James F. Malec

Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 2003 Through 2008

OBJECTIVE To update our clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 2003 through 2008. DATA SOURCES PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognitive, communication, executive, language, memory, perception, problem solving, and/or reasoning combined with each of the following terms: rehabilitation, remediation, and training for articles published between 2003 and 2008. The task force initially identified citations for 198 published articles. STUDY SELECTION One hundred forty-one articles were selected for inclusion after our initial screening. Twenty-nine studies were excluded after further detailed review. Excluded articles included 4 descriptive studies without data, 6 nontreatment studies, 7 experimental manipulations, 6 reviews, 1 single case study not related to TBI or stroke, 2 articles where the intervention was provided to caretakers, 1 article redacted by the journal, and 2 reanalyses of prior publications. We fully reviewed and evaluated 112 studies. DATA EXTRACTION Articles were assigned to 1 of 6 categories reflecting the primary area of intervention: attention; vision and visuospatial functioning; language and communication skills; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria. DATA SYNTHESIS Of the 112 studies, 14 were rated as class I, 5 as class Ia, 11 as class II, and 82 as class III. Evidence within each area of intervention was synthesized and recommendations for Practice Standards, Practice Guidelines, and Practice Options were made. CONCLUSIONS There is substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI. Evidence supports visuospatial rehabilitation after right hemisphere stroke, and interventions for aphasia and apraxia after left hemisphere stroke. Together with our prior reviews, we have evaluated a total of 370 interventions, including 65 class I or Ia studies. There is now sufficient information to support evidence-based protocols and implement empirically-supported treatments for cognitive disability after TBI and stroke.

Mayo's older americans normative studies: WAIS-R norms for ages 56 to 97

Abstract Data obtained in Mayos Older Americans Normative Studies (MOANS) provide age-specific norms for the Wechsler Adult Intelligence Scale-Revised (WAIS-R) on a sample of 512 cognitively normal persons age 56 to 97. IQ scores derived from these norms are termed “MAYO Verbal, Performance and Full Scale IQs” to differentiate them from traditional WAIS-R IQs. MAYO IQs are, by design, estimates of WAIS-R IQs. A normative procedure that adjusts both for age and also for differences between the WAIS-Rs national normative sample and this projects sample is described. The tables needed to convert WAIS-R raw scores to MAYO IQs are presented for ages 56 through 97. The assumptions that underlie the development of MAYO IQs are discussed. Concordance rates are presented which suggest that MAYO IQs are very similar to traditional WAIS-R IQs at ages where both can be validly calculated. The availability of MAYO IQs should enhance the use of the WAIS-R beyond age 74 and should also assist future research designed...

Neuropsychological tests' norms above age 55: COWAT, BNT, MAE token, WRAT-R reading, AMNART, STROOP, TMT, and JLO

Abstract Age- (> 55 years) and education-based norms are presented for eight neuropsychological tests: COWAT, BNT, MAE Token, WRAT-R Reading, AMNART, STROOP, TMT, and JLO. These data were obtained via several research projects that are known collectively as Mayos Older Americans Normative Studies (MOANS). While this normative information should prove useful for each test, the fact that these norms were simultaneously obtained from the same reference group should promote accuracy in the comparison of any persons performance on one test against his or her functioning on any other tests with MOANS norms. Finally, the unique features of this MOANS sample are reviewed. These features must be kept in mind when these norms are applied in any specific clinical or research setting.

Cognitive Rehabilitation Interventions for Executive Function: Moving from Bench to Bedside in Patients with Traumatic Brain Injury

Executive function mediated by prefrontally driven distributed networks is frequently impaired by traumatic brain injury (TBI) as a result of diffuse axonal injury and focal lesions. In addition to executive cognitive functions such as planning and working memory, the effects of TBI impact social cognition and motivation processes. To encourage application of cognitive neuroscience methods to studying recovery from TBI, associated reorganization of function, and development of interventions, this article reviews the pathophysiology of TBI, critiques currently employed methods of assessing executive function, and evaluates promising interventions that reflect advances in cognitive neuroscience. Brain imaging to identify neural mechanisms mediating executive dysfunction and response to interventions following TBI is also discussed.

Mayo's older americans normative studies: Updated AVLT norms for ages 56 to 97

Abstract Data obtained in Mayos Older Americans Normative Studies (MOANS) provide age-specific norms for Reys Auditory-Verbal Learning Test (AVLT) on a sample of 530 cognitively normal persons age 56 to 97. The information reported here updates and revises our previously published AVLT norms for the elderly. In addition to expanding the data set on whom these AVLT norms are based, this report revises the manner in which AVLT scores are summarized. Also, the methodology of converting AVLT scores to age-corrected and normalized MOANS Scaled Scores and then converting MOANS Scaled Score Sums to summary MAYO Indices (as used in related WAIS-R and WMS-R normative reports) is applied to these AVLT data. These revisions result in AVLT MOANS Scaled Scores and MAYO Auditory-Verbal Indices that are comparable to similar indices derived for the WAIS-R and the WMS-R.

The mayo high performance teamwork scale: reliability and validity for evaluating key crew resource management skills.

