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Rehabilitation of Executive Functions in Patients with Chronic Acquired Brain Injury with Goal Management Training, External Cuing, and Emotional Regulation: A Randomized Controlled Trial

  • Sveinung Tornås (a1), Marianne Løvstad (a1) (a2), Anne-Kristin Solbakk (a3) (a4), Jonathan Evans (a5), Tor Endestad (a2), Per Kristian Hol (a6) (a7), Anne-Kristine Schanke (a1) (a2) and Jan Stubberud (a1)...

Executive dysfunction is a common consequence of acquired brain injury (ABI), causing significant disability in daily life. This randomized controlled trial investigated the efficacy of Goal Management TrainingTM (GMT) in improving executive functioning in patients with chronic ABI. Seventy patients with a verified ABI and executive dysfunction were randomly allocated to GMT (n=33) or a psycho-educative active control condition, Brain Health Workshop (BHW) (n=37). In addition, all participants received external cueing by text messages. Neuropsychological tests and self-reported questionnaires of executive functioning were administered pre-intervention, immediately after intervention, and at 6 months follow-up. Assessors were blinded to group allocation. Questionnaire measures indicated significant improvement of everyday executive functioning in the GMT group, with effects lasting at least 6 months post-treatment. Both groups improved on the majority of the applied neuropsychological tests. However, improved performance on tests demanding executive attention was most prominent in the GMT group. The results indicate that GMT combined with external cueing is an effective metacognitive strategy training method, ameliorating executive dysfunction in daily life for patients with chronic ABI. The strongest effects were seen on self-report measures of executive functions 6 months post-treatment, suggesting that strategies learned in GMT were applied and consolidated in everyday life after the end of training. Furthermore, these findings show that executive dysfunction can be improved years after the ABI. (JINS, 2016, 22, 436–452)

Corresponding author
Correspondence and reprint requests to: Sveinung Tornås, Sunnaas Rehabilitation Hospital, Bjørnemyrveien, 1450 Nesoddtangen, Norway. E-mail:
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Baddeley, A. (2010). Working memory. Current Biology, 20, R136R140.
Baumann, C.R., Werth, E., Stocker, R., Ludwig, S., & Bassetti, C.L. (2007). Sleep–wake disturbances 6 months after traumatic brain injury: A prospective study. Brain, 18731883. doi:
Blake, D.T., Heiser, M.A., Caywood, M., & Merzenich, M.M. (2006). Experience-dependent adult cortical plasticity requires cognitive association between sensation and reward. Neuron, 52, 371381. doi:10.1016/j.neuron.2006.08.009
Beck, A.T., & Alford, B.A. (2009). Depression: Causes and treatment. Philadelphia: University of Pennsylvania Press.
Becker, F., Kirmess, M., Tornås, S., & Løvstad, M. (2014). A description of cognitive rehabilitation at Sunnaas Rehabilitation Hospital--balancing comprehensive holistic rehabilitation and retraining of specific functional domains. NeuroRehabilitation, 34, 87100. doi:10.3233/NRE-131015
Benedict, R.H.B. (1997). Brief visuospatial memory test-revised: Professional manual. Odessa, FL: Psychological Assessment Resources, Inc.
Bilbao, A., Kennedy, C., Chatterji, S., Ustün, B., Barquero, J.L.V., & Barth, J.T. (2003). The ICF: Applications of the WHO model of functioning, disability and health to brain injury rehabilitation. Neurorehabilitation, 18, 239250.
Blake, D.T., Heiser, M.A., Caywood, M., & Merzenich, M.M. (2006). Experience-dependent adult cortical plasticity requires cognitive association between sensation and reward. Neuron, 52, 371381. doi:10.1016/j.neuron.2006.08.009
Broadbent, D.E., FitzGerald, P., & Parkes, K.R. (1982). The Cognitive Failures Questionnaire (CFQ) and its correlates. British Journal of Clinical Psychology, 21, 116.
Burgess, P.W., Alderman, N., Evans, J., Emslie, H., & Wilson, B.A. (1998). The ecological validity of tests of executive function. Journal of the International Neuropsychological Society, 4, 547558.
