Assessment & Management of Executive Dysfunction in an Occupational Context

Assessment & Management of Executive Dysfunction in an Occupational Context Deirdre Dawson, PhD, OT Reg. (Ont.) Senior Scientist, Rotman Research Institute Associate Professor, Occupational Science & Occupational Therapy, University of Toronto Ottawa, Ont.: March 1, 2018

Disclosures Received and hold research grants to investigating the Multiple Errands Test and the Cognitive Orientation to daily Occupational Performance: The CO-OP Approach TM Received income from published book on the CO-OP Approach TM CO-OP Certified Instructor Multiple Errands Test Instructor

Schedule Content 8:30 Introductions Overview of 3 Days Goals & Objectives 9:00 Foundational concepts, models and current cognitive neuroscience of executive function 9:30 Considerations for choosing assessments; Overview of Assessment Options ~ 10:30 BREAK 10:45 Multiple Errands Test: Overview, Scoring, Interpretation, MET-Home 11:45 Assessment Wrap-Up Take-home messages Check-in Regarding Objectives related to Asessment 12:00 LUNCH 1:00 Principles for occupational rehabilitation Evidence-based recommendations for rehabilitation of executive function Decision algorithm Overview of Management Approaches 2:00 Introduction to the CO-OP Approach TM & Discussion of active ingredients 2:30 BREAK 3:45 Application to participants clinical cases Check-in regarding Objectives related to Intervention Final questions / comments Wrap-up 4:30 End of Day

Learning Objectives By the end of this workshop, attending OTs will: Ø Have knowledge of foundational concepts and current cognitive neuroscience thinking about executive functions; Ø Be able to identify key considerations in choosing assessments including the differences between differences between occupational performance and cognitive assessment; Ø Be able to apply algorithms related to choosing assessments and rehabilitation approaches; Ø Have familiarity with a repertoire of evidence-based approaches and how these might be tailored to clients in different practice settings.

Foundational Concepts Executive Dysfunction through an Occupational Lens

Occupational Performance the ability to choose, organize and satisfactorily perform meaningful occupations (p. 30, Townsend, 1997)

What are we / should we be (as OTs) assessing & treating? Impairment Level Activity / Task Level Everyday life Participation / Occupational Performance International Classification of Functioning, Disability & Health, WHO, 2000

Principles for Using an Occupational Approach 1. Occupational performance arises from a complex interaction of elements; 2. Contextual factors are accounted for in the context within which the occupation is performed; 3. Using an occupational approach requires a sound theoretical understanding of cognition; 4. Observing occupation allows clinicians to identify barriers and facilitators to performance.

Foundational Concepts Executive Function

Characteristics of Executive Functions Complex processes that integrate and are superordinate over lower-level processes Require cognitive effort Mediated through multiple networks involving frontal lobes, particularly the pre-frontal cortex and brain networks involving frontal and parietal cortices, and subcortical structures including the cerebellum No consensus on one set of domains

Theories of Executive Dysfunction Mesulam: the default mode Stuss: attentional fractionation

The default mode * (Mesulam, 2002) Actions are driven by immediate gratification and / or environmental triggers Behaviour is poorly modulated by context / experience There is a need for a buffer between stimulus and action To overcome this, executive control needs to be reestablished: ü Use of bottom-up strategies (externally-based cueing systems) ü Use of top-down approaches (internally driven, metacognitive strategies)

Think of a situation in which You need to place a buffer between a stimulus and an action

Frontal Functions Terms such as EF, the dysexecutive syndrome, the supervisory system, and frontal lobe functions are challenging to define and measure. The following schema divides what has been loosely termed executive functions into four more clearly defined and circumscribed domains that follow anatomy and evolutionary development: (1) executive cognitive functions, (2) behavioral self-regulatory functions, (3) activation regulating functions, (4) metacognitive processes. Cicerone, Levin, Malec, Stuss & Wyte, 2006, J Cog Neurosci

Energization Process of initiation and sustaining any response Linked to superior medial cortex Observed deficits may include; Slower response time Failure to sustain attention Dynamic relationship between sustained attention & inhibition Involves arousal and goal representation 15 Energization SUPERIOR MEDIAL Stuss, 2006, JINS

Executive Cognitive Functions Control and direction of lower level cognitive functions Monitoring (right lateral prefrontal cortex [PFC]) Task setting (left lateral PFC) Involves skills such as goal selection, flexibility, impulse control, planning, organisation and decision making LEFT LATERAL Task Setting RIGHT LATERAL 16 Stuss, 2006, JINS Monitoring

Self-Regulation Self-regulation of behaviour Automatic routine situations vs. novel and complex situations Linked to ventral medial PFC Involves planning, self-reflection, risk vs. reward assessment, inhibition 17 Stuss, 2006, JINS

Executive Attention Networks (Dopamine & Seratonin) Competing theories exist Commonalities - Widespread cortical connections - Anterior cingulate cortex - Prefrontal cortex - Dorsal and ventral - Medial - Orbitofrontal areas

Executive Attention Networks (dopamine & seratonin) - Allows for high level attentional tasks selection, alternating, dual-tasking - Involved in regulation of thoughts, feelings and behaviours - Includes processes for detection, inhibition, switching & conflict processing all important for error detection and correction - Allows for trial by trial adjustments and maintenance of a stable background for whole task performance

Metacognition Awareness of one s thought processes Integration of energization, emotional or motivational information and executive skills Self-awareness, personality, social cognition Linked to frontal poles 20 Stuss, 2006, JINS

Functions of the Frontal Lobes: Relation to Executive Functioning (Stuss, 2011)

Foundational Concepts Executive Function & Memory

https://www.ncbi.nlm.nih.gov/pmc/articles/pm C3971378/figure/F1/

A Proposed Framework 1. Energization & Initiation 2. Fluency & flexibility 3. Organization 4. Control 5. Decision Making & Problem Solving 6. Meta-cognition

Energization & Initiation ENERGIZATION The process of initiating and sustaining a response.

