ACRM 2015 GOALS-hand-outPOSTER
1
Long Term Follow-up (6ms-2yrs post training) Neuropsychological Assessment Performance Complex Attention & Executive Functions Complex Functional Task Performance Goal Processing Scale (GPS) Emotional Adjustment Self-Assessment of Emotional Adjustment / Regulation Profile of Mood States Conclusion Consistent with the results of the pilot study (Novakovic-Agopian , 2011), preliminary results indicate that post GOALS training participants significantly improved on neuropsychological measures of attention/executive function, complex functional task performance, and indicated improvements in emotional adjustment and daily functioning. At the time of the follow-up, conducted up to 2 years post training, participants maintained most of these gains. Preliminary results suggest that GOALS training may improve cognitive functioning with ecologically significant impacts for Veterans w ith chronic TBI and executive dysfunction. Furthermore, improving executive control functions may also improve functioning in other domains, such as functional performance in daily lives and emotional health. Intervening to improve cognitive functioning may be valuable even during chronic stages of injury. Executive Function Training in Veterans with Chronic TBI: Short and Longer Term Outcomes Novakovic-Agopian T., Abrams G., Chen A., Carlin G., Burciaga, J., Loya F., Madore M., Murphy M., Lau, K., Mayer C., Kornblith, E, Marton K. & Rodriguez N. San Francisco VAMC, VA NCHCS in Martinez, University of California San Francisco and Berkeley Support from VA Rehabilitation Research & Development Contact: [email protected] Introduction Deficits in executive control processes, including selection, maintenance, organization and execution of goal-relevant information and activities, are some of the most disabling consequences of brain injury. Challenges in development and evaluation of intervention effectiveness include defining specific targets of therapy, assessing change in functioning at different levels, as well as maintenance over time. Goal-Oriented Attentional Self-Regulation (GOALS) is an executive function training designed to target deficits in executive control processes with training in attention regulation applied to participant-defined goals. In an initial study individuals with chronic acquired brain injury significantly improved post GOALS, but not post brief control intervention, on measures of: attention/executive function and memory, functional task performance, and goal- directed control over neural processing on fMRI (Novakovic- Agopian, Chen et al 2011; Chen, Novakovic-Agopian et al 2011). The objective of this ongoing study is to assess the short and long term effectiveness of GOALS in Veterans with chronic TBI and executive dysfunction. Interventions The GOALS training focuses on: • Attention regulation skill building • Applying attention regulation and problem solving strategies to participant-defined goals/projects and daily life Participants and Methods Thirty Two Veterans with a history of chronic TBI (6+months) completed a training program consisting of 5 weeks of GOALS training, and 5 weeks Brain Health Education (EDU) comparison training. All participants were on a stable medication regimen and had residual mild to moderate functional deficits, including an evidence of dysfunction in frontal executive functions. Evaluators were blinded to intervention assignment Results Post Training Neuropsychological Assessment Performance Complex Attention & Executive Functions Consistent with the results of the pilot study, participant’s performance significantly improved on measures of complex attention and executive function post GOALS, but not post EDU training. Complex Functional Task Performance Goal Processing Scale- (GPS) Post GOALS training participants performance significantly improved on the: Overall GPS Performance, as well as on Planning, Self-Monitoring, Maintenance of attention, Switching of Attention, Task Execution, and Memory subdomains. Post EDU training there was no significant change in performance. Emotional Adjustment Self-Assessment of Emotional Adjustment / Regulation Profile of Mood States Post GOALS training participants indicated significant decrease POMS Total Mood Disturbance summary score, and in sub-scores of Confusion, Tension, Depression, and Anger. Post EDU training there were no significant changes. Suppression of non-relevant processing Sources of cognitive noise Internal External Goal-directed information processing Selection of Goal-Relevant Information GOALS Session Outline Session 1 Introduction and overview Session 2 Absentmindedness and mindfulness Session 3 Progressive information maintenance: Mindfulness exercices Session 4 Goal selection: Discuss options for group and individual projects Session 5 Breaking down projects into sub-tasks, creating timeline. Apply to group and individual projects Session 6 Execution and dealing with procrastination Session 7 Staying on tasks, error correction and adjustments Session 8 Project