Jan Stubberud: Kognitiv rehabilitering og kognitiv trening

Kogni'vrehabiliteringogkogni'v
trening-fraforskning'lkliniskpraksis
Psykologikongressen2016
Jan Stubberud, spesialist i klinisk nevropsykologi, phd.
Jan Egil Nordvik, psykolog, phd.
Toril Ueland, spesialist i klinisk nevropsykologi, phd.
Evidensbasert kognitiv rehabilitering
– med et særlig fokus på hjernens
kontrollfunksjoner
Spes. i klinisk nevropsykologi/ph.d. Jan Stubberud
Nevropsykologiskpoliklinikk–LovisenbergDiakonaleSykehus,LDPS
Kogni:vesvik;egnharbetydeligekonsekvenserforetfunksjoneltuavhengig
livformangemennesker.Øktkunnskapomhjernensplas:sitetbidrar:len
økendeinteresseforåutviklenymetodikkmedsiktemålåtrene/rehabilitere
hjernefunksjoner(kognisjon)
Kognisjon
•  Kognisjonerdeprosessersomgjøratsanseinntrykkblir:l
meningsfullementaleopplevelserogerfaringer
•  Handleromåbearbeide,forståogfortolkevirkeligheten
•  Etindividskogni:vefunksjonerbådeetresultatavden
enkeltesevne:låtainn-,ognyLggjøresegsanseinntrykk
Vesentligevansker=kogni:vsvikt
Kogni:vsvikt
•  Nårkogni:vfungeringsvikterinnenforetellerflere
funksjonsområderslikatmanfårvanskerrelatert:l....
ü 
ü 
ü 
ü 
ü 
ü 
ü 
ü 
ü 
Sansningog/ellerfortolkningavsanseinntrykk
Hukommelseog/ellerlæring
Bearbeidingavinformasjon
Oppmerksomhet/konsentrasjon
Mentaleffek:vitet
PlanleggingogorganiseringavaUerd
Språkogkommunikasjon
PlanleggingoguUøringavprak:skeoppgaver
Emosjonellregulering
Definisjonkogni:vrehabilitering/kogni:v
trening(cogni:veremedia:on)
”Kogni&vrehabiliteringerenprosesshvormenneskermedhjerneskaderarbeider
sammenmedhelsepersonellforåbedreellerle8ekogni&veproblemerforårsaket
avnevrologiskeinsultellerskader”(Wilson,Gracey,Evans,&Bateman,2009)
“AUerdsbaserttreningsomharsommålåbedrekogni:veprosesser/funksjoner
(dvs.oppmerksomhet,hukommelse,ekseku:vefunksjoner,sosialkognisjonog
metakognisjon)medsiktemålomvarighetoggeneralisering”(Cogni:ve
Remedia:onExpertsWorkshop,2010)
Li;historie
•  2.verdenskrigLuria(Sovjet)ogZangwill(UK)behandlet
soldatermedhjerneskader
•  Beggejobbetutifraetbærendeprinsipp:funksjonell
:lpasning,dvs.,hvorvedenintaktfunksjonblirbrukt:lå
kompensereforenskadeten
•  Ben-YishayogDilleriN.Y.på70-tallet,førstebeskrevne
”kogni:verehabiliteringsprogram”(RUSK),A-L.Christensen
(1985)København,Sunnaas(KReSS)90-tallet
•  Wilson(2008)nyeperspek:ver:MålseLngibehandlingen,
anerkjennelseavatkogni:ve,emosjonelle,ogpsykososiale
vanskermåadresseres,øktbrukavteknologifor
kompensering,behovforbedreteore:skrammeivårtarbeid
•  Kogni:vrehabiliteringkanforegåpåmangenivåer,medsiktemålå
hjelpefolkihverdagen
Detkanomfa=e:
ü  Opplæringavspesifikkekogni:veferdigheter
ü  Utviklekompenserendestrategier
ü  Endringarbeidet/hjemmesituasjon/skolemiljøetforå:lre;eleggeen
gi;oppgavesomskaloppnås:ltrossfornedse;elsen
ü  Hjelpepersonermedfølelsesmessig:lpasning
Toli;ulike:lnærminger:lkogni:vrehabilitering:
•  Goldstein(1918):oppta;avkogni:ve/aUerdsmessigefølgeravhjerneskade,og
diskuterte:“restorelostfunc&oningortocompensateforlostorimpaired
func&ons”
• Kogni'vgjentrening(restore)
– Drillingogøvelser
– Læreåmestrekogni:vevanskermedtreninggjennomøvelseogs:mulering
(mentalmuskel),onetreningpåpc
• Kompensatorisk
– Indreogytrestrategier
Cogni:verehabilita:onmanual
Transla:ngevidence-basedrecommena:onsintoprac:ce
• 
• 
• 
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• 
• 
Hovedforfa;er:EdmundCHaskins
Medforfa;ere:
KeithCicerone
KristenDams-O´Connor
RebeccaEberle
DonnaLangebahn
AmyShapiro-Rosenbaum
Redaktør:LanceE.Trexler
•  ACRM–AmericanCongressofRehabilita:onMedicine
•  BI-ISIG:BrainInjury-InterdisciplinarySpecialInterestGroup2012
