Joan Toglia

Treatment to improve self-awareness in persons with acquired brain injury

Aim: To examine the effects of an awareness training protocol embedded within the practice of instrumental activities of daily living (IADLs) in participants with acquired brain injury on levels of self-awareness and functional performance. Methods: This study used a randomized control trial design: 10 participants with moderate-to-severe brain injury received six sessions of the self-awareness training while they performed IADLs (experimental group) and 10 participants performed the same IADLs but received conventional therapeutic practice (control group). In the experimental group, participants were asked to predict their performance before each task performance and to estimate their performance level after the performance. Outcome measures: Pre- and post-intervention outcome measures taken from the two groups were compared. Instruments were standardized measures of ‘general’ self-awareness with collateral reports by informants (e.g. Awareness Questionnaire); ‘task-specific’ self-awareness (e.g. Assessment of Awareness of Disability) and Self-Regulation Skills Inventory (SRSI). Performance on IADLs was assessed using the Assessment of Motor and Process Skills (AMPS). Results: Compared to the control group, the intervention significantly improved IADL performances and self-regulation. No significant treatment effect was observed for task-specific self-awareness, general self-awareness or community integration. Conclusions: The self-awareness intervention significantly but selectively improved self-awareness during IADL task performance as well as functional performance. The need for a larger study with more treatment sessions is discussed.

The Mini-Mental State Examination and Montreal Cognitive Assessment in Persons With Mild Subacute Stroke: Relationship to Functional Outcome

OBJECTIVES To compare Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) global and subscores in classifying cognitive impairment in persons with mild stroke and to explore the relationship between admission and discharge functional status and improvement. DESIGN Retrospective analysis of data. SETTING Acute rehabilitation unit of a large urban university-affiliated hospital. PARTICIPANTS Inpatients with stroke (N=72; mean age, 70y; median time poststroke, 8.5d) and mild neurologic (median National Institutes of Health Stroke Scale score, 4) and cognitive deficits (median MMSE score, 25). INTERVENTION Not applicable. MAIN OUTCOME MEASURE Admission cognitive status was assessed by using the MMSE and MoCA. The motor subscale of the FIM instrument (mFIM) and motor relative functional efficiency was used to assess discharge functional status and improvement. RESULTS The MoCA classified more persons as cognitively impaired than the MMSE (89% vs 63%, respectively; using a cutoff score of 27 on the MMSE and 26 on the MoCA). The MoCA also showed less of a ceiling effect than the MMSE, higher internal reliability (Cronbach α=.78 compared with α=.60), and marginally stronger associations with discharge functional status (r=.40; P<.001) than the MMSE (r=0.30; P<.05). The MoCA visuoexecutive subscore was the strongest predictor of functional status (P=.01) and improvement (P=.02) in global and subscores for both tests. CONCLUSIONS The MoCA may be an important cognitive screening tool for persons with stroke and mild cognitive dysfunction on an acute rehabilitation unit. Lower visuoexecutive subscores may assist in identifying persons at risk for decreased functional gains in self-care and mobility (mFIM) during inpatient rehabilitation. The findings justify further validation studies of the MoCA in persons with subacute stroke.

A multicontext approach to promoting transfer of strategy use and self regulation after brain injury: An exploratory study.

Background/aim: Persons with brain injury frequently demonstrate decreased ability to monitor and apply strategies learned in treatment to everyday situations. The aim of this study is to refine, explore and provide preliminary testing of the multicontext approach in promoting strategy use across situations and increasing self-regulation, awareness and functional performance. Methods: This study used a single-subject design with repeated measures pre- and post-intervention, with data analysed descriptively and graphically. Four persons with difficulty following multi-step directions, 3–5 years post-TBI, received a nine session intervention programme. Outcome measures included the Awareness Questionnaire, Self-Regulation Skills Interview, Behavior Rating Inventory of Executive Function, Multiple Errands Test and an Executive Function Performance Test sub-task. The process of change within each treatment session was examined with strategy and awareness ratings. Results: All participants demonstrated positive changes in self-regulatory skills and strategy use that was observed across tasks. As expected, general awareness of deficits remained unchanged. Examination of individual participants revealed important, varying patterns of change in strategy use, learning transfer and self-awareness across intervention. Conclusions: Results provide preliminary support for the feasibility and efficacy of the multicontext approach in promoting transfer of strategy use to enhance functional performance and selective aspects of awareness. Further investigation, including a larger controlled study, is needed to confirm or limit these observations.

Weekly Calendar Planning Activity (WCPA): a performance-based assessment of executive function piloted with at-risk adolescents.