Fluency & Flexibility WORKING MEMORY (verbal & non-verbal) COGNITIVE FLEXIBILITY TASK SWITCHING SET-SHIFTING Limited capacity memory held on line for manipulation Changing perspective spatially or interpersonally. Theorized to rely on inhibition, attention and working memory (inhibiting one stimuli, shifting one s attention to a new stimulus and re-focusing. Switching between tasks or sets such as on the Stroop task.

TASK SETTING: Includes: goal-setting goal formation plan formation Organization Forming a connection between a stimulus and response (if-then logic) such that a criterion for response is established. Determining a response is needed. PLANNING Making and executing plans in the sequence needed to achieve a goal.

INHIBITORY CONTROL Attentional Control Volitional attention Higher-level attention Control Suppression of an automatic, habitual or impulsive response to an environmental stimulus, internal thought or emotion in order to make a more relevant response TASK MONITORING Keeping track of performance over time to avoid making errors. SELF-REGULATION Top down control of attention toward goalrelevant information Suppression of ruminative thoughts Inhibition of unwanted affect, desires, craving

DECISION MAKING Decision Making & divergent and convergent reasoning PROBLEM SOLVING involves cognitive flexibility planning and organization decision making working memory Problem-Solving Generating multiple solutions to a problem (divergent) Considering multiple factors and deriving a solution (convergent) Identifying the problem, searching for a solution, determining what the solution will involve, choosing and executing the solution.

Meta-cognition & Self-Awareness SELF-AWARENESS Ability to recognize impairments, understand their functional consequences and anticipate possible future difficulties related to these META-COGNITION Includes self-awareness Ability to think about one s thinking Integrates all other executive functions

Assessment

Objectives By the end of the assessment section, attendees will be able to: Understand how to select an assessment for a particular therapeutic context; Identify a variety of assessment options for evaluating cognitive impairments and their effects in the context of everyday activities; Consider three specific assessments for use in clinical practice.

Overall Process I: Should a cognitive assessment be undertaken? 1. Has client or decision maker consented? 2. Who is asking for the information? What information is required? 3. What is the benefit of determining whether there is cognitive impairment? 4. Has any cognitive testing been done by others? What were the findings? Is further testing needed / required? 5. Are there occupational performance difficulties? If not, why is OT involved? 6. Are there other factors that could be influencing cognition e.g., sleep, mental health, medication, medical history, substance abuse, other, timing? http://alliedhealth.vch.ca/docs/ot_approach_to_evaluation_cog_percep.pdf

CSBPR 2015 (Eskes et al., 2015) 1. All patients with clinically evident stroke or TIA should be considered at risk for vascular cognitive impairment (Evidence Level A); 2. Patients with stroke and TIA should be considered for screening for VCI using a validated screening tool such as the MoCA (Evidence Level C); 3. Patients with demonstrate cognitive impairments when screened should be managed by healthcare professionals with expertise in the assessment and management of neurocognitive functioning. If required a referral could be made to an appropriate cognitive specialist (Evidence Level C).

After deciding a cognitive assessment should be undertaken II: Planning & Preparation 1. What is the assessment purpose? Discharge planning? Treatment planning? Returning to work / school? 2. What kind of assessment is client able to participate in? Consider level of awareness, physical tolerance, language, motor skills, education. 3. What are the pragmatic issues? Availability of space, time, assessment materials Personal expertise / training 4. What background information is available and relevant? Past medical history Information on client s cognitive and functional status from other assessments, team members, family

III: Initial Interview 1. What are the client s occupational difficulties and priorities? Canadian Occupational Performance Measure Activity Card Sort Pre-morbid / current daily log Occupational Repertoire 2. Is there a need to measure capacity and/or performance? 3. Is the goal to identify a problem and/or measure change after intervention?

Process of choosing an assessment 1. Determining whether a cognitive assessment should be done; 2. Planning and preparing for the assessment; 3. Undertaking the initial interview and occupational needs assessment; 4. Decision point

* If more in-depth assessment required after doing step 4 proceed to step 5. IV: Decision Point

Cognitive Assessments cognitive, affective impairments STROKE Real-world measures ICF, WHO, 2000

IV: Screening Assessment Screening at activity / task performance / occupational level Unstructured observation Standardized tools (e.g., Cognitive Performance Test) Screening at the impairment level Quick Screen (e.g., MoCA) Profile Screen (e.g., LOTCA) IV: Decision Point V: In-depth Assessment In-depth assessment at level of activity / task performance / occupational level Unstructured observation Structured observation (e.g., Multiple Errands Test) Standardized assessment (e.g., ADL/IADL Profile) In-depth assessment at the impairment level Standardized cognitive assessments used by OT (e.g., BADS) Refer to neuropsychologist Questionnaires (self / other report) home-made Standardized (e.g., BRIEF-A; DEX)

Principles for Assessment with an Occupational Lens* The assessment should: 1. Be developed from the basis of theory. 2. Focus on the effects of the executive function impairment on occupational performance; 3. Provide the opportunity to understand the effects of real-world contextualization on performance; 4. Allow for observation of clients strategy use and determination of whether generated strategies assist with test performance. Dawson, Bottari, Nalder & Hébert. (forthcoming). Assessment and management of executive dysfunction through an occupational lens.

If your job is to assess at the performance level also consider the following 1. Does the client have the necessary executive function to manage the occupational demands of their current situation? 2. Does the client have the necessary executive function to allow them to manage the occupational demands of novel or non-routine situations? 3. Are the strategies the client is using moving them towards attaining their desired occupational performance goal and/ or is assistance needed? 4. If the client does not have the necessary executive function, where is performance breaking down? 5. If assistance is needed, what type of assistance best optimizes the clients abilities?

