Executive Function Poststroke: Concepts, Recovery, and Interventions.

Executive function is frequently impaired among people who have sustained stroke. This review provides an overview of definitions, concepts, and measures. The review also summarizes current best evidence examining executive function impairment and recovery trajectories after stroke, correlates of change over time, and emerging intervention research. Finally, this review provides recommendations for research and clinical practices, as well as priorities for future executive function research.

Validation of the NIH Toolbox-Cognition Battery against legacy neurocognitive measures in adults with cognitive impairments: An exploratory analysis.

OBJECTIVE: The purpose of this exploratory study was to describe associations between NIH Toolbox-Cognition Battery subtests and legacy measures of neurocognitive function in two samples with neurological conditions (stroke and sickle cell disease (SCD)). METHOD: This exploratory secondary analysis uses data from two studies that assessed cognition at one time point using the NIH Toolbox-Cognition Battery, the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and subtests from the Delis-Kaplan Executive Functions System (DKEFS). People with stroke (n = 26) and SCD (n = 64) were included. Associations between the NIH Toolbox-Cognition Battery subtests and corresponding legacy measures were examined using linear correlations, Bland-Altman analysis, and Lin's Concordance Correlation Coefficient. RESULTS: Linear correlations and Lin's Concordance Correlation Coefficient were poor to strong in both samples on NIH Toolbox-CB subtests: Flanker Inhibitory Control and Attention (r = .35 to .48, Lin CCC = .27 to .37), Pattern Comparison Processing Speed (r = .40 to .65, Lin CCC = .37 to .62), Picture Sequence Memory (r = .19 to .55, Lin CCC = .18 to .48), Dimensional Change Card Sort (r = .39 to .77, Lin CCC = .38 to .63), Fluid Cognition Composite (r = .88 to .90, Lin CCC = .60 to .79), and Total Cognition Composite (r = .64 to .83, Lin CCC = .60 to .78). Bland-Altman analyses demonstrated wide limits of agreement across all subtests (-3.17 to 3.78). CONCLUSIONS: The NIH Toolbox-Cognition Battery subtests may behave similarly to legacy measures as an overall assessment of cognition across samples at risk for neurological impairment. Findings should be replicated across additional clinical samples.

The Moderating Role of Motivation in the Real-Time Associations of Fatigue, Cognitive Complaints, and Pain With Depressed Mood Among Stroke Survivors: An Ecological Momentary Assessment Study.

OBJECTIVE: Stroke symptoms fluctuate during the day as stroke survivors participate in daily activities. Understanding the real-time associations among stroke symptoms and depressed mood, as well as the role of motivation for daily activities, informs, and post-stroke symptom management in the context of everyday living. This study aimed to (1) investigate the real-time associations of fatigue, cognitive complaints, and pain with depressed mood and (2) examine the role of motivation for daily activity participation as a potential moderator of these associations in stroke survivors. DESIGN: A prospective cohort study involving 7 days of ecological momentary assessment (EMA), during which participants completed 8 EMA surveys per day. Multilevel modeling was used to analyze data. SETTING: Community. PARTICIPANTS: Forty community-dwelling stroke survivors (N=40). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: EMA measures of depressed mood, stroke symptoms (physical and mental fatigue, cognitive complaints, and pain), and motivation (autonomous motivation, controlled motivation). RESULTS: Higher levels of within- and between-person physical fatigue, mental fatigue, cognitive complaints, and pain were momentarily associated with greater depressed mood (Ps<.001). Within-person autonomous motivation significantly buffered the momentary associations of physical fatigue (B=-0.06, P<.001), mental fatigue (B=-0.04, P=.032), and pain (B=-0.21, P<.001) with depressed mood. CONCLUSIONS: Findings indicate the momentary associations of fatigue, cognitive complaints, and pain with depressed mood in stroke survivors. Autonomous motivation underpinning daily activity participation was found to buffer the associations of fatigue and pain with depressed mood. Promoting autonomous motivation for daily activity participation may be viable for preventing and mitigating poststroke depression.

Stakeholders' Experiences Using Videoconferencing for a Group-Based Stroke Intervention During COVID-19: A Thematic Analysis.

