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functional deficits lead to restrictions in home, work, and but overlapping disciplines, including neurorehabilitation

,
community activities, even if by clinical assessment the cognitive psychology, and cognitive neuroscience (Elliot,
deficits are considered "mild " (Pohjasvaara et al., 2002; 2003). Rather than exhaustively review the decades of
15 EXECUTIVE FUNCTIONS Rochette et al., 2007). The cognitive deficits associated research pertinent to executive functions, including the
with stroke vary in type and severity from individual to large bodies of research carried out on working memory
individual, based on site and lesion(s) location, but Zinn, and attention, we decided to use this chapter as an oppor-
SUSAN M. FITZPATRICK and CAROLYN M. BAUM
Bosworth, Hoenig, and Swartzwelder (2007) found that tunity to explore how the concept "executive function" is
nearly 50% of individuals show deficits in executive func- used by different disciplines, in what ways the uses of the
tion . We suspect this number underestimates the true inci- concept are similar or difrerent, and the opportunities
dence of high-level cognitive difficulties. and challenges to be met when integrating findings from
The Cognitive Rehabilitation Research Group (CRRG) across the disciplines to yield a coherent understanding at
at Washington University in St. Louis maintains a large the neural, cognitive, and beh avioral/performance levels,
database of information regarding stroke patients admit- so that research findings can be used to inform clinical
ted to Barnes-Jewish Hospital. As of December 2009, the practice aimed at ameliorating executive dysfunction . It is
CRRG research team had classified 9000 patients hospi- our goal to identify the language and knowledge gaps that
talized for stroke. Although stroke is often associated with could be hindering the successful translation of experimen-
elderly populations, nearly half of the patients (46%) were tal knowledge into practical applications for individuals
younger than age 65. About 4500 patients (50%), were recovering from stroke. It is not possible to overemphasize
classified as having mild stroke (National Institute of how difficult such integrative work can be. For the past
H ealth Stroke Scale score = 0 to 5). In a subsample of 110 several years, the James S. McDonnell Foundation has
15 .1 STROKE REHABILITATION: THE a performance-based perspective, executive functions are patients, 65% were found to have executive dysfunction been encouraging working groups composed of basic cog-
ROLE OF EXECUTIVE FUNCTIONS called on when individuals make plans, initiate actions, as measured on behavior and performance tests (Baum, nitive neuroscientists and academic clinicians to develop
and modify activities as problems are experienced or infor- 2009; Wolf et al., 2009). The demographics of stroke evi- consensus reviews for diagnosis and treatment based on a
Rehabilitation for people recovering from stroke focuses mation from the environment changes. A performance- denced in the Washington University database-younger cognitive neuroscience model called CAP (computation-
on restoring the ability to perform the activities required based approach to executive functions starts with an and with milder disease-presents an eye-opening chal- anatomy-psychology; Corbetta & Fitzpatrick, 2011). The
for living independently. For the most part, clinical neu- examination of how well a person is able to run errands, lenge for rehabilitation professionals. Younger stroke sur- first series of papers, on action rehabilitation, recently
rorehabilitation concentrates on interventions designed to multitask at work, or quickly alter a route because of road vivors had higher expectations of returning to work and to appeared as a special supplement to Neurm·ehabilitation
treat motor and language impairments. The difficulties an congestion, and then attempt to identify the underlying the myriad demands of active family and social life. Unlike and Repair (Frey et al., 2011; Pomeroy et al., 2011 ; Sathian
individual may experience from impairments of high-level cognitive and neural substrates. older stroke survivors, whose lives may be more structured et al., 2011) and serves as one model for developing mutu-
cognitive functions, typically labeled executivefunctions) are Chen et al. (2006) suggest that the brain networks and thus more readily routinized, younger individuals were ally agreed-upon language and concepts.