Informal Assessment Observation in naturalistic settings Pay attention to the amount of scaffolding (cues, prompts, structure) required for client to initiate and sustain action Useful for informally identifying a problem and guiding treatment.

Useful resources for choosing an assessment 1. The Occupational Therapy Cognitive Assessment Inventory (04/2014). Available at http://alliedhealth.vch.ca/docs/ot_cog_assess_i nventory.pdf

2. Review Papers & Texts

3. Professionally developed and mediated websites https://www.strokengine.ca/find-assessment/ Funding: Heart & Stroke Foundation Canadian Partnership for Stroke Recovery http://www.ebrsr.com/ Funding: Heart & Stroke Foundation Canadian Partnership for Stroke Recovery https://www.sralab.org/rehabilitation-measures Funding: Shirley Ryan Ability Lab https://www.abiebr.com/module/17-assessment-outcomes Funding: Ontario Neurotrauma Foundation https://www.tbims.org Funding: National Institute on Disability, Independent Living and Rehabilitation Research: Santa Clara Valley Medical Center

17 Performance-based Assessments 1. ADL Profile 10. Naturalistic Action Test 2. Behavioural Assessment of the Dysexecutive Syndrome 11. Observed Tasks of daily living-revised 3. Complex Task Performance Assessment 12. Rabideau Kitchen Evaluation 4. Cooking Task 13. Virtual action planning supermarket 5. Executive Function Performance Test* 14. Assessment of Motor & Process Skills 6. Executive Secretarial Task 15. Functional Assessment of Verbal Reasoning and Executive Strategies 7. Making a cake 16. Kettle Test 8. Multiple Errands Test* 17. Virtual Environment Technology 9. Virtual Multiple Errands Test *Strongest psychometric data

Comments about specific assessments Of 17 performance tests reviewed (Poulin et al., 2013), strongest reliability and validity had been demonstrated for: 1. Executive Function Performance Test (EFPT) 2. Multiple Errands Test (MET)

Executive Function Performance Test Manual & Test Available at: http://www.ot.wustl.edu/about/resources/executive-functionperformance-test-efpt-308 Purpose: To determine: which executive functions are impaired An individual s capacity for independent functioning The amount of assistance necessary for task completion. Example of Adminstration: https://www.youtube.com/watch?v=jdpf_u5vdfe&t=137s Description: 5 tasks: (hand washing), simple cooking, telephone use, medication management, bill payment each scored on initiation, execution, organization, sequencing, judgement & safety, completion

I want you to make oatmeal. Here is an enlarged version of the instructions. Follows these directions and when you are done put the oatmeal in the bowl. The items you need are in the box.

EFPT Psychometric Data in Stroke Reliability: Test-retest: Unknown Inter-rater: Moderate to Excellent Excellent: (Baum et al., 2008) 3 raters, 10 patients chronic Moderate (Cederfeldt et al., 2015) 4 raters, 17 patients acute (lowest agreement on paying bills) Internal Consistency: Excellent (Baum et al., 2008) Validity: (Discriminative): Significant but effect sizes are not reported

Baum et al., 2008 Effect sizes calculated post-hoc Control - Mild Stroke: Cohen s d=1.03 Control-Moderate Stroke Cohen s d=5.48

EFPT Psychometric Data in Stroke Validity: (Baum et al., 2008; Cederfelt et al., 2011; Wolf et al., 2010) Concurrent: moderate relationships with working memory, verbal fluency, attention (r> 0.39) in those with chronic stroke moderate to large relationships with Delis-Kaplan Executive Function System (r= - 0.47 to - 0.57) in those with mild, chronic stroke Moderate to large relationships with FIM scores (r= - 0.68) Moderate relationships with AMPS process scores (r= 0.65)

Formal Assessment Multiple possibilities (see Poncet et al., 2017, Neuropsych Rehabil) Poncet et al., 2017, p. 630

The Multiple Errands Test

Objectives By the end of this section of the workshop, participants will have: Gained familiarity with the development and construction of the Multiple Errands Test (MET); Understand the administration and scoring of the MET; Gained knowledge about psychometric properties of the MET; Considered the clinical utility of the MET. 2

Origins of the MET Frontal lobe lesions can produce a gross effect in the performance of everyday life activities other than the most routine, even though neuropsychological tests suggest that the cognitive changes that have occurred are at most minor (Shallice & Burgess, 1991, p. 727) NEED: a quantifiable analogue of open-ended multiple goal situations in a setting where minor unforeseen events can occur RESPONSE: Multiple Errands Test 3

Knight, Alderman, & Burgess, Hospital Version, 2002 4

Knight, Alderman, & Burgess, Hospital Version, 2002 5

Some of the Published Versions Natural environment 1. Knight et al., 2002. Multiple Errands Test for use in hospital settings. Neuropsych Rehab. 2. Alderman et al., 2003 simplified Multiple Errands shopping Test. J Intl Neuropsych Soc. 3. Dawson et al., 2009... Multiple Errands Test: Baycrest version. Arch Phys Med & Rehab. 4. Maeir et al., 2011. Ecological validity of the 1. Multiple Rand Errands et Test. al., OTJR. 2009, Virtual MET, Revised, Neuropsych AJOT. Rehab 5. Morrison et al., 2013. Multiple Errands Test- 6. Clark et al., 2015 Revised Baycrest Multiple Errands Test, Neuropsych Rehab. 7. Lancely, S. (2015). A new approach to the assessment of drivers: Applying the MET for use in a simple parking exercise. BJOT. 8. Burns et al. (in press). MET-HOME. Neuropsych Rehab & AJOT. Virtual environment 1. Parsons et al., (2008). Assessment of Executive Functioning Using Virtual Reality: Virtual Environment Grocery Store. Gerontechnology. 2. Rand et al., 2009, Virtual MET. Neuropsych Rehab. 3. Raspelli et al., 2011, Neuro VR MET. Stud Health Technol Inform. 4. Logie et al., 2011. Edinburgh VET. Mem Cognit. 5. Jovanovski et al., 2012, Multitasking in the City. Appl Neuropsych: Adult. 6. And others 6

