Valérie Poulin

Efficacy of Executive Function Interventions After Stroke: A Systematic Review

Abstract Purpose: Disorders in executive functions are common post stroke and play a critical role in predicting functional recovery. To establish best practice recommendations, it is necessary to appraise the evidence regarding specific executive function interventions post stroke. This systematic review aims to determine whether executive function intervention is more effective than no or alternative intervention in improving executive functions and functional abilities in the acute, subacute, and chronic stages post stroke. Method: A systematic review was performed up to January 2011 of MEDLINE, CINAHL, PsychINFO, OTseeker, and Cochrane databases. Eligible studies needed to include a cognitive intervention to remediate executive function impairments post stroke or to improve functional tasks compromised by these impairments. Methodological quality of randomized trials was rated by 2 authors. The level of evidence for each intervention, according to stage of recovery, was determined. Results: Ten studies met inclusion criteria – 1 evaluating treatment in the subacute and 9 in the chronic stage. Limited evidence from the 1 study in the subacute stage (level 2b) and 9 studies (including 3 randomized controlled trials) in the chronic stage (level 2a) support using remedial (eg, computerized working memory training) and compensatory interventions (eg, problem-solving strategies, paging system) for improving executive functioning and, possibly, functional abilities. Conclusion: These findings suggest that persons with stroke may possibly benefit from specific executive function training and learn compensatory strategies to reduce the consequences of executive impairments. Further research is needed in acute and subacute stroke, when the impact of treatment is potentially great and where few studies have been undertaken.

Assessing executive function in relation to fitness to drive: a review of tools and their ability to predict safe driving.

BACKGROUND/AIM The assessment of executive functions is an integral component in determining fitness to drive. A structured review was conducted to identify assessment tools used to measure executive function in relation to driving and to describe these tools according to: (i) specific executive function components assessed; (ii) the tools validity in predicting safe driving; and (iii) clinical utility. METHODS Sixty-nine articles were reviewed, identifying 53 executive function tools/assessments used in driving research. Each tool was critically appraised and the findings were compiled in a Driving Executive Function Tool Guide. RESULTS Among the 53 tools, there were 27 general assessments of cognition, 19 driving-specific and seven activities of daily living/instrumental activities of daily living assessments. No single tool measured all executive function components: working memory was the most common (n = 20/53). Several tools demonstrated strong predictive validity and clinical utility. For example, tools, such as the Trail Making Test and the Maze Task, have the shortest administration time (i.e. often less than 10 minutes) and the most easily accessible method of administration (i.e. pen and paper or verbal). Driving-specific tools range from short questionnaires, such as the 10-minute Manchester Driving Behaviour Questionnaire, to more complex tools requiring about 45 minutes to administer. CONCLUSIONS AND SIGNIFICANCE OF THE STUDY: The appropriateness of a tool depends on the individual being assessed and on practical constraints of the clinical context. The Driving Executive Function Tool Guide provides useful information that should facilitate decision-making and selection of appropriate executive function tools in relation to driving.

Reliability of the LIFE-H satisfaction scale and relationship between participation and satisfaction of older adults with disabilities

Purpose. To (1) document the test–retest reliability of the Assessment of Life Habits (LIFE-H 3.1) in measuring the satisfaction of older adults with disabilities regarding their level of participation and (2) explore the relationships between level of participation and satisfaction with the level of participation achieved. Methods. Thirty older adults having functional disabilities were interviewed twice using the LIFE-H. This questionnaire assesses the (1) participation in daily activities and social roles (life domains), and (2) satisfaction with this participation. Results. The test–retest intraclass correlation coefficients (ICC) of the satisfaction total score and its two subscores revealed high reliability (ICCs ≥ 0.84). Moderate to excellent ICCs were also obtained for the life domains (ICCs = 0.65–0.88). Satisfaction was positively associated with participation for the daily activities subscore and LIFE-H total score (p < 0.05) but not the social roles subscore. Half of the life domains showed significant correlations between participation and satisfaction scores (p < 0.01). Conclusion. The results support the reliability of the LIFE-H satisfaction scale in older adults having functional disabilities. Also, as satisfaction is only partly related to the level of participation, the study emphasizes the relevance of considering both participation and satisfaction of older adults with disabilities when evaluating their needs.

