9. Stuss- Frontal Lobe Functioning

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Clinicians Beware!Appearances May Be Deceiving

Donald T. Stuss, PhD, Founding President and Scientific

DirectorOntario Brain Institute

Financial Disclosure

I have no financial relationships to disclose:

• Mick Alexander, Tim Shallice, Terry Picton,

• Antonio Valessi - fMRI

• Susan Gillingham, and a host of others

• Funders: CIHR, OMHF

ACKNOWLEDGMENTS

Share with you for consideration and discussion

some 35 years of lessons learned in the study of

individuals with frontal lobe dysfunction on why to

be wary when you study, diagnose and treat such

individuals

Overarching Objective

4

• Identify and differentiate the four major categories of frontal lobe functioning

• Map the relationship between anatomical development and connectivity to frontal lobe functions

• Identify how “basic” research can be used for the development of neurorehabilitation techniques to patients with frontal lobe dysfunction

Specific Learning Objectives

5

Examples of the “Mystery” of the Frontal lobes

Research findings that shed some light

The value of these findings to clinical application

Summary of the Lessons

OUTLINE

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• Clinical investigation of the frontal lobes has led to many “teachings” that we use for diagnosis

• Using clinical examples, will highlight the reasons for wariness in diagnosis and indeed even understanding the frontal lobes – perhaps because we view the individuals through our cognitive and clinical models

• Through this, will summarize lessons learned7

THERE IS A REASON WHY THE FRONTAL LOBES WERE CALLED A MYSTERY





OUTLINE

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MYSTERY # 1 - GAGE ET AL.

• “No longer Gage” – “the equilibrium ..betweenhis intellectual faculty and animal propensities,seems to have been destroyed.”

• Ackerly & Benton (1947) – congenital bilateral prefrontal lesion. As he grew, significant problems in emotional control

Figure 1. Modeling the path of the tamping iron through the Gage skull and its effects on white matter structure.

Van Horn JD, Irimia A, Torgerson CM, Chambers MC, et al. (2012) Mapping Connectivity Damage in the Case of Phineas Gage. PLoS ONE 7(5): e37454. doi:10.1371/journal.pone.0037454http://www.plosone.org/article/info:doi/10.1371/journal.pone.0037454

EARLY REPORTS – BUT…

• Gage

a) The most dramatic changes occurred in early stages post-injury, and decreased

b) Many of the reports apparently exaggerated (Macmillan)

c) Gage could hold a job – but not consistently

• Ackerley & Benton – patient could hold a job under certain circumstances

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IMPLICATIONS

• There are subtleties to study and understand, which are important for rehabilitation and management

• Context (time since injury, environmental circumstances) appears particularly relevant

MYSTERY # 2 – LEUCOTOMY STUDIES

• In the mid 1970s we studied the effects of pre-

frontal leucotomies 25 years post-surgery

GROUP DESCRIPTIONS

• Five groups of individuals were studied:

• Matched control group

• Four patient groups from the same hospital, diagnosed by the same physicians as psychotic

• Three groups had received a frontal leucotomy as treatment; sub-divided into three groups based on degree of recovery: good, moderate, poor

• The fourth – no surgery even though one had been prepped

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EMOTIONAL SITUATIONS TEST

8

0

1

2

3

4

5

6

7

I II III IV V

I Good RecoveryLeukotomy

II Moderate RecoveryLeukotomy

III No RecoveryLeukotomy

IV NonleukotomizedSchizophrenics

V Controls

LEUCOTOMY IMPACTS SOCIAL BEHAVIOURS - BUT….

• The Boston bus station

• Going dancing

• Catatonia and a sense of humour

• Changing neuropsychological examiners -a lesson about social behaviour

IMPLICATIONS

• Social changes are not an all-or-nothing phenomenon

• There are qualitative differences in abnormal social responsiveness

• Context again is important

MYSTERY # 3 – MORE LEUCOTOMY

• During the leucotomy research, DF Benson was on sabbatical at the Maudsley in the UK

• The Context

• My Response:– even though I had not analyzed the data, I had been working with these individuals for months. I was trained as a clinical psychologist before neuropsychology – I was a confident observer and diagnostician.