IMPORTANCE: Guidance is limited for training protocols that support stakeholders who are new to participating in telerehabilitation interventions using videoconferencing software. OBJECTIVE: To explore stakeholders' experiences participating in a group-based intervention during the coronavirus disease 2019 (COVID-19) pandemic using a videoconferencing software (Zoom). DESIGN: Ad hoc exploratory thematic analysis. SETTING: Community-based telerehabilitation. PARTICIPANTS: Stakeholders included group members (n = 8) who were low-income adults with chronic stroke (≥3 mo) and mild to moderate disability (National Institutes of Health Stroke Scale ≤ 16), group leaders (n = 4), and study staff (n = 4). INTERVENTION: Group-based intervention, ENGAGE, delivered using videoconferencing technology. ENGAGE blends social learning and guided discovery to facilitate community and social participation. OUTCOMES AND MEASURES: Semistructured interviews. RESULTS: Stakeholders included group members (ages 26-81 yr), group leaders (ages 32-71 yr), and study staff (ages 23-55 yr). Group members characterized ENGAGE as learning, doing, and connecting with others who shared their experience. Stakeholders identified social advantages and disadvantages to the videoconferencing environment. Attitudes toward technology, past technology experiences, the amount of time allotted for training, group size, physical environments, navigation of technology disruptions, and design of the intervention workbook were facilitators for some and barriers for others. Social support facilitated technology access and intervention engagement. Stakeholders recommended training structure and content. CONCLUSIONS AND RELEVANCE: Tailored training protocols may support stakeholders who are participating in telerehabilitation interventions using new software or devices. Future studies that identify specific tailoring variables will advance the development of telerehabilitation training protocols. What This Article Adds: These findings provide stakeholder-identified barriers and facilitators, in addition to stakeholder-informed recommendations, for technology training protocols that may support uptake of telerehabilitation in occupational therapy.

Construct validity of the enfranchisement scale of the community participation indicators.

OBJECTIVE: This study examined the construct validity of the Enfranchisement scale of the Community Participation Indicators. DESIGN: We conducted a secondary analysis of data collected in a cross-sectional study of rehabilitation outcomes. SUBJECTS: The parent study included 604 community-dwelling adults with chronic traumatic brain injury, stroke, or spinal cord injury. The sample had a mean age of 64.1 years, was two-thirds male, and included a high proportion of racial minorities (n = 250, 41.4%). MAIN MEASURES: The Enfranchisement scale contains two subscales: the Control subscale and the Importance subscale. We examined correlations between each Enfranchisement subscale and measures of participation, environment, and impairments. The current analyses included cases with at least 80% of items completed on each subscale (Control subscale: n = 391; Importance subscale: n = 219). Missing values were imputed using multiple imputation. RESULTS: The sample demonstrated high scores, indicating poor enfranchisement (Control subscale: M = 51.7; Importance subscale: M = 43.0). Both subscales were most strongly associated with measures of participation (Control subscale: r = 0.56; Importance subscale: r = 0.52), and least strongly associated with measures of cognition (Control subscale: r = 0.03; Importance subscale: r = 0.03). The Importance subscale was closely associated with depression (r = 0.54), and systems, services, and policies (r = 0.50). Both subscales were associated with social attitudes (Control subscale: r = 0.44; Importance subscale: r = 0.44) and social support (Control subscale: r = 0.49; Importance subscale: r = 0.41). CONCLUSIONS: We found evidence of convergent validity between the Enfranchisement scale and measures of participation, and discriminant validity between the Enfranchisement scale and measures of disability-related impairments. The analyses also revealed the importance of the environment to enfranchisement outcomes.

Detecting change in community participation with the Enfranchisement scale of the community participation indicators.

OBJECTIVE: This study determined the sensitivity to change of the Enfranchisement scale of the Community Participation Indicators in people with stroke. DATA SOURCES: We analyzed data from two studies of participants with stroke: an intervention study and an observational study. MAIN MEASURES: The Enfranchisement Scale contains two subscales: the Importance subscale (feeling valued by and contributing to the community; range: 14-70) and the Control subscale (choice and control: range: 13-64). DATA ANALYSIS: Assessments were administered 6 months apart. We calculated minimum detectable change and minimal clinically important difference. RESULTS: The Control subscale analysis included 121 participants with a mean age of 61.2 and mild-moderate disability (Functional Independence Measure, mean = 97.9, SD = 24.7). On the Control subscale, participants had a mean baseline score of 51.4 (SD = 10.4), and little mean change (1.3) but with large variation in change scores (SD = 11.5). We found a minimum detectable change of 9 and a minimum clinically important difference of 6. The Importance subscale analysis included 116 participants with a mean age of 60.7 and mild-moderate disability (Functional Independence Measure, mean = 98.9, SD = 24.5). On the Importance subscale, participants had a mean baseline score of 44.1 (SD = 12.7), and again demonstrated little mean change (1.08) but with large variation in change scores (SD = 12.6). We found a minimum detectable change of 11 and a minimum clinically important difference 7. CONCLUSIONS: The Control subscale required 9 points of change, and the Importance subscale required 11 points of change, to achieve statistically and clinically meaningful changes, suggesting adequate sensitivity to change.

