Rehabilitation of dysexecutive impairments Prof Jon Evans Rehabilitation
Rehabilitation of dysexecutive impairments Prof Jon Evans
Rehabilitation of dysexecutive impairments • It’s good to have a model (or two) to help us make sense of executive impairments • There is evidence for interventions, so our practice should be evidence-based. • One size doesn’t fit all – So as with all of brain injury rehabilitation we have to carefully plan interventions to address executive (and other) impairments in the context of the client’s functional goals.
Theorising & Executive Functions What are the functions of the frontal lobes? How do we understand the deficits caused by damage to the frontal lobes? How do humans solve problems and manage complex everyday activities?
The case of Phineus Gage….
Another case of frontal lobe damage? • Henry VIII – King of England. . . • …demonstrated great intelligence and mental acuity. As a skilful linguist, Henry spoke French, Spanish and Latin. He was a talented musician and composer. He was fond of tennis. . ’a capital horseman, and a fine jouster’. • His first serious accident occurred in 1524 when he failed to lower the visor on his helmet and was hit by his opponent's lance just above the right eye, after which he constantly suffered from migraines. • On the 24 th January 1536, 44 -year-old Henry, in full armour, was thrown from his horse, itself armoured, which then fell on top of him. He was unconscious for two hours and was thought at first to have been fatally injured.
Another case of frontal lobe damage? • After the accident – just before he became estranged from the second of his six wives, Anne Boleyn – the king, once sporty and generous, became cruel, vicious and paranoid, his subjects began talking about him in a new way, and the turnover of his wives speeded up.
Rehabilitation of dysexecutive impairments • It’s good to have a model (or two) to help us make sense of executive impairments • There is evidence for interventions, so our practice should be evidence-based. • One size doesn’t fit all – So as with all of brain injury rehabilitation we have to carefully plan interventions to address executive (and other) impairments in the context of the client’s functional goals.
Stuss (2011)
Adapted from Shallice and Burgess (1996) Contention Scheduling Problem Orientation Phase Goal Setting Process Spontaneous Schema Generation Behaviour Implementation of temporary new schema Special Purpose Working Memory Delayed Intention Marker Realisation Level of Aspiration Setting Progressive Deepening Phase Episodic Memory Retrieval Strategy Generation Phase Solution Checking Phase Intention Marker Activation Assessment and verification of new schema Monitoring Rejection of Schema
Burgess et al, 2007
Rehabilitation of dysexecutive impairments • It’s good to have a model (or two) to help us make sense of executive impairments • There is evidence for interventions, so our practice should be evidence-based. • One size doesn’t fit all
The evidence • • • Kennedy et al. (2008) Systematic review and meta analysis of interventions for executive deficits after brain injury. Primary evidence relating to ‘metacognitive strategy instruction’ (MSI) “…… sufficient evidence to make the clinical recommendation that MSI should be used with young to middle-aged adults with TBI, when improvement in everyday, functional problems is the goal” • Training of formal problem solving strategies and their application to everyday situations and functional activities are recommended as practice guideline. Cicerone et al (2011) • Metacognitive strategy training (self-monitoring and self-regulation) is recommended as practice standard for deficits in executive functioning after TBI. Cicerone et al 2011
Tate et al. , 2014 INCOG guidelines • EXEC 1: Metacognitive strategy instruction should be used with adults with TBI for difficulty with problem solving, planning, and organisation. These strategies should be focused on everyday problems and functional outcomes. – Metacognitive strategy instruction is optimised when the patient has awareness of the need to use a strategy, and can identify contexts in which the strategy should be used. Common elements of all metacognitive strategies are self-monitoring and incorporation of feedback into future performance • EXEC 2: Strategies to improve the capacity to analyse and synthesise information should be used with adults with TBI who have impaired reasoning skills (includes work on autobiographical memory training) • EXEC 3: Direct corrective feedback should be used with adults with TBI who have impaired self-awareness. The feedback should be delivered within the context of a therapeutic, multicontext program to treat awareness deficits • EXEC 4: Group-based interventions may be considered for remediation of executive and problem-solving deficits after TBI
Rehabilitation of dysexecutive impairments • It’s good to have a model (or two) to help us make sense of executive impairments • There is evidence for interventions, so our practice should be evidence-based. • One size doesn’t fit all
Tate et al. , 2014; Executive function and self-awareness algorithm
Executive problem evident from neuropsychological and/or functional assessment Establish goals for rehabilitation programme Are factors other than executive deficits contributing to functional difficulties and preventing goal achievement? No Yes Identify factors and treatment/ management options, e. g. Other cognitive deficits such as memory impairment or Mood/Worry/Anxiety; Sleep; Fatigue; Pain; Medication Does patient have at least some awareness of problem? No Yes How severe is the executive dysfunction? Plan and implement interventions to improve awareness e. g. education, feedback, self/other monitoring of errors in functional settings. Consider education group format. Has awareness improved? No Yes Mild/moderate executive dysfunction Consider: Self-instructional approaches such as Goal Management Training and Timepressure management training Problem-solving Training Alerting Consider modifications to environment to reduce executive demands e. g. establish consistent routines, prompting by carer, checklists. In the case of severe challenging behaviour, behaviour modification techniques may be appropriate. Autobiographical memory cueing Severe executive impairment Identify priority everyday tasks and select strategy to reflect need e. g. Establish consistent routines Checklists Externally directed prompting devices e. g. Neuro. Page Use of carers to monitor/prompt action. Consider use of group format Modifications to the environment behaviour management techniques Train skills/strategies and then support generalisation to everyday functional situations Consider use of group format with additional 1: 1 support.