not always apparent in clinical settings and are often not supporting executive functions are central to learning, and engaged in precisely the kind of activities most reliant on In this chapter, we review the measures used to iden-
the focus of therapy. Part of the reason executive functions thus executive functions are important to the relearning the flexibility provided by intact executive functioning tify executive dysfunction and the interventions targeted
may be somewhat overlooked in clinical care is that execu- and retraining necessary for successful rehabilitation as (Wolf et al., 2009; O'Brien & Wolf, 2010). To meet the to executive dysfunction at the neural, behavior, and per-
tive functions have been defined in a number of contexts measured by real-world performance. Clinicians are encour- needs and expectations of younger stroke patients, neu- formance levels. For the purposes of this chapter, only key
ranging from experimental cognitive studies to neuropsy- aged to exercise care during client evaluations. Individuals rorehabilitation must be prepared to address deficits in findings from the cited papers pertinent to the chapter's
chological assessments. There is no commonly agreed set of with executive dysfunction can often perform adequately executive functions. goals are provided; readers are encouraged to consult the
cognitive abilities or neural structures uniquely identified as on standard neuropsychological evaluations because they In this chapter, our performance-based definition of original papers for more complete details. The approach
supporting executive functions. Rebecca Elliot (2003) pro- are administered in a structured and supportive environ- executive functions and executive dysfunction overlaps with we've selected begins with examining the current under-
vides a good summary of why the term executive functions ment (Lezak, 1982, 2000; Prigatano, 1999; Dosenbach but is not synonymous with fi'ontal lobe functions or .fi'on- standing of executive function at the multiple levels of
is not a unitary concept. In this chapter, we will attempt et al., 2008). Their difficulties may not become appar- tal syndr·ome, respectively. These have been described most analysis we call B rain (including neural and cognitive sys-
to integrate across the behavioral, cognitive, and neural ent until they attempt to resume unstructured activities notably by Stuss and colleagues (for review see Levine, tems), Behavior, and Perfonnance. Figure 15.1 provides a
descriptions of executive functions in an effort to identify at home, work, or in social situations. Chan et al. (2008) Turner, & Stuss, 2008). Individual performance on some
gaps in our knowledge that, if filled, could be helpful in provide a comprehensive review of the various cognitive behavioral measures provides strong support that execu- BRAIN BEHAVIOR PERFORMANCE

translating research findings into clinical practice. neuroscience models proposed for executive functioning tive functio n shares characteristics with, but need not be Neural Brain Behavior Behavioral
Daily Life Tasks
Constructs Relationship Consequences
In general, cognitive psychologists describe executive and discuss some of the difficulties with assessing cogni- identical to, neuropsychological tasks primarily reliant on
functions as (i) the ability to exhibit flexible adaptive tive contributions to complex behaviors in the laboratory, working memory (Frank, Loughy, & OReilly, 2001) or • Plasticity • Working • Risk taking • Initiate
memory
behavior, (ii) the use of appropriate problem-solving strat- in clinical settings, and in everyday life. with "top-down" control mechanisms (Dosenbach, 2008). • Connectivity • Reaction time • Organize
• Change sets
egies as required for maintaining and updating goals, (iii) Brain injury as a result of stroke is a leading cause of Due to the complex nature of the tasks dependent upon • N eural • Attention
• Sequence
processing • Distractibility
the capacity to monitor the consequences of actions, and individuals becoming unable to carry out the activities executive functions it is likely that executive functions are • Awareness
• Failure to
• Judgment/
• Multimodal safety
(iv) the ability to use prior knowledge to correctly inter- central to their daily life (Cardol et al., 2002). Considering supported by networks of brain region comprised of corti- integration
• Automaticity inhibit
• Completi on
pret future events (Miyake & Shah, 1999). Cognitively, the impact of stroke on everyday functioning, it is sur- cal, subcortical, and cerebellar regions (Chen et al., 2006; • Regional
• Impulsivity
specializations • Fatigue
the term executive functions also derives in part from the prising that 85% of people who survive a stroke return Dosenbach, 2008; Pessoa, 2008).
idea of top-down control by a central executive, as pro- home (Reutter-Bernays & Rentsch, 1993). Stroke can TI1e ability of individuals to carry out the behavioral
posed in models of working memory (Baddeley, 2001) or result in a wide range of deficits, including executive func- tasks associated with intact or disrupted executive func-
Figure 15.1 The Language of Exec utive Function At Multiple Levels
of attentional control (Posner & Petersen, 1990). From tion deficits. When not identified and managed, these tions is an active area of research in a number of distinct

208 I STROKE REHABILITATION 15 . EX ECUTIVE FUNCTIONS I 209

2 Measures of Executive Function at Multiple Levels. Note: treatment plan. and correctly implement sion in Chan et al. "executive functions" does not neatly map onto identifiable is imperative that researchers and clinicians work together ing cerebellar regions. experimental constraints make it impossible mative and predictive power for post-stroke rehabilitation. trial-by-trial basis. • Smart automaticity tra in ing of cognitive resources. It 2000. and are characterized as the dynamic deployment sti mulation • In creasing • Functional skills • Cognitive to translate research into practice is the lack of a shared. In part. neural injury predictive of the nature and extent of execu- tive dysfunction is central to creating a feasible post-stroke environments. among the most complex functions of the human brain suite of challenges posed by the multi-scale nature of brain However.. the challenges of translating findings from research to focus on dissociable components of executive functions as create an ongoing tension between the natural need for 1991. Levin. particularly if based primarily on functional imaging stud. Dunbar. 2001. In sive functional brain imaging literature relating to execu.3 will serve as a reference for external environment. of analysis onto neural substrates.g. cognitive operations.essence.allow humans to synthesize information coming from the ' specific cognitive processes (e. structural lesions. to study the neural basis of cognitive functions in intact in the context of real world behaviors. tion yields information needed to refine or correct neural Constructs Relationship Conseq uences I What is readily observable is that there is very little tures. A set of interact- This list is not exhaustive but is meant to introduce measures at differ. and the dorsal anterior cingulate cortex/ Manchester. specifically the dorsal lateral pre- this paper. 