How to Impact Initiation in Brain Injury Recovery Fall 2017 NeuroInstitute Gordon J. Horn, PhD National Deputy Director Analytics & Outcomes
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How to Impact Initiation in Brain Injury RecoveryFall 2017 NeuroInstitute
Gordon J. Horn, PhDNational Deputy Director
Analytics & Outcomes
Objectives
• Participantswilllearnabouttheroleofthefrontallobesandexecutivefunctions.
• Participantswilllearnabouttheimpactofthefrontallobeswithinitiationandinhibition.
• Participantswilllearnstrategiestoassistindividualswithinitiationandinhibitiondeficits.
• Participantswilllearnabouttheroleofmedicationtoreducetheimpactofthesedeficitsindailyfunctioning.
RoleoftheFrontalLobes&ExecutiveFunctions
“Sohowisthatworkingforyou?”
Role of Frontal Lobes
Thefrontallobesaretheexecutivemanager!
Ourentiresystemisregulatedbythefrontallobesbecauseoftheinvolvementofdecisionmaking,self-regulation,andneurobehavioralmanagement.
Resultsincognitive,emotional,andbehaviordysregulation.(DimasioandDimasio,1990-2000;UniversityofIowa).
*Thinkofthismassiveregion(30%ofthebrainmass)astheregulatorandmanageroftheentiresystem*Differencesofleftvs.rightinjury;differenceswithorbitofrontalvs.lateralvs.ventral.*Socialdysregulation;socialawarenessimpairment;overestimationofskillsandunderestimationofdeficit;impairedinitiation.
Role of Frontal Lobes
Attention,moderatetocomplexprocessing,memoryintegrationandstorage,decisionmaking,problemsolving,initiation,inhibition,self-control,moodregulation,moodexpression,andlanguageprocessing.
Self-Monitoring
Creativity
Inhibition
AffectiveExpression
Role of Frontal Lobes
Neurophysiology
Accountsfor1/3 ofthemassofthebrain.
Involvesmultiplesubsectionsthatcrossintoallotherareasofthebrain,andprovidesamanagementeffectofsignalsthatarebothconsciousandoutofawareness.
Role of Frontal Lobes
Neurophysiology
Accountsfor1/3ofthemassofthebrain.
Neurodevelopmentalpathwaysareincompleteuntilage24-25.Disruptionofthepathwaysduetotrauma,injury,illnesswillsubstantiallychangetheoutcomesofadultdevelopment.
Braininjuryoftenresultsindeficitsinexecutivefunctions.Thiscanmanifestasproblemswithself-directedcognitivefunctioningortheycanmanifestasproblemswithself-directedbehavioralandemotionalself-control.
FrontalLobesandInitiationandInhibition
ExecutiveFunctionsandDysexecutiveSyndrome
Executive Functions
Theterm“executivefunctions”referstointegrativecognitiveprocessesthatdeterminegoal-directedandpurposefulbehavior.
Executivefunctionsaresubordinatetomorebasiccognitiveprocessessuchasmemoryandattention.Bysupervisingandcoordinatingunderlyingcognitive,behavioral,andemotionalprocesses,executivefunctionsallowfortheorderlyexecutionofdailylifefunctions.
(Ciceroneetal.,2000)
Thisincludes:Formulatinggoals,solvingproblems,anticipatingconsequences,planningandorganizingbehavior,initiating relevantbehaviors,andmonitoringandadaptingbehaviortofitaparticulartaskorcontext,andhavinganintendedoutcome.
Executive Functions
Disturbancesinthesefunctionsismostlikelytobeevidentinnovelorunfamiliarsituations(Godefroy&Rousseaux,1997).Initiationisimpactedbynoveltyandcomplexity.
Executivefunctionsarenecessarytoadapttodeviationsfromanestablishedroutine,reacttounexpectedevents,orcorrectmistakes.
Braininjury– impairmentofthinkingbeforereacting!
