Luciano Fasotti

Time Pressure Management as a Compensatory Strategy Training after Closed Head Injury

Following severe closed head injury, deficits in speed of information processing are common. As a result, many head-injured patients experience a feeling of “information overload” in daily tasks that once were relatively easy. Many remedial programmes have been designed that treat different aspects of attention (often including mental speed requirements) by repetitive exercises. In the present study, a different approach to slow information processing has been taken, namely Time Pressure Management (TPM). TPM consists of a set of alternative cognitive strategies that allow head-injured patients in real-life tasks to compensate for their mental slowness. In a randomised pre-training vs. post-training vs. follow-up group study, the effectiveness of TPM training was compared with concentration training in which verbal instruction was the key element. The results indicate that specific TPM strategies are learned by the experimental subjects but that both treatments improve task performance significantly for an information intake task. TPM, however, produces greater gains than concentration training and also appears to generalise to other measures of speed and memory function.

Cognitive and Graded Activity Training Can Alleviate Persistent Fatigue After Stroke: A Randomized, Controlled Trial

Background and Purpose— Fatigue is a common, persistent consequence of stroke, and no evidence-based treatments are currently available to alleviate fatigue. A new treatment combining cognitive therapy (CO) with graded activity training (GRAT), called COGRAT, was developed to alleviate fatigue and fatigue-related symptoms. This study compared the effectiveness of the COGRAT intervention with a CO-only intervention after a 3-month qualification period without intervention. Methods— This randomized, controlled, assessor-blind clinical trial was conducted in 8 rehabilitation centers. Eighty-three stroke patients (>4 months after stroke) were randomly assigned to 12 weeks of CO or COGRAT after qualification. Seventy-three patients completed treatment and 68 were available at follow-up. Primary outcomes (Checklist Individual Strength–subscale Fatigue (CIS-f); self-observation list–fatigue (SOL-f)) and secondary outcomes (Hospital Anxiety and Depression Scale, Stroke-Adapted Sickness Impact Profile, SOL-pain, SOL-sleep-D, 6-minute walk test) were collected at baseline (before and after qualification period) and after treatment (immediate and 6-month follow-up). Results— The qualification period showed stable outcome measures. Both treatments showed significant beneficial effects on fatigue (CIS-f: &eegr;p2=0.48, P<0.001) and other outcomes (except pain and anxiety) with intention-to-treat analyses. Gains for the COGRAT group exceeded those in the CO group on number of individuals showing clinical improvement on the CIS-f (≥8 points: 58% versus 24%) and on physical endurance (&eegr;p2=0.20, P<0.001). Conclusions— A 12-week cognitive therapy program can alleviate persistent fatigue after stroke. The best results are obtained when cognitive therapy is augmented with graded activity training. Clinical Trial Registration— URL: http://www.trialregister.nl. Unique identifier: NTR2704.

Effects of different learning methods for instrumental activities of daily living in patients with Alzheimer's dementia: a pilot study

We examined whether errorless learning (EL) and learning by modeling (LM) were more advantageous than trial and error learning (TEL) in the acquisition of instrumental activities of daily living (IADL) in Alzheimer’s dementia (AD) patients (n = 14). Using a counterbalanced within-subject design, participants performed 3 learning conditions. EL consisted of straightforward prompts before any action, LM focused on the modeling of each step of the tasks and standard TEL without cues was used as a control condition. The participants had to (re)learn 3 IADL. Repeated-measure analyses during learning and follow-up assessments were performed 1 and 3 weeks after learning. The LM and the EL procedures resulted in significantly better learning compared to TEL, with effect sizes (partial eta squared) of 0.42 and 0.35, respectively. This is the first controlled study to show that (re)learning of IADL is possible in patients with AD using an error-reduction approach.