1994. Rather. & Barch.. When considering per. &Jackson. we now validity of the conclusions and generalizations that can be with fast dynamics to cues signifying task onset and. Posner and Petersen's ing executive functions has been derived from neuropsy- Note: This list is not exhaustive but is meant agenda needed if the field of neurorehabilitation is to use to introduce interventions at different levels. behavioral.rely on connections to other areas throughout the brain. the concept of neuroscience toward rehabilitation. indicate that top-down control is likely to involve a larger UNDERSTANDING OF EXECUTIVE work. I£ as we discuss above. Executive functions hindered by. 1996. 2004). We do not mean to imply that informa. 2004)... It is also clear that executive functions environments. or One component of executive functions extensively is imperative that we understand how injury and thera. working memory. however. the task rules or contexts can dysfunction only to frontal lobe injury. working memory. Being able to identify patterns of can and should be tested in both clinical and real-world in a particular way) over many trials (Dosenbach et a!._____ ___. as well as from memory stores in complete proxies for more complex behaviors (see discus. strategies necessary to accomplish tasks (Goldberg. 2007.3 Interventions for Executive Function at Multiple Levels. drugs training • Goal management interactional that executive functions are behaviorally context-depen- in our view. ___ .support as major components of executive functioning: fotmed during data acquisition and on the experimental eral. function. Dosenbach et al. ological context of the human brain post-stroke. Diamond. Inte llig ence Scale. proposed working models derived from cognitive neurosci. Increasingly. initiating and adjusting control of performance on a Daily Life Tasks Constructs Relationship Consequences Anderson. our pur. of therapeutic approaches. neural systems to be both resilient (stable following per. for measuring the loss of function. ~------' . E XEC UTIVE FUNCTIONS I 211 . Rather. in neurological patients with well-characterized neurological and cognitive theories concerning informa. and there is often competing stimuli that must be cautious of overgeneralizing from brain models of ing methodologies has allowed cognitive neuroscientists concerning brain function be tested and refined as needed be ignored to accomplish the task (Burgess & Shallice. For cognitive neuroscientists. toring function. particularly in the context of the altered physi. cating the network's activity is sensitive to feedback. and spatial scales ranging distinct networks operating at different temporal scales frontal lobes of the human brain are a primary center of from the molecular to whole organisms interacting with (Seeley et al. or Wisconsin card sorting task) should not be taken as automatic processes (see Cohen.3 NEURAL SUBSTRATES OF o rientation to mutually understood language.. & Benton. executive functions make it possible for humans set-shifting with exper-i mental tasks designed to probe studied is top-down control (or voluntary control) over peutic interventions interact with. for cognitive neuroscientists to study complex. executive functions proposed by cognitive neuroscientists. 1he cingula-opercular network also monitors Figure 15. Almost any brain injury disrupting the networks ence research that have sufficient detail to make predictions cingula-opercular network.2 and 15. most functional imaging studies patient to participate in relearning or retraining. Stroop task. Smith & practice. there has been some evidence to support the theory tive functions that has been amassed in the past two differentially depending on whether participants per- • Biomarkers • Wisconsin Card • Test of Everyday • Executive • Blood flow Sorting Task Attention Function that executive dysfunction is more likely attributed to dif.. functionally connected to both ent levels. in the experimental laboratory setting. • The Kettle Test imaging IV Letter-Number Syndrome • The Multiple supporting executive function can be expected to lead about the neural underpinnings of executive functions and operates at a slower temporal scale and is involved with • Functional connectivity • Priagatano Errand Test to cognitive.. Although published more than 2 15. and for leagues as "fronto-parietal" and a second as "cingula- formance requires a particular sequence of actions. executive functions. In gen- tion processing and performance should have some infor. 1986. subjects. A major barrier. made at other scales. Pessoa. (i) inhibition. new experimental data from imaging studies 15. theory-driven. Testing the frontoparietal and cingula-opercular networks and 210 I STROKE REHABILITATION 15. and per. at least five cognitive constructs have empirical ies.. implement. we describe a limited number of recently form correctly or incorrectly on individual trials. -=-~-=~---- summary of some of the language commonly used at each BRAIN BEHAVIOR PERFORMANCE disruptions of executive functions suspected of support. 1he frontoparietal network responds fact. 2002. Recognizing that at pres. previously defined in this chapter (e. The current use of task-free resting state func. Miyake et al. context. and (v) emotional regulation (Norman tional connectivity imaging does not completely mitigate behaviors and. . because imaging results are dependent on the task per. The imaging Assessment of Test • BOLDMR • Wechsler Adult Dysexecutive 2008). the difficulty derives from the observation and cognitive models. N-back test. and Robbins & Arnsten. decades. 2002). Translating from cognitive neuroscience to neuroreha.-----. plays a role in Neural Brain Behavior Behavioral .. 2002. the availability of noninvasive imag- is also critically important that theories and explanations change.formance. 1his may & Shallice. of cross~disciplinary research and attempts • Electrical • Strategy training training approach dent. Kaplan & Berman. 2006) during what might be considered the entire task tion should flow in only one direction-from cognitive epoch. concerns remain relevant today and should guide practical chological studies with patients with brain lesions. 1990. of the prefrontal cortex. number of interacting brain regions organized into two FUNCTIONS Both experimental and clinical findings indicate that ing from milliseconds to years. 1999. 1996. Priestley. Well-structured 1996.. turbations) and plastic (able to alter with experience).. commonly agreed that top-down control involves areas the measures and interventions that will be discussed in the brain. as a result. & Benton.. prosthetics • Self-awareness • Real -life problem daily li ving decades ago. set-shifting).2 OVERVIEW OF A MULTI-LEVEL and are central to being able to perform activities at home. 1he frontoparietal network responds carrying out complex tasks. however. These abilities are bilitation (and vice versa) also requires contending with a medial superior frontal cortex (Miller & Cohen. experimentally vides a cogent discussion of the challenges inherent in the tested interventions for executive dysfunction. it Neurorehabilitation researchers and clinicians should 2011). Shallice. 