Burgess, P.W., Alderman, N., Forbes, C., Costello, A., Coates, L.M., Dawson, D.R., Channon, S. (2006). The case for the development and use of ‘‘ecologically valid’’ measures of executive function in experimental and clinical neuropsychology. Journal of the International Neuropsychological Society, 12, 194209. doi:10.1017/S1355617706060310
Burgess, P.W., Alderman, N., Wilson, B.A., Evans, J.J., & Emslie, H. (1996). The Dysexecutive Questionnaire. In B.A. Wilson, N. Alderman, P.W. Burgess, H. Emslie & J.J. Evans (Eds.), Behavioural assessment of the dysexecutive syndrome. Bury St. Edmunds, UK: Thames Valley Test Company.
Cantor, J., Ashman, T., Dams-O’Connor, K., Dijkers, M.P., Gordon, W., Spielman, L., Tsaousides, T., & Oswald, J. (2014). Evaluation of the short-term executive plus intervention for executive dysfunction after traumatic brain injury: A randomized controlled trail with minimization. Archives of Physical Medicine and Rehabilitation, 95, 19.
Chan, R.C.K., Shum, D., Toulopoulou, T., & Chen, E.Y.H. (2008). Assessment of executive functions: Review of instruments and identification of critical issues. Archives of Clinical Neuropsychology, 23, 201216.
Chen, A.J.W., Novakovic-Agopian, T., Nycum, T.J., Song, S., Turner, G.S., Hills, N.K., & D’Esposito, M. (2011). Training of goal-directed attention regulation enhances control over neural processing for individuals with brain injury. Brain, 134, 15411554. doi:10.1093/brain/awr067
Chiesa, A., Calati, R., & Serretti, A. (2011). Does mindfulness training improve cognitive abilities? A systematic review of neuropsychological findings. Clinical Psychology Review, 31, 449464. doi:10.1016/j.cpr.2010.11.003
Cicerone, K., Levin, H., Malec, J., Stuss, D., & Whyte, J. (2006). Cognitive rehabilitation interventions for executive function: Moving from bench to bedside in patients with traumatic brain injury. Journal of Cognitive Neuroscience, 18, 12121222. doi:10.1162/jocn.2006.18.7.1212
Cicerone, K.D., Langenbahn, D.M., Braden, C., Malec, J.F., Kalmar, K., Fraas, M., & Ashman, T. (2011). Evidence based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Archives of Physical Medicine and Rehabilitation, 92, 519530. doi:10.1016/j.ampr.2010.11015
Cicerone, K.D. (2012). Facts, theories, values: Shaping the course of neurorehabilitation. The 60th John Stanley Coulter memorial lecture. Archives of Physical Medicine and Rehabilitation, 93, 188191. doi:10.1016/j.apmr.2011.12.003
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: L. Erlbaum Associates.
Conners, C.K. (2000). Connors’ CPT II continuous performance test II. North Tonawanda, NY: Multi Health Systems.
Coull, J.T. (1995). Monoaminergic modulation of human attentional and executive function. Unpublished PhD thesis. Cambridge University.
Dams-O’Connor, K., & Gordon, W.A. (2013). Integrating Interventions after Traumatic Brain Injury: A Synergistic Approach to Neurorehabilitation. Brain Impairment, 14, 5162. doi:10.1017/Brimp.2013.9
Delis, D.C., Kaplan, E., Kramer, J.H., & Ober, B. (2000). California Verbal Learning Test-II. San Antonio, TX: The Psychological Corporation.
Delis, D.C., Kaplan, E., & Kramer, J.H. (2001). Delis-Kaplan Executive Functioning System (D-KEFS). San Antonio, TX: The Psychological Corporation.
Derogatis, L.R., Lipman, R.S., Rickels, K., Uhlenhuth, E.H., & Covi, L. (1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioural Sciences, 19, 115.
Draper, K., & Ponsford, J. (2008). Cognitive functioning ten years following traumatic brain injury and rehabilitation. Neuropsychology, 22, 618625.
Duncan, J., Emslie, H., Williams, P., Johnson, R., & Freer, C. (1996). Intelligence and the frontal lobe: The organization of goal-directed behavior. Cognitive Psychology, 30, 257303.
D’Zurilla, T.J., & Nezu, A.M. (2001). Problem solving therapies. In K.S. Dobson (Ed.), Handbook of cognitive behavioral therapies (2nd ed., pp. 221245). New York: Guilford Press.