• FRANK, TRUST ME – the major deficit after frontal leucotomy is a severe attentional deficit

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BUT…

• THEN – I ANALYZED THE DATA

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SPAN TESTS

0

1

2

3

4

5

6

7

8

I II III IV V

Mean Span

Length

Group

Digit Span

Forward

Backward

Stuss et. al., 1981

0

2

4

6

8

10

12

14

I II III IV V

Mean Trials Correct

Group

Knox Cube

I – Good RecoveryII – Moderate RecoveryIII – No RecoveryIV – Schizophrenic ControlsV – Normal Controls

27

ATTENTION MEASURES

0

50

100

150

200

250

300

350

400

Time Time Errors Time A Time B Errors B

Tim

e

I - Good Recovery

II - Moderate Recovery

III - No Recovery

IV - Schizophrenic Controls

V - Normal Controls

Count by three

Serial sevens Trail-makingStuss et. al., 1981

IMPLICATIONS

• What you see is not necessarily indicative of theactual abilities; it may represent the unfolding ofabilities under certain contexts

• You can become the frontal lobes of the patient, compensating for the problems – and this itself is a type of context

MYSTERY # 4 – PSYCHOSIS OR NOT

• Canadian volunteer to US Army in Vietnam way discharged for psychiatric reasons

• One year later – recalled

• The day before recall – ended up in hospital with tentative diagnosis of acute psychotic reaction with catatonic symptoms

• Description of patient examination

• Lesion – small left posterior frontal ventrolaterallesion

IMPLICATIONS

• One more lesson on the importance of under-standing context when you examine a patient

• Lesion location within the frontal lobes is important

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MYSTERY # 5 - TBI CASE STUDY

• Patient suffers mild-moderate TBI. After initialrecovery, has normal intelligence, attention,language, relatively good ability to learn new information, good visual-spatial skills, goodgeneral knowledge of the world.

• BUT – has lost all episodic memory. That is, he has no memory of his personal past, but can remember all factual information.

• TBI – loss of all pre-injury personal memories,but semantic memories intact

• Post injury, he could remember past memories , but devoid of emotion

• Questions: malingerer? If a real deficit, how to explain?

MYSTERY # 5 – CLINICAL FACTS

• More recent research indicated importance of right frontal lobe to a) retrieval; b) self-awareness and episodic memories

• Hypothesis: if right frontal lobe important to self-awareness and episodic memories, a focal lesion disconnecting RFL could theoretically result in a) lost of pre-injury episodic memories because could notretrieve; b) post-injury lost of “episodic” (warm, personal) nature of memories (Levine et al., Brain, 1998, 121)

BUT…a

+ 1 mm-4 mm-9 mm

b

47

10

45

10

47

1010

47

1111

IMPLICATIONS

• You need both anatomy and cognitive theory tounderstand the functions of the frontal lobes

• Experimental attempt to demonstrate focused attention deficit after TBI

• Moderate to severe TBI group compared to matched control group

• Procedure was developed to isolate the process of focused attention

• And – to show that effect was reliable, groups were tested twice, same time of day, one week apart

MYSTERY # 6 – TBI and FL Dysfunction

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3737

FEATURE INTEGRATION TEST

Test Target Distractors

Simple

Easy Choice

Complex Choice

Redundant Choice

none

blue bluered yellow

yellow red bluegreen37

Inconsistency in TBI

38

Stuss & Binns, 2008

Controls TBI

Inconsistency in Concussion

39

-15

-10

-5

0

5

10

15

20

25

30

Dif

fere

nce

(m

s)

Visit

Control

Concussed

1 2 3 4 5

Performance on correct trials in all three conditions of the

Multiple Choice Reaction Time Task over five visits

Stuss & Binns, 2008

LESSON

• Had to use my own frontal lobes to break my mental set from training as experimental psychologist which suggests that if resultsare not replicable, they are not valid; the results are “noise”

• Had to think as a clinician and listen to patients

• And one can show that variability itself is reliable in its own way

• But what causes variability? We postulated some “type” of frontal lobe control dysfunction

IMPLICATIONS

• The variability WAS THE DATA

• We use the terms “frontal functions” or “frontal dysfunction”

MYSTERY # 7 –FRONTAL LOBE ANATOMY

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• Look at the anatomy

BUT….