Rehabilitationofexecutivefunctionsisnecessarytoteachmetacognitiveskillsthatcanbeappliedacrossdiversesituations.
Rehabilitationhastoincorporatethefollowing,initiationof…CognitiveskillsEmotionregulationBehavioralcontrol
NeurobehavioralSyndromes
NeurobehavioralSyndromeshavebeendescribedintheliteratureforyears.Itincludesaspecificregionofthebrainandnegativebehavioraloutcomes.Itinvolvesimpairmentofinitiationandinhibitionwithinexecutivedysfunction.
Criteriaforthissyndromeinpost-acutecare:Injurymustbe >8monthsdurationThefollowingbehavioralfeaturesarepresentatleastmildly:
Irritability,Agitation,andAggressionImpairedAwarenessImpairedSocialInteractionImpairedProblemSolvingImpairedInitiation
*ImpairedInhibitionskillsmayalsofactorintothissyndromeofimpairment
Horn,G.,Lewis,F,&Russell,R.(2016).BehavioralDyscontrolFollowingAcquiredBrainInjury:EffectivenessofPost-hospitalNeurobehavioralIntensivePrograms.Jr.ofNeurologyandNeuromedicine,1(8),29-33.
Initiation/Inhibition
Initiationisthestarting ofanact,behavior,thought,orcommunicationattheappropriatetimesandundertheappropriateconditions.
Inhibitionisthestopping ofanact,behavior,thought,orcommunicationattheappropriatetimesandundertheappropriateconditions.
Whenthissystemhasdysfunction,thenthethoughts,mood,andbehaviorbecomeeasilytriggeredandsomewhatrandom.Contextnolongermatters.
Initiationstartswithbasicactivitiessuchasbrushingyourteeth,washing,usingthetoiletappropriately,orcheckingmail.Itisalsowithinhighlycomplexbehaviorsandactionssuchasdrivingacar,listeningtoalecture,ormakingfinancialdecisions.
Initiationandinhibitionincludecost-benefitanalysis;whenthissystemisnotworking,thenimmediatebenefitmayoutweighlong-termbenefit,andleadtolossoverall.
Examples:cases,gambling,substanceuse.
CognitiveHierarchy
WhereisInitiationinthehierarchy?
Cognitive Data Hierarchy - Basics
Data Mining and Cognitive Hierarchy (Kendell & Kendell, 2013)
Cognitive Hierarchy – Brain Model
I/AMood &
PersonalityIntegrate
Executive Fxs.Judgment
Problem SolvingMemory
(Visual, Verbal, Complex)Learning – ComplexLearning - Immediate
Visual-Perceptual SkillsDimension, Gestalt, Constancy, Topography
Language - Express/ComprehensionSpeech Articulation/Dysarthria
Information Processing - Immediate & Complex
Sensory PerceptionArousal – Alertness – Immediate Attention
(NAB,2003)
Initiation/Inhibition
Rehabilitation Hierarchy – A New Model
AuditionDizzinessMotorSpeechPain/Headache,Vision,UseofHands--InappropriateSocial,Irritability,SymptomSensitivityDepression,FundofInformation,VisualPerceptionAnxiety,Fatigue,Mobility,Non-VerbalCommunication,VerbalCommunication--Self-CareFamilyFunction--Initiation, ProductivityAttention,ImpairedAwareness,MemoryNovelProblemSolving,SocialContact--LeisureandRecreationMoneyManagementHomeSkillsTransportationUse
Horn,Lewis&Malec,2016RaschAnalysis
Cognition impact on Rehabilitation
Horn,Lewis&Malec,2016Regression
HierarchicalRegressionOutcomemeasure:ParticipationT-scoreatdischargeBlocknumbersandDependentVariables
ChangeinR2
(variance/contributiontooutcome)
Sig.Level
1. Initiation 32% .00052. VisualSpatial*
MemoryFundofInfo*ProblemSolv*AttentionConcentration
Block2combined9%
.0005
3. Mobility 6% .00054. VerbalComm <1% .08(n.s.)5. Depression
AnxietyBlock5combined
1%.01
6. IrritabilityInappropriateSocial
Block6combined1%
.01
7. ImpairedAwareness 2% .01Visualspatialskills(6%),Fundofinformation(2%),andNovelProblemSolving(1%)werethelargestcognitivecontributorstooutcomeafterinitiation.Sample:NeuroRehabilitation(n=1385)
StrategiesforInitiationandInhibitiondeficits.