Monitoreringavfremdrinikogni:vrehabilitering
Detanbefalesatpasientensfremdrinsystema:sknoteresnedforåholdefokuspå
behandlingsmål(ene).Totommelfingerregler:
• Lageendetaljertoversiktoverpasientensprestasjoner(bådedethan/hunfår:l,ogikke
får:l)påspesifikkeoppgaverover:d.Hensiktenmedålageenslikoversiktmedobjek:ve
dataeråhjelpebehandlerogpasient:låiden:fiserefaktorersomfremmerellerhemmer
fremskri;
• Holdefokuspå”detstorebildet”.Kogni:vrehabiliteringeroneenlangoguUordrende
prosess,ogimange:lfellerkandetværevanskeligforpasientenåseegenfremdrin.Detå
loggføre/journalførepasientensfremgang,ognoterenedogiden:fiseremilepæleri
behandlingenkanværemedpååskapeop:misme,mo:vasjonoghåp
Faktorersomkanpåvirkebehandlingen
ü 
ü 
ü 
ü 
ü 
ü 
Innsikt
Tidsidenskade/sykdom/lidelse
Omfangavskaden/sykdom
Premorbidfunksjon
Følelsesmessigereaksjoner
Familie/ne;verk
Arbeidsskjema: GOAL - PLAN - DO - REVIEW
Fra Cognitive Rehabilitation Manual: Translating Evidence-Based Recommendations into Practice av Haskins
Shapiro-Rosenbaum, Dams-O'Connor, Eberle, Cicerone, og Langenbahn (2012).
Oversatt til norsk av Anne-Margrethe Linnestad (2014)
MÅL
Hva ønsker jeg å oppnå?
PLAN:
Hvordan skal jeg fullføre målene mine?
Materialer/utstyr
1.
2.
3.
4.
5.
Trinn/oppgaver
1.
2.
3.
4.
5.
FORVENTNING:
Hvor bra kommer jeg til å gjøre det? Hvor mye kommer jeg til å få gjennomført?
___________________________________________________________________________
___________________________________________________________________________
GJENNOMFØRING:
Hvilke hindre ser jeg?
1.
2.
3.
EVALUERING:
Hvordan gjennomførte jeg det?
HVA FUNGERTE?
1.
2.
3.
Hvilke løsninger ser jeg?
1.
2.
3.
EGEN EVALUERING
1 2 3 4 5 6 7 8 9 10
KOMPARENT EVALUERING (eks. pårørende)
1 2 3 4 5 6 7 8 9 10
HVA FUNGERTE IKKE?
1.
2.
3.
HVA VIL JEG GJØRE ANNERLEDES NESTE GANG?
___________________________________________________________________________
___________________________________________________________________________
Forenklet arbeidsskjema: GOAL - PLAN - DO - REVIEW
Fra Cognitive Rehabilitation Manual: Translating Evidence-Based Recommendations into Practice av Haskins
Shapiro-Rosenbaum, Dams-O'Connor, Eberle, Cicerone, og Langenbahn (2012).
Oversatt til norsk av Jan Stubberud (2014)
MÅL: Hva er det jeg skal oppnå? Hva er målet?
PLAN: Hvordan skal jeg oppnå målet? Sett opp stegene.
GJENNOMFØRING: Gjennomfør planen.
EVALUER: Hvordan gikk det? Hva fungerte? Hva fungerte ikke?
Tippe – Gjøre prosedyre (”Predict - Perform Procedure”)
Goverover, Y., Johnston, M., Toglia, J. og Deluca, J. (2007). Treatment to improve self-awareness in persons
with acquired brain injury. Brain Injury, 21, 913-923.
Til norsk ved Jan Stubberud (2014)
1. Terapeuten introduserer en oppgave. Dette kan være en papir-penn oppgave eller det kan
være en reell eller simulert ADL- oppgave, for eksempel lage matpakke, betale
telefonregning, avtale en legetime, etc.
2. Pasienten blir deretter bedt om å:
a. Definere målene i oppgaven (for eks. matpakken skal inneholde to brødskiver med to ulike
pålegg, maten skal pakkes inn i matpapir, oppgaven vil bli fullført ila. 15 minutter).
b. Tippe hvordan dette kommer til å gå (for eks. ”Grader hvor vanskelig du tror dette kommer
til å bli”)
c. Prøve å forutse og være forberedt på feil eller hindringer han/hun kan forvente å møte
under utføringen av oppgaven (for eks. "Vil denne oppgaven kreve fysisk assistanse,
påminnelser, etc.")
d. Velge en strategi for å omgå slike vansker (for eks. skriftlige instrukser, sjekkliste)
e. Vurdere mengde hjelp han/hun trenger for å lykkes med oppgaven.
