INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part III: Executive Functions

Introduction: Moderate-to-severe traumatic brain injury (MS-TBI) causes debilitating and enduring impairments of executive functioning and self-awareness, which clinicians often find challenging to address. Here, we provide an update to the INCOG 2014 guidelines for the clinical management of these impairments. Methods: An expert panel of clinicians/researchers (known as INCOG) reviewed evidence published from 2014 and developed updated recommendations for the management of executive functioning and self-awareness post-MS-TBI, as well as a decision-making algorithm, and an audit tool for review of clinical practice. Results: A total of 8 recommendations are provided regarding executive functioning and self-awareness. Since INCOG 2014, 4 new recommendations were made and 4 were modified and updated from previous recommendations. Six recommendations are based on level A evidence, and 2 are based on level C. Recommendations retained from the previous guidelines and updated, where new evidence was available, focus on enhancement of self-awareness (eg, feedback to increase self-monitoring; training with video-feedback), meta-cognitive strategy instruction (eg, goal management training), enhancement of reasoning skills, and group-based treatments. New recommendations addressing music therapy, virtual therapy, telerehabilitation-delivered metacognitive strategies, and caution regarding other group-based telerehabilitation (due to a lack of evidence) have been made. Conclusions: Effective management of impairments in executive functioning can increase the success and well-being of individuals with MS-TBI in their day-to-day lives. These guidelines provide management recommendations based on the latest evidence, with support for their implementation, and encourage researchers to explore and validate additional factors such as predictors of treatment response

Cognitive Variability in High-functioning Individuals & its Implications for the Practice of Clinical Neuropsychology

Knowledge of the literature pertaining to patterns of performance in normal individuals is essential if we are to understand intraindividual variability in neurocognitive test performance in neuropsychiatric disorders. Twenty-five healthy individuals with a high-level of education were evaluated on a short neuropsychological battery which spanned several cognitive domains. ---Results indicated that cognitive abilities are not equally distributed within a sample of healthy, high-level functioning individuals. This may be of interest to neuropsychologists who might base clinical inference about the presence of cerebral dysfunction, at least in part, on marked variation in a patient’s level of cognitive test performance. The practice of deductive reasoning in clinical neuropsychology may be prone to false-positive conclusions about cognitive functioning in neuropsychiatric disorders where base-rates of cognitive impairments are low and pre-existing educational achievements are high.MAS

The Ecological Validity of Traditional Pen-and-paper, Ecologically Oriented, and Virtual Reality Neuropsychological Test Measures to Cognitive Impairment and Real-World Function after Mild Traumatic Brain Injury

A growing concern in neuropsychology is whether neuropsychological test measures (NTMs) can predict functional outcome (i.e., ecological validity). Ecological validity can be understood in two ways: veridicality (i.e., prediction of functional outcome is independent of how the test reflects the outcome being measured) and verisimilitude (i.e., tests resemble the functional outcome they are predicting). Historically, the veridicality approach has been utilized (i.e., by way of traditional, pen-and-paper NTMs), but there has been a movement to employ verisimilitude approaches (e.g., Behavioural Assessment for Dysexecutive Syndrome; BADS). These approaches were examined in patients experiencing ongoing cognitive complaints in the post-acute period of recovery (> 3 months) following a mild traumatic brain injury (mTBI). This was the principal inclusion criteria for the studies described here. A meta-analytic study was conducted and found that traditional NTMs were not sensitive to persistent cognitive complaints in this population across all domains. Studies 2 and 3 utilized archival data to determine whether NTMs could predict return to work (RTW) status. The BADS predicted employment status by way of medium-to-large effects, while traditional NTMs did not. Overall, these findings suggest the verisimilitude approach is more ecologically valid than the veridicality approach. As such, two virtual reality tests (VRTs) evaluating attention and executive function were developed to investigate their ability to predict RTW. Tests of attention (VR and traditional tests) significantly predicted group membership at 82% accuracy, with 82.6% sensitivity and 81.5% specificity. The attention shift trial of the VRT and to a lesser degree the total speed score of the Ruff 2 7 were predictive of employment status. Overall, this research provides empirical evidence for the verisimilitude approach when evaluating RTW status in patients who are in the post-acute period of recovery following mTBI. Moreover, it provides initial evidence for the clinical utility of VRTs to evaluate real-world functioning.Ph.D