Effect of interventions on activity and participation outcomes for adults with brain injury: a scoping review.

OBJECTIVE: To characterize the intervention elements associated with improvements in activity and participation outcomes for adults with brain injury. DATA SOURCES: PubMed and PsycINFO/Ovid. STUDY SELECTION: We included RCTs that examined interventions for adults with acquired brain injury with an activity or participation outcome measure. DATA EXTRACTION: We classified intervention elements and extracted effect sizes. We examined patterns of effect sizes associated with each intervention element based on time of follow-up and level of outcome (home versus community). DATA SYNTHESIS: Thirty-nine articles were included. Outcomes focused on the performance of home and community activities. There was wide variation in effect sizes across all intervention elements, as well as by time and by outcome level (home versus community). Metacognitive interventions and daily life skills interventions showed the greatest promise for improving performance of home and community activities. Additionally, cognitive training interventions may play a role in improving home activity performance and social skills training interventions may play a role in community activity performance. Physical activity interventions showed the least promise for improving home and community activity performance. CONCLUSION: This study highlights the importance of interventions that incorporate explicit strategies and task-specific training, rather than only addressing specific injury-related impairments.

Promoting Routines of Exploration and Play during Mealtime: Estimated Effects and Identified Barriers.

Promoting Routines of Exploration and Play during Mealtime (Mealtime PREP) is an intervention designed to support healthy dietary variety in children. To estimate the effects of this intervention, we recruited 20 parents and children (aged 1-5 years) with sensory food aversions to participate in a pilot study. Parents were coached to enhance daily child meals using Mealtime PREP. Our primary outcome was acceptance of targeted food (number of bites) over time. Descriptive statistics and effect sizes are reported. Moderate effects were observed for acceptance of targeted food. Mealtime PREP warrants additional research to examine effects in larger, more diverse samples.

A Framework for Addressing Clients' Functional Cognitive Deficits After COVID-19.

Occupational therapy's focus on functional cognition offers a distinct approach to the assessment of and intervention for occupational performance deficits that may follow coronavirus disease 2019 (COVID-19). Although the majority of people survive COVID-19, many people experience persistent functional cognitive sequelae severe enough to interfere with occupational performance. After COVID-19, people may be categorized as either (1) those who experience severe or critical illness requiring hospitalization or (2) those with mild to moderate presentations of the virus without hospitalization. A third group of those who do not have ongoing signs of active infection but who experience new, lasting, or deteriorating symptoms has begun to emerge and may represent a distinct COVID-19 long-haul syndrome. By following the Occupational Therapy Practice Framework and using established processes for occupational therapy assessment and treatment of functional cognition, occupational therapy practitioners can tailor assessments and interventions to meet clients' needs.

Activating Behavior to Reduce Sedentary Behavior After Stroke: A Nonrandomized Pilot Feasibility Study.

IMPORTANCE: Reducing poststroke sedentary behavior is important for reducing recurrent stroke risk, yet interventions to achieve this are scant. OBJECTIVE: To assess the feasibility of, and estimate change in sedentary behavior over time associated with, a behavioral intervention. DESIGN: Single-arm delayed baseline with postintervention and 8-wk follow-up assessment. SETTING: Community based. PARTICIPANTS: Ambulatory, community-dwelling people with chronic stroke and reported ≥6 hr daily sitting time (N = 21). INTERVENTION: Activating Behavior for Lasting Engagement (ABLE) was delivered by an occupational therapist 3×/wk for 4 wk. ABLE involves activity monitoring, activity scheduling, self-assessment, and collaborative problem solving. OUTCOMES AND MEASURES: Feasibility (participant safety, adherence, satisfaction, and reliable intervention delivery) was assessed against preestablished benchmarks. Changes over time in sedentary behavior (assessed with an ActivPAL micro3 device) and participation (Stroke Impact Scale-Participation subscale) were described. RESULTS: ABLE was safe (0 serious adverse events), adhered to (11.95 sessions/participant), and reliably delivered (90.00%-97.50% adherence). Participant satisfaction was unmet (Client Satisfaction Questionnaire-8, M = 28.75, SD = 3.84). ABLE was associated with a mean group reduction in prolonged sitting of 54.95 min (SD = 81.10) at postintervention and 14.08 (SD = 58.95) at follow-up. ABLE was associated with a negligible mean group increase over time in participation at postintervention (M = 1.48%, SD = 8.52) and follow-up (M = 1.33%, SD = 15.38). CONCLUSIONS AND RELEVANCE: The ABLE intervention is feasible and may be associated with within-group reduction in sedentary behavior over time. Further refinement is indicated. WHAT THIS ARTICLE ADDS: The ABLE intervention uses engagement in meaningful daily activities to reduce sedentary behavior after stroke. These findings suggest that ABLE can be delivered safely and consistently. Further research is required to enhance participant satisfaction and determine the effects of ABLE on stroke survivors' sedentary behavior.

