A. Krasny-Pacini

Goal Attainment Scaling in rehabilitation: A literature-based update

Goal Attainment Scaling (GAS) is a method for quantifying progress on personal goals. Turner-Stokess guide to GAS is a method for quantifying progress towards personal goals. Turner-Stokess guide and the use of Kiresuks T-score are the most widely used GAS-based approaches in rehabilitation. However, the literature describes a number of other approaches and emphasizes the need for caution when using the T-score. This article presents the literature debates on GAS, variations of GAS (in terms of the score level assigned to the patients initial status and description of the scales different levels), the precautions to be taken to produce valid GAS scales and the various ways of analyzing GAS results. Our objective is to (i) provide clinical teams with a critical view of GAS (the application of which is not limited to a single research groups practices) and (ii) present the most useful resources and guidelines on writing GAS scales. According to the literature, it appears to be preferable to set the patients initial level to -2 (even when worsening is a possible outcome) and to describe all five GAS levels in detail. The use of medians and rank tests appears to be appropriate, given the ordinal nature of GAS.

Goal Management Training for rehabilitation of executive functions: a systematic review of effectivness in patients with acquired brain injury

Abstract Purpose: To determine if Goal Management Training (GMT) is effective for the rehabilitation of executive functions following brain injury when administered alone or in combination with other interventions. Method: Systematic review, with quality appraisal specific to executive functions research and calculation of effect sizes. Results: 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. The most effective interventions appeared to be those combing GMT with: Problem Solving Therapy; personal goal setting; external cueing or prompting apply GMT to the current task; personal homework to increase patients’ commitment and training intensity; ecological and daily life training activities rather than paper-and-pencil, office-type tasks. Level of support for GMT was higher for studies measuring outcome in terms of increases in participation in everyday activities rather than on measures of executive impairment. Conclusion: Comprehensive rehabilitation programs incorporating GMT, but integrating other approaches, are effective in executive function rehabilitation following brain injury in adults. There is insufficient evidence to support use of GMT as a stand-alone intervention. Implications for Rehabilitation Goal Management Training (GMT) is a well-studied metacognitive intervention for executive dysfunction. Comprehensive rehabilitation programs relying partly on GMT and integrating other approaches are effective in executive function rehabilitation following brain injury in adults. GMT alone does not have sufficient evidence to support it as a training on its own.

Context-sensitive goal management training for everyday executive dysfunction in children after severe traumatic brain injury

Objectives:To assess the effectiveness of a metacognitive training intervention, based on an adapted Goal Management Training and Ylvisakers principles, on 3 activity domains of executive functions: (1) prospective memory (PM) performance in ecological setting, (2) complex cooking task management, and (3) daily executive functioning (EF) at home and at school. Participants:Five children aged 8 to 14 years, who were 3 to 11 years post–severe traumatic brain injury, experiencing severe EF difficulties in daily life. Design:Single-case experimental design and assessment of EF twice prior to intervention, postintervention, and 3 and 6 months postintervention. Progress was monitored by a weekly ecological PM score. The effect on EF was assessed using the Childrens Cooking Task. Transfer to the childs natural context was assessed by parental and teacher questionnaires and Goal Attainment Scaling. Results:All children improved both on the measure of PM and on questionnaires of daily EF. Two children improved on the Childrens Cooking Task but returned to their preintervention level in a novel cooking task at follow-up. Participation of school personnel and parents in the program was low. Conclusions:It is feasible but challenging to use Goal Management Training in children with traumatic brain injury. Further research is needed in relation to how to promote generalization and how to increase the involvement of the childs “everyday people” in the intervention.

Proposed Criteria for Appraising Goal Attainment Scales Used as Outcome Measures in Rehabilitation Research.