3. Etter å ha tippet hvordan det kommer til å gå og gjort noen vurderinger, utfører pasienten
oppgaven.
4. Etter at oppgaven er fullført skal pasienten selv vurdere hvordan han/hun klarte seg på
oppgaven. (for eks. oppgavens vanskelighetsgrad, tid brukt på oppgaven etc.).
5. En diskusjon mellom terapeut og pasient følger der pasienten beskriver hans/hennes svar på
de ulike spørsmålene og terapeut beskriver hans/hennes observasjon ifht. de samme
spørsmålene.
6. Etter dette oppmuntres pasienten til å skrive i en journal/dagbok om erfaringen av å utføre
oppgaven.
studies to improve complex visuospatial abilities required for
functional activities (eg, driving). In the current review, one
class I study suggests limited benefit from targeting visual
attention deficits skills and the need for specific, functional
skill training to improve driving ability after stroke.18
munication. There was greater improvement in communication
effectiveness among participants who received additional communication exercises.
One class I study37 investigated the effects of semantic
versus phonologic treatment on verbal communication in 55
patients with aphasia after left hemisphere stroke. Both groups
improved on a measure of verbal communication, with no
difference between groups. Treatment-specific effects were
related to type of impairment, with semantic treatment related
to improved semantic processing and phonologic treatment
related to improvement of phonologic processing. The authors
Evidensbasertrehabiliteringavekseku:ve
Remediation of Language and Communication Skills
funksjoner
We reviewed 6 class I
or Ia studies, 3 class II stud36-40
42-44
41
45-76
and 32 class III studies
in the area of cognitiveies,
linguistic rehabilitation. As in past reviews, most of the studies
involved persons with stroke, although 4 of the class I studies
Cicerone et al., 2011
Table 6: Remediation of Executive Function Deficits
Intervention
Metacognitive strategy training (self-monitoring and self-regulation) is recommended for deficits in executive
functioning after TBI, including impairments of emotional self-regulation, and as a component of
interventions for deficits in attention, neglect, and memory.
Training in formal problem-solving strategies and their application to everyday situations and functional
activities is recommended during postacute rehabilitation after TBI.
Group-based interventions may be considered for remediation of executive and problem solving deficits
after TBI.
Level of
Recommendation
Practice Standard
Practice Guideline
Practice Option
Arch Phys Med Rehabil Vol 92, April 2011
•  Prac'ceStandard:“substan'alevidence”
•  Prac'ceGuideline:“probableeffec'veness”
•  Prac'ceOp'on:“possibleeffec'venessbutrequiresfurtherresearch”
GoalManagementTraining(GMT)
• GMTerenteoridrevenintervensjonsformforbehandlingav
ekseku:vevansker
• Opprinneligutvikletforpasientermedtrauma:skhjerneskade
• Måletmedbehandlingenerålærepersonerstrategierforå
forbedreevnen:låplanleggeak:viteterog:låstrukturere
handlinger-kompensering-generalisering:l
hverdagssituasjonererforventet
GoalManagementTraining(GMT)
• Behandlingsformenharenteore:skforankringiteorierom
vedvarendeoppmerksomhet(e.g.,Levineetal.,2011)
• Behandlingenmålre;esmotbasaleoppmerksomhetsfunksjoner
(inkludertinhibisjonogvedvarendeoppmerksomhet),somigjener
enforutsetningformerkompleksproblemløsning
• Forskningharvistatetlavtnivåavarousalkanmedførenedsa;
ekseku:vefunksjoner(EF).Avdennegrunninngårogså
oppmerksomhets-ogak:veringsteknikkeriGMTforåforbedreEF
STOPP!-Klargjør-Delopp
STOPP!
“Hva
gjør
jeg?”
Sjekk!
NorwegianversionStubberud,J.(2010)
©2012BaycrestCentreforGeriatricCare
InnholdGMT
•  Ihovedsakgruppebasert
•  7(9)modulera2-3:mer(hvermodulinneholderspesifikke
temaellerområder)
•  Mentaltverksted
•  Hjemmeoppgaver
•  GMTstyresfraPowerpoint,ledsagetavnotater(manualisert)
present-mindedness is introduced as a contrast to absentmindedness.
mindedness is introduced and assigned as homework.
sessions. They are also asked to continue recording the slips they make AHomework
mindfulnessassignments:
(“present-mindedness”)
exercise is used to illustrate
Expanded absentmindedness
and
and also any successes, as well as the longer “Breathing Exercise.”
present-mindedness.
