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

Goal Management Training combined with external cueing and an emotional regulation module in the chronic phase of acquired brain injury. A randomized controlled trial

Willful control of thoughts, emotions and behavior is an intrinsically human capacity and a prerequisite for adaptive functioning. This capacity relies on complex higherorder mental processes often denoted as executive functions (EF). Executive control is called for in non-familiar situations, in performing activities involving many sub-goals, or when the circumstances change in unpredictable ways – demanding a volitional change in thinking, behavior and emotions in order to adapt. Thus, habitual responses and prior experience will not be sufficient to achieve current goals. When the ability to maintain top-down control over mental processes is impaired, the information processing systems of the brain become more inflexible and reliant on habitual responses and prior experience. In daily life, executive dysfunction (ED) is often indicated by problems with planning, strategy application, self-regulation, inhibition, goal-directed behavior, initiation of activity, regulation of emotions, and self-awareness. Such impairments may have devastating consequences for the individual’s ability to perform daily life activities and participate in society. They result in noticeable handicaps and, sometimes, dependence on others. Several brain regions contribute to executive control, but the prefrontal cortex plays a crucial role. Given the extensive connectivity between the frontal lobes and most other brain areas, ED can result from a wide range of conditions affecting normal brain functioning, and is common following acquired brain injury (ABI). Metacognitive strategy training, such as Goal Management Training (GMT), is recommended as a practise standard for rehabilitation of EF after ABI. These interventions aim at improving sustained attention and problem solving skills, through the training of verbally mediated metacognitive strategies, closely tied to the individual’s daily life activities and goals. Previous GMT studies involving patients with ABI have several limitations, particularly related to study-design and sample size, long-term effects, and lack of knowledge about predictors of outcome. The main aim of this randomized controlled trial (RCT) was to investigate the efficacy of GMT in patients with ABI in the chronic phase, compared to an active control treatment (Brain Health Workshop; BHW). Secondly, it was a goal to identify possible predictors of treatment outcome. The study included a new module addressing emotional dysregulation to investigate whether the GMT strategy could improve emotional regulation in addition to cognitive aspects of EF. Both groups also received external cueing short message service in order to facilitate goal management. The study applied a repeated-measures design across three time points; baseline, post-intervention, and six-month follow-up. Neuropsychological tests and questionnaires assessing EF, psychological distress, and QoL were administered at all three time-points. The aim of Paper I was to investigate the efficacy of GMT on cognitive aspects of EF, including attention and measures of daily life EF. Paper II aimed at evaluating the efficacy of GMT in improving emotional regulation, while Paper III explored possible predictors of outcome, in terms of cognitive EF, emotional regulation, and psychological distress. The results demonstrated that GMT combined with external cueing is effective in ameliorating self-reported ED in daily life for patients with chronic ABI. Improved performance on attention demanding cognitive tests was most prominent for the group receiving GMT, indicating improved executive attention (Paper I). Goal Management Training had beneficial effects on emotional regulation skills in everyday life, and was associated with improved QoL (Paper II). In Paper I and II, the strongest effects were seen at six-month follow-up, suggesting that the GMT strategies were applied and consolidated in everyday life after the end of training. In Paper III, the majority of the identified predictors of outcome were unspecific to the interventions, and showed how higher levels of self-reported symptoms predicted weaker treatment effects irrespective of intervention type. Age, IQ, and cognitive impairments related to verbal memory and planning ability, emerged as significant predictors in both interventions. However, inhibitory control was identified as a unique GMT-specific mediator of treatment effects. In summary, the study confirms that GMT is an efficient metacognitive training for improving EF, including emotional regulation, even many years’ post-injury. Of particular interest and in line with the theoretical underpinnings of GMT, the results support a specific improvement of cognitive inhibitory control. Still, the findings underscore that interventions targeting specific cognitive domains, such as attention or working memory (WM), also need to take into account the patients’ overall cognitive and emotional functioning in order to facilitate the best possible outcomes

Emotional regulation following acquired brain injury: Associations with executive functioning in daily life and symptoms of anxiety and depression

Objective: To examine whether a questionnaire measuring emotional regulation after acquired brain injury adds clinical information beyond what can be obtained with a comprehensive executive function questionnaire and an anxiety and depression measure. Method: Seventy adult persons (age 19–66 years, Mage = 43, SDage = 13) with acquired brain injury in the chronic phase and executive function complaints. All were recruited to participate in a randomized controlled trial (NCT02692352) evaluating the effects of cognitive rehabilitation. Traumatic brain injury was the dominant cause of injury (64%), and mean time since injury was 8 years. Emotional regulation was assessed with the Brain Injury Trust Regulation of Emotions Questionnaire (BREQ). Executive function was assessed with the Behavior Rating Inventory of Executive Function Adult Version (BRIEF-A). The Hopkins Symptom Checklist 25 (HCSL-25) was employed to measure anxiety and depression symptoms. Results: Overall, significant correlations were found between reports of emotional regulation (BREQ) and executive function in daily life (BRIEF-A). Furthermore, our analyses revealed a significant relationship between self-reported scores of emotional regulation (BREQ) and symptoms of anxiety and depression (HSCL-25). Conclusion: The significant associations between the BREQ and most of the other clinical measures indicate that, for patients with acquired brain injury, the BREQ does not add substantial information beyond what can be assessed with the BRIEF-A and the HSCL-25

A Mindfulness-Based Stress Reduction Program via Group Video Conferencing for Adults With Cerebral Palsy ? A Pilot Study

Purpose: Adults with cerebral palsy experience challenges related to lifelong disability, such as stress, fatigue, pain and emotional issues. E-health services can be delivered regardless of residence and level of functioning. The aim of this pilot study was to explore the potential benefits and feasibility of a mindfulness-based program delivered to adults with cerebral palsy via group video conferencing. Methods: Six adults with cerebral palsy received an 8 week mindfulness group-based program via video conferencing. A multiple single-case study design was applied, including quantitative and qualitative elements. Pain was assessed 16 times through the study period. Questionnaires were administered to gather data on pain catastrophizing, stress, fatigue, emotional distress, positive and negative affect, and quality of life. A focus group interview addressed experiences with the intervention and the mode of delivery. Results: The participants' pain levels showed varied trajectories. Pain catastrophizing and negative affect were statistically significant decreased. Qualitative data indicated benefits from mindfulness in coping and stress management. The video conferencing delivery was evaluated as feasible, with no major adverse effects. Conclusion: Since the pilot study had a small sample size, potential treatment benefits should be interpreted with caution. However, this pilot study provides important information in the planning of future larger and controlled studies on mindfulness-based interventions programs via video conferencing for adults with cerebral palsy and other persons living with long-term disability