Yael Goverover

Evidenced-Based Cognitive Rehabilitation for Persons With Multiple Sclerosis: A Review of the Literature

OBJECTIVES To conduct evidence-based review of cognitive rehabilitation intervention research conducted in persons with multiple sclerosis (MS), to classify level of evidence, and to generate recommendations for interventions in this area. DATA SOURCES An open (no year limits set) search of Medline, PsychInfo, and CINAHL (eliminating repetitions) using combinations of the following terms: attention, awareness, cognition, cognitive, communication, executive, executive function, language, learning, memory, perception, problem solving, reasoning, rehabilitation, remediation, training, and working memory. Reference sections of articles found through the sites were also searched. STUDY SELECTION Studies were chosen based on criteria from previous evidence-based reviews such that articles are excluded from the review if (1) the study was not an intervention, (2) it was a theoretic article, (3) it was a review article, (4) detail was lacking to fully evaluate the intervention, (5) it was not MS-specific, (6) it included a pediatric sample, (7) it was a case report without empirical data to evaluate outcomes, (8) it was not peer-reviewed (also excludes book chapters), (9) it was a pharmacologic intervention, or (10) it was not available for review in English. DATA EXTRACTION Articles were categorized into interventions for attention, learning and memory, executive functioning, or nonspecified/combined cognitive domains. There were 4 reviewers in the current study. All articles were reviewed independently by at least 2 persons and abstracted according to predetermined criteria. There was a final total of 16 articles, which underwent a full review and classification of a level of evidence based on previously published peer-reviewed methodology used for evidence-based reviews. DATA SYNTHESIS The current review yielded 16 studies of cognitive rehabilitation for persons with MS, including 4 class I studies, 5 class II studies, 2 class III studies, and 5 class IV studies. Two intervention methodologies in the area of verbal learning and memory received support for a practice guideline and practice option, respectively. CONCLUSIONS Cognitive rehabilitation in MS is in its relative infancy. More methodologically rigorous research is needed to determine the effectiveness and efficacy of various cognitive rehabilitation interventions. Specific recommendations for future research are given.

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.

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.

The relationship between self-awareness of neurobehavioral symptoms, cognitive functioning, and emotional symptoms in multiple sclerosis.

Objective: To examine self-awareness of neurobehavioral symptoms in multiple sclerosis (MS) across three domains of function (apathy, disinhibition, and executive control), and examine the relationship between self-awareness and cognitive functioning. Methods: Twenty-six individuals with MS completed neuropsychological testing, measures of emotional functioning, and self-ratings of neurobehavioral symptoms using the Frontal Systems Behavior Scale (FrSBe), a 46-item questionnaire with subscales assessing frequency of symptoms in executive dysfunction, disinhibition, and apathy. Informants’ ratings of the FrSBe were also obtained. Decreasing differences between patient and informant reports on each subscale of the FrSBe (concordance) indicate higher levels of self-awareness. Results: Results showed significant positive correlations between cognitive abilities and self-awareness of executive dysfunction and disinhibition. In contrast, affect symptomatology (measures of anxiety and depression) were negatively correlated with self-awareness of executive dysfunction. Conclusions: Level of self-awareness of neurobehavioral symptoms in MS is related to level of cognitive impairment. In addition, symptoms of depression and anxiety reduced the accuracy of self-reporting. Thus, a clinician who relies on self-reports in creating an evaluation and treatment plan should consider the patient’s cognitive and emotional states.

The relationship between neuropsychological measures and the Timed Instrumental Activities of Daily Living task in multiple sclerosis

Multiple sclerosis (MS) can result in cognitive deficits and a loss of functional independence. To date, little research has linked the observed cognitive and behavioral deficits in MS, especially those in the processing speed domain, to performance on tasks of everyday functioning. The present study examined the relationship between neuropsychological test performance and performance on the Timed Instrumental Activities of Daily Living task (TIADL) in individuals with MS, and in healthy controls (HCs). The TIADL is a functional measure, which assesses both accuracy and speed in ones performance of everyday activities. The MS group performed significantly worse on the TIADL relative to the HC group. Additionally, TIADL scores of individuals with MS were significantly correlated with neuropsychological measures of processing speed. TIADL scores were not, however, correlated with neuropsychological measures of verbal episodic memory or working memory. These results indicate that the impairments in processing speed may contribute to impairments in activities of everyday living in persons with MS. Multiple Sclerosis 2007; 13: 636-644. http://msj.sagepub.com

Effects of Contextual Interference and Age on Acquisition, Retention, and Transfer of Motor Skill:

This experiment was designed to Investigate the varying conditions of contextual interference within three age groups. 40 5-yr.-olds, 40 7-yr.-olds, and 40 11-yr.-olds practiced the task of throwing beanbags under either low contextual interference (blocked practice), high contextual interference (random practice), or medium contextual interference (combined practice). All subjects performed 30 acquisition trials, 12 retention trials and 6 transfer trials. Analysis indicated that only the 7-yr.-old subjects differed in their performance in the various practice groups. As hypothesized and suggested by developmental theories, the combined and blocked practice groups acquired the task better. On the other hand, the 5- and 11-yr.-olds did not differ in performance in the different practice groups. Whether this is associated with difficulty of the task or the length of practice can be assessed in further study. Contextual interference in different age groups needs further investigation.