Goal Attainment Scaling (GAS) is a method for writing personalized evaluation scales to quantify progress toward defined rehabilitation goals. In the published literature, GAS methodology is used with different levels of rigor, ranging from precisely written GAS scales that ensure minimal bias and explicitly describe 5 levels of goal attainment to subjective ratings of goal attainment by adjectives (eg, worse/better than expected), which are transformed into a T score, wrongly giving the reader the impression of a truly standardized, interval scale. A drawback of GAS methodology is that it is highly dependent on the ability of the GAS setting team/person to generate valid, reliable, and meaningful scales; therefore, reliability and validity of GAS scales are idiosyncratic to each study. The aims of this article were to (1) increase awareness of potential sources of bias in GAS processes; (2) propose GAS quality appraisal criteria, allowing judgment of the quality of GAS methodology in individual rehabilitation studies; and (3) propose directions to improve GAS implementation to increase its reliability and validity as a research measurement tool. Our proposed quality appraisal criteria are based on critical appraisal of GAS literature and published GAS validity studies that have demonstrated that precision, validity, and reliability can be obtained when using GAS as an outcome measure in clinical trials. We recommend that authors using GAS report accurately how GAS methodology was used based on these criteria.

Executive function after severe childhood traumatic brain injury - Age-at-injury vulnerability periods: The TGE prospective longitudinal study.

BACKGROUND Executive function (EF) impairment is a major predictor of overall outcome after traumatic brain injury (TBI). TBI severity is a factor of poor outcome, but most studies include a majority of children with mild and moderate TBI. The aims of this study were to estimate EF impairment after severe childhood TBI and to explore factors predicting EF outcome. The secondary aim was to compare recovery trajectories by age-at-injury groups. METHODS This was a prospective longitudinal study of children with severe TBI who were tested for EFs by performance-based tests and questionnaires at 3, 12 and 24 months. RESULTS Children with TBI (n=65) showed significant impairment in working memory, inhibition, attention and global EF, with little or no recovery at 24 months. For flexibility and performance-based EF score, children were impaired at 3 months only and showed normal scores by 12 months. No impairment was found in planning. At 3 and 24 months, Glasgow Coma Scale score and parental education predicted global EF. Coma length was not a significant predictor of outcome. Age at injury predicted progress in EF, but the relationship was not linear; children 10-12 years old at injury showed better outcome than older and younger children. CONCLUSIONS EFs are impaired after severe TBI in childhood. The relationship between age at injury and outcome is not linear. Relying on only performance-based EF tests can underestimate EF impairment.

Self-awareness assessment during cognitive rehabilitation in children with acquired brain injury: a feasibility study and proposed model of child anosognosia

Abstract Purpose: To compare three ways of assessing self-awareness in children with traumatic brain injury (TBI) and to propose a model of child anosognosia. Method: Five single cases of children with severe TBI, aged 8–14, undergoing metacognitive training. Awareness was assessed using three different measures: two measures of metacognitive knowledge/intellectual awareness (a questionnaire and illustrated stories where child characters have everyday problems related to their executive dysfunction) and one measure of on-line/emergent awareness (post-task appraisal of task difficulty). Results: All three measures showed good feasibility. Analysis of awareness deficit scores indicated large variability (1–100%). Three children showed dissociated scores. Conclusions: Based on these results, we propose a model of child self-awareness and anosognosia and a framework for awareness assessment for rehabilitation purposes. The model emphasizes (1) the role of on-line error detection in the construction of autobiographical memories that allow a child to build a self-knowledge of his/her strengths and difficulties; (2) the multiple components of awareness that need to be assessed separately; (3) the implications for rehabilitation: errorless versus error-based learning, rehabilitation approaches based on metacognition, rationale for rehabilitation intervention based on child’s age and impaired awareness component, ethical and developmental consideration of confrontational methods. Implications for Rehabilitation Self-awareness has multiple components that need to be assessed separately, to better adapt cognitive rehabilitation. Using questionnaires and discrepancy scores are not sufficient to assess awareness, because it does not include on-line error detection, which can be massively impaired in children, especially those with impaired executive functions. On-line error detection is important to promote and error-based learning is useful to allow a child to build a self-knowledge of his/her strengths and difficulties, in the absence of severe episodic memory problems. Metacognitive trainings may not be appropriate for younger children who have age appropriate developmentally immature self-awareness, nor for patients with brain injury if they suffer anosognosia because of their brain injury.

Single-case experimental designs (SCEDs) to assess intervention effectiveness in rehabilitation: A practical guide.

