Do Old Errors Always Lead to New Truths? A Randomized Controlled Trial of Errorless Goal Management Training in Brain-Injured Patients.

Both errorless learning (EL) and Goal Management Training (GMT) have been shown effective cognitive rehabilitation methods aimed at optimizing the performance on everyday skills after brain injury. We examine whether a combination of EL and GMT is superior to traditional GMT for training complex daily tasks in brain-injured patients with executive dysfunction. This was an assessor-blinded randomized controlled trial conducted in 67 patients with executive impairments due to brain injury of non-progressive nature (minimal post-onset time: 3 months), referred for outpatient rehabilitation. Individually selected everyday tasks were trained using 8 sessions of an experimental combination of EL and GMT or via conventional GMT, which follows a trial-and-error approach. Primary outcome measure was everyday task performance assessed after treatment compared to baseline. Goal attainment scaling, rated by both trainers and patients, was used as secondary outcome measure. EL-GMT improved everyday task performance significantly more than conventional GMT (adjusted difference 15.43, 95% confidence interval [CI] [4.52, 26.35]; Cohen's d=0.74). Goal attainment, as scored by the trainers, was significantly higher after EL-GMT compared to conventional GMT (mean difference 7.34, 95% CI [2.99, 11.68]; Cohen's d=0.87). The patients' goal attainment scores did not differ between the two treatment arms (mean difference 3.51, 95% CI [-1.41, 8.44]). Our study is the first to show that preventing the occurrence of errors during executive strategy training enhances the acquisition of everyday activities. A combined EL-GMT intervention is a valuable contribution to cognitive rehabilitation in clinical practice.

A randomized controlled trial on errorless learning in goal management training: study rationale and protocol.

BACKGROUND: Many brain-injured patients referred for outpatient rehabilitation have executive deficits, notably difficulties with planning, problem-solving and goal directed behaviour. Goal Management Training (GMT) has proven to be an efficacious cognitive treatment for these problems. GMT entails learning and applying an algorithm, in which daily tasks are subdivided into multiple steps. Main aim of the present study is to examine whether using an errorless learning approach (preventing the occurrence of errors during the acquisition phase of learning) contributes to the efficacy of Goal Management Training in the performance of complex daily tasks. METHODS/DESIGN: The study is a double blind randomized controlled trial, in which the efficacy of Goal Management Training with an errorless learning approach will be compared with conventional Goal Management Training, based on trial and error learning. In both conditions 32 patients with acquired brain injury of mixed etiology will be examined. Main outcome measure will be the performance on two individually chosen everyday-tasks before and after treatment, using a standardized observation scale and goal attainment scaling. DISCUSSION: This is the first study that introduces errorless learning in Goal Management Training. It is expected that the GMT-errorless learning approach will improve the execution of complex daily tasks in brain-injured patients with executive deficits. The study can contribute to a better treatment of executive deficits in cognitive rehabilitation. TRIAL REGISTRATION: (Dutch Trial Register): NTR3567.

Who benefits from treatment for executive dysfunction after brain injury? Negative effects of emotion recognition deficits.

Deficits in emotion recognition, a crucial aspect of social cognition, are common after serious brain injury, as are executive deficits. Since social cognition and executive function are considered to be separate constructs, our first aim was to examine the presence of emotion recognition problems in brain injury patients with dysexecutive problems. We studied 65 brain injury patients of mixed aetiology participating in a randomised controlled trial evaluating the effects of a multifaceted treatment for executive dysfunction (Spikman, Boelen, Lamberts, Brouwer, & Fasotti, 2010 ) and 84 matched controls with a test for emotion recognition. Results showed that, in patients with acquired brain injury exhibiting executive deficits, emotion recognition deficits are also present. Male patients are more impaired than female patients, irrespective of aetiology. Our second aim was to investigate whether emotion recognition problems negatively predict the results of the treatment programme. Pre-treatment emotion recognition performance significantly predicted resumption of roles in daily life (Role Resumption List; RRL) and performance on an ecologically valid test for everyday executive functioning (Executive Secretarial Task; EST) post-treatment and, in addition, interfered negatively with treatment condition. Moreover, worse pre-treatment emotion recognition skills affect the learning of compensatory strategies for executive dysfunction negatively, whereas pre-treatment dysexecutive deficits do not.

Script generation and the dysexecutive syndrome in patients with brain injury.