Robertson, Levine, & Manly’s Goal Management Training (1) (2) (3) (4) (5) Stop and think what I am doing Define the main task List the steps required Learn the steps Whilst implementing the steps, check that I am on track or doing what I intended to do. Centre for Brain Fitness Use the Mental Blackboard
• 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.
Problem Solving Framework
Executive problem evident from neuropsychological and/or functional assessment Establish goals for rehabilitation programme Are factors other than executive deficits contributing to functional difficulties and preventing goal achievement? No Yes Identify factors and treatment/ management options, e. g. Other cognitive deficits such as memory impairment or Mood/Worry/Anxiety; Sleep; Fatigue; Pain; Medication Does patient have at least some awareness of problem? No Yes How severe is the executive dysfunction? Plan and implement interventions to improve awareness e. g. education, feedback, self/other monitoring of errors in functional settings. Consider education group format. Has awareness improved? No Yes Mild/moderate executive dysfunction Consider: Self-instructional approaches such as Goal Management Training and Timepressure management training Problem-solving Training Alerting Consider modifications to environment to reduce executive demands e. g. establish consistent routines, prompting by carer, checklists. In the case of severe challenging behaviour, behaviour modification techniques may be appropriate. Autobiographical memory cueing Severe executive impairment Identify priority everyday tasks and select strategy to reflect need e. g. Establish consistent routines Checklists Externally directed prompting devices e. g. Neuro. Page Use of carers to monitor/prompt action. Consider use of group format Modifications to the environment behaviour management techniques Train skills/strategies and then support generalisation to everyday functional situations Consider use of group format with additional 1: 1 support.
Adapted from Shallice and Burgess (1996) Contention Scheduling Problem Orientation Phase Goal Setting Process Spontaneous Schema Generation Behaviour Implementation of temporary new schema Special Purpose Working Memory Delayed Intention Marker Realisation Level of Aspiration Setting Progressive Deepening Phase Episodic Memory Retrieval Strategy Generation Phase Solution Checking Phase Intention Marker Activation Assessment and verification of new schema Monitoring Rejection of Schema
Improving monitoring • Monitoring – Sustaining attention – Goal maintenance • Failures lead to tendency to get ‘stuck in set’, persist with activity that is no longer goal directed. • Manly, Hawkins, Evans Woldt and Robertson (2002) periodic non-contingent alerts improved task management on a desktop task. • Fish, J. , Evans, J. J. , Nimmo, M. , Martin, E. , Kersel, D. , Bateman, A. , Wilson, B. A. and Manly, T. (2007) showed that combining a brief goal management training improved performance on a daily prospective memory task of leaving a voicemail message four times a day.
A randomized controlled trial of Assisted Intention Monitoring (AIM) for the rehabilitation of executive impairments following acquired brain injury (ABI). Fergus Gracey, Jessica E Fish, Eve Greenfield, Andrew Bateman, Donna Malley Gemma Hardy, Jessica Ingham, Jonathan J Evans, and Tom Manly • In press, Neural Repair and Neuro. Rehabilitation • Randomised, controlled, parallel group crossover design with three phases (baseline phase, intervention phase 1, intervention phase 2) each of which lasted 3 weeks, with a one week break between phases for completion of measures • A study of brief GMT followed by randomly-timed SMS text messages, for improving achievement of everyday intentions.
AIM Trial • Brief GMT was provided in participants’ homes or a community setting on a one-to-one basis over 2 sessions not more than 5 days apart each lasting between 90 and 120 minutes. • Participants were told that after training they would receive eight “STOP” texts each day, designed to increase the frequency of goal reviews. • Compared with active control - one-to-one sessions of the same duration as AIM consisting of brain injury information (excluding reference to executive functioning) and a computerized visuo-spatial game involving increasingly speeded mental rotation (‘Tetris’) plausibly linked to improving cognitive skills but not hypothesized to improve prospective memory. • Participants in the control phase also received eight daily SMS text messages reading: ‘AIM research study. Please ignore’
AIM Trial • Outcomes – Phone call task (similar to Fish et al) – Individual tasks identified by participants (proportion of intentions achieved) • Results – Comparing groups post intervention phase 1 there was no evidence of significant benefit of the AIM intervention versus placebo on achievement of intentions or mood. – There was evidence of benefit of AIM for the phone task ( in a per protocol analysis). – Taking the whole crossover data, participants achieved their everyday intentions at a significantly higher frequency during the AIM phases of the study than the control conditions. – Effect strongest for the phone task.
