Assessing executive performance during cognitive rehabilitation

Profiles of executive functioning following traumatic brain injury and stroke using the assessment of participation and executive functions: combined cross-sectional and longitudinal designs

OBJECTIVES

The Assessment of Participation and Executive Functions (A-PEX) evaluates executive functioning through daily participation in complex daily activities. This study examines its ability to discriminate between executive functioning profiles post-traumatic brain injury and post-stroke and its sensitivity to changes.

DESIGN

Cross-sectional with a longitudinal component.

PATIENTS

Adults with post-traumatic brain injury (n = 28) and post-stroke (n = 26) in a rehabilitation facility.

METHODS

Patients were administered the A-PEX, Multiple Errands Test-Hospital version and Color Trail Test at 2 time-points 1 month apart. The Montreal Cognitive Assessment was administered at the first time-point, and Executive Functions Performance Test's Internet-based Bill Payment subtest at the second. The analysis used Mann-Whitney and Wilcoxon signed-rank tests.

RESULTS

The stroke group's A-PEX scores were higher than the traumatic brain injury group's at the first time-point (p < 0.05). No differences were found in the other assessments. Within-group differences in both groups were significant in the A-PEX (-3.7 < r < - 2.3, p < 0.05) and Multiple Errands Test-Hospital version (-3.4 < r < -3.3, p < 0.01).

CONCLUSION

The A-PEX may provide valuable information about the uniqueness of executive functioning profiles and patients' progress.

Intelligence and executive function are associated with age at insult, time post-insult, and disability following chronic pediatric acquired brain injury

Background

Pediatric acquired brain injury (pABI) profoundly affects cognitive functions, encompassing IQ and executive functions (EFs). Particularly, young age at insult may lead to persistent and debilitating deficits, affecting daily-life functioning negatively. This study delves into the intricate interplay of age at insult, time post-insult, and their associations with IQ and EFs during chronic (>1 year) pABI. Additionally, we investigate cognitive performance across different levels of global function, recognizing the multifaceted nature of developmental factors influencing outcomes.

Methods

Drawing upon insult data and baseline information analyzing secondary outcomes from a multicenter RCT, including comprehensive medical and neuropsychological assessments of participants aged 10 to 17 years with pABI and parent-reported executive dysfunctions. The study examined associations between age at insult (early, EI; ≤7y vs. late, LI; > 7y) and time post-insult with IQ and EFs (updating, shifting, inhibition, and executive attention). Additionally, utilizing the Pediatric Glasgow Outcome Scale-Extended, we explored cognitive performance across levels of global functioning.

Results

Seventy-six participants, median 8 years at insult and 5 years post-insult, predominantly exhibiting moderate disability (n = 38), were included. Notably, participants with LI demonstrated superior IQ, executive attention, and shifting compared to EI, [adjusted mean differences with 95% Confidence Intervals (CIs); 7.9 (1.4, 14.4), 2.48 (0.71, 4.24) and 1.73 (0.03, 3.43), respectively]. Conversely, extended post-insult duration was associated with diminished performances, evident in mean differences with 95% CIs for IQ, updating, shifting, and executive attention compared to 1-2 years post-insult [-11.1 (-20.4, -1.7), -8.4 (-16.7, -0.1), -2.6 (-4.4, -0.7), -2.9 (-4.5, -1.2), -3.8 (-6.4, -1.3), -2.6 (-5.0, -0.3), and -3.2 (-5.7, -0.8)]. Global function exhibited a robust relationship with IQ and EFs.

Conclusion

Early insults and prolonged post-insult durations impose lasting tribulations in chronic pABI. While confirmation through larger studies is needed, these findings carry clinical implications, underscoring the importance of vigilance regarding early insults. Moreover, they dispel the notion that children fully recover from pABI; instead, they advocate equitable rehabilitation offerings for pABI, tailored to address cognitive functions, recognizing their pivotal role in achieving independence and participation in society. Incorporating disability screening in long-term follow-up assessments may prove beneficial.