OBJECTIVE We piloted the Weekly Calendar Planning Activity (WCPA), a performance-based measure of executive function (EF), to establish a baseline for at-risk adolescents. METHOD Participants were 113 youths ages 16-21 who were enrolled at a charter school for youth returning to high school after dropping out. We administered the WCPA and collected demographic information. RESULTS On average, participants spent 15.9 min on the WCPA, made 7.9 errors, and followed 4.0 of 5 possible rules. No ceiling effect was observed in overall accuracy. Participants used a mean of 3.1 strategies (standard deviation = 1.9) while completing the WCPA. Participants who used more strategies spent more time planning and completing the task and were more accurate. CONCLUSION The WCPA may be useful to occupational therapists as a performance measure of EF. This assessment allows evaluation of complex task performance, strategy use, self-evaluation of performance, and error patterns, which can be used in developing intervention strategies.

Application of the Multicontextual Approach in Promoting Learning and Transfer of Strategy Use in an Individual with TBI and Executive Dysfunction

The multicontext approach addresses strategy use and self-monitoring skills within activities and contexts that are systematically varied to facilitate transfer of learning. This article illustrates the application of the multicontext approach by presenting a case study of an adult who is 5 years post-traumatic brain injury with executive dysfunction and limited awareness. A single case study design with repeated pre-post measures was used. Methods to monitor strategy generation and specific awareness within intervention are described. Findings suggest improved functional performance and generalization of use of an external strategy despite absence of changes in general self-awareness of deficits. This case describes the multicontext intervention process and provides clinical suggestions for working with individuals with serious deficits in awareness and executive dysfunction following traumatic brain injury.

Exploring the brain's structural connectome: A quantitative stroke lesion-dysfunction mapping study

The aim of this work was to quantitatively model cross‐sectional relationships between structural connectome disruptions caused by cerebral infarction and measures of clinical performance. Imaging biomarkers of 41 ischemic stroke patients (72.0 ± 12.0 years, 20 female) were related to their baseline performance in 18 cognitive, physical and daily life activity assessments. Individual estimates of structural connectivity disruption in gray matter regions were computed using the Change in Connectivity (ChaCo) score. ChaCo scores were utilized because they can be calculated using routinely collected clinical magnetic resonance imagings. Partial Least Squares Regression (PLSR) was used to predict various acute impairment and activity measures from ChaCo scores and patient demographics. Statistical methods of cross‐validation, bootstrapping and multiple comparisons correction were implemented to minimize over‐fitting and Type I errors. Multiple linear regression models based on lesion volume and lateralization information were constructed for comparison. All models based on connectivity disruption had lower Akaike Information Criterion and almost all had better goodness‐of‐fit values (R2: 0.26–0.92) than models based on lesion characteristics (R2: 0.06–0.50). Confidence intervals of PLSR coefficients identified brain regions important in predicting each clinical assessment. Appropriate mapping of eloquent functions, that is, language and motor, and replication of results across pathologies provided validation of this method. Models of complex functions provided new insights into brain‐behavior relationships. In addition to the potential applications in prognostication and rehabilitation development, this quantitative approach provides insight into the structural networks underlying complex functions like activities of daily living and cognition. Quantitative analysis of big data will be invaluable in understanding complex brain‐behavior relationships. Hum Brain Mapp 36:2147–2160, 2015.

Structural connectome disruption at baseline predicts 6-months post-stroke outcome

In this study, models based on quantitative imaging biomarkers of post‐stroke structural connectome disruption were used to predict six‐month outcomes in various domains. Demographic information and clinical MRIs were collected from 40 ischemic stroke subjects (age: 68.1 ± 13.2 years, 17 female, NIHSS: 6.8 ± 5.6). Diffusion‐weighted images were used to create lesion masks, which were uploaded to the Network Modification (NeMo) Tool. The NeMo Tool, using only clinical MRIs, allows estimation of connectome disruption at three levels: whole brain, individual gray matter regions and between pairs of gray matter regions. Partial Least Squares Regression models were constructed for each level of connectome disruption and for each of the three six‐month outcomes: applied cognitive, basic mobility and daily activity. Models based on lesion volume were created for comparison. Cross‐validation, bootstrapping and multiple comparisons corrections were implemented to minimize over‐fitting and Type I errors. The regional disconnection model best predicted applied cognitive (R2 = 0.56) and basic mobility outcomes (R2 = 0.70), while the pairwise disconnection model best predicted the daily activity measure (R2 = 0.72). These results demonstrate that models based on connectome disruption metrics were more accurate than ones based on lesion volume and that increasing anatomical specificity of disconnection metrics does not always increase model accuracy, likely due to statistical adjustments for concomitant increases in data dimensionality. This work establishes that the NeMo Tools measures of baseline connectome disruption, acquired using only routinely collected MRI scans, can predict 6‐month post‐stroke outcomes in various functional domains including cognition, motor function and daily activities. Hum Brain Mapp, 2016.