Participants
are
instructed
to apply
this technique
present-mindedness monitoring worksheets,
“Breathing
MODULE 4: STOP THE AUTOMATIC PILOT
xvi to
everyday activities.
Exercise”
SUMMARY OF MODULES
Concept:
toYOUR
stop the
automatic pilot
MODULETraining
6: STATE
GOAL
A new task designed to elicit absentminded slips, a Card Dealing Task,
Tasks:
Clapping
Task,
Card
Dealing
Task,
and
“Breath
Focus”
–
MODULE
2: ABSENTMINDED
The construct of SLIP-UPS
the automatic pilot is explained. The
“Breath Focus”
exercise.
are also required
to create
in is introduced.
Concept:
Goal loss
and They
reinstatement
(STATING
your subgoals
goal)
MODULE
1: THE ABSENT MIND, THE PRESENT MIND
using
STOPPING
automatic
pilot
is
useful
for
many
tasks, butto
can
lead abilities,
to errors if it is
order toComplex
STOP each
element
Tasks:
Task
I & II of the Complex Task in order to maximize Concepts: Relation of absentmindedness
other
Homework
assignments:
Continue
slips
chart,
daily
STOPPING
followed
blindly.
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examples
(e.g.
football
player
wrong
Concepts:
Introduction
of
goal
hierarchies,
the
mental
points. The notion of indecision is introduced through an illustrative consequences of slips, conditions for slips, how GMTruns
will in
reduce
Homework
assignments:
30 min practicing STOP!-STATE
(using
chart),
“Breath
Focus”
direction
and
scores
for
other
team)
are
used
to
illustrate
this
point.
In
laboratory,
absentmindedness,
and
present-mindedness
example. To solve the problem of indecision, participants are encourcycle, continue with longer “Breathing Exercise” and “Slips and slips
the
homework
assignment,
participants
are
instructed
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focus
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aged
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use the
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accept that
there
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cons,asbe xv
Tasks:
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exercise
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concept
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automatic
pilot iscycle,
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previous
weeks’
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chart
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situations that give rise to slips. Present-mindedness is reframed as opdecisive
(just
do
it!),
and
love
their
decision.
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between-session
assignments
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reviewed and discussed.
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of STOPPING
Homework
Absentmindedness
present- the Homework assignments: Expanded absentmindedness
posite to automatic pilot. A “Breathing Exercise” to increase presentThe
complex
tasks
are multitasking
exercisesor
designed
to evoke
attensignments
include
bringing
a pad,
organizer,
day
planner
for
To-Do
xiv monitoring worksheets, practicing the “Body Scan” exercise
automatic
pilot
is introduced
and discussed.
The
automatic
pilot
can
mindedness
monitoring
worksheets
tional
errors
in which
goalcontinue
attainment
is sidetracked.
The
tasksand
consist
lists for
the
next
session,
practicing
STOP!-STATE,
the mindedness is introduced and assigned as homework.
either
be
stopped
through
other people
(i.e. someone
saying
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to bring attention to the present, and to purposely direct attention to
Absentmindedness
is
illustrated
by
an
example
with
absentminded
of
5 elements
that cannot
be
completed
theTrainer’s
time allotted,
there“Breathing
Exercise,”
and Management
completing
theinCatalogue
Task
from
the A more in-depth discussion of absentmindedness includes its relation
Goal
Training
Manual
xvi
are
you doing?”)
or interruptions
(i.e. phone
ringing).
Participants
are
the primary goal. This technique builds on the strengths developed
Professor
Norbert
Fertwinkle,
who
gets distracted
when are
trying
to buy
tidyto other abilities (such as intelligence) and how it varies across and
fore
requiring
advanced
time
management
skills.
They
designed
workbook.
The
Catalogue
Task
involves
deciding
which
gifts
to
MODULE
3: THEtoAUTOMATIC
PILOT
then encouraged
make a habit out
of stopping to check whether the MODULE
through prior
practice
of AUTOMATIC
the breathing exercises.
4: STOP
THE
PILOT Participants are enhisengage
room for
electrician.
Different
types
of goals
are discussed,
ran-within individuals. Participants discuss their absentminded slips that
to
the the
automatic
pilotscenario
and induce
slips
of intention.
Following
for
individuals
a fictional
with
several
constraints
(e.g.
Ted
automatic
pilot in
is doing
the right
thing.
Participants
practice this
techcouraged to practice the STOP!-FOCUS-CHECK technique in daily
Concept:
automatic
pilot
how
it of
leads
to errors
gingMonica
fromThe
simple
(e.g.
buying
aand
sandwich)
to STATING
complex
(e.g.
Concept:
Training
to
stop
the
automatic
pilot
completion
of the
complex
task,
the
notion
one’splanning
goal
and
got
married
and
have
requested
kitchen
items)
and is
“Breath
Focus”
exercise.