Patient-Reported Outcome of Functional Cognition for Traumatic Brain Injury: Item-Level Psychometrics

A patient-reported functional cognition measure that can bridge neuropsychological tests and ecological validity is lacking. The purpose of this study was to present the initial item-level psychometrics of a functional cognition item bank, the Functional Cognition-Patient-Reported Outcome (FC-PRO). Confirmatory factor analysis, Rasch analysis, and convergent validity were conducted to establish item-level psychometrics of the FC-PRO item bank. Four of the six domains met essential unidimensionality criteria; all domains met rating scale criteria; domains had relatively few misfitting items (3%-13%); person reliability (.8-.92), and person strata (2.97-4.29) were satisfactory; the domains showed convergent validity for five of six domains. The FC-PRO showed adequate initial item-level psychometrics for researchers/clinicians to measure specific functional cognitive domains in patients with traumatic brain injury (TBI). This study provides the foundation for the development of future short forms, computer adaptive tests, and keyform recovery maps of patient-reported functional cognition to facilitate clinical utilization.

Establishing the Validity of the Internet-Based Bill-Paying Task to Assess Executive Function Deficits Among Adults With Traumatic Brain Injury

IMPORTANCE

Executive function (EF) deficits are common after traumatic brain injury (TBI). During rehabilitation, it is important to identify EF deficits and understand their impact on daily function. The internet-based Bill-Paying Task, modified from the Executive Function Performance Test, has not yet been validated for use with people with TBI.

OBJECTIVE

To examine the known-groups, convergent, and ecological validity of the internet-based Bill-Paying Task for assessing EF deficits after TBI.

DESIGN

Cross-sectional study with two consecutive parts based on the study's objectives.

SETTING

Inpatient rehabilitation and community.

PARTICIPANTS

Part 1 included 42 adults with TBI and 47 healthy adults; Part 2 included 28 of the 42 adults with TBI.

MEASURES

Assessments included the Internet-based Bill-Paying Task, WebNeuro neurocognitive computerized battery, Semantic Verbal Fluency test, Behavioural Assessment of the Dysexecutive Syndrome (BADS), Dysexecutive Questionnaire (DEX), and cognitive items of the FIM® and the Functional Assessment Measure (cognitive FIM+FAM).

RESULTS

For Part 1, participants with TBI required significantly more cues and longer completion time to perform the internet-based Bill-Paying Task. For Part 2, moderate significant correlations were found between the internet-based Bill-Paying Task total score and the WebNeuro, Semantic Verbal Fluency test, BADS, DEX, and cognitive FIM+FAM.

CONCLUSIONS AND RELEVANCE

This study supports the known-groups, convergent, and ecological validity of the internet-based Bill-Paying Task for assessing EF deficits among adults with preserved basic cognitive abilities after TBI. Therefore, it can be used to assist with rehabilitation treatment planning after TBI. What This Article Adds: The internet-based Bill-Paying Task, an online payment task relevant to today's technological world, is valid to assess higher cognitive abilities of people after a traumatic brain injury. This assessment may contribute to a better understanding of patients' cognitive profiles and their potential impact on daily performance.

Assessment of Executive Function in Everyday Life—Psychometric Properties of the Norwegian Adaptation of the Children’s Cooking Task

Background: There are few standardized measures available to assess executive function (EF) in a naturalistic setting for children. The Children’s Cooking Task (CCT) is a complex test that has been specifically developed to assess EF in a standardized open-ended environment (cooking). The aim of the present study was to evaluate the internal consistency, inter-rater reliability, sensitivity and specificity, and also convergent and divergent validity of the Norwegian version of CCT among children with pediatric Acquired Brain Injury (pABI) and healthy controls (HCs).