CENTRAL SULCUS CENTRAL

SULCUS

47 48

POLAR10Superior

Inferior 10

14INFERIOR MEDIAL

Ventromedial

Cingulate 24, 25

Paracingulate

SUPERIORMEDIAL

Superior Posteromedial 6a, 4

Superior Anteromedial 8b, 9

Cingulate 24

Ventrolateral 47/12, 45a, 45b, 44, 6b, 4

9, 46, 9/46d, 9/46v, 8b, 8ad, 8av, 6a, 4

Dorsolateral

LATERAL

SURFACE REGION

ORBITO-FRONTAL

14, 11, 13, 47/12

Paracingulate 32

32

CYTOARCHITECTURE

Stuss et al., 2002

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49

Summary of Lessons

• The reason that it is difficult to understandthe functions of the frontal lobes is that one has to consider many factors:

- functional/anatomical specificity- context of different types- the sophistication of cognitive theory- possible different types of control- the effect of disturbance in control onconsistency of performance





OUTLINE

50

51

QUESTION

• If the frontal lobes have a dominant central organizing role, is this system unitary (an “executive”) or fragmented (a series of domain general control processes)?

• Frame within the role of the frontal lobes in “attention”

ContentionScheduling

(3)

TriggerDataBase

Special-purposeCognitiveSubsystems (1)

PerceptualSystem

SupervisoryAttentional System (4)

SchemaControl Units

(Action)

(2)

ANTERIOR ATTENTIONAL SYSTEMShallice (1991)

• Shallice, Alexander, Picton and myself

• Start with patients with focal lesions, to evaluate which brain regions are necessary for functions

• Differentiated “task” from “process”

• Differentiated “descriptive term” from “fundamental process”

• Scaffolded difficulty - why? – to demonstrate that frontal lobe patients could do simple tasks, and highlight at which level of difficulty problems arose

WE STARTED FROM SCRATCH

• We proposed five different frontal attentional processes, related to different frontal regions

• These processes are fundamental, in that they can explain performance on a series of differenttasks

- Energization- Inhibition- Contention Scheduling (setting of)- Monitoring- Logic – adjusting goals and energization based

on monitoring (setting the task)(Stuss et al., ANYAS, 1995, 769)

WITH THIS APPROACH

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5555

LET’S START WITH ATTENTION

• There are (at least) three separate processesrelated to attention within the frontal lobes, each related to a different frontal region

• Energization

• Task Setting

• Monitoring

55 5656

• TOP: Bar graph by coarse lesion localization:

RL – right lateral;

LL – left lateral;

SM – superior medial;

IM – inferior medial

• BOTTOM: Architectonic localization

STRUCTURE of DATA PRESENTATION

56

5757

• ENERGIZATION

– “The process of initiation and sustaining of any response made”

TELL THEM

57 58

ENERGIZATIONCONCENTRATE (ROBBIA)

Press Button

59

ENERGIZATIONCONCENTRATE (ROBBIA)

400

500

600

700

RT

(m

s)

LL RL IM SM CTL

Stuss et al., 2005; Stuss & Alexander, 2007 60

IMPLICATIONS

• Frontal processes are important even for simple

tasks – have to rethink idea of complexity

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IMAGING EVIDENCE of ENERGIZATION

Experimental Aim:

– to investigate the brain mechanisms and associated distinct processes related to the regulation of speed-accuracy strategy trial-by-trial by using fMRI.

62

METHOD:Speed/Accuracy Tradeoff

• Participants: 12 right-handed healthy subjects (6 F; mean age: 24 years, range: 19-37).

• Session: 6 runs (6 practice and 40 test trials per each run), preceded by two practice runs with feedback (on the 0 T scanner).

Targ

et-R

elat

ed

Brain Cluster

The Anterior Cingulate was mostly activated when it was necessary to

sustain a speeded response (no-switch SPD trials), consistently with a

role in energization (Paus, 2001; Stuss et al., 2005).Vallesi et al., 2012

RESULTS

6464

Anatomical Connectivity

FunctionalConnectivity

• Slower RT

• Inability to sustain task

Energization

65

TASK SETTING

– “The ability to establish a stimulus-response relationship”, requiring formation of a criterion to respond to a defined target with specific attributes, organization of the schemata to do a task, and adjustment of contention scheduling

66

TASK SETTING

• Can also be seen as a “sculpting” activity (Fletcher et al., 2000; Frith, 2000), where surface material to be carved represents a prepotent habitual response that needs to be overcome

• Emerging shape is the new strategy, or S-R association

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TASK SETTINGCONCENTRATE (ROBBIA)