They
are
also required
to
create
subgoals
in
inwith
between
sessions,
and
discuss
consequences
of
these
nique
with thejust
Clapping
and Card
Dealing
Tasks. For
homework,
par-a occurred
life along
the
“Breathing
Exercise”
tothe
help
them
focus.
They
are
a
holiday).
The
different
causes
of
absentmindedness
are
explained.
introduced
as an aidTask
to reducing these slips. This occurs after check- and
fixed Card
budget.
Task:
Dealing
Tasks:
Clapping
Task,
Card
Dealing
Task,
and
“Breath
Focus”
–
order
to
STOP
each
element
of
the
Complex
Task
in
order
to
maximize
other
slips,
such
as
airline
disasters.
The
conditions
under
which
ticipants practice STOPPING for 30 min per day during activities and requested to fill the “STOP!-FOCUS-CHECK” chart, recording the
A challenging
mental
laboratory
task
is introduced
that
requires
the points.
ing
the mental
blackboard
in order
to absentmindedness
refresh
working
memory
with
using
STOPPING
The
indecision
is introduced
through
illustrative
areactivity,
morenotion
orand
lessof
likely
toofoccur
are
reviewed.
The Clapping
Task
Homework
assignments:
Expanded
and
record this on
the “Daily Stopping”
chart. A briefer “Breath
Focus” slips
date,
number
stops
and
checks
they
doanbetween
the
participants
to
focus
their
attention
on a through
specific goal.
The task
is the
de-isexample.
the
goal
that
may
have
been
sidetracked
distraction
and
To
solve
the
problem
of
indecision,
participants
are
encourrepeated.
The
elements
of
GMT
are
previewed.
The
homework
aspresent-mindedness
monitoring
worksheets,
exercise
is introduced
to
encourage
time-outs
in “Breathing
daily life to suspend Homework
sessions. They
are also askedContinue
to continue
recording
the slips
they make
assignments:
slips
chart, daily
STOPPING
MODULE
8: SPLITTING
TASKS INTO
SUBTASKS
signed to elicit
slips
and is used
to generate
discussionsignment
automatic
pilot. absentminded
Participants are
encouraged
to use
the STOP!-STATE
aged
to chart),
use
the
STOP!-STATE
cycle,
that
there
will
be cons,of
be
of
tracking
slipsas
iswell
expanded
to include
the consequences
Exercise”
the automatic pilot and quickly re-focus their attention.
and also
any
successes,
as theaccept
longer
“Breathing
Exercise.”
(using
“Breath
Focus”
about
the
role
of
attention
(as
opposed
to
basic
abilities
or
memory)
cycle
in
which
they
would
use
the
“Breath
Focus”
to
bring
their
minds slips.
Concept: Dealing with overwhelming tasks by splitting them
decisive
doScan”
it!), and
love their
decision.is The
between-session
asThe(just
“Body
meditation
technique
introduced
as a method
Aback
task
designed
elicit
absentminded
a Card
Dealing Task,
innew
task
performance.
The
participants
thenslips,
volunteer
examples
of
ab-to
into
the
presenttoand
restate
their goal.
Once
this technique
is exThe
concept
of automatic
pilot
is reintroduced;
the
weeks’
asinto
smaller
tasks
signments
include
bringing
a pad,
organizer,
or and
dayprevious
planner
for
To-Do
focus
attention,
along with
its
instructions
an
assignment
to
is
introduced.
The
construct
of
the
automatic
pilot
is
explained.
The
sentmindedness
from
their
own
lives.
They
are
given
instructions
onpractice
MODULE
5:
THE
MENTAL
BLACKBOARD
plained
and
discussed,
participants
are
requested
to
do
the
“Breathing
MODULE
6:
STATE
YOUR
GOALpracticing
signments
reviewed
and
discussed.
The concept
of STOPPING
the
lists
forthis
theare
next
session,
continue
STOP!-STATE,
and the
daily.
Tasks: Splitting task, Bookkeeping Task, Catalogue Tasks II and III
automatic
pilot
is useful
for many
tasks,state.
but
can
leadare
tothen
errors
ifwell
it is
how to raise
their
awareness
to everyday
absentmindedness,
as
as “Breathing
Exercise”
to achieve
a present-minded
They
asked
to
automatic pilot
is introduced
and discussed.
The automatic
pilot can
Exercise,”
andreinstatement
completing
the(STATING
Catalogue
Taskgoal)
from
the
Concept:
Mental
blackboard
Homework
assignments:
STOP!-STATE-SPLIT
chart,
“Breathing
Concept: Goal
loss and
your
followed
blindly.
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MODULE
MAKING memory.
DECISIONS
working
or7:short-term
The mental blackboard has limited MODULE
The complex tasks are multitasking
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plex
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MODULE
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they are
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MENTAL
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using
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STATE
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ies.