Fernandez-Duque, D., Baird, J.A., & Posner, M.I. (2000). Executive attention and metacognitive regulation. Conscious Cognition, 9, 288307.
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, 13181330.
Fischer, S., Trexler, L.E., & Gauggel, S. (2004). Awareness of activity limitations and prediction of perfromance in patients with brain injuries and orthopedic disorders. Journal of the International Neuropsychological Society, 10, 190199. doi:10.1017/S1355617704102051
Gioia, G.A., Isquith, P.K., Guy, S.C., & Kenworthy, L. (2000). Behavior rating inventory of executive function: Professional manual. Lutz, FL: Psychological Assessment Resources, Inc.
Grant, M., Ponsford, J., & Bennett, P.C. (2012). The application of Goal Management Training to aspects of financial management in individuals with traumatic brain injury. Neuropsychological Rehabilitation, 22(6), 852873. doi:10.1080/09602011.2012.693455
Greene, C.M., Bellgrove, M.A., Gill, M., & Robertson, I.H. (2009). Noradrenergic genotype predicts lapses in sustained attention. Neuropsychologia, 47, 591594. doi:10.1016/j.neuropsychologia.2008.10.003
Hart, T., Whyte, J., Kim, J., & Vaccaro, M. (2005). Executive function and self-awareness of “real-world” behavior and attention deficits following traumatic brain injury. The Hournal of Head Trauma Rehabilitation, 20, 333347. doi:10.1097/00001199-200507000-00005
Kabat-Zinn, J. (1990). Full catastrophe living. New York: Dell Publishing.
Kennedy, M.R.T., Coelho, C., Turkstra, L., Ylvisaker, M., Sohlberg, M.M., Yorkston, K., & Kan, P.F. (2008). Intervention for executive functions after traumatic brain injury: A systematic review, meta-analysis and clinical recommendations. Neuropsychological Rehabilitation, 18, 257299.
Krasny-Pacini, A., Chevignard, M., & Evans, J. (2013). Goal management training for rehabilitation of executive functions: A systematic review of effectiveness in patients with acquired brain injury. Disability and Rehabilitation, 112. doi:10.3109/09638288.2013.777807
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, 299312.
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 behaviour in relation to goal management. Journal of the International Neuropsyhological Society, 13, 143152.
Levine, B., Schweizer, T.A., O’Connor, C., Turner, G., Gillingham, S., Stuss, D.T., &Robertson, I. (2011). Rehabilitation of executive functioning in patients with frontal lobe brain damage with goal management training. Frontiers in Human Neuroscience, 5, 19.
Lewis, M.W., Babbage, D.R., & Leathem, J.M. (2011). Assessing executive performance during cognitive rehabilitation. Neuropsychological Rehabilitation, 21, 145163. doi:10.1080/09602011.2010.543867
Lezak, M.D. (1995). Neuropsychological assessment. New York: Oxford University Press.
Logan, D.E., Claar, R.L., & Scharff, L. (2008). Social desirability response bias and self-report of psychological distress in pediatric chronic pain patients. Pain, 136, 366372. doi:10.1016/j.pain.2007.07.015
Manchester, D., Priestley, N., & Jackson, H. (2004). The assessment of executive functions: Coming out of the office. Brain injury, 18, 10671081. doi:10.1080/02699050410001672387
Manly, T., Hawkins, K., Evans, J., Woldt, K., & Robertson, I.H. (2002). Rehabilitation of executive function: Facilitation of effective goal management on complex tasks using periodic auditory alerts. Neuropsychologia, 40, 271281.
Manly, T., & Murphy, F.C. (2012). Rehabilitation of executive function and social cognition impairments after brain injury. Current Opinion in Neurology, 25, 656661. doi:10.1097/WCO.0b013e3283594872
Mausbach, B.T., Harvey, P.D., Goldman, S.R., Jeste, D.V., & Patterson, T.L. (2007). Development of a brief scale of everyday functioning in persons with serious mental illness. Schizophrenia Bulletin, 33, 13641372.