Remotely delivered environmental enrichment intervention for traumatic brain injury: Study protocol for a randomised controlled trial

Introduction Individuals with moderate-severe traumatic brain injury (m-sTBI) experience progressive brain and behavioural declines in the chronic stages of injury. Longitudinal studies found that a majority of patients with m-sTBI exhibit significant hippocampal atrophy from 5 to 12 months post-injury, associated with decreased cognitive environmental enrichment (EE). Encouragingly, engaging in EE has been shown to lead to neural improvements, suggesting it is a promising avenue for offsetting hippocampal neurodegeneration in m-sTBI. Allocentric spatial navigation (ie, flexible, bird’s eye view approach), is a good candidate for EE in m-sTBI because it is associated with hippocampal activation and reduced ageing-related volume loss. Efficacy of EE requires intensive daily training, prohibitive within most current health delivery systems. The present protocol is a novel, remotely delivered and self-administered intervention designed to harness principles from EE and allocentric spatial navigation to offset hippocampal atrophy and potentially improve hippocampal functions such as navigation and memory for patients with m-sTBI.Methods and analysis Eighty-four participants with chronic m-sTBI are being recruited from an urban rehabilitation hospital and randomised into a 16-week intervention (5 hours/week; total: 80 hours) of either targeted spatial navigation or an active control group. The spatial navigation group engages in structured exploration of different cities using Google Street View that includes daily navigation challenges. The active control group watches and answers subjective questions about educational videos. Following a brief orientation, participants remotely self-administer the intervention on their home computer. In addition to feasibility and compliance measures, clinical and experimental cognitive measures as well as MRI scan data are collected pre-intervention and post-intervention to determine behavioural and neural efficacy.Ethics and dissemination Ethics approval has been obtained from ethics boards at the University Health Network and University of Toronto. Findings will be presented at academic conferences and submitted to peer-reviewed journals.Trial registration number Version 3, ClinicalTrials.gov Registry (NCT04331392)

An Examination of the Multi-Faceted Motivation System in Healthy Young Adults

Background: Amotivation is a prevalent symptom in schizophrenia (SZ) and depression (MDD), and is linked to poor functional outcomes in affected individuals. Conceptualizations of motivation have outlined a multi-faceted construct comprised of reward responsiveness, reward expectancy, reward valuation, effort valuation, and action selection/preference-based decision making. To date, findings from studies utilizing variable-centered approaches to examining isolated facets of motivation in SZ and MDD have been inconsistent. Thus, the present study adopted a person-centered approach, and comprehensively examined the reward system in a non-clinical sample in an attempt to explore potential subtypes of motivation impairments, while minimizing the effects of illness-related confounds.Methods: Ninety-six healthy undergraduate students were evaluated for amotivation, schizotypal traits, depressive symptoms, and cognition, and administered objective computerized tasks to measure the different facets of motivation. Cluster analysis was performed to explore subgroups of individuals based on similar motivation task performance. Additionally, correlational analyses were conducted in order to examine inter-relationships between motivation facets, and relations between clinical measures and facets of motivation.Results: Cluster analysis identified two subgroups of individuals with differential motivation performance profiles. Correlational analyses revealed that reward responsiveness was associated with amotivation, depressive symptoms, and negative schizotypy. Further, significant inter-correlations were found between reward responsiveness and reward expectancy, as well as between reward valuation and effort valuation.Conclusions: Our results mark important steps forward in understanding motivation in a non-clinical sample, and guide future dimensional and comprehensive analyses of the multi-faceted reward system. It remains to be seen whether these patterns of results will be similar in clinical populations such as SZ and MDD