Strategies
Goal:createastructuredplanleadingtothedesiredoutcome;executionofresponses;useoffeedbacktocomparetheplanwiththeachievedoutcome.
1. Identifythedemandsofthetask(identify)2. Plantheappropriatesequenceofresponses(prediction–>expected=
awareness)3. Implementationoftheplanwithself-monitoringofperformancewithuseof
strategies(structureandcuesareflexible)4. Comparisonsaremadebetweentheeffectivenessoftheiractionwiththe
predictedeffectsandconsequences;incorporationoftherapistfeedbackaswell.
5. Changetheapproachiftheinformationindicatestochange.
Strategies – Decision Tree
Ispersonawareofdeficits?
No,thenworkonincreasing
awarenessofdeficit
Yes,thenproceedtoproblemsolving
strategies
Definethelevelofimpairment
Increasedawarenesshelpstogettofunctionssuchasinitiatingunderappropriateconditions.
Strategies – Define Impairment
Whatisthelevelofimpairment?
Mild – Useofinternalizedstrategies;useofexternalstrategiesExample– concussion;personishavingheadaches;pre-injurywasrunningtwobusinessesandnowishavingdifficultyunderstandingwhyheadachesaretriggered.Internalizedstrategyistolearnpacing(initiating) andhavea“stressscale”ofwhensymptomsincreaseto5-6/10withtheuseofa“stop”(inhibition) strategyforrest.
Moderate – Useofinternalizedstrategies;useofexternalstrategieswithassistExample– moderateTBIwith+LOCfor2hours;personhasdifficultieswithroutineandmanagingdailyneeds/demands;requirestheuseofaphoneforpromptsandreminders(Initiating),anddevelopsapatternofreviewinghislistofto-doseachnightandeachmorninguponawakening(Inhibition).
Severe – UseofexternalstrategieswithassistanceExample– ModeratetosevereTBIwith+LOCfor24hourswithamnesiaof3days.Herequirestheuseofapromptingsystem(phone,computer),andhasfamilyprompthimeachmorningoftheday’sactivities(ExternalInitiation);whenhegets“stuck”,thenhecallsafamilymemberforprompting.Healsohasdailyremindersofhisdeficits.Supervisionrequired(ExternalInhibition).
Strategies – Person or Environment
Internalizedvs.ExternalizedStrategies
Internalized – thisiswhentheinjuredindividualisactivelyworkingondevelopingproblemsolving,planning,organization,andself-monitoringtechniques.Top-downapproach.
Thegoalistodevelopstrategiesthatcontinuouslyhelptomanageinchangingconditions,whichleadstoappropriateinitiationofthought,behavior,andmood.
Externalized – thisiswhentheinjuredindividualhasinitiationimpairmentthatimpactssimpletocomplexdailyactivities;outsidesourcesareusedtoprovidesprompts,cues,andfeedbackofperformance.Thismayincludeelectronicaids,otherpersons,oranenvironmentthatallowsanddisallowscertainactivitiesorbehaviors.Bottom-upapproach.
Thegoalistohavecontinuoususeofexternalaidstoshapebehaviorandthoughtsintoappropriateoutcomes.
Strategies – Metacognition
Metacognitionrefersto“thinkingaboutthinking.”Itisatop-downapproach.
Thisincludes….KnowledgeandControl.
MetacognitiveKnowledge – representsboththeperson’smoment-to-momentawarenessofhisorherthinkingandmorestablebeliefsaboutone’scognitiveability.