Single-case experimental designs (SCED) are experimental designs aiming at testing the effect of an intervention using a small number of patients (typically one to three), using repeated measurements, sequential (±randomized) introduction of an intervention and method-specific data analysis, including visual analysis and specific statistics. The aim of this paper is to familiarise professionals working in different fields of rehabilitation with SCEDs and provide practical advice on how to design and implement a SCED in clinical rehabilitation practice. Research questions suitable for SCEDs and the different types of SCEDs (e.g., alternating treatment designs, introduction/withdrawal designs and multiple baseline designs) are reviewed. Practical steps in preparing a SCED design are outlined. Examples from different rehabilitation domains are provided throughout the paper. Challenging issues such as the choice of the repeated measure, assessment of generalisation, randomization, procedural fidelity, replication and generalizability of findings are discussed. Simple rules and resources for data analysis are presented. The utility of SCEDs in physical and rehabilitation medicine (PRM) are discussed.

Ecological Assessment of Everyday Executive Functioning at Home and at School Following Childhood Traumatic Brain Injury Using the Brief Questionnaire

Objectives: To describe dysexecutive symptoms in children with traumatic brain injury (TBI) using the Behavior Rating Inventory of Executive Function (BRIEF); to compare parent- and teacher-ratings, to analyze the differential impairment in the BRIEF subscales, and factors influencing outcome. Participants: Children aged 5 to 18 years 11 months, referred to a rehabilitation department following TBI. Outcome Measures: Parent- and teacher reports of the BRIEF. Results: A total of 194 patients participated in the study: mild (n = 13), moderate (n = 12), severe (n = 169); mean 4.92 (standard deviation = 3.94) years post-injury. According to parent ratings (n = 193), all BRIEF subscales and indices were significantly elevated (23.8%–48% in the clinical range). The Working Memory subscale score was significantly higher than all other subscales. Results of teacher ratings (n = 28) indicated similar significantly elevated scores in all subscales (39.3%–57.2% in the clinical range). No significant difference was found between parent and teacher ratings, which were significantly correlated. Regression analyses indicated that, in children with severe TBI, parental BRIEF overall and metacognition indices were significantly predicted by younger age at injury and older age at assessment, whereas no significant predictor of behavioral regulation index was identified. Discussion and Conclusion: This study highlights significant executive dysfunction in everyday life several years after childhood TBI, evident in home and school environments.

Ecological prospective memory assessment in children with acquired brain injury using the Children’s Cooking Task

Abstract Prospective memory (PM) has been shown to be impaired in children with acquired brain injuries (ABI) and is a major concern for parents. Few studies have addressed this issue and most used tasks that are not ecologically valid. The aims of this study were (1) to explore if children who have sustained an ABI suffer PM impairment, measured both by the Children’s Cooking task (CCT) PM score and using the 2 PM subtests of the Rivermead Behavioral Memory Test (RBMT), and (2) to explore if the CCT PM score is sensitive to developmental changes in PM in typically developing children and in children with ABI. Fifty-four children with ABI and 33 typically developing controls participated in the study. Children with ABI had significantly lower PM scores and poorer performance in the CCT than their typically developing peers. PM scores increased significantly with age, indicating developmental progress of PM performance.

Prospective memory 7 years after severe childhood traumatic brain injury – the TGE 2 prospective longitudinal study

ABSTRACT Objective: To investigate the long-term outcome in prospective memory (PM), seven years after childhood severe traumatic brain injury (TBI), in a prospective longitudinal cohort. Participants: 76 young individuals (aged 7–22 years): 39 patients with a severe accidental TBI included prospectively seven years earlier, aged 0–15 years at injury, and 37 controls individually matched on age, gender and parental education. Main outcome measures: Three novel short PM tasks varying in the delay, motivation and context (ecological versus paper and pencil task). Results: Individuals with severe TBI showed significantly poorer PM than matched controls in the two low-motivation PM tasks: (1) the ecological long-delay task consisting of sending a letter on a rainy day (p=0.047, odds ratio = 2.6); (2) the non-ecological short-delay task consisting of taking off post-its while identifying facial emotions (p=0.004, r=0.34). Differences in PM on the high motivation were not significant. PM is impaired several years post severe TBI.