognitive deficits, especially when it was associated with other intervention strategies, Running head: EXTERNAL DEVICE AND GOAL-DIRECTED BEHAVIOUR such as external cueing, or when the GMT was implemented in daily life activities and not only in a laboratory task (Krasny-Pacini, Chevignard, & Evans, 2014). For example, Tornås et al (2016) showed that GMT associated with a daily text message that read "STOP" (the first stage of GMT), indicating to the participant that he had to interrupt his ongoing action to direct his attention towards a relevant goal, was effective in improving goal attainment in daily living activities in 33 patients who had chronic brain injury without severe cognitive impairment. Other studies showed the efficiency of an external device in the realisation of GDB, such as NeuroPage, a paging system that sends reminders according to prearranged schedules.…”