MetacognitiveControl – representstheperson’sself-monitoringoftheirthinkingandtheabilitytoadapttochangesintheenvironmentortask-demand(s).
Highlycomplexbehaviorsaretheproductofself-regulationskillsincluding…(Initiation) Settinggoals>>Comparingperformance>>Makingdecisionstochangeorselectanalternativeapproach>>Executingthebehaviororchangeinbehavior(outcomeleadstostopping)
Strategies – Metacognition
FrameworkforMetacognitionTraining(referenceguide)Guide– 4partsincludingAwareness,Planning,Executeandself-monitor,Self-evaluate.
AwarenessIntervention(Cheng&Man,2006)Awarenessofknowledge,performanceprediction,performandmonitor,feedbackwithshort-termgoals.
Self-AwarenessTraining(Goveroveretal.,2007)Generalself-awareness,define-predict-anticipateerrors,choosestrategyandassessassistanceneed,self-assessandtherapyassess,keepajournal
TimepressureManagement(Winkensetal.,2009)Awarenessofprocessingspeed;Timepressuremanagement(competingtasks,feelingoverwhelmedordistracted,lossofpriority,plan);monitorperformanceandexpecttheunexpected;generalizetheoutcometodifferingtasksanddifferinglevelsofcomplexity.
Strategies – Metacognition
FrameworkforMetacognitionTraining(referenceguide)Guide– 4partsincludingAwareness,Planning,Executeandself-monitor,Self-evaluate.
SocialProblem-solving(VonCramen,VonCramen&Mai,1991)Problemorientation,generatealternatives,decisionmakingandsolutions,andsolutionverification(diditwork?).
GoalManagementTraining[stop-think-plan](Levineetal.,2000)Stop– raiseawareness;Defineorthinkthroughtheproblem(whatamIdoing?);learnthestepsandreduceanxietyandpressure;Check– whatisthemaingoalandhowwillthishelp?
ICRPActivityAnalysis(Ciceroneetal.,2008)Whatisthetasktobeaccomplished?;Whatarethepartsofthetaskoractivity(anticipatesuccess);Identifystrategiesforuseduringthetask–perform– self-monitorlimitsandapplication;Self-evaluatewithfeedbackfromothers.
Strategies – Awareness & Education
Recognizethedeficitsbyhavingsomeonepointthemout andshowingdifferencebetweenwhatisperceivedversuswhatisactual(useofexamresultscanhelp).
Showhowthedeficitsimpactdailyfunctioning – havethepersonperformatask.
Ifbehavior,emotion,orcognitivecontrolislost,thencommentandbringthistotheperson’sattentiontoimproveawarenessoftheimpactoftheproblem.
Provideeducation – thiscanbethroughwrittenmaterial,throughinternetarticlesorwebsitesthatareintendedforeducation.UseofYouTubetoshowexamplesofproblemsandtheirimpact.
Provideevidenceorexamples ofwhentheimpairmenthasimpactedperformance.
AlternativeExplanationsforoutcome– Iamnotinterested,maymeanthetaskisbeyondtheleveloftheindividual.
Strategies – Additional Thoughts
Considerresistancetobecognitiveratherthanpsychological…
Psychologicalresistance isrelatedto“notwantingtodoit”.
Cognitiveresistance isrelatedtobeing“cognitivelyoverwhelmed”bythetaskandnotbeingabletoformulatearesponsetomakeachange.
Example:1. IfItellyouthatyouhavetogotoworkbyanewroute,butIdonottellyouwhichroute
totakeorwhenyouhavetodothisby,thenyouwillcomeupwithvariousoptionswithoutmucheffort.Youinitiatethetaskalmostimmediatelybecausethesolutionisrelativelysimpleandyouhavealreadydonethisinthepast.