Categorization, deductive reasoning, and self-awareness: Association with everyday competence in persons with acute brain injury

The present study examined the relationship between executive function, self-awareness and everyday functional competence in individuals with brain injuries. Executive function was assessed using measures of categorization and deductive reasoning ability, both of which were shown by multiple regression analysis to make significant contributions to the performance of Instrumental Activities of Daily Living (IADL), suggesting that both measures can serve as predictors of everyday functioning in persons with brain injuries. Self-awareness contributed significantly to functional competence, but its contribution was mediated through categorization ability. Executive function was correlated significantly with posttest performance estimation (self-evaluation of own performance), but not with self-prediction of test performance prior to testing. The results are discussed within the framework of a conceptual model illustrating the multifaceted nature of executive function and its relationship to self-awareness and everyday functional competence. The results of this study indicate that categorization, deductive reasoning, and self-awareness of individuals with brain injury are good predictors of IADL functional performance, and can help in planning better treatment interventions.

A functional application of the spacing effect to improve learning and memory in persons with multiple sclerosis

The present study examined the utility of using spaced learning trials (when trials are distributed over time) versus massed learning trials (consecutive learning trials) in the acquisition of everyday functional tasks. In a within-subjects design, 20 participants with multiple sclerosis (MS) and 18 healthy controls (HC) completed two route learning tasks and two paragraph reading tasks. One task in each area was presented in the “spaced” condition, in which the task was presented to the participants three times with 5-minutes break between each trial, and the second task in each area was presented in the “massed” condition, in which the task was presented three consecutive times to the participants. The dependent variables consisted of recall and recognition of the paragraphs and routes both immediately and 30 minutes following initial learning. Results showed that for paragraph learning, the spaced condition significantly enhanced memory performance for this task relative to the massed condition. However, this effect was not demonstrated in the route learning task. Thus, the spacing effect can be beneficial to enhance recall and performance of activities of daily living for individuals with MS; however, this effect was significant for verbal tasks stimuli, but not for visual tasks stimuli. It will be important during future investigations to better characterize the factors that maximize the spacing effect.

Self-Generation to Improve Learning and Memory of Functional Activities in Persons With Multiple Sclerosis: Meal Preparation and Managing Finances

OBJECTIVE To examine the utility of using a self-generation strategy to improve learning and performance of everyday functional tasks in persons with multiple sclerosis (MS). DESIGN Mixed-design with both a within- and between-subject factor. SETTING Nonprofit rehabilitation research institution. PARTICIPANTS Participants (n=20) with MS and healthy controls (n=18). INTERVENTIONS Participants completed 2 meal preparation and 2 financial management tasks. One task in each area was presented in the provided condition, in which all instructions were provided to and read by the participants, and the other task was presented in the generated condition, in which participants were asked to generate (fill in the blank) the necessary items needed to perform each step of the task. MAIN OUTCOME MEASURES Correct recall of task items and step sequence immediately and 1 week after initial learning and correct performance of task items and step sequence 30 minutes after initial learning. The maximum possible score in each of the recall tests was 24. RESULTS Although the MS and healthy groups did not differ in overall items recalled, in both groups tasks learned in the generated condition enhanced memory performance significantly for the tasks used when compared with similar tasks learned in the provided condition. CONCLUSIONS Self-generation during learning can significantly improve subsequent recall of information and performance of activities of daily living for persons with MS. Implications of these findings for cognitive rehabilitation in MS are discussed.

Actual reality: a new approach to functional assessment in persons with multiple sclerosis.

OBJECTIVE To examine the use of an innovative approach for assessing everyday life activities of people with multiple sclerosis (MS): Actual Reality. Actual Reality is a performance-based assessment approach that involves the use of the internet to perform real, everyday life activities. DESIGN A between-subjects design. SETTING Outpatient rehabilitation institute. PARTICIPANTS Persons (n=21) with clinically definite MS and healthy controls (HCs) (n=18) without any reported neurologic disabilities participated in this study. Participants were between the ages of 21 to 60 years, and the sample consisted of volunteer sample. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Participants were asked to access the internet to purchase airline tickets for a round trip flight and were administered the Minimal Assessment of Cognitive Functioning in Multiple Sclerosis. Participants also completed questionnaires to assess quality of life (Functional Assessment of Multiple Sclerosis), functional status (Functional Behavior Profile), and prior Internet experience. RESULTS The MS group displayed significantly more difficulties than the HC group in accurately and independently completing the Actual Reality task primarily because of cognitive impairment. Self-report of quality of life and functional status were not correlated with Actual Reality performance in the group of people with MS. However, the self-report measures were significantly associated with affective symptomatology. CONCLUSIONS These results provide initial evidence supporting the use of the Actual Reality approach in assessing persons with MS performing everyday life activities. Actual Reality is a significant step forward in increasing the sensitivity, accessibility, and relevancy of functional assessments in people with cognitive and physical disabilities.