Adapting Strategy Training for Adults With Acquired Brain Injury: A Feasibility Study in a Chinese Population.

IMPORTANCE: Before introducing strategy training into a cross-cultural (Chinese) context, it is necessary to evaluate its feasibility. OBJECTIVE: To examine the feasibility of applying strategy training to improve participation outcomes of rehabilitation patients in Taiwan and evaluate the potential intervention effects. DESIGN: A single-group, repeated-measures study. SETTING: Rehabilitation outpatient settings. PARTICIPANTS: A convenience sample of adults (N = 20) with a primary diagnosis of acquired brain injury (ABI) and with cognitive impairment received the intervention and were assessed before and after it. INTERVENTION: The participation-focused strategy training intervention, a modified version of the strategy training intervention, was provided to participants in 1-2 sessions weekly for a total of 10-20 intervention sessions. OUTCOMES AND MEASURES: Feasibility indicators, Participation Measure-3 Domains, 4 Dimensions (PM-3D4D), and Canadian Occupational Performance Measure (COPM). RESULTS: Eighteen participants completed 100% of the scheduled intervention sessions. Participants had very good engagement in the intervention sessions with sufficient comprehension. Participants reported moderate to high satisfaction. Positive score changes were observed for the PM-3D4D (d = 0.46-1.25) and COPM scales (d = 1.82 and 2.12). CONCLUSIONS AND RELEVANCE: This study demonstrated the feasibility of delivering participation-focused strategy training in Taiwan to people with cognitive impairment after ABI. The preliminary evidence also showed that participants who received the strategy training intervention had positive changes in participation outcomes and in performance of their self-identified goals. On the basis of this study's findings, a larger clinical trial is warranted to evaluate the efficacy of the strategy training intervention. WHAT THIS ARTICLE ADDS: Participation-focused strategy training is feasible and acceptable for Taiwanese community-dwelling adults with cognitive impairment after ABI. However, because strategy training is quite different from traditional rehabilitation delivered in Taiwan, additional instructions and discussion among the therapist, client, and caregiver may be needed before the intervention is provided.

Clinical Predictors of Engagement in Inpatient Rehabilitation Among Stroke Survivors With Cognitive Deficits: An Exploratory Study.

OBJECTIVES: The purpose of this exploratory study was to identify clinical predictors that could distinguish clients' level of engagement in inpatient rehabilitation following stroke. METHODS: This is a secondary analysis of pooled data from three randomized controlled trials that examined the effects of a behavioral intervention. The sample (n=208) consisted of clients with stroke who had cognitive deficits (Quick-EXIT≥3) and were admitted to inpatient rehabilitation facilities associated with a university medical center. Individuals with pre-morbid dementia, aphasia and mood disorders were excluded. The Pittsburgh Rehabilitation Participation Scale was used to measure engagement. Clinical predictors were measured using the Functional Independence Measure, National Institutes of Health Stroke Scale, Repeatable Battery for the Assessment of Neuropsychological Status, selected subtests of the Delis-Kaplan Executive Function System, Patient Health Questionnaire-9, and Chedoke McMaster Stroke Assessment. Simple logistic regression identified individual clinical predictors associated with engagement. Hierarchical logistic regression identified the strongest predictors of engagement. RESULTS: Impairments in executive functions [mean D-KEFS, odds ratio (OR)=4.062; 95% confidence interval (CI)=.866, 19.051], impairments in visuospatial skills (RBANS Visuospatial Index Score, OR=3.940; 95% CI=1.317, 11.785), impairments in mood (Patient Health Questionnaire-9, OR=2.059, 95% CI=.953, 4.449), and male gender (OR=2.474; 95% CI=1.145, 5.374) predicted levels of engagement in inpatient rehabilitation after controlling for study intervention group, baseline stroke severity, and baseline disability. CONCLUSIONS: Executive functions, visuospatial skills, mood, and gender distinguished individuals with high or low engagement in inpatient rehabilitation following stroke. Further studies should examine additional factors that may influence engagement (therapist-client relationship, treatment expectancy). (JINS, 2018, 24, 572-583).