2. IfItellyouthatyouhavetogotoworkbyanewroute,andtheroutecanonlybeusingsideroadsandonlyroadsthattravelnorth,anditmustbedonebytomorrow,theninitiationofthetaskbecomesdifficultbecauseyoucalculatetheprobabilityofbeingcorrectandhavingaresponse– thereisnoanswertothisproblem– whenyoufigurethisout,thenyoudonotinitiatetheact.
Medication(s)reducetheimpactofdeficitsindailyfunctioning
Stimulant type medication
Stimulantsmayhelp,buttherefocusiswithinthefrontalsystemsonly.However,initiationmaybealackofdopamineinmultiplelocations,notjustinthefrontallobes.StimulantsincludeRitalin/Methylphenidate,Cylert,Vyvanse,etc.Theeffectismostlydopamineandnorepinephrineinthefrontalsystems.
Broadbasedmedicationthatcanbeusedmayimpactinitiationandothercognitivefunctionsthatserveinitiationhaveabroaderimpact.Amantadineisalong-standingmedicationthathasbeenusedinbraininjuryrecoveryandrehabilitationtohelpenhancetheprocessingwithindopaminepathwaysthroughoutthebrain.
Dopamine Receptors
Mood Stabilizers / Mood changers
Typesofmedicationtoconsiderforbehavioralandmoodinitiationandinhibitioncontrol.
1. Moodstabilizers thatareseizuremedication(regulatestheintegrationoffrontalandtemporalcentersforbehaviorcontrol,impulsivityreduction,andimprovedinsightregardingbehavior).
2. Antidepressants (fordepression)
3. Anxiolytics (anti-anxiety)
4. Antipsychotics forseverebehavioraldyscontrol
Final thoughts…
Initiationisacomplexcognitive,behavioral,linguistic,andemotionalfunctionthatrequiresintegrityofotherfunctionsbeforeyoucanexternallyandself-regulateeffectively.
Initiationiscomplexbecauseitisinfluencedbytheenvironmentandbyprocessingofinformation.
Inhibitionistheconverseofinitiationandthesetwofunctionsworkhandandglovetoproduceappropriateoutcomes.
Inexecutivefunctions,initiationistheplanningandbeginningpartofproblemsolving,whileinhibitionistheendoftheactorbehavior(stoppingappropriately).Decisionmakingisusinginitiationandinhibition.
References
CiceroneK&GiacinoJ(1992).Remediationofexecutivefunctiondeficitsaftertraumaticbraininjury.NeuroRehabilitation,2, 12-22.
GodefroyO&RousseaxM.(1997).Noveldecisionmakinginpatientswithprefrontalorposteriorbraindamage.Neurology,49.695-701.
HaskinsEC,CiceroneK,Dams-O’ConnorK,EberleR,Langenbahn D,Shapiro-RosenbaumA.(2014).Cognitiverehabilitationmanual.Translatingevidencebasedrecommendationsintopractice.AmericanCongressofRehabilitationMedicine.Reston,VA.
Horn,GJ,Lewis,FD(2016)BehavioralDyscontrolfollowingacquiredbraininjury:Effectivenessofpost-hospitalneurobehavioralintensiveprograms.JournalofNeurologyandNeuromedicine,1(8),29-33.
Horn,GJ,Lewis,FD&Malec,JF(2016).RehabilitationModeling:UsingtheRaschAnalysisforevidenced-basedcare,ArchivesofPhysicalMedicineandRehabilitation.(Presentedatthe93rd AnnualAmericanCongressofRehabilitationMedicine– Chicago,Illinois).
KennedyMRT,CoelhoC,TurkstraL,YlvisakerM,SohlbergMM,YorkstonK,ChiouHH,&KanPF.(2008).Interventionforexecutivefunctionsaftertraumaticbraininjury:Asystematicreview,meta-analysisandclinicalrecommendations.NeuropsychologicalRehabilitation,12:3, 257-299.
White,R&Stern,RA(2003).NeuropsychologicalAssessmentBattery.PsychologicalAssessmentResources,Inc.:Lutz,FL.
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