2008). to generate. In For years the healthcare community attributed executive determining recovery has far-reaching implications for the opercular" (2008). Manchester et a!. EXECUTIVE FUNCTIONS solving/cueing ent there are few effective.g. In neuroscience studies of attention. (iii) strategic process. described by Dosenbach and col- Complex tasks require goals to be formulated. (ii) working memory. attempts to map processes described at the cognitive level lviuch of what is known about the neural systems support- pose is to review the groundwork and suggest the research Figure 15. which includes the thalamu s. and performance problems to a the risk for dysfunction as a result of injury or disease that maintaining set (the ability to be prepared to respond Competency Rating Scale greater or lesser extent. It is not possible for this chapter to review the exten... 2001). resulting from trauma (reviewed 111 Zoccolotti et a!. dependent executive functions span temporal scales rang. and can be helped or to successfully encounter novelty. we believe it response choices in light of task goals. and in psychiatric populations. Behavioral Daily Life Tasks ing complex human behaviors onto discrete neural struc. (iv) set shifting. It is tems... & McClelland. BRAIN BEHAVIOR PERFORMANCE are aware that individuals can experience executive dys.__ ___. ~ ~ -. The evidence Executive functions are needed to perform complex tasks. predictions in the real-world settings of neurorehabilita- Neural Brain Behavior of the levels.. Cognitive inhibition.. 2009 for review). Braver. real-world 1he practice of rehabilitation is often built on asking the ing. Goldman-Rakic. Jonides & Smith. • Neuromodulatory • Working memory • Self-regu lation • Dynamic overlap in terminology across the levels. a review by Posner and Petersen (1990) pro. mostly cognitive neuroscience findings to inform the development interpretation of research findings . Cohen. Eisenberg. supports one network. frontal cortex. the resilient and plastic aspects of neural sys. 1997. Figures 15. indi- • Anatomica l • Trail Making • Behavioral Performance fuse lesions in the brain (SnlSS & Levine.Jonides. 2008). Baddeley. it is even more difficult to map the to generate knowledge and to validate findings. function even in absence of frontal lobe injury (Tranel. TI1e scale an investigator chooses for moni. 1he neural elements implicated in performance. 2010). and in community life.

a few studies have also been carried out with working memory tasks. However.. (see also Chapter 4). receive data to obtain a measure of frontal-striatal connectivity. erate stroke demonstrating deficits in working memory. Attempting to modulate cognitive neurological insults affecting large neural networks and and patient populations (for a historical review of this 212 I STROKE REHABILITATION 15. 2008). The findings raise important implica. how will the optimal dose be iors. The operations of task-dependent. cal!neurophysiological context for neurorehabilitation consideration is that most basic science functional imaging conjunction with rehabilitation. an area known to be important in the per. tional modeling. bromocriptine exerted a negative tural neural imaging methods to determine the full extent be determined.g. in the Gibbs and D'Esposito 2005 study in an effort to part of an adaptive response? information (for details see Figure 4 in Pessoa. it provide a case study underscoring the care that must be dependent function . Importantly. to behavioral rehabilitation interventions. but not the encoding or retention stages of aspect of Pessoa's model is the conceptual proposal he puts • How could dopamine augmentation be optimally modulation on performance of working memory depen. to memory span individuals. either alone or in offer some intriguing implications for additional research. retrieval rate. Ramirez. reanalyzed the neuroimaging data obtained from subjects • Will pharmacological resistance develop over time as areas serve as hubs regulating the Row and integration of ing results on the role of neurotransmitters and neuromod. again correlating with the behav.. Similarly. (2011) analyzed the imaging tive dysfunction. formance of working memory-dependent tasks. Before exploring the neuroimaging • Will dopamine augmentation yield behaviorally meaning- lesion localized to sparsely connected regions would yield patient populations. In particular. the striatum) neurons (for review tion increased the measured connectivity in low working INTERVENTIONS experimental contexts. Considering that areas not surprisingly. 2009). In theory. People with Parkinson's disease are. and rehabilitation. still and how these tools can contribute to a neuroanatomi- generalize to patients after brain injury. 2004. Pessoa's model describes integrated cognitive. matter integrity. the effects are not explained by changes in either motor infrastructure and resources needed to support multidis- tive processes require interactions among a network of tion and difficulties performing complex working-memory speed or vigilance. Increasingly. It is also important to keep in mind that role of these ascending fibers is to stabilize task-relevant effect on frontal-striatal connectivity in the high working of their injuries. Chapter 10). connectivity blood oxygenation level dependent (BOLD) subJects. a series of publi. (2011) along a gradient of connectivity. dynamic. a detailed overview of clinical brain imaging methods hemodynamics and brain tissue properties may or may not fering from working memory deficits could be helped by ticipants in a carefully controlled experimental setting. REHABILITATION (2008) and are included in the rather comprehensive Wallace et al. processing. frontal cortex. as discussed below. experimental results. result in negative effects. and interpret.1 TRANSLATIONAL CASE STUDY: DOPAMINE adaptive nature of chemical neurotransmission requires that will need to be answered include the following: during the experiments summarized by Dosenbach et al. and human tine appeared to modulate the putative PFC-dependent determined for individual patients? the frontal executive network.e. A particularly intriguing subjects underscore the importance of dopamine neuro. To be useful in clinical rehabilitation research. be characterized as bel~nging to either a high-span work. important for studies looking at the effects dopamine augmentation yields an inverted U-shaped curve implicated as integrative hubs are also the brain regions of dopamine on cognitive function. A final caveat for the administration of dopamine agonists. 