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Participants
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then
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plained
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requested
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either
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people
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someone
saying
occurred
in between
and
discuss
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minds
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working
or short-term memory.
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doing?”)
interruptions
(i.e. phone
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are
facilitates
appropriate
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STATING.
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and
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and they
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GMTharoppnåddsværtlovenderesultateribehandlingen
avekseku:vdysfunksjoniforskjelligepasientgrupper:
–  Ervervethjerneskade(Levineetal.,2000;2011,Chenetal.,2011;Fishetal.,
2007;Grantetal.,2012;McPherson,etal.,2009;Novakovic-Agopianetal.,
2011;Tornåsetal.,2016;Stubberudetal.,2015)
–  Friskeeldre(Levineetal.,2007,VanHooren,2007)
–  Rusmiddelavhengighet(Alfonsoetal.,2011)
–  Traumepasienter(Jacksonetal.,2011)
–  Ryggmargsbrokk(Stubberudetal,2013;2014;2015)
–  Schizofreni(Levauxetal.,2012)–RCTiNorge(Hovedveileder:MereteØie;
UiO)
–  ADHD(IndeBraeketal.,2012)–RCTiNorge(Hovedveileder:LinSørensen,
s>pendiat:DanielJensen;UiB)
–  Casestudieravpasientermedlillehjerneskade(Schweizeretal.,2008),
hjernesvulst(Metzler-BaddeleyogJones,2010)
–  Barneversjonpilothjerneskade(pGMT:Stubberudetal.,2015)
Journal of the International Neuropsychological Society (2016), 21, 1–17.
Copyright © INS. Published by Cambridge University Press, 2016.
doi:10.1017/S1355617715001344
Rehabilitation of Executive Functions in Patients with Chronic
Acquired Brain Injury with Goal Management Training, External
Cuing, and Emotional Regulation: A Randomized Controlled Trial
Sveinung Tornås,1 Marianne Løvstad,1,2 Anne-Kristin Solbakk,3,4 Jonathan Evans,5 Tor Endestad,2 Per Kristian Hol,6,7
Anne-Kristine Schanke,1,2 AND Jan Stubberud1
1
Sunnaas Rehabilitation Hospital, Norway
Department of Psychology, University of Oslo, Norway
Department of Neurosurgery, Division of Surgery and Clinical Neuroscience, Oslo University Hospital – Rikshospitalet, Norway
4
Department of Neuropsychology, Helgeland Hospital, Mosjøen, Norway
5
Department of Mental Health and Wellbeing, Institute of Health & Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, Scotland,
United Kingdom
6
The Intervention Center, Oslo University Hospital – Rikshospitalet, Norway
7
Institute of Clinical Medicine, University of Oslo, Norway
2
3
(RECEIVED August 20, 2015; FINAL REVISION December 4, 2015; ACCEPTED December 7, 2015)
Abstract
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 TrainingTM (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. (JINS, 2016, 21, 1–17)
Keywords: Cognitive rehabilitation, Goal management, Executive functioning, Brain injury, Evidence based, Randomized
controlled trail
INTRODUCTION
Executive 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
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).
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Archives of Physical Medicine and Rehabilitation
journal homepage: www.archives-pmr.org
Archives of Physical Medicine and Rehabilitation 2016;-:-------
ORIGINAL RESEARCH
Goal Management Training Combined With External
Cuing as a Means to Improve Emotional Regulation,
Psychological Functioning, and Quality of Life in
Patients With Acquired Brain Injury: A Randomized
Controlled Trial
Q29
Q2
Q3
Sveinung Tornås, Cand Psychol,a Marianne Løvstad, PhD,a,b
Anne-Kristin Solbakk, PhD,b,c,d Anne-Kristine Schanke, PhD,a,b Jan Stubberud, PhDa
From aSunnaas Rehabilitation Hospital, Nesodden; bDepartment of Psychology, University of Oslo, Oslo; cDivision of Surgery and Clinical
Neuroscience, Department of Neurosurgery, Oslo University HospitaleRikshospitalet, Oslo; and dDepartment of Neuropsychology, Helgeland
Hospital, Mosjøen, Norway.
Abstract
Objective: To investigate whether goal management training (GMT) expanded to include external cuing and an emotional regulation module is
associated with improved emotional regulation, psychological functioning, and quality of life after chronic acquired brain injury (ABI).
Design: Randomized controlled trial with blinded outcome assessment at baseline, posttraining, and 6-month follow-up.
Setting: Outpatient.
Participants: Persons with ABI and executive dysfunction (NZ70; 64% traumatic brain injury; 52% men; mean age ! SD, 43!13y; mean time
since injury ! SD, 8.1!9.4y).