Feasibility of a cognitive strategy training intervention for people with Parkinson’s disease

Abstract Purpose: To investigate the feasibility of a novel client-centered cognitive strategy training intervention for people with Parkinson’s disease (PD). Materials and methods: This was a case series of seven people with PD without dementia but with subjective cognitive decline. The intervention involved ≥5 treatment sessions at the participant’s home. Participant acceptance and engagement were assessed by the Credibility/Expectancy Questionnaire (CEQ), Client Satisfaction Questionnaire (CSQ), enjoyment and effort ratings, and homework completion. Logistical information was tracked, and the Canadian Occupational Performance Measure (COPM) was an exploratory outcome measure. Data analysis was descriptive. Results: CEQ scores were positive and increased over time. CSQ scores were high (M = 30.8, SD = 0.75), with all participants rating all items positively. Almost all (95%) effort and enjoyment ratings were ≥3 (Much), and homework completion rates averaged 84% (SD = 18). Intervention duration was 6–15 weeks (M = 9.2, SD = 2.8), with treatment sessions averaging 1.7 h (SD = 0.5). Group and most individual COPM ratings improved ≥2 points. Conclusions: These findings support the feasibility of the intervention for people with PD. It was acceptable, engaging, and promising in terms of its effect on self-identified functional cognitive problems. Implications for Rehabilitation People with Parkinson’s disease (PD) without dementia can experience cognitive decline that negatively impacts function and quality of life. Strategy-based interventions that explicitly train for transfer may mitigate the negative functional consequences of cognitive decline in this population. We developed a client-centered cognitive strategy training intervention for people with PD. This small case series supports its feasibility, indicating that it is acceptable and engaging for people with PD and promising in terms of its effect on self-identified functional cognitive problems.

Association Between 2 Measures of Cognitive Instrumental Activities of Daily Living and Their Relation to the Montreal Cognitive Assessment in Persons With Stroke

OBJECTIVES To explore the relation between a computer adaptive functional cognitive questionnaire and a performance-based measure of cognitive instrumental activities of daily living (C-IADL) and to determine whether the Montreal Cognitive Assessment (MoCA) at admission can identify those with C-IADL difficulties at discharge. DESIGN Prospective cohort study. SETTING Acute inpatient rehabilitation unit of an academic medical center. PARTICIPANTS Inpatients (N=148) with a diagnosis of stroke (mean age, 68y; median, 13d poststroke) who had mild cognitive and neurological deficits. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Admission cognitive status was assessed by the MoCA. C-IADL at discharge was assessed by the Executive Function Performance Test (EFPT) bill paying task and Activity Measure of Post-Acute Care (AM-PAC) Applied Cognition scale. RESULTS Greater cognitive impairment on the MoCA was associated with more assistance on the EFPT bill paying task (ρ=-.63; P<.01) and AM-PAC Applied Cognition scale (ρ=-.43; P<.01). This relation was nonsignificant for higher MoCA scores and EFPT bill paying task scores. The AM-PAC Applied Cognition scale and the EFPT bill paying task had low agreement in classifying functional performance (Cohens κ=.20). A receiver operating characteristic curve identified optimal MoCA cutoff scores of 20 and 21 for classifying EFPT bill paying task status and AM-PAC Applied Cognition scale status, respectively. For values above 20 and 21, sensitivity increased whereas specificity decreased for classifying functional deficits. Approximately one third of the participants demonstrated C-IADL deficits on at least 1 C-IADL measure at discharge despite having a MoCA score of ≥26 at admission. CONCLUSIONS Questionnaire and performance-based methods of assessment appear to yield different estimates of C-IADL. Low MoCA scores (<20) are more likely to identify those with C-IADL deficits on the EFPT bill paying task. The results suggest that C-IADL should be assessed in those who have mild or no cognitive difficulties at admission.

The diagnostic accuracy of the Montreal Cognitive Assessment in inpatient stroke rehabilitation

ABSTRACT The Montreal Cognitive Assessment (MoCA) is a commonly used screening measure for cognitive impairment; however, the diagnostic accuracy and optimal cutoff points in inpatients with mild stroke severity is unknown. We examined the diagnostic accuracy of the MoCA in an acute inpatient stroke rehabilitation unit (N = 95). The criterion neuropsychological assessment was the 30-minute National Institute of Neurological Disorders and Stroke-Canadian Stroke Network battery, modified to include the Symbol-Digit Modalities Test and Trail Making Test A & B. The MoCA had moderately strong diagnostic accuracy in receiver operating curve analyses, with areas under the curve ranging from .80 to .89 depending on the threshold for defining cognitive impairment. Sensitivity ranged from .72 to .87, and was generally greater than specificity, which ranged from .60 to .81. The optimal cutoff on the MoCA for detecting mild or greater cognitive impairment was <25/30. The optimal cutoff using more conservative definitions of cognitive impairment ranged from <23–24/30. Exploratory analyses of MoCA subgroups (“normal,” “mildly impaired,” and “functionally impaired”) differed in the frequency and magnitude of impairment on the criterion neuropsychological assessment. These findings inform the clinical use of the MoCA in individuals with mild stroke in an inpatient rehabilitation setting.