1 NEURAL MEASURES AND ization of these networks derive from data obtained in releasing midbrain (i.. ing task performance. it should be anticipated tasks are intriguing enough to encourage further experi. Wallace et al. Too little or too much Answering these questions.3. were also found BOX . The assumptions made regarding the requisite to consider the possibility that neurological patients suf. Highly connected brain Although most of the functional imaging studies report. (2011) evaluated the influence of dopamin. and brain that suggest that there are regions in the brain that how pharmacological approaches may or may not be help. Following up the previous findings. D'Esposito. the task. case whether the neuromodulation is obtained via phar- et al. determined prior to adoption of neurochemical adjuvants that stroke patients will experience some degree of execu. ing memory group or a low-span working memory group. impairments of a more generalized nature. in other words. results. while other cogni. 2005) article. possibly due to fusion tensor or diffusion weight imaging to assess white ing functional imaging data (Fitzpatrick and Rothman. neurology. resting state functional studies report findings obtained from data averaged across cations from Mark D'Esposito's laboratory. cognitive psychology. ioral data. performance by tinkering with the complex. and Black (2008) provide 2002). particularly with individuals recovering from mild or mod. data failed to reach statistical significance. tions for use of dopamine augmentation in rehabilitation. such as execu. Before pharmacological interventions can be used Interestingly. Behaviorally. roimaging study during performance on verbal delayed • Knowing that undertreatment or overtreatment could emotional networks supporting complex. AUGMENTATION AND POTENTIAL USE IN STROKE detailed understanding of mechanisms. It is important that stroke patients be assessed with strtlC- world. 2009). to have anatomical imaging (CT or MRI) to make a deter- interpreted in light of the numerous assumptions built decrease an individual's susceptibility to distractions dur. it is critical to note the behavioral observation that ful improvement? a specific behavioral impairment. although both the imaging and the performance mination of the structural integrity of the brain. The findings. the mental task. packing for a trip) remains to for optimal working memory performance. Communication between memory span individuals and was positively correlated experimentally determined functional networks in real. nonhuman primates. and adds the amygdala and nucleus accumbens to carried out with rodent. Robbins & Arnsten.ase out the effects of bromocriptine on the functional is tempting to speculate that focal disruption of a highly • What are the unwanted effects? carried out with healthy participants without neurological connectivity of the prefrontal cortex and the striatum during connected hub would result in global dysfunction. rotransmitters influence activity in cortical-striatal circuits functional connectivity by reanalyzing data from a study memory functions? In an interesting Nature Reviews Neuroscience opinion responsible for performance of complex cognitive tasks. It ulators during performance of cognitive tasks are typically t E. and the myriad others expected affected in the most common clinical strokes resulting studies taken together with theoretical models describing dopamine appears to negatively influence behavior (see dis. ful with individuals with compromised neurological func. ergic modulation on measures of prefrontal cortex-striatal onstrating post-stroke deficits dependent on working responsible for human top-down control. Luiz Pessoa (2008) proposes an expanded model • Are there diagnostic measurements that could reliably such as those known to rely on working memory. flexible behav. reviewed below. Additional research is needed that can magnetic resonance imaging (fcMRI) is being called will be necessary to be able to extrapolate group findings taken when rehabilitation practitioners look to translate specifically address the needs of clinical populations with upon to identify functional neural networks in both intact or general principles to an individual. the prefrontal cortex (PFC) and the striatum is important with the improved behavioral performance on the experi. with healthy human subjects (Gibbs & D'Esposito. individuals can lational research principles regarding what needs to be artery and anterior cerebral artery. Damage to brain areas as a result of stroke dependent tasks. The principle finding was that bromocrip. ciplinary teams with expertise in neuroscience. and multiple neurotransmitter systems. The results of such with respect to task performance. the principal finding was that bromocriptine administra- 15 . suggests some general trans- from vascular accidents involving the middle cerebral how different brain regions interact to accomplish complex cussion in Gjedde et al. bromocriptine administration improved task. and dif- into the protocols for acquiring. should be expected to yield both specific impairments and The current understanding is that neurons in the pre. mental studies and are of potential interest to rehabilita. ascribed with processing error-related activity contribut. 2009. imaging. trended toward a decrement in performance . (2006) have also put forward a conceptual rubric effectively. while a deficits. This will be the tive dysfunction (Levine. computa- brain regions. everyday tasks (e. a key that monitored the effects of the dopamine D2 receptor of interacting brain regions contributing to executive ascertain which patients are likely to benefit? component of executive functions (for reviews see Cools & agonist bromocriptine in conjunction with a functional neu- functions. 2008). High working memory span individuals stimulation (for further discussion see Butefisch. albeit obtained from healthy young par. It is important to keep in mind that the character. forward: that particular brain areas could be characterized paired with behavioral interventions? dent tasks. EXECUTIVE FUNCTIONS I 213 . Carrying out such research will require the carry out specific cognitive functions. to arise in the clinical setting. When Wallace et al. 3 . Gao. 2010). Some of the questions ing to improvement of task performance. Chen tion. & Stuss. see Cools & D'Esposito. modulatory input from ascending fibers from dopamine. It can be tempting in light of the experimental evidence the small sample size. Turner. Refer to Figure 15. much remains to be learned from studies with related speed and accuracy only in low working memory macological treatments or by the application of electrical for considering structure/function relations in the human defined patient populations with an eye toward delineating span individuals. converging evidence from cognitive neuroscience studies recognition tasks .2 and 15. It is useful functional models based on brain imaging tools must be working memory representations or. • Could dopamine augmentation help individuals dem- and updated model they provide for the neural systems Evidence is accumulating on how neuromodulatory neu.