Methods: The present study has a cross-sectional design, based on baseline data derived from a multicenter RCT. Seventy-five children with pABI from two university hospitals with parent-reported executive dysfunction and minimum of 12 months since injury/completed cancer therapy, as well as 59 HCs aged 10–17 years, were assessed with CCT using total errors as the main outcome measure. The pABI group completed tests assessing EF (i.e., inhibition, cognitive flexibility, working memory, and planning) on the impairment level within the ICF framework (performance-based neuropsychological tests and the Behavioral Assessment of the Dysexecutive Syndrome for Children), and on the participation level (questionnaires). In addition, they completed tests of intellectual ability, processing speed, attention, learning, and memory. Finally, overall functional outcome (pediatric Glasgow Outcome Scale-Extended) was evaluated for the children with pABI.

Results: Acceptable internal consistency and good inter-rater reliability were found for the CCT. Children with pABI performed significantly worse on the CCT than the HCs. The CCT identified group membership, but the sensitivity and specificity were overall classified as poor. Convergent validity was demonstrated by associations between the CCT and performance-based tests assessing inhibition, cognitive flexibility, and working memory, as well as teacher-reported executive dysfunction (questionnaires). Divergent validity was supported by the lack of association with performance-based measures of learning and memory, attention, and verbal intellectual ability. However, there was a moderate association between the CCT and performance-based tests of processing speed. Lastly, better performance on the CCT was associated with a better functional outcome.

Conclusion: Our study with a relatively large sample of children with pABI and HC’s demonstrated good psychometric properties of the CCT. CCT performance was associated with the overall level of disability and function, suggesting that CCT is related to the level of activity in everyday life and participation in society. Hence, our study suggests that the CCT has the potential to advance the assessment of EF by providing a valid analysis of real-world performance. Nevertheless, further research is needed on larger samples, focusing on predictors of task performance, and evaluating the ability of CCT to detect improvement in EF over time. The patterns of error and problem-solving strategies evaluated by the CCT could be used to inform neuropsychological rehabilitation treatmentand represent a more valid outcome measure of rehabilitation interventions.

Rehabilitation of executive function in chronic paediatric brain injury: a randomized controlled trial

BACKGROUND

Impaired executive functions (EFs, i.e., purposeful, goal-directed behaviour) cause significant disability after paediatric acquired brain injury (pABI) warranting efficient interventions. Goal Management Training (GMT) is a metacognitive protocol proven effective for executive dysfunction in adults. This pre-registered, blinded, parallel-randomized controlled trial evaluated efficacy of a paediatric adaptation (pGMT) compared to a psychoeducative control (paediatric Brain Health Workshop, pBHW) to improve EF.

METHODS

Children aged 10 to 17 years with pABI (e.g., traumatic brain injury, brain tumour), ≥ 1 year post-onset or ended treatment, with parent-reported EF complaints were eligible. Participants were randomized (computer-algorithm) to either group-based pGMT (n = 38) or pBHW (n = 38). The active control was tailored to keep non-specific factors constant. Thus, both treatments comprised of 7 sessions at hospitals over 3 consecutive weeks, followed by 4 weeks of telephone counselling of participants, parents, and teachers. Parent-reported daily life EF, assessed by the questionnaire Behavior Rating Inventory of Executive Function (BRIEF; Behavioral Regulation Index (BRI) and Metacognition Index (MI)), were co-primary outcomes 6 months post-intervention. Secondary outcomes included neuropsychological tests and a complex naturalistic task (Children's Cooking Task).

RESULTS

Seventy-three participants (96%) completed allocated interventions and 71 (93%) attended the 6-month follow-up. The results demonstrated no significant difference in effectiveness for the two interventions on parent-reported EF: For BRIEFBRI, mean (SD) raw score for pGMT was 42.7 (8.8) and 38.3 (9.3) for pBHW. Estimated difference was - 2.3 (95% CI - 5.1 to 0.6). For BRIEFMI, the corresponding results were 80.9 (20.4) for GMT and 75.5 (19.3) for pBHW. Estimated difference was - 1.4 (95% CI -8.5 to 5.8). In performance-based tests, pGMT was associated with improved inhibition and executive attention, while pBHW was associated with fewer errors in the naturalistic task.