• RCT comparing GMT (n=33) with active control group, Brain Health Workshop (n=37). + • • • STOP! + Emotion Regulation VS Brain Health Workshop Each group met for one day every other week over period of 8 weeks (i. e. eight 2 hour sessions over four days). GMT – Standard GMT programme with addition of an emotion regulation module and STOP! Texts from week four to prompt use of GMT. Brain Health Workshop - educational materials and various lifestyle interventions that are typically part of psycho-educative programs delivered at brain rehabilitation centres
• • • Patients receiving GMT showed significant improvement in selfreported cognitive EF in daily life, with the greatest improvements evident after 6 months. A general trend toward improved neuropsychological functioning was found. There was a tendency toward improved performance on attention demanding tasks for GMT, with error reduction indicating improved executive attention. The overall pattern of results confirmed that GMT had a more favourable effect on cognitive EF than an active psycho-educative control condition. 35 DEX Questionnaire 30 25 20 GMT 15 BHW 10 5 0 Baseline Follow Up
• RCT, 67 participants, comparing standard GMT with an ‘errorless GMT’ • EL-GMT: Both the acquisition and application of the Goal Management Training strategy were taught using error reducing methods, including verbal and written instructions, cue cards and modeling. • Primary outcome – performance on two individually selected everyday tasks on which participants are having difficulty, rated blind. • EL-GMT improved everyday task performance significantly more than conventional GMT Cohen’s d = 0. 74)
Adapted from Shallice and Burgess (1996) Contention Scheduling Problem Orientation Phase Goal Setting Process Spontaneous Schema Generation Behaviour Implementation of temporary new schema Special Purpose Working Memory Delayed Intention Marker Realisation Level of Aspiration Setting Progressive Deepening Phase Episodic Memory Retrieval Strategy Generation Phase Solution Checking Phase Intention Marker Activation Assessment and verification of new schema Monitoring Rejection of Schema
Autobiographical memory and planning • Dritschel, Kogan, Burton and Goddard (1998). – People with TBI are less likely to use autobiographical memories to support problem solving. • Hewitt, Evans and Dritschel (2006) – Training in recollection from autobiographical memory improves problem solving effectiveness
Executive problem evident from neuropsychological and/or functional assessment Establish goals for rehabilitation programme Are factors other than executive deficits contributing to functional difficulties and preventing goal achievement? No Yes Identify factors and treatment/ management options, e. g. Other cognitive deficits such as memory impairment or Mood/Worry/Anxiety; Sleep; Fatigue; Pain; Medication Does patient have at least some awareness of problem? No Yes How severe is the executive dysfunction? Plan and implement interventions to improve awareness e. g. education, feedback, self/other monitoring of errors in functional settings. Consider education group format. Has awareness improved? No Yes Mild/moderate executive dysfunction Consider: Self-instructional approaches such as Goal Management Training and Timepressure management training Problem-solving Training Alerting Consider modifications to environment to reduce executive demands e. g. establish consistent routines, prompting by carer, checklists. In the case of severe challenging behaviour, behaviour modification techniques may be appropriate. Autobiographical memory cueing Severe executive impairment Identify priority everyday tasks and select strategy to reflect need e. g. Establish consistent routines Checklists Externally directed prompting devices e. g. Neuro. Page Use of carers to monitor/prompt action. Consider use of group format Modifications to the environment behaviour management techniques Train skills/strategies and then support generalisation to everyday functional situations Consider use of group format with additional 1: 1 support.
Adapted from Shallice and Burgess (1996) Contention Scheduling Problem Orientation Phase Goal Setting Process Spontaneous Schema Generation Behaviour Implementation of temporary new schema Special Purpose Working Memory Delayed Intention Marker Realisation Level of Aspiration Setting Progressive Deepening Phase Episodic Memory Retrieval Strategy Generation Phase Solution Checking Phase Intention Marker Activation Assessment and verification of new schema Monitoring Rejection of Schema
Improving implementation/ initiation Evans, Emslie and Wilson (1998)/ Fish, Manly & Wilson (2008) • RP: 50 year old woman with bilateral frontal lobe damage arising from rupture of Anterior Communicating Artery. • Preserved IQ/Memory/Perception/Language • Impaired attention and problem solving • Main problems – Failure to translate intention into action – Distractibility
Improving implementation/ initiation • Various strategies aimed at supporting initiation and maintenance of intentions A 1 B 1 A 2 B 2
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