Translating from experimental results to a clinical service for people with brain injury

 

The brain can be injured by trauma (for example, in a traffic accident), by an interruption to its blood supply (stroke), or by disease. Traumatic brain injuries occur predominantly among young people and can disrupt education, the development of relationships and employment prospects. Very serious injuries can lead to a lifetime of dependence on others. Brain injury form stroke, which tends to occur later in life, is the single greatest cause of long-term disability in UK.

The brain performs lots of different functions and an injury to the brain can have highly variable effects that range from barely detectable through to severe impairment of a function. Some of our abilities seem particularly vulnerable, however, a complaints of “poor concentration”, “mental fatigue”, and “forgetting to do things” are common following a range of injuries. These functions are crucial to achieving goals (e.g. being able to keep a focus on the job in hand, being able to make and follow realistic plans). For over a century the observation of disrupted goal-directed behaviour following injuries to the frontal lobes has indicated the importance of this region in these abilities; evidence that has been supported by imaging methods (such as functional magnetic resonance imaging) that allow us to observe the brain in action.

A particular interest at the Cognition and Brain Sciences unit is on techniques and strategies that may help reduce or minimize the consequences of attention and mental coordination functions (sometimes called executive functions). In collaboration with Brian Levine in Toronto and Ian Robertson in Dublin we have developed a programme called Goal Management Training. This is a group or individual therapy approach that increases awareness of common attentional and executive lapses and works with participants to develop individually tailored strategies to make their occurrence less likely or to minimize negative consequences.

Goal-neglect refers to situations in which we have formed and are able to remember a particular intention but, when the moment comes, we fail to act on it (see link to John Duncan’s pages for more info). This type of lapse is more common following brain injury. Part of our research has been to examine whether we can help people to manage their intentions by providing automated text (SMS) message reminders. These don’t give people specific information about their intentions but instead serve to briefly interrupt current activity and cue a process of reviewing one’s intentions. We have shown this can dramatically improve performance on experimental tasks but does it work in the real world?

We recently addressed this in a collaboration with our colleagues at the Oliver Zangwill Centre for Neuropsychological Rehabilitation in a project funded by the National Institute of Health Research. Sixty people with everyday organisational problems following brain injury received were randomised either to a brief form of Goal Management Training + daily text messages linked to the process of goal review, or a placebo intervention. The results of this project, which is an excellent example of the benefits of the CBU’s close collaboration with working clinicians, will be published soon.

The CBU does not itself operate a clinical service for people with brain injuries. If you or someone you know has a brain injury and are interested in talking about rehabilitation, please contact the Oliver Zangwill Centre. The centre, which is internationally recognised as an excellent cognitive rehabilitation service, was established in a collaboration established by Professor Barbara Wilson (OBE) between the National Health Service and the Medical Research Council.

 

Further reading

Fish, J., Evans, J. J., Nimmo, M., Martin, E., Kersel, D., Bateman, A., Manly, T. (2007). Rehabilitation of executive dysfunction following brain injury: “Content-free cueing” improves everyday prospective memory performance. Neuropsychologia, 45(6), 1318-1330.

Levine, B., Robertson, I. H., Clare, L., Carter, G., Hong, J., Wilson, B. A., Stuss, D. T. (2000). Rehabilitation of executive functioning: An experimental-clinical validation of Goal Management Training. Journal of the International Neuropsychological Society, 6, 299-312.

Levine, B., Schweizer, T. A., O’Connor, C., Turner, G., Gillingham, S., Stuss, D. T., Robertson, I. H. (2011). Rehabilitation of executive functioning in patients with frontal lobe brain damage with goal management training. Frontiers in Human Neuroscience, 5.

Levine, B., Stuss, D. T., Winocur, G., Binns, M. A., Fahy, L., Mandic, M., Robertson, I. H. (2007). Cognitive rehabilitation in the elderly: Effects on strategic behavior in relation to goal management. Journal of the International Neuropsychological Society, 13(1), 143-152.

Miotto, E. C., Evans, J. J., de Lucia, M. C., & Scaff, M. (2009). Rehabilitation of executive dysfunction: a controlled trial of an attention and problem solving treatment group. Neuropsychological Rehabilitation, 19(4), 517-540.

Schweizer, T. A., Levine, B., Rewilak, D., O’Connor, C., Turner, G., Alexander, M. P., Stuss, D. T. (2008). Rehabilitation of executive functioning after focal damage to the cerebellum. Neurorehabilitation and Neural Repair, 22(1), 72-77.

Spikman, J. M., Boelen, D. H., Lamberts, K. F., Brouwer, W. H., & Fasotti, L. (2010). Effects of a multifaceted treatment program for executive dysfunction after acquired brain injury on indications of executive functioning in daily life. Journal of the International Neuropsychological Society : JINS, 16(1), 118-129.