OBJECTIVE: The authors investigated whether patients with brain injury suffering from dysexecutive symptoms had difficulties with script generation. METHOD: Forty-eight patients with brain injury of various etiology with complaints of executive dysfunctioning and deficient scores on executive tests were included in this study. They were compared with 99 healthy control subjects in a script-generation task. Participants were asked to describe how they would perform eight everyday activities. The script items were manipulated so that they varied in structure (open-ended vs. closed) and in frequency of performing (high vs. low). RESULTS: Patients and control subjects evoked an equal number of actions, but patientsproduced significantly more irrelevant actions and made significantly more perseverative errors. Their most pronounced problems were found in open-ended and low-frequency scripts. CONCLUSION: This investigation shows that not only patients with prefrontal damage are impaired in script generation. The consequences for treatment are discussed.

Effects of a multifaceted treatment program for executive dysfunction after acquired brain injury on indications of executive functioning in daily life.

A multicenter randomized control trial (RCT) was conducted to evaluate the effects of a treatment for dysexecutive problems after acquired brain injury (ABI) on daily life functioning. Seventy-five ABI patients were randomly allocated to either the experimental treatment, multifaceted strategy training for executive dysfunction, or a control treatment, computerized cognitive function training. Assessment took place before, directly after, and 6 months post-treatment. The primary outcome measure, the Role Resumption List (RRL), and two other follow-up measures, the Treatment Goal Attainment (TGA) and the Executive Secretarial Task (EST), were indications of daily life executive functioning. The experimental group improved significantly more over time than the controls on the RRL and attained significantly higher scores on the TGA and EST. We conclude that our treatment has resulted in significant improvements of executive functioning in daily life, lasting at least 6 months post-treatment. Although control patients' satisfaction and subjective well-being were at the same level, the experimental group had better abilities to set and accomplish realistic goals, to plan, initiate, and regulate a series of real-life tasks, and to resume previous roles with respect to work, social relations, leisure activities, and mobility.

Executive dysfunction in chronic brain-injured patients: assessment in outpatient rehabilitation.

In this study 81 chronic brain-injured patients referred for outpatient rehabilitation, who complained of executive impairments in daily life situations and were observed by proxies and therapists to have such problems, were assessed using various tests and questionnaires of executive functioning, such as the BADS and the DEX Questionnaire. The main purpose was to examine the sensitivity of these instruments in this particular group of patients. The tests and the DEX were also administered to healthy controls to investigate which of the instruments discriminate optimally between patients and controls. The results indicate that the tests as well as the questionnaires were sensitive to the executive problems of the patients. There were no significant differences between DEX ratings of patients, proxies and therapists. This suggests that patients who were eligible for outpatient rehabilitation showed relatively intact awareness into their executive problems. A specific combination of three "open-ended" tests and the DEX contributed significantly to the prediction of group membership.

Structured relearning of activities of daily living in dementia: the randomized controlled REDALI-DEM trial on errorless learning.

BACKGROUND: Errorless learning (EL) is a method for optimizing learning, which uses feed-forward instructions in order to prevent people from making mistakes during the learning process. The majority of previous studies on EL taught patients with dementia artificial tasks of little or no relevance for their daily lives. Furthermore, only a few controlled studies on EL have so far been performed and just a handful of studies have examined the long-term effects of EL. Tasks were not always trained in the patients' natural or home environment, limiting the external validity of these studies. This multicenter parallel randomized controlled trial examines the effects of EL compared with trial and error learning (TEL) on the performance of activities of daily living in persons with Alzheimer's or mixed-type dementia living at home. METHODS: Patients received nine 1-hour task training sessions over eight weeks using EL or TEL. Task performance was measured using video observations at week 16. Secondary outcome measures were task performance measured at week 26, satisfaction with treatment, need for assistance, challenging behavior, adverse events, resource utilization and treatment costs. RESULTS: A total of 161 participants were randomized, of whom 71 completed the EL and 74 the TEL arm at week 11. Sixty-nine EL patients and 71 TEL patients were assessed at the 16-week follow-up (the primary measurement endpoint). Intention-to-treat analysis showed a significantly improved task performance in both groups. No significant differences between the treatment groups were found for primary or secondary outcomes. CONCLUSIONS: Structured relearning improved the performance of activities of daily living. Improvements were maintained for 6 months. EL had no additional effect over TEL. TRIAL REGISTRATION: German Register of Clinical Trials DRKS00003117 . Registered 31 May 2011.