The MET and Ecological Validity Representativeness (verisimilitude) ü corresponds to the form and context of the everyday environment üreflects the cognitive processes necessary to complete the everyday activity; Generalisability (veridicality) ücorresponds to and/or predicts realworld performance. 7

MET s & EFPT s characteristics in relation to principles of assessment Principle MET EFPT 1. Based on theory Based on the Supervisory? Not stated Attentional System 2. Focuses on the effects of executive dysfunction on occupational performance Tasks and rules are drawn from everyday life activities. -- To some extent, controlled test administration and environment 3. Real-world contextualization Versions have been developed for hospitals, shopping malls, home. -- Simulated tasks and environment 4. Allows for observation of Although no structure --To some extent but cues clients strategy use. for observation has been published. provided to ensure success. 8

Scoring the MET: Recommended Workflow During performance of the MET Participants / clients are observed (and recorded if possible) by therapist Therapist makes thorough notes on observations An additional person may video-record Scoring specific items occurs after performance 9

Administering the MET Refer to: 10

Preliminary Scoring: Task completion and Rule Adherence 1. Tasks completed accurately, tasks completed partially, tasks omitted. 2. Rule breaks: where a specified rule is broken. 11

12 Interruption task Please pick up a Baycrest Matters flyer and give it to your experimenter at the end of the task.

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What about strategies used? 15

Considerations regarding strategy use* 1. Is the strategy directed internally (towards the person) or externally (towards the task or environment? 2. Is the strategy being used to enhance skill or performance, to cope with a challenge and/or to self-regulate behaviour? 3. Is the strategy being used before, during or after the activity? 4. Is the strategy specific to a particular task or domain and/or does it have the potential to be used in a more general manner? * Adopted from Toglia et al., 2012 17

Strategy Selection Process* 18

What is standardization? Any test that: 1. Requires all test takers to answer the same questions or selection of questions from a common bank 2. Requires all testees to take the test in the same way; 3. Is scored in a standard or consistent manner. 19

Psychometric Evidence 20

Studies Reviewed & Samples Knight et al.. 2002 n=20 pts; -12 TBI, 5 CVA, 3 others; - all severe 20 hospital staff matched on age, gender, IQ Alderman et al., 2003 n=50 pts, 36 inpts; - 39 TBI, 9 CVA; - 90% severe 46 hospital staff and associates Dawson et al., 2009 n=27 community dwelling; -13 TBI, 14 CVA; ~ 60% modsevere 25 friends, family, volunteers individually matched age, educ, gender Maier et al., 2011 n=30 rehab pts; - 19 CVA, 8 TBI, 3 others Morrison et al., 2013 n=25 pts; - all acute mild CVA n/a n=21 volunteers, matched 21 Clark et al., 2015 n=15 community dwelling; - all ABI / CVA with ED on neuropsych testing 16 friends, family, volunteers individually matched on age, educ, gender

Psychometrics Reliability Internal consistency: Cronbach s α = 0.77, MET-HV (Knight et al., 2002) Inter-rater reliability: ICC-0.71-1.00, MET-HV & BMET (Knight et al., 2002; Dawson et al., 2009; Morrison et al., 2013) Test-retest reliability: significant, strong correlations between two versions (r=0.52-0.69) (Clark et al., 2015) Responsivity No published data available 22

Validity Concurrent executive dysfunction: Associations between sub-scores and perseverative errors on MCST, BADS (profile score & Zoo map), DEX, and EFPT: r=0.39 0.90 (Alderman et al., 2003; Knight et al., 2002; Dawson et al., 2009; Morrison et al., 2013; Rand et al., 2009) Concurrent everyday life: Associations between rule breaks and errors and Sickness Impact Profile, MPAI participation index, Assessment of Motor and Process Skills (AMPS) and IADL: 0.32 0.80 (Dawson et al., 2009; Rand et al., 2013) Negative associations between frequency of strategy use and AMPS: -.46 to-.53 (Dawson et al., in prep) Predictive everyday life at 3 mos post-d/c associations between rule break, errors, inefficiencies and MPAI Participant Index, r=0.33-0.52 (Maier et al., 2011) 23

Sensitivity A test with 100% sensitivity correctly identifies all of the people with the problem. Using a cut-off of 7 or more overall errors: ² Clark et al. (2015): 73.3% sensitivity (11/15 participants made 7+ errors) (Baycrest MET Version A) ² Knight et al. (2002): 85% sensitivity (17/20 participants made 7+ errors) *Sensitivity of breast screening ranges from 75% to 90%. 24

Specificity A test with 100% specificity correctly identifies all people without the problem. Using a cut-off of 7 or more overall errors: ² Clark et al. (2015): 81.3% specificity (3/16 controls made 7+ errors) (Baycrest MET Version A) ² Knight et al. (2002): 95% specificity (1/20 controls made 7+errors) *Specificity of breast screening ranges from 90 to 95%. 25

In summary The MET is a highly reliable, ecologically valid assessment used to characterize how executive function difficulties influence performance in everyday life. Abnormal performance is suggested by 7 or more errors. Ms. XX had 14 errors suggesting her executive function difficulties are impacting in a significantly negative way on her everyday life. Examples of this are. 26

Score Interpretation & Clinical Reasoning: 27

MET Data which Guides Clinical Reasoning Overall consistency & organisation of performance 1. Functional skills important in everyday life 2. Observations of executive functions 3. Quantitative MET data 4. Strategy use (Bottari et al., 2014; Nalder et al., 2015) 28

1. Functional Skills for Everyday Life Money management & calculations Social interactions Navigational skills Ability to work under pressure Finding information (Bottari et al., 2014; Nalder et al., 2015) 29