McCambridge, J., de Bruin, M., & Witton, J. (2012). The effects of demand characteristics on research participant behaviours in non-laboratory settings: A systematic review. PLoS One, 7, e39116 doi:10.1371/journal.pone.0039116
Metzler-Baddeley, C., & Jones, R.W. (2010). Brief communication: Cognitive rehabilitation of executive functioning in a case of craniopharyngioma. Applied Neuropsychology, 17, 299304. doi:10.1080/0908428282-2010.523394
Miotto, E.C., Evans, J.J., de Lucia, M.C., & Scaff, M. (2009). Rehabilitation of executive dysfunction: A controlled trail of an attention and problem solving treatment group. Neuropsychological Rehabilitation, 19, 517540. doi:10.1080/09602010802332108
Miyake, A., Friedman, N.P., Emerson, M.J., Witzki, A.H., Howerter, A., & Wager, T.D. (2000). The unity and diversity of executive functions and their contributions to complex “Frontal Lobe” tasks: A latent variable analysis. Cognitive Psychology, 41, 49100.
Norman, D.A., & Shallice, T. (1986). Attention to action: Willed and automatic control of behaviour. In D. Shapiro & G.E. Schwartz (Eds.), Consciousness and Self-Regulation: Advances in Research and Theory. New York: Plenum Press.
Novakovic-Agopian, T., Chen, A.J.W., Rome, S., Abrams, G., Castelli, H., Rossi, A., & D’Esposito, M. (2011). Rehabilitation of executive functioning with training in attention regulation applied to individually defined goals: A pilot study bridging theory, assessment, and treatment. Journal of Head Trauma Rehabilitation, 26, 325338. doi:10.1097/HTR.0b013e3181flead2
Patterson, T.L., Goldman, S., McKibbin, C.L., Hughs, T., & Jeste, D.V. (2001). UCSD performance-based skills assessment: Development of a new measure of everyday functioning for severely mentally ill adults. Schizophrenia Bulletin, 27, 235245.
Petersen, S.E., & Posner, M.I. (2012). The attention system of the human brain: 20 years after. Annual Review of Neuroscience, 35, 7389. doi:10.1146/annurev-neuro-062111-150525
Peterson, D.B. (2005). International classification of functioning, disability and health: An introduction for rehabilitation psychologists. Rehabilitation Psychology, 50, 105112.
Posner, M.I., & Petersen, S.E. (1990). The attention system of the human brain. Annual Review of Neuroscience, 13, 2542. doi:10.1146/
Prigatano, G.P., & Altman, I.M. (1990). Impaired awareness of behavioral limitations after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 71, 10581064.
Rath, J.F., Simon, D., Langenbahn, D.M., & Sherr, R.S. (2003). Group treatment of problemsolving deficits in outpatients with traumatic brain injury: A randomised outcome study. Neuropsychological Rehabilitation, 13, 461488.
Rees, L., Marshall, S., Hartridge, C., Mackie, D., & Weiser, M. (2007). Cognitive interventions post acquired brain injury. Brain Injury, 21, 161200. doi:10.1080/02699050701201813
Robertson, I.H. (1996). Goal management training: A clinical manual. Cambridge, UK: PsyConsult.
Robertson, I.H., Mattingley, J.B., Rorden, C., & Driver, J. (1998). Phasic alerting of neglect patients overcomes their spatial deficit in visual awareness. Nature, 395, 169172. doi:10.1038/25993
Robertson, I.H., & Murre, J.M. (1999). Rehabilitation of brain damage: Brain plasticity and principles of guided recovery. Psychological Bulletin, 125, 544575.
Robertson, I.H., & Garavan, H. (2000). Vigilant attention. In M.S. Gazzaniga (Ed.), The new cognitive neurosciences (pp. 631640). Cambridge, MA: MIT Press.
Robertson, I.H., & Levine, B. (2013). Attention and arousal in neurorehabilitation. In D.T. Stuss & R.T. Knight (Eds), Principles of frontal lobe function (pp. 742749). New York, NY: Oxford University Press.
Roca, M., Parr, A., Thompson, R., Woolgar, A., Torralva, T., Antoun, N., & Duncan, J. (2010). Executive function and fluid intelligence after frontal lobe lesions. Brain, 133, 234247. doi:10.1093/brain/awp269
Roca, M., Torralva, T., Meli, F., Fiol, M., Calcagno, M., Carpintiero, S., & Correale, J. (2008). Cognitive deficits in multiple sclerosis correlate with changes in fronto-subcortical tracts. Multiple Sclerosis, 14, 364369. doi:10.1177/1352458507084270
Schulz, K.F., Altman, D.G., & Moher, D. (2010). CONSORT 2010 statement: Updated guidelines for reporting parallel group randomised trials. British Medical Journal, 340, c332 doi:10.1136/bmj.c332
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, 7277. doi:10.1177/1545968307305303
Segal, Z.V., Willams, J.M.G., & Teasdale, J.D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapses xiv. New York, NY: Guilford Press.