Novel Insights in the Rehabilitation of Neglect

Visuospatial neglect due to right hemisphere damage, usually a stroke, is a major cause of disability, impairing the ability to perform a whole range of everyday life activities. Conventional and long-established methods for the rehabilitation of neglect like visual scanning training, optokinetic stimulation, or limb activation training have produced positive results, with varying degrees of generalization to (un)trained tasks, lasting from several minutes up to various months after training. Nevertheless, some promising novel approaches to the remediation of left visuospatial neglect have emerged in the last decade. These new therapy methods can be broadly classified into four categories. First, non-invasive brain stimulation techniques by means of transcranial magnetic stimulation (TMS) or transcranial direct current stimulation (tDCS), after a period of mainly diagnostic utilization, are increasingly applied as neurorehabilitative tools. Second, two classes of drugs, dopaminergic and noradrenergic, have been investigated for their potential effectiveness in rehabilitating neglect. Third, prism adaptation treatment has been shown to improve several neglect symptoms consistently, sometimes during longer periods of time. Finally, virtual reality technologies hold new opportunities for the development of effective training techniques for neglect. They provide realistic, rich, and highly controllable training environments. In this paper the degree of effectiveness and the evidence gathered to support the therapeutic claims of these new approaches is reviewed and discussed. The conclusion is that for all these approaches there still is insufficient unbiased evidence to support their effectiveness. Further neglect rehabilitation research should focus on the maintenance of therapy results over time, on a more functional evaluation of treatment effects, on the design and execution of true replication studies and on the exploration of optimal combinations of treatments.

Executive dysfunction in children with neurofibromatosis type 1: a study of action planning.

In this study, we tested the hypothesis that action planning is impaired in children with neurofibromatosis type 1 (NF1). Thirty-six children with NF1 were pair-matched to 36 healthy controls (HC) on age (range, 7-12 years), sex, and parental education level, and both groups were administered three action-planning tasks. To examine the relation of task performance to attention deficit hyperactivity disorder (ADHD), the NF1 group was divided into subsets of children who met or did not meet criteria for ADHD. Children with NF1 performed less well than HC on all planning tasks, and differences remained when controlling for IQ or a measure of visuospatial skill. Both the NF1 with ADHD subset and NF1 without ADHD subset performed more poorly than HC on two of the tasks, whereas only the NF1 with ADHD subset performed worse than HC on the third planning task. The results underscore the importance of evaluating executive function in children with NF1 and suggest that deficits in this domain may be only partially related to ADHD. Planning deficits in children with NF1 may be part of their cognitive phenotype. Identifying these deficits is relevant in determining factors contributing to learning problems and in developing appropriate interventions.

Executive dysfunction in chronic brain-injured patients: Assessment in outpatient rehabilitation

In this study 81 chronic brain-injured patients referred for outpatient rehabilitation, who complained of executive impairments in daily life situations and were observed by proxies and therapists to have such problems, were assessed using various tests and questionnaires of executive functioning, such as the BADS and the DEX Questionnaire. The main purpose was to examine the sensitivity of these instruments in this particular group of patients. The tests and the DEX were also administered to healthy controls to investigate which of the instruments discriminate optimally between patients and controls. The results indicate that the tests as well as the questionnaires were sensitive to the executive problems of the patients. There were no significant differences between DEX ratings of patients, proxies and therapists. This suggests that patients who were eligible for outpatient rehabilitation showed relatively intact awareness into their executive problems. A specific combination of three “open-ended” tests and the DEX contributed significantly to the prediction of group membership.

Rehabilitation of executive disorders after brain injury: Are interventions effective?

In this paper, the effectiveness of interventions for executive disorders was reviewed. The objective was to evaluate the internal and external validity of intervention studies. A total of 46 papers, describing 54 studies, conducted in the last two decades meeting several preset inclusion criteria, was included in this review. The studies were categorized into three treatment approaches in order to enhance comparability. The overall results show that many interventions yield positive outcomes and seem to be effective in reducing executive problems in brain-injured subjects. However, several studies have only an explorative intent and are based on less sophisticated experimental designs. The verification of their results is generally more tenuous. The internal validity, or the set-up of experimental conditions necessary to draw valid conclusions about treatment effectiveness, including the choice of well-matched control groups, or the randomization of patients over treatment and control conditions, is not always strong. The same conclusion can be drawn for the external validity of a number of the intervention studies; often evidence of generalization to real-life situations, long-term follow-up, and transfer to non-trained situations, were (partially) lacking in the studies under review. The authors are aware that the design of proper randomized controlled trials for the investigation of the treatment effectiveness of executive disorders is cumbersome and time consuming. Nonetheless, the provisional results of several well-designed studies described in this review make the effort worthwhile.