Clinical Reasoning & Error Interpretation Qualitative analyses revealed 8 clinical signs: 1. Excessive time to execute task 2. Task omitted 3. Atypical behaviour (e.g., forgets bag and doesn't retrieve it) 4. Rule broken 5. Task completed only partially 6. Request for help 7. Interpretation failure 8. Inefficiency (Bottari & Dawson, 2011; Bottari, Iliopoulos, Shun, & Dawson, 2014) 30

When Interpreting Errors, Draw On... Scoring templates & test structure Psychometric evidence sensitivity & specificity Theories of EF Clinical experience and familiarity with the MET Debrief interview Referring back to client s therapy goals 31

The MET-Home Burns*, S.P., Dawson, D.R., et al. (2018). Inhome contextual reality: A qualitative analysis using the Multiple-Errands Test Home Version (MET-Home). Neuropsychological Rehabilitation, Online first. Burns*, S.P., Dawson, D.R., et al. (in press). Development, Reliability, and Validity of the MET-Home. AJOT, 73(3). *sburns3@twu.edu) 32

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Questions about the MET? 34

Workshop Part II Evidence-based Intervention

Objectives Participants in Part II of the workshop will: Know the principles of occupationally-focused intervention; Be able to follow and algorithm to assist with treatment decisions; Gain several new ideas / techniques to add to their intervention toolkit and understand the evidence supporting this technique; Understand the key elements of the CO-OP Approach TM and their application in clinical practice; Apply at least one new technique to a personal clinical problem.

Principles of Intervention The primary goal of therapy is to enable occupation, thus to focus on task acquisition (or improvement) and goal attainment. Thus, occupational goals must be identified. Clients should be provided with the resources that are necessary to support the maintenance of gains made in therapy. Whenever possible, intervention strategies should be selected that promote generalization and transfer of learning to situations and tasks that have not been included in the treatment context. Clients should be provided with the necessary resources to be able to meet new occupational challenges following their rehabilitation.

Criteria for Successful Rehabilitation ª clinically significant improvements in performance of and participation in everyday roles and activities; ª maintenance of gains over time; ª generalization of effects to untrained roles and activities.

Classifying interventions in relation to transfer distance Wilson, Giles & Baxter, 2014, Brain Injury

Stages of (Motor) Learning (Fitts & Posner, 1967; Magill, 1998) Cognitive cognition guides behavior individual gets the general idea of the movement Individual reflects on prior knowledge of task and attends to information from the environment

Cognitive phase I have to turn my head to check my blind spot when I change lanes At a curve in the road, I have to brake as I start into the curve and halfway through the turn, I have to begin accelerating Hand at 2 o clock, hand at 10 o clock 7 Look in front To stop, I have to brake gradually

Cognitive stage of transfer learning the plans

Cognitive Stages of Motor Learning Associative (Fitts & Posner; 1967; Magill, 1998) individual learns to perform movement with some degree of accuracy individual uses feedback to correct movement patterns Autonomous skill is performed fluently and automatically

I have to slow down at the nets exit Associative The Associative and Autonomous Stages I have to take the highway to get to the theatre Autonomous 10

The Associative and Autonomous Stages of Motor Learning The Plans Associative I m in the tub I didn t fall. Autonomous I m going to have a bath. Polatajko and Mandich 11

Stage of Treatment: Acquisition Application Adaptation Goals: Ensure objectives are clear; Connect to prior knowledge where possible and relevant; Introduce new knowledge; Provide cues, guidance, opportunity for practice. Facilitate improved performance and independence; Promote internalization of cues & strategies; Provide opportunities for generalization of skills from the structured therapy setting to clients realworld environments (home, community, work); Promote transfer of underlying strategies to new occupational performance problems.

Class I/Ia Class II Class III Levels of Evidence Studies with well designed, prospective, randomized controlled trials Prospective, nonrandomized cohort studies; or clinical series with well-designed controls that permitted between subject comparisons of treatment conditions; well designed single-case experimental design Clinical series w/o concurrent controls, or studies with results from 1 or more single cases w/ appropriate methods

Practice Standard / Level A Recommendation Practice Guideline/ Level B Recommendation Practice Option / Level C Recommendation LEVELS OF EVIDENCE (Haskin et al., 2012; INCOG, 2014) Based on at least 1 well-designed class I study with an adequate sample, with support from class II/III evidence; providing substantive evidence to support a recommendation. Based on 1 or more class I studies with methodologic limitations (e.g., small sample), or well-designed class II studies. Based on class II or class III studies that directly address the efficacy of a treatment; for Level C, recommendations supported by expert opinion.

CSBPR Levels of Evidence

Selected Sources of Evidence Eskes, G. A. (2015). Canadian stroke best practice recommendations: Mood, cognition and fatigue: Following stroke practice guidelines update 2015. International Journal of Stroke, 10(7), 1130-1140. Gillen, G. et al. (2015). Effectiveness of interventions to improve occupational performance in people with cognitive impairments after stroke: A systematic review. AJOT, 69 (1), 6901180040. Haskins, et al., (2012). Cognitive rehabilitation manual: Translating evidence-based recommendations into practice. Reston, Virginia: ACRM. (TBI & Stroke) INCOG guidelines for cognitive rehabilitation following traumatic brain injury (2014). Journal of Head Trauma Rehabilitation, 29 (4). Poulin, V., Korner-Bitensky, N., Dawson, D., & Bherer, L. (2012). Efficacy of executive function interventions after stroke: A systematic review. Topics in Stroke Rehabilitation, 19(2), 158-171. Radomski, M. et al. (2016). Effectiveness of interventions to address cognitive impairments and improve occupational performance after traumatic brain injury: A systematic review. AJOT, 70(3), 7003180050. Stroke best practice recommendations. http://www.strokebestpractices.ca/

Practice Standard: Level A Evidence Strategies to improve the capacity to analyze and synthesize information should be used with adults with TBI who have impaired reasoning skills (problem-solving training). Direct corrective feedback should be used with adults with impaired self-awareness should be delivered in therapeutic, multi-contextual program.