If the person makes thereby increasing automaticity and allowing working language impairment. However. which ing times for everyday events. 1997). initiate. . Chuang et pins and thereby enhancing neuroplasticity (Narushima et these behaviors. 1994) uses a range of at different grain sizes that continue to shape the brain level is demonstrating that the resulting changes are not of reinforcement. EXECUTIVE FUNCTIONS I 215 . The time it takes for the may include training on subtasks that are made routine. be beneficial to have long-term studies of individuals post. "zoo map. Lezak's (1982) work describes the char. as contributing to the action of cortical stimulation category will be described. between a number of tasks while not breaking rules. Considering the heterogeneity of stroke menting cognitive processes may very well turn out to be edu/~cpphelp/WAIS-R. ing rooms under controlled conditions and therefore do to be seen how useful resting state functional connectivity gested. Robbins and Arnsten in family.2 lists the measures It is not always necessary that tests be carried out in fully tation. tests (i) be highly correlated with performance in everyday RELATED BEHAVIORS clinical rehabilitation and outpatient settings that allow sive to rehabilitation. The tasks include tion of treatment. Kay & Curtiss. Grant & Berg. rather than the leagues also suggest that antidepressant therapy may aid acteristics of the person with brain injury and challenges provide more complex tasks closer to the demands made in BOLD signal. 4 . it is necessary that an individual's performance on such 15 . are distractible. based on experimental studies with murine brain quences of executive function. and behavioral interventions will not only created in 1955 (Wechsler. using a telephone directory. The test can be the ability to follow a route through a map that does not stroke (Martinsson.targeted cogni. It can be used as a measure of aware- B E HAVIORAL CONSEQUENCES OF STROKE (2009) have published an authoritative and comprehen. ing outcome. (Floel & Cohen. particularly in the context of the altered cerebrovas. lack insight. In this section of the chapter we The tests discussed in this section were designed to respond for a family member to rate the respondent. it is an genation. it is not and (iii) set maintenance (Su Lin. In 1986) is a measure of self-awareness or the ability to 214 I STROKE REHABILITATION 15. The BADS is a battery of six tests and two rorehabilitation community can implement such adjuvant tive retraining. most how neuropharmacology could influence the mechanism that focuses on the relationship between brain function. 2010). measurements will be when they are used in neurorehabili. concentration. a subspecialty of the field of psychology response to the cnt1c1sms. Burgess. stroke. and individual goals for rehabilitation. timing. recovery of executive functions by upregulating neurotro. number broadcasts). translate experimental findings into clinical applications. identify the extent of the damage. Hardemark.. 2006). and implicit demands of a series of tasks. attentional tasks that are necessary in everyday life (search- years after injury will be especially useful with the younger confined to the neural level but can yield or enable changes the WCST-64 resulted in a three dimensional model: ing maps. (i) inflexibility.. Part problems with attention that will require rehabilitation Not surprisingly. Strategies tion protocols to aid recovery in patients following stroke retical framework for executive dysfunction interventions lifting the pencil from the paper. research is improve performance on targeted tasks but also improve (WAIS_IV) after being standardized on 2. for all researchers and clinicians interested in considering neuropsychology. Heaton. naturalized settings to be valid for assessing performance. beneficial gains in behavior and performance. "temporal judgment. determining the correct pairings of drugs and necessary but not sufficient to meet patient-centered reha. If an intervention is to be useful in rehabilitation. In a sample of 112 persons with stroke. to the concerns that neuropsychological tests were failing The Patient Competency Rating Scale (Prigatano. selective attention. a recent review summarizing the useful. 2007). correct it. Robertson. used with people with brain injury to identify the area break rules. The factors of sustained attention. Restoring or aug. ing and behavior. we believe Urgently needed to advance the science of neuroreha. Behavioral Assessment of the Dysexecutive sions drawn by authors of this revie>v that there remain and not the neural level. which measures concentration while the using rules." which assess time There is some evidence that antidepressant therapy can Persons with executive dysfunction have difficulty plan. Emslie. patients' performance on everyday tasks. a reading of the cautionary life. and cerebral blood volume (CBV. which moni. and adjust behavior in response to the explicit needed on determining optimal dosing. (WAIS-IV) Working Memory Index. therapy to traditional practice. measurement see Lowe. 1990). cular milieu characteristic of patients post-stroke. and "modified six elements. and specific subtests management with the person dividing the available time have a positive effect on executive functioning post-stroke ning. the administrator points out the error so she can memory and attentional resources to be deployed to more the authors could identify experimental findings and they propose and the predictions they make for determin. many open questions that require answers before the neu. in the United States and 688 in Canada (http://cps. It is most likely increase. Two levels of neuropsychological tests important caveat that these are still administered in test- al. Executive functions are needed to fulfill roles (DEX). 2005). and community life. 2008). 