Post-stroke fatigue: a treatment protocol that is being evaluated

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is the neuropsychologist. AbstractPurpose: Post-stroke fatigue is a common and debilitating complaint, which has only recently received attention in clinical rehabilitation. Until now, no evidence-based treatments have been available for the condition. Therefore, a new treatment was designed to reduce post-stroke fatigue complaints: Cognitive and Graded Activity Training (COGRAT). Rationale: Following the premise that post-stroke fatigue is primarily caused by brain damage, the treatment aims to prevent fatigue and to manage existing fatigue symptoms. The purpose of the added graded activity programme is to reduce fatigue by changing cognitions and enhancing physical fitness. Theory into practice: COGRAT consists of a cognitive treatment and graded activity programme in small groups over 12 weeks. In the cognitive treatment, patients receive education on post-stroke fatigue and register their activities and fatigue to gain insight into their daily agenda and fatigability. Patients are then taught several compensation strategies. Cognitive behavioural therapy is used to diminish anxiety, facilitate behavioural change and manage fatigue symptoms. The graded activity programme consists of walking on a treadmill, strength training and home work assignments. Maximum heart rate and strength are increased from 40% at the beginning of the training to a maximum of 70%. Considerations for future improvements: COGRAT is currently being evaluated in outpatients with severe post-stroke fatigue in a multicentre randomized controlled trial. Preliminary data suggest both positive short- and long-term effects. Adaptations for other neurological patient groups suffering from fatigue are suggested.

Prospective and retrospective time perception are related to mental time travel: evidence from Alzheimer's disease.

Unlike prospective time perception paradigms, in which participants are aware that they have to estimate forthcoming time, little is known about retrospective time perception in normal aging and Alzheimers disease (AD). Our paper addresses this shortcoming by comparing prospective and retrospective time estimation in younger adults, older adults, and AD patients. In four prospective tasks (lasting 30s, 60s, 90s, or 120s) participants were asked to read a series of numbers and to provide a verbal estimation of the reading time. In four other retrospective tasks, they were not informed about time judgment until they were asked to provide a verbal estimation of four elapsed time intervals (lasting 30s, 60s, 90s, or 120s). AD participants gave shorter verbal time estimations than older adults and younger participants did, suggesting that time is perceived to pass quickly in these patients. For all participants, the duration of the retrospective tasks was underestimated as compared to the prospective tasks and both estimations were shorter than the real time interval. Prospective time estimation was further correlated with mental time travel, as measured with the Remember/Know paradigm. Mental time travel was even higher correlated with retrospective time estimation. Our findings shed light on the relationship between time perception and the ability to mentally project oneself into time, two skills contributing to human memory functioning. Finally, time perception deficits, as observed in AD patients, can be interpreted in terms of dramatic changes occurring in frontal lobes and hippocampus.

Stroop interference and disorders of selective attention

Fourteen patients with right-hemisphere CVA and 8 patients with a left-hemisphere CVA were examined for selective attention deficits using a variant of the Stroop color-word task: the picture-word interference task. Experiments 1 and 2 first compared the performance of the two patient groups and a control group in three tasks of increasing difficulty: picture-word detection, word reading, and picture naming. The results showed that (a) the two patient groups were significantly slower than the control group, but did not differ from each other, and (b) the difference in mean RT between the two patient groups and the control group did not increase with task difficulty. In Experiment 3, the subjects were required to name pictures while ignoring accompanying distractors: nonletter symbols, unrelated words or semantically related words. In this task, the right hemisphere patients showed a much larger semantic interference effect than both the left hemisphere patients and the control group. It is argued that this finding most probably reflects problems in visual selective attention with the right hemisphere patients.