0

0.5

1.0

1.5

2.0

# o

f F

als

e A

larm

s

LL RL IM SM CTL

Stuss et al., 2005; Stuss & Alexander, 2007


Simple

Easy Choice

Complex Choice

Redundant Choice

none

blue bluered yellow



69

TASK SETTINGCOMPLEX (FIT)

LL RL IM SM CTL

Fa

lse

Ala

rms

–F

als

e N

eg

ati

ve

s

0

2

4

6

10

8

70

TASK SETTINGIMAGING EVIDENCE

Experimental Aim:

– Speed-accuracy trade-off

71

-8

-6

-4

-2

0

2

4

6

8

10

ACC NS ACC SW SPD NS SPD SW

Be

ta V

alu

es

at

[-3

2 3

0 2

8]

Brain Cluster fMRI parameter estimate

Correlation with Accuracy

Cu

e-R

elat

ed

Correlation with Speed

r = .596, p<.05 r = -.64, p<.05r = -.64, p<.02

Vallesi et al., HBM, 2012.

SPEED-ACCURACY TRADE-OFFfMRI STUDY

7272



• Initial Errors

• False Alarms

Left: Task Setting

• Slower RT


Energization

Executive Function

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73

MONITORING

– “The process of checking the task over time for ‘quality control’ and the adjustment of behaviour ”

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MONITORINGSIMPLE RT (ROBBIA)

• 5 different Inter-stimulus Intervals(ISI) (3,4,5,6, or 7 seconds), each occurring 10 times randomly

• Short ISI = 3 and 4 seconds

• Long ISI = 6 and 7 seconds

75

MONITORINGSIMPLE RT (ROBBIA)

-40

-30

-20

-10

0

10

20

ISIShort Long

ISI

Eff

ec

t

RL

Stuss et al., 2005; Stuss & Alexander, 2007


Simple

Easy Choice

Complex Choice

Redundant Choice

none

blue bluered yellow



77

MONITORINGCOMPLEX (FIT)

LL RL IM SM CTL

# o

f F

als

e N

eg

ati

ve

s

0

1

2

3

4

5

Stuss et al., 2005; Stuss & Alexander, 2007 78

or Foreperiod (FP)

*

Target Stimulus(0.3 sec)

Warning Stimulus

Task: choice RT (shape discrimination)

ITI(0.5-2.5 sec)

(2 sec)

Paradigm:

Fixed

Variable FP 1 sec

FP 3 sec

FP 1 secFP 3 sec

Baseline

MONITORING FOREPERIOD & fMRI

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Vallesi, McIntosh,Shallice & Stuss., J Cog Neurosc, 2009

Talairach coord. of right DLPFC: 52 40 26

r = .53, p < .05

8080



• Initial Errors

• False Alarms

Left: Task Setting

• Slower RT


Energization

• Within/Between task variability

• Errors of all types (sensitivity)

• Impaired variable foreperiod effect

• Inability to maintain count

Right: Monitoring

Executive Function

8181

LEFT LATERAL

Task Setting

RIGHT LATERAL

MonitoringEnergization

SUPERIOR MEDIAL 81 8282

THREE FRONTAL LOBE ATTENTIONAL CONTROL PROCESSES

• There are (at least) three separate processesrelated to attention within the frontal lobes, each related to a different frontal region

• Energization

• Task Setting

• Monitoring

8383

LET’S RETURN TO VARIABILITY

• Can the three separate processes related to attention within the frontal lobes, explain variability

• Examine response to errors within a task;

• The common response in a reaction time task is often to speed up over time, and thenwhen an error is made, slow down for the to trial to adapt to the situation and not makeanother error

83

Frontal Processes Underlying Variability

84

300

600

900

1200

Antecedent Error Subsequent

Mea

n R

eact

ion

Tim

e

Relationship in RT speed for trials antecedent and subsequent to an error

Stuss et. al., 2003

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85

Observations on Variability

• Individual variability can be caused by impairment in different control processes

• These different control processes are revealed by examining performance under a specific context – reaction to making an error

• The observation, the measurement of variability, is not the process; one has to unveil the process to develop focused rehabilitation

8686

FROM ATTENTION TO EMOTIONS AND META-COGNITION

• Let’s look at possible other functions associated with the frontal lobes

- Behavioural/emotional self-regulation

- Meta-cognition/integration

86

8787

BEHAVIOURAL/EMOTIONALSELF-REGULATION

• Emotional Processing:

♦ Difficulty in understanding the emotionalconsequences of behaviour

• Behavioural Self-Regulation:

♦ Required in situations where cognitive analysis, habit, or environmental cues are not sufficient to determine the most adaptive response

87 8888

Knower SubjectBasic Paradigm

?