Self-Awareness and Recovery of Independence With Strategy Training.

OBJECTIVE: Poor self-awareness co-occurs with cognitive impairments after stroke and may influence independence in daily activities. Strategy training promotes independence after stroke, but poor awareness may attenuate treatment response. We examined the degree to which awareness status affected changes in independence attributed to strategy training. METHOD: We conducted a secondary analysis of 30 participants with cognitive impairments after acute stroke randomized to strategy training or attention control in addition to typical inpatient rehabilitation. We measured awareness with the Self-Awareness of Deficits Interview and independence with the FIM™. Data were analyzed using general linear models. RESULTS: Poor awareness attenuated improvements in independence over time, F(3, 55) = 3.04, p = .038. Strategy training promoted greater improvements in independence over time relative to attention control, F(3, 55) = 5.93, p = .002. However, the interaction between awareness and intervention was not significant, F(1, 19) = 0.025, p = .877. CONCLUSION: Awareness status may not affect the response to strategy training, indicating that strategy training may benefit people with poor awareness.

Behavioral Activation Approach to Parent Training: Feasibility of Promoting Routines of Exploration and Play During Mealtime (Mealtime PREP).

OBJECTIVE: Systematic approaches are needed to help parents with young children adopt healthy routines. This study examined the feasibility (home data collection, protocol adherence, intervention acceptance) of using a behavioral activation (BA) approach to train parents of children with sensory food aversions. METHOD: Parents of young children (18-36 mo) were trained using the novel Promoting Routines of Exploration and Play During Mealtime intervention. Measures included video-recorded meals, Fidelity Checklist, Treatment Acceptability Questionnaire, and Behavioral Pediatrics Feeding Assessment Scale. Descriptive statistics were used. RESULTS: Eleven children and their parents completed the study. Two of three feasibility benchmarks were met. Intervention acceptance was high (mean score = 43/48). On average, parents used three more intervention strategies after training than at baseline. CONCLUSION: Using a BA approach to parent training shows promise for altering daily mealtime routines. Delivering this intervention in the home is feasible and received acceptable ratings among this sample.

Guided Training Relative to Direct Skill Training for Individuals With Cognitive Impairments After Stroke: A Pilot Randomized Trial.

OBJECTIVE: To examine the effects of direct skill training and guided training for promoting independence after stroke. DESIGN: Single-blind randomized pilot study. SETTING: Inpatient rehabilitation facility. PARTICIPANTS: Participants in inpatient rehabilitation with acute stroke and cognitive impairments (N=43). INTERVENTIONS: Participants were randomized to receive direct skill training (n=22, 10 sessions as adjunct to usual inpatient rehabilitation) or guided training (n=21, same dose). MAIN OUTCOME MEASURE: The FIM assessed independence at baseline, rehabilitation discharge, and months 3, 6, and 12. RESULTS: Linear mixed models (random intercept, other effects fixed) revealed a significant intervention by time interaction (F4,150=5.11, P<.001), a significant main effect of time (F4,150=49.25, P<.001), and a significant effect of stroke severity (F1,150=34.46, P<.001). There was no main effect of intervention (F1,150=.07, P=.79). Change in FIM scores was greater for the direct group at rehabilitation discharge (effect size of between-group differences, d=.28) and greater for the guide group at months 3 (d=.16), 6 (d=.39), and 12 (d=.53). The difference between groups in mean 12-month change scores was 10.57 points. CONCLUSIONS: Guided training, provided in addition to usual care, offered a small advantage in the recovery of independence, relative to direct skill training. Future studies examining guided training in combination with other potentially potent intervention elements may further advise best practices in rehabilitation for individuals with cognitive impairments after acute stroke.

Heart Rate Variability Is Associated with Motor Outcome 3-Months after Stroke.