progress review and adjustments Session 9 Individual project presentation Session 10 Group project presentation and graduation celebration Applied Mindfulness Based Attention Regulation Applied Goal Management Baseline Weeks 1 - 5 Weeks 6 - 10 Follow-up 6 – 24 Month Group 1 GOALS Training: 23 hour group/individual 20 hour homework Self maintained practice Self maintained practice Group 2 EDU Training 23 hour group/individual 20 hour homework GOALS Training: 23 hour group/individual 20 hour homework Assessment 1 Assessment 2 Assessment 3 Brain Health Education - EDU Control intervention matching GOALS in therapist time and intensity Session 1 Introduction and Basic Brain Anatomy Session 2 Neuroplasticity Session 3 Movement, Vision and Language Session 4 Memory Session 5 Attention and Executive Functions Session 6 Sleep and the Brain Session 7 Diet and Physical Activity and the Brain Session 8 Stress and the Brain Session 9 Emotions and the Brain Session 10 Social Bonds and the Brain/ Lessons Learned Neuropsychological Assessment Complex Attention and Executive Function Working Memory Letter Number Sequencing Auditory Consonant Trigrams Sustained Attention Digit Vigilance–time & errors Mental Flexibility Design & Verbal Fluency Switching Trails B Stroop Inhibition /Switching- time & errors Inhibition Stroop Inhibition –time & errors Learning and Memory Hopkins Verbal Memory Test - Revised Brief Visual Memory Test - Revised Functional Performance Complex Functional Task Performance Goal Processing Scale (GPS) Self-Assessment of Functional Performance in Daily Life Mayo Portland Adaptability Inventory (MPAI) Goal Processing Questionnaire (GPQ) Emotional Adjustment Self-Assessment of Emotional Adjustment / Regulation Profile of Moods States (POMS) Beck Depression Inventory II (BDI II) Post-Traumatic Checklist-Military (PCL-M) 79% (22/28) completed structured interview 68% (19/28) completed assessments 91% (20/22) participants reported continuing to use some of trained strategies in their daily lives: • Stop Relax Refocus • Stop and review one’s w ork • Prioritize daily tasks / Break larger tasks into subtasks 45% (10/22) reported returning to competitive work, as compared to 23% (5/22) prior to training. 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Transcript of ACRM 2015 GOALS-hand-outPOSTER
Long Term Follow-up(6ms-2yrs post training)
Neuropsychological Assessment PerformanceComplex Attention & Executive Functions
Complex Functional Task PerformanceGoal Processing Scale (GPS)
Emotional Adjustment Self-Assessment of EmotionalAdjustment / Regulation
Profile of Mood States
ConclusionConsistent with the results of the pilot study (Novakovic-Agopian ,2011), preliminary results indicate that post GOALS trainingparticipants significantly improved on neuropsychologicalmeasures of attention/executive function, complex functional taskperformance, and indicated improvements in emotional adjustmentand daily functioning. At the time of the follow-up, conducted up to2 years post training, participants maintained most of these gains.
Preliminary results suggest that GOALS training may improvecognitive functioning with ecologically significant impacts forVeterans with chronic TBI and executive dysfunction. Furthermore,improving executive control functions may also improvefunctioning in other domains, such as functional performance indaily lives and emotional health. Intervening to improve cognitivefunctioning may be valuable even during chronic stages of injury.
Executive Function Training in Veterans with Chronic TBI: Short and Longer Term OutcomesNovakovic-Agopian T., Abrams G., Chen A., Carlin G., Burciaga, J., Loya F., Madore M., Murphy M., Lau, K., Mayer C., Kornblith, E, Marton K. & Rodriguez N.
San Francisco VAMC, VA NCHCS in Martinez, University of California San Francisco and BerkeleySupport from VA Rehabilitation Research & Development
Contact: [email protected]
IntroductionDeficits in executive control processes, including selection,maintenance, organization and execution of goal-relevantinformation and activities, are some of the most disablingconsequences of brain injury. Challenges in development andevaluation of intervention effectiveness include defining specifictargets of therapy, assessing change in functioning at differentlevels, as well as maintenance over time.
Goal-Oriented Attentional Self-Regulation (GOALS) is an executivefunction training designed to target deficits in executive controlprocesses with training in attention regulation applied toparticipant-defined goals. In an initial study individuals with chronicacquired brain injury significantly improved post GOALS, but notpost brief control intervention, on measures of: attention/executivefunction and memory, functional task performance, and goal-directed control over neural processing on fMRI (Novakovic-Agopian, Chen et al 2011; Chen, Novakovic-Agopian et al 2011).
The objective of this ongoing study is to assess the short and longterm effectiveness of GOALS in Veterans with chronic TBI andexecutive dysfunction.