CONCLUSIONS

In pABI, metacognitive training (pGMT) did not demonstrate additional effectiveness on parent-reported daily life EF at 6-month follow-up, when compared to a psychoeducative control. Both interventions were well-tolerated and demonstrated distinct improvements at different EF assessment levels. To conclude on pGMT efficacy, larger studies are needed, including further investigation of appropriate assessment levels and possible differences in effect related to treatment duration, developmental factors, and injury characteristics.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT0321534211, 11 July 2017.

Improvement of Planning Abilities in Adults with Prader-Willi Syndrome: A Randomized Controlled Trial

Prader-Willi Syndrome (PWS) is a neurodevelopmental genetic disorder with executive deficits. Planning is one of the impaired executive functions implied in the regulation of behavior and everyday actions. We aimed to explore the feasibility and the effectiveness of a metacognitive strategy training designed to improve planning in adults with PWS using a double-blind between-group (training versus usual care) randomized controlled trial, with computerized tests and paper-pencil ecological outcome measures targeting planning, other executive functions, and achievement of personalized goal. Results showed better performances in several executive tasks and in achievement of personalized goals after both interventions, but better improvement for the experimental group (n = 27) compared to control (n = 26) only on the task assessing planning abilities. Interviews with occupational therapists demonstrated the feasibility of this training with this population. Despite a small number of sessions, the metacognitive strategy training showed encouraging results on planning abilities of patients.

What do people respond to when rating executive function? - a cognitive interviewing investigation of BRIEF-A informant ratings in severe aphasia

PURPOSE

Executive dysfunction is common in persons with severe aphasia. Assessing these functions in this population is challenging. Informant ratings, such as the BRIEF-A, might be a useful alternative to neuropsychological tests. However, research has shown weak relationships between tests and ratings. The aim of this study was to understand how significant others of people with severe aphasia interpret and respond to questions about executive function in the informant report version of BRIEF-A.

METHODS

Eleven significant others were interviewed about a subset of the BRIEF-A items, using cognitive interviewing. Interviews were subjected to thematic analysis.

RESULTS

There was variation in the interpretation of the items of BRIEF-A which frequently corrupted the items' relation to what it was intended to measure. Further, informants wavered between considering the person with aphasias' ability or actual performance and many had lowered their expectations. The language problems caused by the aphasia affected the validity of some items.

CONCLUSIONS

The quantitative results of BRIEF-A informant ratings should be interpreted with caution, since it is unclear to what extent the responses represent executive function. The use of informant ratings does not solve the problem with aphasia being a confounding factor in assessment of executive function.IMPLICATIONS FOR REHABILITATIONAssessing executive function in people with severe aphasia is important but challenging.Quantitative results of informant ratings of executive function, such as BRIEF-A, in this population should be interpreted with caution, since it is unclear to what extent the ratings represent executive function.Using informant ratings does not solve the problem of the aphasia being a confounding factor, since the aphasia impacts on the validity of some of the items.

Paediatric goal management training in patients with acquired brain injury: study protocol for a randomised controlled trial

INTRODUCTION

Compromised integrity of the brain due to paediatric acquired brain injury (pABI) has been associated with cognitive impairment, particularly executive dysfunction, in addition to somatic and emotional symptoms and reduced everyday function. Goal Management Training (GMT) is a cognitive rehabilitation intervention for improving executive function (EF) that has received empirical support in studies of adults with ABI. The purpose of the present study is to determine the efficacy of a recently developed paediatric version of GMT (pGMT) for children and adolescents with ABI and reported executive dysfunction.

