Goal Management Training combined with external cueing and an emotional regulation module in the chronic phase of acquired brain injury. A randomized controlled trial
Appears in the following Collection
- Psykologisk institutt 
AbstractWillful 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.
List of papers
|Paper I Tornås, S., Løvstad, M., Solbakk, A-K., Evans, J., Endestad, T., Hol, P.K., Schanke, AK. & Stubberud, J. (2016). Rehabilitation of executive functions in patients with chronic acquired brain injury with Goal Management Training, external cuing and emotional regulation: A randomized controlled trial. Journal of the International Neuropsychological Society, 21, 1–17. doi:10.1017/S1355617715001344 The paper is available in DUO: http://hdl.handle.net/10852/59210|
|Paper II Tornås, S., Løvstad, M., Solbakk, A-K., Schanke, A-K., & Stubberud, J. (2016). 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. Archives of Physical Medicine and Rehabilitation, 97, 1841-52. doi: 10.1016/j.apmr.2016.06.014 The paper is not available in DUO due to publisher restrictions. The published version is available at: https://doi.org/10.1016/j.apmr.2016.06.014|
|Paper III Tornås, S., Stubberud, J., Solbakk, A-K., Evans, J., Schanke, A-K. & Løvstad, M. (2017). Moderators, mediators, and nonspecific predictors of outcome after cognitive rehabilitation of executive functions in a randomized controlled trial. Neuropsychological Rehabilitation. Advance online publication. doi: 10.1080/09602011.2017.1338587 The paper is not available in DUO due to publisher restrictions. The published version is available at: https://doi.org/10.1080/09602011.2017.1338587|