BEHAVIOURAL/EMOTIONALSELF-REGULATION

Deception Task

88

8989

BF RNF LNF

Per

cen

t p

er G

rou

p (

SD

>2)

RF LF

80-

0

10-

20-30-

40-50-60-70-

ImpairedNon-Impaired

DECEPTION TASK

89 9090



• Initial Errors

• False Alarms

Left: Task Setting

• Slower RT


Energization





Right: Monitoring

Executive Function

• Normal executive

• Decreased awareness of deception

• Impaired reward/riskprocessing

Behavioural/Emotional

Self-Regulation

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9191



• Initial Errors

• False Alarms

Left: Task Setting

• Slower RT


Energization





Right: Monitoring

Executive Function





Self-Regulation

Superior MedialCircuit

9, 24, 32

9292



• Initial Errors

• False Alarms

Left: Task Setting

• Slower RT


Energization





Right: Monitoring

Executive Function





Self-Regulation


9, 24, 32

DorsolateralCircuit9, 46

9393

Lateral/MedialOrbitofrontal

Circuit11,12,13,14



• Initial Errors

• False Alarms

Left: Task Setting

• Slower RT


Energization





Right: Monitoring

Executive Function





Self-Regulation


9, 24, 32


9494


Circuit11,12,13,14



• Initial Errors

• False Alarms

Left: Task Setting

• Slower RT


Energization





Right: Monitoring

Executive Function





Self-Regulation


9, 24, 32


Caudate

GlobusPallidus

Thalamus

MotorCircuit

Oculo-motorCircuit

5 circuits - Figure Motor CircuitDorsolateral

prefrontal-subcortical circuit

Oculomotor Circuit

SuperiorMedialCircuit


Circuit

Origin:9, 46

Origin:AC & SM

Origin:Lateral & orbital 12

Origin:8

Origin:Motor Cortex

Executive Function

Affect & Social Behaviour

Executive Function

Motivational Function

Executive Function

Behavioural Effects: What the literature says

Behavioural &Emotional

Self-Regulation

Energization Executive Function

Behavioural Effects: What we say

Caudate

Globus Pallidus

Thalamus

9696

METACOGNITIVE PROCESSES

• A reflective representation of one’s own mental states, beliefs, attitudes and experiences

• Affects ability to make inferences about the world, to empathize with and understand the actions of others, and to serve as a base forappropriate social judgments

96

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9797

• Paris Hotel-“Leave your values at the front desk”

• Bangkok Cleaners-“Drop you trousers here for best results”

• Hong Kong Dentist-“Teeth extracted by the latest Methodists”


Humour Study – Is this funny?

Shammi & Stuss, 1999

97

• In a Rhodes tailor shop-“Order your summers suit. Because is big rush we

will execute customers in strict rotation.”

• In a restaurant in Paris-“Lunch will be served to patrons between noon

and 3 p.m.”

• In a Bangkok temple-“It is forbidden to enter a woman even a foreigner

if dressed as a man.”

9999


Difference Between Rating of Humourous and Neutral Items

99 100100


Circuit11,12,13,14



• Initial Errors

• False Alarms

Left: Task Setting

• Slower RT


Energization





Right: Monitoring

Executive Function





Self-Regulation


9, 24, 32


Caudate

GlobusPallidus

Thalamus

MotorCircuit

Oculo-motorCircuit

Metacognition

• Integration and coordination ofmotivational, emotional, executivecapacities

101101


Circuit11,12,13,14



• Initial Errors

• False Alarms

Left: Task Setting

• Slower RT


Energization





Right: Monitoring

Executive Function





Self-Regulation


9, 24, 32


Caudate

GlobusPallidus

Thalamus

MotorCircuit

Oculo-motorCircuit

Metacognition

• Integration and coordination ofmotivational, emotional, executivecapacities

LATERAL PARIETAL&

TEMPORAL POLE

ROSTRAL‐STGMID‐STGINSULA

AMYGDALAROSTRAL

PREFRONTALCORTEX

10

102102

PROPOSAL – THERE ARE FOURCATEGORIES OF FL DYSFUNCTION

• The four categories of frontal functions map onto general anatomical localization based onprinciples of anatomical development andconnectivity