PARTICIPATION AFTER STROKE: COMPARING PROXIES' AND PATIENTS' PERCEPTIONS

OBJECTIVE This study aimed: (i) to determine the level of agreement between responses of people with stroke and their proxies on a participation questionnaire, and (ii) to explore patient and proxy characteristics related to disagreement between their responses. DESIGN Cross-sectional study. SUBJECTS A total of 40 community-dwelling people with stroke and their proxies (total n = 80). METHODS Participants were evaluated separately in face-to-face interviews using the Assessment of Life Habits questionnaire (LIFE-H 3.1), which documents participation in daily activities and social roles. Sociodemographic and clinical variables, such as severity of motor impairment and cognitive functions, were also collected. RESULTS Moderate to excellent agreement was found for the LIFE-H total score (intraclass correlation coefficient (ICC): 0.82), daily activities (ICC: 0.87) and social roles (ICC: 0.73) sub-scores. Proxies perceived more disruptions in participation than patients in several life domains (p = 0.035-0.001), but the differences between their scores were generally not clinically meaningful. Severity of motor disabilities was the best predictor of disagreement between patients and proxies. CONCLUSION These acceptable levels of agreement support the use of proxy responses to estimate the participation of people unable to respond themselves. However, some characteristics contributing to disagreement between respondents, such as severity of motor disabilities, should be considered when interpreting proxy information.

Comparison of two cognitive interventions for adults experiencing executive dysfunction post-stroke: a pilot study

Abstract Purpose This pilot partially randomised controlled trial compared the feasibility and preliminary efficacy of two promising interventions for persons with executive dysfunction post-stroke: (1) occupation-based strategy training using an adapted version of the Cognitive Orientation to daily Occupational Performance (CO-OP) approach; and (2) Computer-based EF training (COMPUTER training). Method Participants received 16 h of either CO-OP or COMPUTER training. We assessed feasibility and acceptability of each intervention, and change in intervention outcomes at baseline, post-intervention and one-month follow-up. Performance and satisfaction with performance in self-selected everyday life goals were measured by the participant and the significant other-rated Canadian Occupational Performance Measure (COPM). Other intervention outcomes included changes in EF impairment, participation in daily life and self-efficacy. Results Six participants received CO-OP and five received COMPUTER training: one in each group discontinued the intervention for medical reasons unrelated to the intervention. The remaining nine participants completed all 16 sessions. Participants expressed high levels of satisfaction with both interventions. Both treatment groups showed large improvements in self and significant other-rated performance and satisfaction with performance on their goals immediately post-intervention and at follow-up (CO-OP: effect sizes (ES) = 1.6–3.5; COMPUTER: ES = 0.9–4.0), with statistically significant within-group differences in CO-OP (p < 0.05). The COMPUTER group also showed large improvements in some areas of EF impairment targeted by the computerised tasks (ES = 0.9–1.6); the CO-OP group demonstrated large improvements in self-efficacy for performing everyday activities (ES = 1.5). Conclusions Our findings provide preliminary evidence supporting the feasibility of using both CO-OP and COMPUTER training with patients with executive dysfunction post-stroke. Implications for Rehabilitation Computerised executive function training and occupation-based strategy training are feasible to deliver and acceptable to persons with executive dysfunction post-stroke. Preliminary evidence suggests that both interventions have a positive impact on real-world outcomes; and, that CO-OP might have a greater impact on improving self-efficacy for performing everyday activities.

Managing cognitive difficulties after traumatic brain injury: a review of online resources for families

Abstract Purpose: To identify and critically appraise the content, readability, reliability and usability of websites providing information for managing cognitive difficulties in everyday life for the families of adults with moderate to severe traumatic brain injury. Method: Systematic searches on the Internet for relevant websites were conducted using five search engines, and through consultation of the lists of resources published on websites of traumatic brain injury organizations. Two team members assessed eligibility of the websites. To be included, they had to provide information related to management of cognitive difficulties following moderate to severe traumatic brain injury, to be in English or French and available free of charge. Two reviewers evaluated each website according to: (1) its readability using Flesch–Kincaid Grade Level; (2) the quality of its content using a checklist of eight recommendations for managing memory, attention and executive function problems; (3) its usability (e.g., clear design) and reliability (e.g., currency of information) using the Minervation Validation Instrument for Health Care Web Sites. Results: Of the 38 websites included, 10 provide specific tips for families that cover several domains of cognitive function, including memory, attention and executive function. The most frequent recommendations focused on the use of environmental supports for memory problems (n = 33 websites). The readability of information is below the recommended grade 7 for only nine of the websites. All sites show acceptable usability, but their quality is variable in terms of reliability of the information. Conclusions: This review provides useful information for selecting online resources to educate families about the management of cognitive difficulties following moderate to severe traumatic brain injury, as a complement to information and training provided by the rehabilitation team. Implications for rehabilitation This review describes standardized criteria for the evaluation of the content, readability, reliability and usability of websites for family education post-TBI. Given the variability in the content, the readability and the reliability of websites providing information for families about the management of cognitive difficulties post-TBI, careful attention to the selection of appropriate resources is required. Findings from this review may facilitate clinicians’ identification of relevant websites to educate families about the management of cognitive difficulties post-TBI, as a complement to other information and training from the rehabilitation team.