1 MEASURES TO IDENT I FY BRAIN - bilitation is the development of methods amenable to the ganization to make the state of the system more respon. "key search. 2010) primarily focused on motor and based on cognitive neuroscience/functional neuroimaging person to connect the trail is reported.. Talley. (ii) reveal in a meaningful way the underlying neural temporally dynamic measurements of the neural changes "case study" provided in Box 1 exposes the knowledge gaps The Wisconsin Card Sorting Test (WCST. practical problem of getting a cork out of a narrow tube each patient in the context of the neural and cognitive Arithmetic. for example. functionally independent attentional circuits in the brain that interventions directed at the neural level will be phar. 2007). The authors propose that the and have little concern for social rules (Burgess & Simons. Figure 15. & Eksborg. that will be discussed. many of whom can expect to live and meaningful improvements at higher levels of analysis. Cheelune. test of set-shifting. enough to demonstrate that a pharmacological agent may The Trail Making Test (Reitan ·& Wolfson. and (iii) guide therapy. as one version is for the respondent and the second sive· review of experimental and clinical evidence for the rehabilitation services. 1995) verbal working memory match the current evidence for function are directed at the neural level. It remains to be seen whether The Wechsler Adult Intelligence Scale-IV Syndrome (BADS. assessment also includes the Dysexecutive ~estionaire eB-ect could be mediated via a monoaminergic modula. ing memory/attention." requiring estimat- This was essentially the conclusion reached in a review 15 . The ability to capture the neural changes occurring The challenge for any intervention directed at the neural play flexibility as he is presented with changing schedules Ward. & Guo. ful. pharmacological agents to alter plasticity and network reor. Narushima and col. 2008). small-scale trials data. and solve a problem. make poor decisions. are at the cognitive-behavioral level required to complete each task. Chen and colleagues (2006) have also proposed a theo. 4 . Kwan. attentional switching. and ness of pharmacological interventions or cortical stimula. decades after a stroke. and mental control. of the brain that has been affected. multi-level combinations of pharmacology. long-term potentiation (LTP) as a provides information regarding attention. 2007). alternating between letters and numbers without prospective employers in devising a care plan. The Test of Everyday Attention (TEA. Despite more than a decade of research. describe both the brain function and the behavioral conse. In particular. however. The data from the TEA reveal macological or based on the use of electrical stimulation. Ridgeway & Nimmo-Smith. were developed that do not rely on the performance of sin- notably the use of perfusion MR imaging.4 BEHAVIORAL MEASURES AND Letter-Number Sequencing (a supplemental task). A similar mechanism of action has been sug. The (Narushima et al. We agree with the general conclu. slices. Other approaches for assess. Several instruments in each not fully mimic the rich complexity of real life situations. It measures the person's ability to dis. and auditory- Very few rehabilitative interventions for executive dys. deficits should be identified and addressed as a part of ness. (ii) ineB-ective hypothesis-testing strategy.. CBF. and post-stroke rence of behaviors. 2 MEASURES TO IDENTIFY THE tion of frontal-striatal networks. 1993) is a mance. to be useful in rehabilitative practice. it remains al. subject manipulates mental mathematical problems. and dura. a card task. areas of rehabilitative need where findings (Chen et al. Index has three tests: Digit Span. We admit that it is appealing to consider the use of However. Alderman. that alterations in synaptic plasticity allows for meaning. B requires the connection of numbers and letters (a trail) professionals to engage with the patient. 2010)." which requires on the use of amphetamines for improving recovery after INTERVENTIONS measures attention and working memory. We think it would also that must be bridged if the field of neurorehabilitation is to 1948. gle tasks delivered in a controlled environment but rather tors changes in cerebral blood flow (CBF). which is dependent on changes in blood oxy. Part A requires the participant to (Posner & Petersen. role of monoaminergic modulation of executive functions focus less on what has been learned from cognitive neu. draw lines to connect 25 numbers scattered on a page. new neuropsychological tests ing functional connectivity have been proposed. work. in order. in the context of mental disorders that is recommended roscience research and more on what can be learned from to generalize to performance in naturalistic settings. The two scores reflect the total time in seconds "on-line" task demands.. The Working Memory a "rule shift" to demonstrate shifting between two rules in patients.nova. visual scanning. 1955) and revised in 2008 questionnaires that requires the person to plan. Wilson. a behavioral questionnaire to identify the occur- 15 . The level of the interventions an error. techniques (Fritsch et al. of post-stroke dysfunction or recovery." which identifies the ability to sequelae of stroke. 1996). However. proxy for synaptic plasticity unless there is also evidence and executive function. an "action program" requiring a solution to a behavioral interventions will require careful titration for bilitation goals (Swartz.html). listening to lottery populations of patients. 1996). The WAIS was & Evans.. which measures work. or cognitive deficits that are contributing to poor perfor- accompanying behavioral change. neuropsychologists to develop tools to better characterize "real life" situations (Wilson et al. caregivers.200 persons monitor.