♦ Energization: Superior medial frontal

♦ Executive: Lateral prefrontal cortex

♦ Behaviour/Emotional Self-Regulation: Ventralmedial prefrontal cortex

♦ Metacognition (Theory of Mind): polar(Stuss, JINS, 2011) 102

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ASSESSMENT: FOUR DOMAINS

A. Energization/regulation: superior medial

B. Executive/cognitive: lateral

C. Metacognitive: frontal poles, primarily right

A. Behavioural Self-regulatory: orbital/ventromedial

Frontal Pole

Ventromedial

Ventrolateral

SMA

Ventromedial

Frontal Pole

Anterior Cingulate

SuperiorMedial

Supplementary Motor Area (SMA)

Premotor Area

Primary Motor Area

Frontal Pole

Ventrolateral

Dorsolateral

THIS CATEGORIZATION is COMPATIBLE with ANATOMY and

CONNECTIVITY

• Two major divisions are based on evolution of cortical architectonics (e.g.,Sanides; Pandya; Stuss & Levine, 2002)

– Dorsolateral: from hippocampal, archicortical trend• Spatial and conceptual reasoning: executive cognitive

– Ventral(medial): from olfactory, paleocortical trend• Emotional processing: behavioural self-regulatory

• Network connectivity (Alexander et al., 1986) – adds action regulation (e.g., energization)

• Metacognitive – role of area 10 in frontal interconnectivity

CONCLUSIONS

“The frontal lobes do not equal a central executive. Executive functions represent only one functional category within the frontal lobes. These frontalfunctions are domain general, possibly because ofthe extensive reciprocal connections with virtually all other brain regions, integrating information fromthese regions. Further integration of these processeswith emotional and motivational processes allows the most complex behaviors.”

Stuss (2011). JINS, p.763

IMPLICATION

• The frontal lobes are not a monolith. There are at least four functional categories within the frontal lobes.

• There are likely subdivisions within the categories; e.g., different types of monitoring (Petrides, in Stuss & Knight, 2012); potential hierarchies of “task setting” (D’Esposito); fractionation of area 10 (Burgess, in Stuss & Knight, 2012).





OUTLINE

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WHY IS FRACTIONATION RELEVANT?

• This is the era of neural networks, inter-connectivity, system analysis –- fractionation is so old school

• ANSWER: I can work on rehabilitation andtreatment of separate processes, the outcome of which I can measure on its effect on the system network – but I don’tknow how to rehab a system without understanding its component parts

110

APPLICATION OF FRAMEWORK TO COGNITIVE

NEUROREHABILITATION• For reviews and elaboration of concepts, see

- Cicerone et al., 2006- Levine, Turner & Stuss, 2008 - Stuss, 2008- Stuss, 2011

110

111

• Externally cuing initiation (Sohlberg et al., 1988)

• Pharmacological dopamine agonist (Powell et al., 1996)

REHABILITATION of FUNCTION

Task Setting

• Simplification of complex problems (Von Cramon et al, 1991)

• Cueing and feedback (Fox et al., 1989)

Executive Functions

• Goal Management Training (Levine et al, 2000, 2007)

Energization

Behavioural/Emotional Self‐Regulation

• Prompts/rewards – Monitoring – Control (Alderman et al, 1995)

Meta‐cognitive Processes

• Problem solving and role play (Ownsworth et al, 2000)

• Modifying people’s predictions, not behaviour (Rebmann & Hannon et al, 1995)(Youngjohn & Altman, 1989)

The Stuss Frontal Lobe Model Is Useful For Rehabilitation Purposes

• The 3 clients showed dissociable patterns broadly seen on all measures

• The Activation and Executive Cognition domains showed clear relative relationships in all cases

• Structured behavioural observations were easy, highly useful, and directed rehab planning





OUTLINE

113

I AM STILL LEARNING!

AND I HAVE LEARNED MOST WHEN I HAVE OPENED

MYSELF UP TO PATIENTS AND WHAT THEY “TELL”

ME

LESSONS

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THANK YOU

9. Stuss- Frontal Lobe Functioning

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