METHODS AND ANALYSIS

This study protocol describes a parallel randomised controlled trial including allocation concealment and assessor blinding. Eighty survivors after pABI, aged 10-17 years at the time of intervention, will be recruited. Participants will be randomly allocated to either pGMT (n=40) or a psychoeducative control intervention (n=40; paediatric Brain Health Workshop). Both interventions consist of seven group sessions for participants and parents, followed by external cueing and telephone counselling. The study also includes involvement of teachers. Assessments will be performed at baseline, immediately postintervention and at 6 months' follow-up. Primary outcome measure will be changes in daily life EF as reported by parents (The Behavior Rating Inventory of Executive Function). Secondary outcomes include other assessments of EF (neuropsychological tests and questionnaires). Furthermore, we aim to assess generalisation effects of pGMT on other cognitive functions, as well as emotional, behavioural, adaptive and family function, academic performance, fatigue and quality of life.

ETHICS AND DISSEMINATION

Results from this study will be disseminated to relevant research, clinical, health service and patient communities through publications in peer-reviewed and popular science journals, in addition to presentations at scientific conferences. The study will be conducted in accordance with the Helsinki declaration and the Ethical Research Involving Children (ChildWatch International and Unicef). In accordance to Good Clinical Practice our study includes safety and quality monitoring guarantees in compliance with research ethics and safety. The trial will be reported in accordance with the Consolidated Standards of Reporting Trials 2010 statement and Standard Protocol Items for Reporting in Trials recommendations, in addition to being registered at ClinicalTrials.gov. The study has been approved by the Regional Committees for Medical and Health Research Ethics Norway (2017/772).

TRIAL REGISTRATION NUMBER

NCT03215342.

Moderators, mediators and nonspecific predictors of outcome after cognitive rehabilitation of executive functions in a randomised controlled trial

Moderators, mediators and nonspecific predictors of treatment after cognitive rehabilitation of executive functions in a randomised controlled trial Objective: To explore moderators, mediators and nonspecific predictors of executive functioning after cognitive rehabilitation in a randomised controlled trial, comparing Goal Management Training (GMT) with an active psycho-educative control-intervention, in patients with chronic acquired brain injury.

METHODS

Seventy patients with executive dysfunction were randomly allocated to GMT (n = 33) or control (n = 37). Outcome measures were established by factor-analysis and included cognitive executive complaints, emotional dysregulation and psychological distress.

RESULTS

Higher age and IQ emerged as nonspecific predictors. Verbal memory and planning ability at baseline moderated cognitive executive complaints, while planning ability at six-month follow-up mediated all three outcome measures. Inhibitory cognitive control emerged as a unique GMT specific mediator. A general pattern regardless of intervention was identified; higher levels of self-reported cognitive-and executive-symptoms of emotional dysregulation and psychological distress at six-month follow-up mediated less improvement across outcome factors.

CONCLUSIONS

The majority of treatment effects were nonspecific to intervention, probably underscoring the variables' general contribution to outcome of cognitive rehabilitation interventions. Interventions targeting specific cognitive domains, such as attention or working memory, need to take into account the patients' overall cognitive and emotional self-perceived functioning. Future studies should investigate the identified predictors further, and also consider other predictor candidates.

Dysexecutive symptoms and carer strain following acquired brain injury: Changes measured before and after holistic neuropsychological rehabilitation

BACKGROUND

Following acquired brain injury (ABI), deficits in executive functioning (EF) are common. As a result many brain-injured patients encounter problems in every-day functioning, and their families experience significant strain. Previous research has documented the benefits of cognitive rehabilitation for executive dysfunction, and rehabilitation programmes designed to ameliorate functional problems associated with ABI.

OBJECTIVES

This study primarily aims to evaluate whether a neuropsychological rehabilitation programme reduces reported symptoms of everyday dysexecutive behaviour and carer strain.

METHODS

In this study 66 ABI outpatients attended comprehensive holistic neuropsychological rehabilitation programme. A repeated-measures design was employed to determine the effect of rehabilitation on EF and carer strain, as part of a service evaluation. Outcome measures comprised the dysexecutive questionnaire (DEX/DEX-I) and carer strain index (CSI), applied pre- and post-rehabilitation.

RESULTS

Results indicate rehabilitation benefited clients and carers in 5 of 6 DEX/DEX-I subscales, and 2 of 3 CSI subscales, (p < 0.05). An effect of aetiology on rehabilitation was found on the metacognitive scale of the DEX-I.