InterventionsThe GOALS training focuses on:
• Attention regulation skill building• Applying attention regulation and problem solving strategies
to participant-defined goals/projects and daily life
Participants and MethodsThirty Two Veterans with a history of chronic TBI (6+months)completed a training program consisting of 5 weeks of GOALStraining, and 5 weeks Brain Health Education (EDU) comparisontraining. All participants were on a stable medication regimen andhad residual mild to moderate functional deficits, including anevidence of dysfunction in frontal executive functions. Evaluatorswere blinded to intervention assignment
ResultsPost Training
Neuropsychological Assessment PerformanceComplex Attention & Executive Functions
Consistent with the results of the pilot study, participant’sperformance significantly improved on measures of complexattention and executive function post GOALS, but not post EDUtraining.
Complex Functional Task PerformanceGoal Processing Scale- (GPS)
Post GOALS training participants performance significantlyimproved on the: Overall GPS Performance, as well as on Planning,Self-Monitoring, Maintenance of attention, Switching of Attention,Task Execution, and Memory subdomains. Post EDU training therewas no significant change in performance.
Emotional AdjustmentSelf-Assessment of Emotional Adjustment / Regulation
Profile of Mood States
Post GOALS training participants indicated significant decreasePOMS Total Mood Disturbance summary score, and in sub-scores ofConfusion, Tension, Depression, and Anger. Post EDU training therewere no significant changes.
Suppressionof non-relevant
processing
Sources ofcognitive noise
InternalExternal
Goal-directedinformationprocessing
Selection ofGoal-Relevant
Information
GOALS Session Outline
Session 1 Introduction and overview
Session 2 Absentmindedness and mindfulness
Session 3 Progressive information maintenance:Mindfulness exercices
Session 4 Goal selection:Discuss options for group and individual projects
Session 5 Breaking down projects into sub-tasks, creating timeline.Apply to group and individual projects
Session 6 Execution and dealing with procrastination
Session 7 Staying on tasks, error correction and adjustments
Session 8 Project progress review and adjustments
Session 9 Individual project presentation
Session 10 Group project presentation and graduation celebration
App
lied
Min
dful
ness
Bas
edA
tten
tion
Reg
ulat
ion
App
lied
Goa
lMan
agem
ent
Baseline Weeks 1 - 5 Weeks 6 - 10 Follow-up6 – 24 Month
Group 1
GOALS Training:23 hourgroup/individual20 hour homework
Self maintainedpractice
Self maintainedpractice
Group 2
EDU Training23 hourgroup/individual20 hour homework
GOALS Training:23 hourgroup/individual20 hour homework
Asse
ssm
ent
1
Asse
ssm
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2
Asse
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Brain Health Education - EDUControl intervention matching GOALS
in therapist time and intensitySession 1 Introduction and Basic Brain Anatomy
Session 2 Neuroplasticity
Session 3 Movement, Vision and Language
Session 4 Memory
Session 5 Attention and Executive Functions
Session 6 Sleep and the Brain
Session 7 Diet and Physical Activity and the Brain
Session 8 Stress and the Brain
Session 9 Emotions and the Brain
Session 10 Social Bonds and the Brain/ Lessons Learned
Neuropsychological Assessment
Complex Attention and Executive FunctionWorking MemoryLetter Number SequencingAuditory Consonant Trigrams
Sustained AttentionDigit Vigilance–time & errors
Mental FlexibilityDesign & Verbal Fluency SwitchingTrails BStroop Inhibition /Switching- time & errors
InhibitionStroop Inhibition –time & errors
Learning and MemoryHopkins Verbal Memory Test - Revised Brief Visual Memory Test - Revised
Functional Performance
Complex Functional Task PerformanceGoal Processing Scale (GPS)
Self-Assessment of Functional Performance in Daily LifeMayo Portland Adaptability Inventory (MPAI)Goal Processing Questionnaire (GPQ)
Emotional Adjustment
Self-Assessment of Emotional Adjustment / RegulationProfile of Moods States (POMS)Beck Depression Inventory II (BDI II)Post-Traumatic Checklist-Military (PCL-M)
79% (22/28) completed structured interview68% (19/28) completed assessments91% (20/22) participants reported continuing to use some oftrained strategies in their daily lives:
• Stop Relax Refocus• Stop and review one’s work• Prioritize daily tasks / Break larger tasks into subtasks
45% (10/22) reported returning to competitive work, ascompared to 23% (5/22) prior to training.
Asse
ssm
ent
4