Practice Guideline: Level B Evidence Group-based interventions may be considered for remediation of executive and problem-solving deficits

CSBP Recommendations (Eskes et al., 2015) Interventions for cognitive impairment should be tailored a) Goals should be patient-centred (Level B) b) Goals & interventions should take into account the cognitive and communication profile (Level C) c) Interventions should be individualized, based on best available evidence and have the long-term goal to facilitate resumption of desired activities (e.g., leisure, financial management); d) Compensation strategy training should focus on teaching strategies to manage impairments and is often directed at specific activity limitations to promote independence (Level B); e) It is reasonable to treat attention impairments with computerized skill training under the supervision of a therapist (Level B).

Can they understand the parts of the approach Is something is happening, does the client recognize it, and do something about it? Can the person generalize and transfer? What supports are needed in order for people use a problem-solving approach We are particularly concerned about online awareness in the moment & anticipatory Haskins et al., 2012 if awareness if very poor might need some experiential stuff second question would be goal setting or relating to everyday tasks so have new experience of themselves With an occupational focus. Create supportive environment, environmental supports NB: Awareness is an ongoing issue so have to keep coming back to this.

Self-awareness may ultimately be understood as the result of a complex combination of psychological and neuropsychological factors, which are affected by the (pathology) and by the individual s personality and previous experiences (Hart et al., JHTR, 2005)

Crosson s Model (1989) Anticipatory Emergent Intellectual

Intervene when. Ownsworth & Clare, 2006 1. The likelihood of heightened emotional distress is relatively low*... 2. AD represent a probable barrier to client's own goals 3. AD pose a significant safety risk which cannot managed effectively in other ways 4. Resources are available closely monitoring the individual's emotional well-being and coping reactions. *Rarely measured: Engel, Chui, Goverover & Dawson, 2017, Neuropsych Rehabil

Addressing Deficits in Awareness (Fleming & Ownsworth, 2006) Build a collaborative alliance Select personally relevant tasks engage in goal setting Structure opportunities to identify errors and correct performance Compare performance to the person s own expectations (predict/perform) Provide clear & tailored feedback Engage in goal setting

Awareness interventions that optimize occupational performance outcomes Engel, Chui, Goverover & Dawson, 2017, Neuropsych Rehab

But

1. Therapist introduces task Predict-Perform 2. Clients asked to Define performance goals including task completion time Predict performance Anticipate and pre-plan for errors / obstacles Choose a strategy to circumvent difficulties Assess amount of assistance needed 3. Perform task (experiential participation in everyday life task) 4. Self-estimate performance / self-evaluate 5. Discussion / feedback with therapist 6. Client records the experience including tips for success the next time

Perceive Predict - Perform Paradigm Perceive Predict Perform (Ap)Prove

What kind of feedback? Schmidt, Fleming et al. (2013). Neurorehabil & Neural Rep RCT Participants were videotaped doing a meal preparation task four times Pause, prompt, praise feedback throughout Primary outcome was error count during task Feedback session after every meal prep Watched video together and discussed Verbal feedback and discussion only Self-rating of independence on meal prep / experiential feedback

Feedback to enhance error awareness (Ownsworth et al., 2006) PAUSE to provide an opportunity for client to self-correct PROMPT - Non-specific: What is happening? - Specific: Check the recipe and find the first ingredient. Put it in the mixing bowl. PRAISE

Meta-cognitive & Problem-Solving Training

Self-instructional techniques ª Woman with bilateral parietal strokes ª Able to follow single step commands ª Dependent in many ADLs, behaviours were erratic ª Visual cue cards and routine therapy ineffective

Basic occupational example

A General Algorithm for Training of Executive Function Awareness (of problem to be addressed or goal to be attained) Anticipation and planning Execution and self-monitoring Self-evaluation

Comparison of some rubrics Problem-Solving (Ben-Yishay & Diller, 1983 ) ORIENT to problem FORMULATE problem ANALYZE conditions of problem Formulate STRATEGY & PLAN of Action Choose relevant TACTICS EXECUTE plan COMPARE solution to problem GPDR (Ylvisaker & Feeney, 1998) Goal Plan Do Review Levine 2000, 2011 Stop Define List Learn Do Check CO-OP (Polatajko & Mandich, 2001) Goal Plan Do Check Executive Plus (Gordon et al., 2006) Stop What is the problem? Alternative? Pick, Plan Satisfied? SWAPS

Common Elements in Formal Problem-Solving Training Awareness: Is there a problem? Acquisition: Therapist trains patient in the rationale and procedures of the model being used. Application: Client begins to use the model on various tasks in the clinic. Adaptation: Client applies the skills learned in the first two stages to problems and tasks outside the clinic.

Manualized Theoretically based primary objective is to train patients to stop ongoing behaviour in order to define goal hierarchies and monitor performance (Levine et al., 2011) 9 modules, 2 hours each STOP, mindfulness, task splitting

Evidence for Benefits http://goalmanagementtraining.weebly.com/ Has been studied in relation to aging, TBI, stroke, spina bifida, multiple sclerosis, abstinent polysubstance abuse, post-critical patients

Goal Management Training (Levine et al,. 2011)

Task-Specific Training

What about those with more severe cognitive impairments? Direct corrective feedback should be used with adults with impaired self-awareness should be delivered in therapeutic, multi-contextual program.

The Neurofunctional Approach Giles, 2005; Wilson, Giles & Baxter, 2014 1. Development of therapeutic alliance focus on client s value and goals; 2. Gather and assimilate information to understand client s current functioning in their own environment and to identify their likely responses to intervention; 3. Task Analysis task, client, environment; 4. Reconcile client s goals with available resources divide task into relevant units that can be learned. 5. Create specific skill-retraining programmes incorporating aids and supports as needed including errorless learning during acquisition if necessary; 6. Repetition keeping in mind principles of motor learning; 7. Generalize to client s context and facilitate maintenance of skill consider ongoing supports that will be necessary; 8. Provide feedback to encourage progress and engagement.