CONCLUSIONS

Therefore, this study supports a comprehensive holistic neuropsychological rehabilitation programme as effective in reducing reported symptoms of dysexecutive behaviour and carer strain following ABI.

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

Executive dysfunction is a common consequence of acquired brain injury (ABI), causing significant disability in daily life. This randomized controlled trial investigated the efficacy of Goal Management Training (GMT) in improving executive functioning in patients with chronic ABI. 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 follow-up. Assessors were blinded to group allocation. 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. 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 findings show that executive dysfunction can be improved years after the ABI.

Executive function in fibromyalgia: Comparing subjective and objective measures

BACKGROUND

There is evidence to suggest the existence of an executive dysfunction in people diagnosed with fibromyalgia, although there are certain inconsistencies between studies. Here, we aim to compare executive performance between patients with fibromyalgia and a control group by using subjective and objective cognitive tests, analyzing the influence of patient mood on the results obtained, and studying associations between the two measures.

METHOD

82 patients diagnosed with fibromyalgia and 42 healthy controls, matched by age and years of education, were assessed using the Behavioral Rating Inventory of Executive Function - Adult Version (BRIEF-A) as a subjective measure of executive functioning. A selection of objective cognitive tests were also used to measure a series of executive functions and to identify symptoms of depression and anxiety.

RESULTS

Patients with fibromyalgia perceived greater difficulties than the control group on all of the BRIEF-A scales. However, after adjustments were made for depression and anxiety the only differences that remained were those associated with the working memory scale and the Metacognition and Global Executive Composite index. In the case of the objective cognitive tests, a significantly worse overall performance was evidenced for the fibromyalgia patients. However, this also disappeared when adjustments were made for depression and anxiety. After this adjustment, fibromyalgia patients only performed significantly worse for the interference effect in the Stroop Test. Although there were no significant associations between most of the objective cognitive tests and the BRIEF-A scales, depression and anxiety exhibited strong associations with almost all of the BRIEF-A scales and with several of the objective cognitive tests.

CONCLUSIONS

Patients with fibromyalgia showed executive dysfunction in subjective and objective measures, although most of this impairment was associated with mood disturbances. Exceptions to this general rule were observed in the impairment of working memory evidenced on the BRIEF-A scale and the inhibition impairment exhibited by the interference effect from the Stroop Test. The two types of measurement provide different yet complementary information.

Updating the Cognitive Performance Scale

This study presents the first update of the Cognitive Performance Scale (CPS) in 20 years. Its goals are 3-fold: extend category options; characterize how the new scale variant tracks with the Mini-Mental State Examination; and present a series of associative findings. Secondary analysis of data from 3733 older adults from 8 countries was completed. Examination of scale dimensions using older and new items was completed using a forward-entry stepwise regression. The revised scale was validated by examining the scale's distribution with a self-reported dementia diagnosis, functional problems, living status, and distress measures. Cognitive Performance Scale 2 extends the measurement metric from a range of 0 to 6 for the original CPS, to 0 to 8. Relating CPS2 to other measures of function, living status, and distress showed that changes in these external measures correspond with increased challenges in cognitive performance. Cognitive Performance Scale 2 enables repeated assessments, sensitive to detect changes particularly in early levels of cognitive decline.

Response to goal management training in veterans with blast-related mild traumatic brain injury

Veterans with blast-related mild traumatic brain injury (TBI) experience cognitive deficits that interfere with functional activities. Goal Management Training (GMT), which is a metacognitive intervention, offers an executive function rehabilitation approach that draws upon theories concerning goal processing and sustained attention. GMT has received empirical support in studies of patients with TBI but has not been tested in Veterans with blast-related mild TBI. GMT was modified from 7 weekly to 10 biweekly sessions. Participants included six combat Veterans that reported multiple blast exposures resulting in symptoms consistent with mild TBI. Group analysis showed a significant improvement in measures of executive function derived from performance on the computerized Tower of London. There were no significant changes on self/informant questionnaires of executive function, indicating a lack of generalization of improvement from the clinic to everyday activities. Overall, while the data indicate efficacy of GMT in the rehabilitation of combat Veterans with executive function deficits because of blast-related mild TBI, enhancement of generalization is needed.