Intervention: Eight sessions of GMT in groups, including a new module addressing emotional regulation, and external cuing. A psychoeducative
control condition (Brain Health Workshop) was matched on amount of training, therapist contact, and homework.
Main Outcome Measures: Emotional regulation was assessed with the Brain Injury Rehabilitation Trust Regulation of Emotions Questionnaire,
the Emotional Control subscale and the Emotion Regulation factor (Behavior Rating Inventory of Executive FunctioneAdult Version), and the
Positive and Negative Affect subscales from the Dysexecutive Questionnaire. Secondary outcome measures included psychological distress
(Hopkins Symptom Checklist-25) and quality of life (Quality of Life After Brain Injury Scale).
Results: Findings indicated beneficial effects of GMT on emotional regulation skills in everyday life and in quality of life 6 months
posttreatment. No intervention effects on measures of psychological distress were registered.
Conclusions: GMT is a promising intervention for improving emotional regulation after ABI, even in the chronic phase. More research using
objective measures of emotional regulation is needed to investigate the efficacy of this type of training.
Archives of Physical Medicine and Rehabilitation 2016;-:------ª 2016 by the American Congress of Rehabilitation Medicine
Executive functions (EFs) help formulate goals, initiate goaldirected behavior, anticipate consequences, and organize, monitor,
and adapt behavior1-4 through top-down control of cognition,
Supported by the Norwegian Extra Foundation for Health and Rehabilitation through EXTRA
funds (grant no. 2011/2/0204).
Clinical Trial Registration No.: NCT02692352.
Disclosures: none.
emotion, and motivation.5,6 Executive dysfunction (ED) can have
a profound negative impact on everyday functioning,7,8 community integration, vocational functioning, and goal attainment.9-12
Impaired emotional regulation plays a central role in ED.13,14
Emotional regulation involves the initiation, inhibition, and/or
modulation of experience, as well as the expression and direction
of emotions.15,16 Emotional dysregulation can be a primary
symptom of injury as a result of neuropathologic processes, can
0003-9993/16/$36 - see front matter ª 2016 by the American Congress of Rehabilitation Medicine
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ń
ń
Ɲ
Ɲ
Ƒ
õ
Ƒ
õ
ï
ï
Resultater
•  Ethovedfunnvarensignifikantforbedringavoppmerksomhetskontroll
(vedvarendeoppmerksomhetoginhibitoriskkontroll)e;erGMT
•  Oppmerksomhetskontrollharstorbetydningforevnen:låplanleggeog
strukturereoppgaverogdagligegjøremål
•  EnuUordringeråoppnågeneraliseringseffekter;simulerthverdagsoppgave
•  FlerefunnpåmålsomomhandlerEFihverdagen(spørreskjema),
oppre;holdtved6mndoppfølging–generalisering
•  Behandlingseffekterforpsykiskhelse;psykiskeplager(angstogdepresjon)og
emosjonsregulering
Konklusjon
•  Viseratdemestsammensa;eogkompleksekogni:vefunksjonene,
mestringogpsykiskhelsekanbedresvedhjelpavetstrukturertogmålre;et
behandlingsprogram,ogsåhospersonermedmedfødtevansker
•  Allehovedfunnvedvarte6månedere=eravslu=ettrening.Detkanbetyat
deinnlærtestrategieneharbli;automa:sertoggeneraliserti:dene;er
intervensjonen
•  Studienerdenførsteisi;slaginternasjonalt,ogkanhapotensiellny;everdi
forandrealders-ogdiagnosegruppermedsviktiekseku:vefunksjoner
S. Tornås et al.
Hjerneskadestudie
Patients with acquired brain injury (age 18-67)
requested to participate (n= 178)
Responded and assessed for
eligibility (n= 90)
Enrollment
Excluded (n= 20)
- Not meeting inclusion criteria (n= 6)
- Declined to participate due to
practical reasons (n= 14)
Randomized (n= 70)
Allocation
Allocated to intervention (GMT) (n= 33)
- Received allocated intervention (n= 31)
- Did not receive allocated intervention (pregnancy
1, personal reasons 1) (n= 2)
Follow-Up
Lost to follow-up (n= 0)
Discontinued intervention (n= 0)
Analysis
Analysed (n= 31)
Excluded from analysis (n= 0)
Allocated to control (BHW) (n= 37)
- Received allocated intervention (n= 36)
- Did not receive allocated intervention (personal
reasons 1) (n= 1)
Lost to follow-up (n= 0)
Discontinued intervention (n= 0)
Analysed (n= 36)
Excluded from analysis (n= 0)
gram.
nd External Cuing
Powerpoint
slides
and
participant
workbooks.