Vanderploeg et al., 2008, Arch Phys Med Rehab: Benefits Evidence (independence in everyday life) for more severely injured individuals (possibly for older, less education individuals) Rotenberg et al., 2012, Neuropsych Rehabil: Benefits for community dwelling severely impaired adults with chronic stroke

Cognitive Process-Specific Training? CSBPR: Direct remediation/cognitive skill training should focus on providing intensive specific training to directly improve the cognitive domain. It can include drill & practice exercises or computer-based tools directed at specific deficits (Level B evidence). Evidence for impact on activity or participation limitations is limited and requires more research (Level C). However, sole reliance on repeated exposure and practice on computer-based tasks without some involvement and intervention by a therapist is not recommended.

Recent review results

Sigmundsdottir et al., 2016

Recent review results

CogMed* Study Design Results Akerulnd et al., 2013 Bjorkdahl et al., 2012 Johannson et al., 2012 RCT, PeDRO 5, n-47 RCT, PeDRO 3, n=45 Case series No OP changes Sign but small changes on AMPS Imp on COPM Lundqvist et al., 212 RCT, PeDRO 4, n=21 Imp on satisfaction (COPM) not performance *Bogdanova et al., 2015

Exercise

Don t forget to exercise! CSBPG: Aerobic exercise can improve EF although evidence for transfer to participation is limited. (Level B)

Managing the manifestation of executive dysfunction in everyday life: The CO-OP Approach TM GOAL CHECK PLAN DO

Learning objectives At the end of this mini-workshop you will have: 1.An understanding of how and why CO-OP is used with adults and older adults with executive cognitive dysfunction (ED); 2.An understanding of the key elements of CO-OP and their application for individuals with ED. 3.Knowledge regarding the evidence relating to the use of CO-OP with adults with ABI and stroke. 4.Practiced techniques of dynamic performance analysis and guided discovery. 5.Considered how these techniques can be applied to personal clinical practice.

Cognitive Orientation to daily Occupational Performance (CO-OP) a client-centred, performance-based, problem solving, approach that enables skill acquisition through a process of strategy use and guided discovery. (Polatajko & Mandich, 2004, p. 2).

CO-OP engages the client at a metacognitive level in an iterative process of dynamic performance analysis and solution creation and evaluation. -International CO-OP Academy Executive, 2014 http://co-opacademy.ca/

Four major objectives 1. Skill acquisition 2. Strategy use 3. Generalization 4. Transfer Polatajko and Mandich 58 CO-OP: Goal

Theory for use with Impairments in We hypothesize that: Frontal Processes üglobal strategy use compensates for executive cognitive impairments and for impairments in the integrative functions in the frontal poles; üimpairments in self-regulation may be partially addressed through the use of this strategy, which by its very nature encourages people to monitor their behaviours; ühaving clients actively involved in identifying problems in their daily lives is engaging - they want to change and set goals accordingly.

Evidence (in adults with cognitive impairments) Adults with ABI 1. Dawson et al. (2009). Using the cognitive orientation to occupational performance (CO-OP) with adults with traumatic brain injury. Canadian Journal of Occupational Therapy, 76, 115-127. 2. Dawson et al. (2013). Occupation-based strategy training for adults with traumatic brain injury: A pilot study. Archives of Physical Medicine & Rehabilitation, 94(10), 1959-1963.. 3. Dawson et al. (2013). Managing executive dysfunction following acquired brain injury and stroke using an ecologically valid rehabilitation approach: A protocol for a randomized, controlled trial. Trials, 14. 4. Ng, E., Dawson, D. (2013). Telerehabilitation for addressing executive dysfunction after traumatic brain injury. Brain Injury, 27(5), 548-564. Adults with Stroke 5. Skidmore Dawson, D. et al. (2011). The feasibility of meta-cognitive strategy training in acute inpatient stroke rehabilitation: A case report. Neuropsychological Rehabilitation, 21, 208-223. 6. Skidmore, E. R., Dawson, D. R., et al. (2014). Developing complex interventions: Lessons learned from a pilot study examining strategy training in acute rehabilitation. Clinical Rehabilitation, 28(4), 378-387. 7. Skidmore, E., Dawson, D., et al. (Dec. 2015). Strategy training may reduce disability in the first six months post-stroke. Neurorehabilitation and Neural Repair. 8. Poulin, V., Dawson, D. (2016). Comparison of two cognitive interventions for adults experiencing executive dysfunction post-stroke: A pilot study. Disability & Rehabilitation. Older Adults with Age-related Executive Changes 9. Dawson, et al. (2014). An occupation-based strategy training approach to managing age-related executive changes: A pilot randomized controlled trial. Clinical Rehabilitation, 28(2), 118-127.

CO-OP Key Features

Client Chosen Goals COGNITIVE ORIENTATION to daily OCCUPATIONAL PERFORMANCE CO-OP Dynamic Performance Analysis Cognitive Strategy Use Essential Elements Guided Discovery Enabling Principles Parent Significant other involvement Structural Elements Intervention Format

Establish goal Establish baseline performance Do the DPA (iteratively) Use GPDC (throughout) Plan DSS The CO-OP Process Goal DPA GD Use Guided Discovery (throughout) Identify DSS s (throughout) Use Enabling Principles (throughout) Post-test No Check Do Skill Acquisition Yes Polatajko and Mandich

Pre-requisites Client Polatajko and Mandich 67 CO-OP: Getting Started Able to identify at least 3 occupational performance difficulties. Sufficient language fluency Behavioural responsiveness

Pre-requisites Therapist Polatajko and Mandich 68 CO-OP: Getting Started Client-centred philosophy Understanding of disability Behavioural management Effective communication Activity analysis Learning theory Working with parents

Goal Setting 1. The COPM 2. The Activity Card Sort 3. Daily Log

Establish Baseline Performance

Establishing Baseline Performance Performance Quality Rating Scale - Observational, performance measure - 10 point Likert-type scale - 1=no activity criteria are met - 10=all activity criteria are met with good quality

Dawson, 2012 72 Establishing baseline with goals you cannot observe

Dynamic Performance Analysis

DYNAMIC PERFORMANCE Objectives ANALYSIS to identify performance problems to begin hypothesizing about potential strategies to enable performance Refers to ongoing analysis with client of their performance. Use of activity analysis to identify performance problems or areas of breakdown, use of guided discovery to assist client in problem-solving regarding where performance is breaking down Iterative process Intervention is then guided accordingly.