Can Teleneuropsychology Help Meet the Neuropsychological Needs of Western Africans? The Case of Ghana

In Ghana, the services of psychologists, particularly clinical psychologists and neuropsychologists, remain largely inaccessible to a large proportion of those in need. Emphasis has been placed on "physical wellness" even among patients with cognitive and behavioral problems needing psychological attention. The small number of clinical psychologists and neuropsychologists, the deplorable nature of road networks and transport systems, geopolitical factors, and a reliance on the face-to-face method in providing neuropsychological services have further complicated the accessibility problem. One way of expanding and making neuropsychological services available and accessible is through the use of information communication technology to provide these services, and this is often termed teleneuropsychology. Drawing on relevant literature, this article discusses how computerized neurocognitive assessment and videoconferencing could help in rendering clinical neuropsychological services to patients, particularly those in rural, underserved, and disadvantaged areas in Ghana. The article further proposes recommendations on how teleneuropsychology could be made achievable and sustainable in Ghana.

Disexecutive functions and depression in patients with Parkinson disease: the impact on rehabilitation outcome

BACKGROUND

Studies relating to patients with Parkinson disease that assess neuropsychologic, psychologic, and clinical aspects are very uncommon.

OBJECTIVE

The aim of this study was to analyze the impact of executive functioning (impaired vs. not impaired) or depression (depressed vs. nondepressed) on the outcome of rehabilitation treatment in patients with Parkinson disease without dementia at the medium stage of disease.

METHODS

Forty consecutive inpatients affected by Parkinson disease were psychologically and neuropsychologically assessed by means of standardized tests during the first week of admission and at discharge after undergoing an intensive rehabilitation training.

RESULTS

At baseline, the patients (mean [SD] age, 70.1 [8.0]; Mini-Mental State Examination [MMSE], ≥24) showed impairment in the following executive functions: frontal functions (32.5%), selective and divided attention (55.0% and 41.9%, respectively), and word fluency (17.5%). Depressive symptoms reported using the Geriatric Depression Scale were distributed as follows: mild (n = 13), 32.5%; moderate (n = 4), 10.0%; and severe (n = 5), 12.5%. As for the outcome of the intensive rehabilitation treatment, a general improvement in the Unified Parkinson's Disease Rating Scale, the Berg's scale, the 6-min walking test, and the Timed Up and Go test was observed (P < 0.0001). The improvement was homogeneous for all groupings of the patients for all of the considered variables, indicating that the changes in performance as a result of treatment were unaffected by the presence of executive function deficits or moderate-to-severe depression.

CONCLUSIONS

The patients' executive function impairment or moderate-to-severe depressive symptoms did not seem to interfere with the outcome of the intensive physical and occupational rehabilitation. Therefore, these aspects in patients without dementia should not be considered a contraindication to an intensive rehabilitation program. Furthermore, despite the presence of impaired executive functions and/or of depressive symptoms, the 4-wk multidisciplinary rehabilitation program resulted to be highly effective.

Definition of Impulsivity and Related Terms Following Traumatic Brain Injury: A Review of the Different Concepts and Measures Used to Assess Impulsivity, Disinhibition and other Related Concepts

Impulsivity is a common and debilitating sequela following traumatic brain injury (TBI), but there is no consensual definition or measure to assess this construct. The following review aims to elucidate the differences and resemblances between impulsivity, disinhibition and other related terms following brain injury and the instruments that are commonly used to measure these constructs. To do so, a search through different databases was conducted in order to find articles that mention and define impulsivity, disinhibition, impulse control, regulation deficits, dyscontrol and risky behavior. The concepts that stand out from the literature, the measures used, the similarities, the differences between these concepts are observed. The fit with the UPPS model of impulsivity, according to which impulsivity is a multidimensional concept composed of four distinct dimensions (urgency, perseverance, premeditation and sensation-seeking) is discussed.