OBJECTIVES: The primary objective of this paper was to determine whether heart rate variability (HRV) acquired upon admission to inpatient rehabilitation is associated with motor outcome 3 months after stroke. The secondary objective of this paper was to determine whether HRV shows a strong association with the motor outcome 3 months after stroke in individuals with severe initial motor impairments. METHODS: We recruited 13 patients with acute stroke from an acute inpatient rehabilitation hospital. A Holter monitor was placed upon admission and Fugl-Meyer Upper Extremity and Lower Extremity Subscales were used to assess the movement of the affected upper and lower extremities 3 months after admission. The standard deviation of R-R intervals was used to quantify HRV. RESULTS: A Spearman rank correlation revealed a strong positive and significant correlation between HRV upon admission and movement of the affected upper extremity (r = .70, P = .01) and affected lower extremity (r = .60, P = .03) at 3 months. For patients with severe initial motor impairments, HRV showed a strong positive association with the movement of the affected upper (r = .61, P = .04) and lower (r = .70, P = .04) extremities at 3 months. CONCLUSION: HRV is strongly associated with motor outcome after stroke and provides a promising marker to explore the mechanisms associated with motor recovery after stroke.

Examining the Feasibility, Tolerability, and Preliminary Efficacy of Repetitive Task-Specific Practice for People With Unilateral Spatial Neglect.

OBJECTIVE: We examined the feasibility, tolerability, and preliminary efficacy of repetitive task-specific practice for people with unilateral spatial neglect (USN). METHOD: People with USN ≥6 mo poststroke participated in a single-group, repeated-measures study. Attendance, total repetitions, and satisfaction indicated feasibility and pain indicated tolerability. Paired t tests and effect sizes were used to estimate changes in upper-extremity use (Motor Activity Log), function (Action Research Arm Test), and attention (Catherine Bergego Scale). RESULTS: Twenty participants attended 99.4% of sessions and completed a high number of repetitions. Participants reported high satisfaction and low pain, and they demonstrated small, significant improvements in upper-extremity use (before Bonferroni corrections; t = -2.1, p = .04, d = .30), function (t = -3.0, p < .01, d = .20), and attention (t = -3.4, p < .01, d = -.44). CONCLUSION: Repetitive task-specific practice is feasible and tolerable for people with USN. Improvements in upper-extremity use, function, and attention may be attainable.

Pilot feasibility of an mHealth system for conducting ecological momentary assessment of mood-related symptoms following traumatic brain injury.

OBJECTIVE: This study assessed pilot feasibility and validity of a mobile health (mHealth) system for tracking mood-related symptoms after traumatic brain injury (TBI). DESIGN: A prospective, repeated measures design was used to assess compliance with daily ecological momentary assessments (EMA) conducted via a smartphone application over an 8-week period. METHODS: An mHealth system was developed specifically for individuals with TBI and utilized previously validated tools for depressive and anxiety symptoms (Patient Health Questionnaire-9, Generalized Anxiety Disorder-7). Feasibility was assessed in 20 community-dwelling adults with TBI via an assessment of compliance, satisfaction and usability of the smartphone applications. The authors also developed and implemented a clinical patient safety management mechanism for those endorsing suicidality. RESULTS: Participants correctly completed 73.4% of all scheduled assessments, demonstrating good compliance. Daily assessments took <2 minutes to complete. Participants reported high satisfaction with smartphone applications (6.3 of 7) and found them easy to use (6.2 of 7). Comparison of assessments obtained via telephone-based interview and EMA demonstrated high correlations (r = 0.81-0.97), supporting the validity of conducting these assessments via smartphone application in this population. CONCLUSIONS: EMA conducted via smartphone demonstrates initial feasibility among adults with TBI and presents numerous opportunities for long-term monitoring of mood-related symptoms in real-world settings.

Activity interventions for cognitive problems.

Cancer and its life-saving treatments often result in long-term impairments in neurocognitive functions. These neurocognitive impairments are not only problematic, but they also limit the ability to perform meaningful everyday activities critical to independence in the home, school, and community. The "bottom-up" and "top-down" models inherent in many neurological rehabilitation interventions provide a gross framework for describing interventions designed to address neurocognitive functions. Activity interventions show promise for improving performance of everyday activities, as well as improving underlying neurocognitive functions. However, additional empirical examination is warranted. Future studies examining activity interventions should clearly specify the active ingredient of the intervention, and evaluate the impact of the intervention on neurocognitive as well as activity-based outcomes.