Minor
translation and adaptation of Levine and colleagues’ (2011)
protocol, administered following a script with accompanying
personal communication with Dr. Levine. Participants received
the same amount of training, support from trainer, and
Table 1. Demographic and brain injury characteristics of the participants
Age, mean ± SD
Gender, M = men, F = female (%)
Education, years ± SD
Time since injury, months ± SD
Injury etiology n (%)
TBI
Stroke
Tumor
Anoxic
Other
Vocational status n (%)
Work (full-,part time)
Voc rehab/sick leave
Student
Disabled
Relationship status n (%)
Married
Partner
Single
Divorced
Girl/boyfriend
GMT (n = 33)
BHW (n = 37)
Total (n = 70)
Significance
42.12 (13.72)
19 M (57.6), 14 F (42,4)
13.23 (2.54)
106.94 (126.82)
43.57 (12.39)
19 M (51.4), 18 F (48.6)
13.55 (2.36)
81.46 (98.08)
42.89 (12.96)
38 M (54.3), 32 F (45.7)
13.4 (2.43)
97.47 (112.44)
.64
.60
.58
.35
.28
23 (32.9)
6 (8.6)
2 (2.9)
0 (0)
2 (2.9)
22 (31.4)
9 (12.9)
4 (5.7)
2 (2.9)
0 (0)
45 (64.3)
15 (21.5)
6 (8.6)
2 (2.9)
2 (2.9)
.12
8 (11.4)
12 (17.1)
5 (7.1)
8 (11.4)
5 (7.1)
16 (22.9)
1 (1.4)
15 (21.4)
13 (18.5)
28 (40)
6 (8.5)
23 (32.8)
.95
14 (20)
6 (8.6)
9 (12.9)
2 (2.9)
2 (2.9)
14 (20)
5 (7.1)
12 (17.1)
3 (4.3)
3 (4.3)
28 (40)
11 (15.7)
21 (30)
5 (7.1)
5 (7.1)
Note. Percentage totals may not add to 100% due to rounding.
GMT = Goal Management Training; BHW = Brain Health Workshop; Voc rehab = Vocational vocational rehabilitation.
“Pa&entsreceivingGMTshowedsignificantimprovement
inself-reportedcogni>veEFandemo>onalregula>on
indailylife,withthegreatestimprovementsevident
aEer6months....Therewasatendencytowardimproved
performanceona8en&ondemandingtasksforGMT,
witherrorreduc&onindica&ngimprovedexecu>ve
aNen>on.”
Kogni'vesvik=egndepresjon
•  Blantkjernesymptomerinkl.idiagnos:skekriteria(Major
DepressiveDisorder:MDD)1
•  >30%avpasientersomellersrespondererpåan:depressiva
rapporterkogni:vevansker(glemsel,uoppmerksomhet,
redusertmentalprosessering,apa:,ogordle:ngsvansker)2
•  Prevalens:
–  VoksnemedMDD:30%-40%1
–  MDDpasienter>65år:50%-60%2
1.PoleLS,etal.JAffectDisord.2014;156:144-149.2.FavaM,etal.JClinPsychiatry.2006;67:1754-1759.
Hvordanserdetutfordesomrespondererpå
an:depressivamenikkeblirheltbra?Restsymptomer
Andelavrespondentersomhaddesymptomervedbaselinesomvedvarte*
81.6
Søvnvanskerna=
Tristhet
Konsentrasjon/Beslutningstak.
Energi
Rastløshet
Hypersomni
Innsovningsvansker
Generellinteresse
Søvnløshetmorgen
Nega'vtselvbilde
Nedstemthet
Vektøkning
Redusertape'=
Øktape'=
Redusertvekt
Suicidalitet
• 
70.8
70.6
64.6
63
60.4
57.5
55
49
38.9
35.6
35.5
31
27.8
25.1
17.1
0
20
40
60
80
Prosentrapportert:resterendeprosentavdesomhaddesymptometvedbaselinesomfortsa;eåha
symptomvedavslutning.Behandlingsresponsbledefinertsom≥50%reduksjoniQIDS-SR16.
TilstedeværelseavsymptomerpåetQIDS-SR16domenepoengsum≥1.
McClintockSM,etal.JClinPsychopharmacol.2011;31:180-186.
100
Kogni'vsviktiMDD:Meta-analyse
•  Signifikantenedse;elseriekseku:vefunksjoner,
hukommelse,ogoppmerksomhet
–  700MDDpas.og700kontroller(24studier)
•  Signifikantenedse;elseriekseku:vefunksjonerog
oppmerksomhet
–  270umedisinertepas.medMDDog270kontroller(8studier)
Kogni'vevanskerrepresenteretsentraltaspektved
depresjon,ogbørikkebetraktessometsekundært
fenomensomfølgeavaffek'vesymptomer.
Behandlingenburdeogsåmålre=esmotog'lpasses
kogni'vesvik=egn.
RockPL,etal.PsycholMed.2014;44:2029-2040.
Takk for oppmerksomheten!
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