Conceptualization and Rehabilitation of Executive Functions

Publications on executive functions have increased in the last few years, reflecting the importance of this area of study. The scientific output on executive functions is now extremely diverse, comprising variations around terminology, assessment, and rehabilitation practices, and ranging in topics from neuroanatomical correlates of executive functions to effects of executive dysfunction. This review seeks to explore this diversity around executive functions in order to provide an integrative overview of the topic that systematizes the current knowledge in this area, and to point to trends and future directions for research and practice. The literature review was conducted in the ISI Web of Knowledge databases. The analysis was conducted in NVivo9. Two independent coders applied an inductive analysis to all relevant papers, building a hierarchical model with categories and subcategories of themes emerging from the literature. A confirmatory analysis followed, with the same independent coders applying the model to the papers. The process was validated by a third expert researcher. Out of 187 titles and abstracts, 91 were analyzed. The outcomes were structured in six main categories: central nervous system, diagnosis, population, assessment, intervention, and theoretical models. Key findings included promising trends in executive function assessment and rehabilitation as well as potential implications for current health approaches and future research.

Goal Management Training improves everyday executive functioning for persons with spina bifida: self-and informant reports six months post-training

Executive dysfunction accounts for significant disability for many patients with spina bifida (SB), thus indicating the need for effective interventions aimed at improving executive functioning in this population. Goal Management Training™ (GMT) is a cognitive rehabilitation approach that targets disorganised behaviour resulting from executive dysfunction, and has received empirical support in studies of other patient groups. The purpose of this study was to determine if GMT would lead to perceived improved executive functioning in the daily lives of patients with SB, as evidenced by reduced report of dysexecutive problems in daily life on self- and informant questionnaires. Thirty-eight adults with SB were included in this randomised controlled trial (RCT). Inclusion was based upon the presence of executive functioning complaints. Experimental subjects (n = 24) received 21 hours of GMT, with efficacy of GMT being compared to results of subjects in a wait-list condition (n = 14). All subjects were assessed at baseline, post-intervention, and at six-month follow-up. Self-report measures indicated that the GMT group's everyday executive functioning improved significantly after training, lasting at least 6 months post-treatment. There were no significant effects on informant-report questionnaires. Overall, these findings indicate that executive difficulties in everyday life can be ameliorated for individuals with congenital brain dysfunction.

Cognitive assessment across the continuum of care: the importance of occupational performance-based assessment for individuals post-stroke and traumatic brain injury

BACKGROUND/AIM

When working with individuals following stroke or traumatic brain injury, an important role of the occupational therapist is to assess the impact of cognitive impairment on their ability to engage in occupations and resume important life roles. The aim of this study was to survey therapists' reasons for selection of and challenges with using various cognitive assessment approaches, across the continuum of care, when working with individuals following stroke and traumatic brain injury.

METHODS

A cross-sectional survey, completed via post or online, with responses from 209 Australian occupational therapists was conducted. Participants included clinicians working in acute, inpatient rehabilitation and community settings.

RESULTS

Occupational performance-based assessments were ranked as the most important assessment method, with 69% of participants reporting using these assessments for more than 75% of their clients with cognitive impairment. Participants identified the lack of quantitative data provided by these assessments as a frequent challenge. The identification of cognitive deficits was the highest ranked reason for using cognitive screens and batteries. Challenges identified with using cognitive screens and batteries included difficulty linking assessment results to occupational performance, and difficulty using results to generate intervention strategies. The majority of participants reported using a combined approach to assessment, and used screens and batteries to support findings of occupational performance-based assessments.

CONCLUSIONS

Targeted efforts to further incorporate standardised occupational performance-based methods into clinical practice, research, and ongoing professional development is required to enhance occupational therapy services when working with individuals with cognitive impairment.

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.