Purpose: To develop and evaluate a participant rating scale for assessing high performance teamwork skills in simulation medicine settings. Methods: In all, 107 participants in crisis resource management (CRM) training in a multidisciplinary medical simulation center generated 273 ratings of key CRM skills after participating in two or three simulation exercises. These data were analyzed using Rasch and traditional psychometric approaches to develop the 16-item Mayo High Performance Teamwork Scale (MHPTS). Sensitivity to change as a result CRM training was also evaluated. Results: The MHPTS showed satisfactory internal consistency and construct validity by Rasch (person reliability = 0.77; person separation = 1.85; item reliability = 0.96; item separation = 5.04) and traditional psychometric (Cronbach’s alpha = 0.85) indicators. The scale demonstrated sensitivity to change as a result of CRM training (pretraining mean = 21.44 versus first posttraining rating mean = 24.37; paired t = −4.15, P < 0.0001; first posttraining mean = 24.63 versus second posttraining mean = 26.83; paired t = −4.31 P < 0.0001). Conclusions: The MHPTS provides a brief, reliable, practical measure of CRM skills that can be used by participants in CRM training to reflect on and evaluate their performance as a team. Further evaluation of validity and appropriateness in other simulation and medical settings is desirable.

Subjective memory complaints, psychological distress, and longitudinal change in objective memory performance.

Between 1992 and 1993, the Memory Function Questionnaire General Frequency of Forgetting Scale (MFQ-GEN), the Symptom Checklist-90-Revised General Severity Index (GSI), and Mayo Cognitive Factor Scales Learning and Retention (MCFS-LRN and MCFS-RET) current and change scores were obtained for 294 of 397 (74%) participants, ages 55-97 years, originally assessed in a 1988-1990 normative study. In multiple regression modeling, the GSI and MCFS-LRN current score contributed 20% and 3%, respectively, to MFQ-GEN variance. Thus, emotional status was a better predictor of subjective memory ratings than either absolute objective memory performance or objective longitudinal memory change. Persons who developed cognitive impairment over the longitudinal interval reported greater memory problems, but memory complaints had little sensitivity in identifying these persons. In an approximate census sample of these older people, minor memory problems were reported to be frequent but not serious.

Goal Attainment Scaling in Rehabilitation

Applications, controversies, and statistical issues related to goal attainment scaling (GAS) in rehabilitation are examined on the basis of available literature and outcome data from a postacute brain injury rehabilitation programme. Prior studies suggest that GAS is a promising method for measuring progress towards the type of highly individualised goals that characterise rehabilitation. GAS appears useful for (1) monitoring progress in a time-limited epoch of care, (2) structuring team conferences, (3) planning and making decisions about ongoing rehabilitation, (4) ensuring concise, relevant communication to the client, significant others, referral source, and funding sources, (5) guiding the delivery of social reinforcement, and (6) evaluating the programme. In brain injury rehabilitation specifically, the highly structured, systematic, and concrete goal-setting process provided by GAS may be helpful in (7) encouraging more accurate self-awareness, and for (8) redeveloping the capacity for goal setting...

Mayo's older americans normative studies : WMS-R norms for Ages 56 to 94

Abstract Data obtained in Mayos Older Americans Normative Studies (MOANS) provide age-specific norms for the Wechsler Memory Scale-Revised (WMS-R) on a sample of 441 cognitively normal persons age 56 to 94. Memory Indices derived from these norms are termed “MAYO Verbal Memory (MVeMI), MAYO Visual Memory (MViMI), MAYO General Memory (MGMI), MAYO Attention/Concentration (MACI), MAYO Delayed Recall (MDRI) and MAYO Percent Retention (MPRI) Indices” to differentiate them from traditional WMS-R Memory Indices. MVeMI, MViMI, MGMI and MACI values are, by design, estimates of WMS-R Indices. Test administration and index computation differences employed in these projects prohibit extension of the WMS-R Delayed Memory Index to older ages. However, two new indices (MDRI and MPRI) are presented to serve similar purposes. Tables needed to convert WMS-R subtests raw scores to age-corrected scaled scores and to determine the summary MAYO Indices are presented for ages 56 through 94. A different methodology was used to ...

Outcome evaluation and prediction in a comprehensive-integrated post-acute outpatient brain injury rehabilitation programme

Outcomes for 29 individuals with brain injuries (BI) were examined following a comprehensive-integrated rehabilitation programme. From programme admission to completion, proportion living with no supervision increased from 59% to 93%; proportion in transitional or competitive work placements increased from 7% to 59%; unemployment decreased from 76% to 31%. Significant changes in behaviour and functional abilities and achievement of individual goals were also documented with the Portland Adaptability Inventory (PAI) and Goal Attainment Scaling. One year follow-up of 21 graduates indicated general maintenance of gains in independent living and work. At follow-up 86% were living without supervision; 48% were in competitive work; one in transitional work; and 29% unemployed. Although individuals entering treatment less than 1 year after injury showed greater gains than those injured more than 1 year prior to admission, both early and late intervention groups showed significant changes on outcome measures. More extensive disabilities as measured by the PAI had a negative impact on programme outcome. Except for reading ability, neuropsychological measures obtained prior to admission did not significantly predict outcome. Programme costs are reported. Results indicate that the group-oriented comprehensive-integrated approach to post-acute brain injury rehabilitation is effective and cost-effective, and recommend early intervention for optimal outcomes.