DPA What s going wrong with: individual environment task? behavioral analysis CO-OP: DPA Task analysis What s the underlying problem: neurodevelopmental sensory-motor visual perceptual? component analysis Polatajko and Mandich 75

Key Feature: Cognitive Strategy Use

Polatajko and Mandich 77 CO-OP: Skill Acquisition Through Strategy Use Cognitive Strategy: a cognitive tool put into place to help learn, memorize and problem solve a goal directed, cognitive operation used to facilitate learning and problem solving a skill under consideration (Paris 1989)

Polatajko and Mandich 78 Why use strategies? Learners should know more about how to manage their own cognitive strategies, and how to analyse themselves and the situational demands in order to improve learning and performance.

Types Global Strategy Polatajko and Mandich 79 CO-OP: Cognitive Strategies Domain Specific Strategy (DSS)

Introducing the global strategy Introduce the strategy Go over definitions for each part of the strategy Check participant s understanding using examples GOAL PLAN DO CHECK

What are Domain Specific Strategies? Strategies that are specific to a particular task & situation (cognitive and/or other strategies). They are introduced to solve specific performance issues as they arise. Domain specific strategies may differ between people performing the same task. DPA is used in CO-OP to determine the need for DSS. Used only when needed! (Polatajko & Mandich, 2004)

V E R B A L G U I D A N C E Domain Specific Strategies Body position Attention to task Task specification/modification Supplementing task knowledge Feeling the movement 2V s Verbal motor mnemonic / Verbal rote script Polatajko and Mandich 82

Body Position Verbalization of attention to or shift of the body, whole or part relative to the task Therapist: Is that the foot you usually start with?

Attention to Doing Verbalization to cue attending to the doing of the task Therapist: The kettle is boiling. Polatajko and Mandich 84

Task Modification Discussions regarding the modification of the task or parts of the task that facilitate performance Decrease speed to accomplish task Use non-impaired hand to do task Provision of any adapted equipment, such as modified cutting board Polatajko and Mandich

Supplementing Task Knowledge Verbalization of the specifics of a task -things - things that cannot be discovered or that are not central to the focus of attention. Therapist To save the file, click on file and then on save. Polatajko and Mandich

Circumstance Polatajko and Mandich 87 Strategies as Solutions When the Client does not have enough information to specify the GOAL or PLAN When the Client does not DO the plan When the Client can do the task but required verbal guidance to practice Strategies Used Supplementing task knowledge Task specification Mnemonic Attention to doing Task modification Body position Feeling the movement Verbal Guidance Verbal self-guidance Verbal Rote Script

Bottari et al., 2014. 88 Consider cognitive demand related to strategy use

Key Feature: Guided Discovery

Guided Discovery Guided discovery is a way of using language to guide the participant to discover strategies and make plans to solve their problems or to make plans to work toward their goals.

Figure it out on your own! Low: Discovery Learning Instructor Control Try to do it out on your own but I will help you if you get stuck. Continuum Mid: Guided Discovery High: Explicit Instruction I will tell you what to do! 91

Ask, don t tell! Guided Discovery Coach, don t adjust! Guided Discovery Make it obvious! One thing at a time!

How much guided discovery do we usually do in our practice? Urquhart & Skidmore, OTJR, 2014

Purpose Study on Guided Discovery Brennan, Morrison, Bottari, Hunt, LeDorze & Dawson, in prep. 1. To describe the verbalizations utilized by the therapist in the context of guided discovery; 2. To determine if some verbalizations were more effective than others at promoting plan formulation.

Results: Effectiveness of strategy for promotion of goal attainment Frequency of progress

Guided Discovery: Hierarchy Asking broadly Coaching (e.g., Can you tell me more about that? ) One thing at a time (e.g., I m hearing a few different things in the plan can you tell it to me one part at a time?) Describing alternatives (e.g., from another client or self) Suggesting alternatives Dawson & Hunt, 2013

Guided Discovery Cues ü What do you usually do? (What have you done in the past?) ü How did that work? ü How are you doing? (How is it going?) ü Tell me more about that. ü What s next? ü That s the good thing about plans, if one doesn t work you can always make another one. ü I think we re a little off track here, let s bring it back to G-P-D-C. ü Okay, let s stick with the plan. ü How will you know that plan worked? ü You said your plan didn t work, but your plan actually did work. ü So let me understand what you are saying ü Sometimes a plan will be that we can do it together. ü Affirmations (good, great idea, etc.) Dawson & Hunt, 2013

Scenario: Guided Discovery David is trying to find a phone number in his daytimer. Mary said where do you keep your phone numbers? What other GD verbalizations might you use?

Scenario: Guided Discovery A participant s goal is to stop burning food on the stove. Rather than directly telling the participant how to solve the problem (e.g. by setting a timer) the facilitator guides the participant to discover a solution on their own.

Guided Discovery Examples

Key Feature: Enabling Principles

ü Make it fun ü Promote learning Polatajko and Mandich 102 Enabling Principles ü Work towards independence ü Promote generalization and transfer

Promoting Learning?