Smith, A., & Nutt, D. (1996). Noradrenaline and ayyention lapses. Nature, 380, 291. doi:10.1038/380291a0
Sohlberg, M.M., McLaughlin, K.A., Pavese, A., Heidrich, A., & Posner, M.I. (2000). Evaluation of attention process training and brain injury education on persons with acquired brain injury. Journal of Clinical and Experimental Neuropsychology, 22, 656676.
Spencer, R.J., Drag, L.L., Walker, S.J., & Bieliauskas, L.A. (2010). Self-reported cognitive symptoms following mild traumatic brain injury are poorly associated with neuropsychological performance in OIF/OEF veterans. Journal of Rehabilitation Research and Development, 47, 521530.
Spikman, J.M., Boelen, D.H.E., Lamberts, W.H.B., & 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, 16, 118129.
Stubberud, J., Langenbahn, D., Levine, B., Stanghelle, J., & Schanke, A.-K. (2013). Goal management training of executive functions in patients with spina bifida: A randomized controlled trail. Journal of the International Neuropsychological Society, 19, 672685. doi:10.1017/S1355617713000209
Stuss, D.T., & Alexander, M.P. (2007). Is there a dysexecutive syndrome? Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, 362, 901915. doi:10.1098/rstb.2007.2096
Stuss, D.T., & Levine, B. (2002). Adult clinical neuropsychology: Lessons from studies of the frontal lobes. Annual Review of Psychology, 53, 401433.
Stuss, D.T., Murphy, K.J., Binns, M.A., & Alexander, M.P. (2003). Staying on the job: the frontal lobes control individual performance variability. Brain, 126, 23632380. doi:10.1093/brain/awg237
Stuss, D.T. (2011). Function of the frontal lobes: Relation to executive functions. Journal of the International Neuropsychological Society, 17, 759765. doi:10.1017/S1355617711000695
Toplak, M.E., West, R.F., & Stanovich, K.E. (2013). Practitioner Review: Do performance-based measures and ratings of executive function assess the same construct? Journal of Child Psychology and Psychiatry, 54, 131143. doi:10.1111/jcpp.12001
Torralva, T., Strejilevich, S., Gleichgerrcht, E., Roca, M., Martino, D., Cetkocivh, M., & Manes, F. (2012). Deficits in tasks of executive functioning that mimic real-life scenarios in bipolar disorder. Bipolar Disorder, 14, 118125. doi:10.1111/j.1399-5618.2012.00987
von Cramon, D.Y., Matthes-von Cramon, G., & Mai, N. (1991). Problem-solving deficits in brain-injured patients: A therapeutic approach. Neuropsychological Rehabilitation, 1, 4564. doi:10.1080/09602019108401379
van Hooren, S.A., Valentijn, S.A., Bosma, H., Ponds, R.W., van Boxtel, M.P., Levine, B., & Jolles, J. (2007). Effect of a structured course involving goal management training in older adults: A randomized controlled trail. Patient Education and Counseling, 65, 205213. doi:10.1016/j.pec.2006.07.010
Wechsler, D. (1997). Wechsler Adult Intelligence Scale III. San Antonio, TX: Psychological Corporation.
Wechsler, D. (1999). Manual for the Wechsler Abbreviated Scale of Intelligence. San Antonio, TX: Psychological Corporation.
Whyte, J., Dijkers, M.P., Hart, T., Zanca, J.M., Packel, A., Ferraro, M., & Tsaousides, T. (2014). Development of a Theory-Driven Rehabilitation Treatment Taxonomy: Conceptual Issues. Archives of Physical Medicine and Rehabilitation, 1, 2432. doi:10.1016/j.apmr.2013.05.034
Wilson, B.A. (2008). Neuropsychological Rehabilitation. Annual Review of Clinical Psychology, 4, 141162.
Ylvisaker, M., & Feeney, T. (2000). Construction of identity after traumatic brain injury. Brain Impairment, 1, 1228.
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