Transfer effects of errorless Goal Management Training on cognitive function and quality of life in brain-injured persons.

BACKGROUND: Previous findings had shown that the addition of errorless learning to traditional Goal Management Training (GMT) resulted in superior results when training everyday tasks in persons with executive deficits after brain injury. OBJECTIVE: To investigate the additional effects of an errorless GMT on cognitive function and quality of life after acquired brain injury. METHODS: This is a supplementary analysis of findings from an RCT in which 67 patients with executive impairments after acquired brain injury were randomly allocated to an experimental errorless GMT (n = 33) or conventional GMT (n = 34) to train two individually chosen everyday tasks. Objective cognitive function using neuropsychological tests, subjective cognitive complaints and quality of life using questionnaires were assessed before and after training. RESULTS: No significant interaction effects between these three types of outcome measures and the two forms of GMT were found. Irrespective of treatment, performance on two executive tests (Modified Six Elements Test; p = 0.006, Zoo Map test; p = 0.001) improved and daily executive function problems as reported by the participants (EFI; p = 0.001) and proxies (DEX; p = 0.01) diminished. CONCLUSIONS: Besides the previously found superiority of errorless GMT when training everyday tasks, additional improvements in cognition and quality of life did not differ between the two treatments.

Reliability of an Adapted Version of the Modified Six Elements Test as a Measure of Executive Function.

The Modified Six Elements Test (MSET) is used to examine executive deficits-more specifically, planning deficits. This study investigates the reliability of an adapted version of the MSET and proposes a novel scoring method. Two parallel versions of the adapted MSET were administered in 60 healthy participants in a counterbalanced order. Test-retest and parallel-form reliability were examined using intraclass correlation coefficients, Bland-Altman analyses, standard errors of measurement, and smallest real differences, representing clinically relevant changes over time. Moreover, the ecological validity of the adapted MSET was evaluated using the Executive Function Index, a self-rating questionnaire measuring everyday executive performance. No systematic differences between the test occasions were present, and the adapted MSET including the proposed scoring method was capable of detecting real clinical changes. Intraclass correlations for the test-retest and parallel-form reliability were modest, and the variability between the test scores was high. The nonsignificant correlations with the Executive Function Index did not confirm the previously established ecological validity of the MSET. We show that both parallel versions of the test are clinically equivalent and can be used to measure executive function over the course of time without task-specific learning effects.

Interrater Reliability and Concurrent Validity of a New Rating Scale to Assess the Performance of Everyday Life Tasks in Dementia: The Core Elements Method.

Errorless learning (EL) is an instructional procedure involving error reduction during learning. Errorless learning is mostly examined by counting correctly executed task steps or by rating them using a Task Performance Scale (TPS). Here, we explore the validity and reliability of a new assessment procedure, the core elements method (CEM), which rates essential building blocks of activities rather than individual steps. Task performance was assessed in 35 patients with Alzheimer's dementia recruited from the Relearning methods on Daily Living task performance of persons with Dementia (REDALI-DEM) study using TPS and CEM independently. Results showed excellent interrater reliabilities for both measure methods (CEM: intraclass coefficient [ICC] = .85; TPS: ICC = .97). Also, both methods showed a high agreement (CEM: mean of measurement difference [MD] = -3.44, standard deviation [SD] = 14.72; TPS: MD = -0.41, SD = 7.89) and correlated highly (>.75). Based on these results, TPS and CEM are both valid for assessing task performance. However, since TPS is more complicated and time consuming, CEM may be the preferred method for future research projects.

Validity of an adapted scoring method for a Modified Six Elements Test in individuals with brain injury.

The Modified Six Elements Test (MSET) assesses several executive functions. We examined whether an adapted scoring method is appropriate for discriminating between brain-injured persons with and without executive deficits. A MSET was administered to 70 participants with acquired brain injury in the chronic phase. The group was divided into individuals with and without executive impairments based on several other executive tests. The discriminative value for both the conventional raw score and the adapted scoring method was evaluated using receiver operating characteristic analyses. Both scoring methods discriminated significantly between persons with impaired and unimpaired executive functions (raw score: area under the curve, AUC = 0.703, p = .004; adapted score: AUC = 0.780, p = .000). Only the adapted scoring method proved sensitive (81%) and specific (67%) within a clinically useful range. Within this range, an acceptable cut-off score could be determined. Altogether, the proposed MSET scoring index is a potentially clinically useful contribution to the measurement of executive functions.