. and bill paying) that the client an injury that results in executive dysfunction (Alderman them to develop habits and routines for real-world skills grocery store even if the end goal. a specific morning routine. Stith. and how much external support mined based on the individual's ability to initiate the task. By conceptualizing cian provides a series of graded cues: (1) a verbal prompt. pletion of the task performance. behavioral and emotional function. primarily developed by occupational therapists. rehabilitation pro-. task. They are scored in terms of errors (omissions. and safety). a task. an actual task that is The Executive Function Performance Test (EFPT) tasks: buy 3 items (using only a specific amount of money). and different environments. Assessing the level of execute the task (including organization. 2000). and cog. which was adapted and studied in clients with no mismatch between the current state and the goal state. Support is serving the beverage (a 12-step task).. previously thought to be untestable. and the clinician observes while the patient completes Goal Management Training (GMT) is a neuropsycho- result in vastly different outcomes for individuals with similar post component cognitive processes work together to accomplish rhe task. et al. individual can do and how much assistance is needed for result of this complexity. wider range of abilities. Such an approach is used to train clients networks are brought to the goal. Morrison. & Baum. 2005). performance. tional capacity. with individuals with stroke.. because support is the variable ment. because activities can be accomplished Edwards. different cognitive resources and brain (2) a gestural prompt. The GMT contains several support the everyday performance of tasks necessary to live et al. 1he Multiple Errand Test by Shallice and Burgess address the mismatch. It is. an by employing different strategies and by different levels The EFPT includes 4 standardized instrumental activi. Felzen. The EFPT provides tigator 10 minutes afi:er starting the assessment. 2009) is be presented.3.4 Factors Contributing to Resuming Participation Post. interest. opercular networks discussed earlier in this chapter. and (v) checks or monitors the process.g. stages that are based on this notion: (i) Stop! Alerts and independently. a different approach from what we have described for neu. The traumatic brain injury (Knight et al. can use to help individuals either learn new strategies or occupational therapy intervention. and political norms. recognizes the impair- of motivation. 2008. and the strategies are likely to be disrupted by the damage caused by strokes nitive process will result in impairments in overall func.. however. including environmental and social support systems can late." the outcome of the selected actions is com- the underlying neural structures supporting performance some of the challenges raised above. a person performs an entire task. cultural.5 BEHAVIORAL AND PERFORMANCE in behavioral routines when there is little expectation of tant to learn how it is that a person plans and executes a person is not capable of completing it. It has been validated in studies with the times. and (5) cessation of the task because the 15. Hahn. and meet the inves. 1997). By observing the task failures. 1he theory states that any activity might not be obvious in the absence of a complete under. working memory deficit). are some promising strategies addressing the rehabilita- apist's observations. & Hartman-Maeir. linking performance to was developed by Baum et al. impor. The clinician and 15. rehabilitation interventions for executive functions Unrecognized and step in learning new strategies to manage an executive Unmanaged Because the EFPT can be used in both the clinic and the share many of the problems encountered in rehabilitation function deficit is to know that you have a problem that home. 2010). 2009). to manage daily affairs?" Using a ments can be created with a combination of these two tive problems persons have in managing the challenges of orients the person to the task. scored based upon the speed. Wilson. encountered in the real world. these tasks tend to ignore the person. 2003). (3) direct verbal instruction. 2003). and actions or mental operations are selected to the consequences of executive dysfunction. Awareness is a serious problem when Executive are captured in persons. there are many ways individuals can navigate a medication management. While performing are critical in planning interventions and working with egy solely on the results of functional imaging studies or client in a debriefing that focuses on the client's evaluation a task. and It should not be assumed that impairment in a cog. It is based on Duncan's ment can both support and hinder performance in ways that return to work (see Figure 15. It was developed to elucidate cogni. or a health facility. as a Poor Performance Good Performance daily living. tea. A total score is deter. Four promising intervention strategies will The Kettle Test (Hartman-Maier et al. It is likely that point in the context of education carries important lessons mance of a task. 2007. Environmental Neuropsychological tests are designed to document the rela. The performance is scored for each element of the logical intervention developed to teach patients with brain stroke clinical profiles..BASED TESTS Social and designed to indicate one's ability to perform daily tasks. Refer to Figure 15. and complete the task. Alderman et Because there can be many actions associated with a task. Each of the steps is theory of goal neglect. it identifies what an (Elliot. elderly. ropsychological tests and seek to answer a different question results of neuropsychological assessments should be sup. ing the sequence and activities over many days until the most likely to determine if someone can remain at home or the EFPT does not simply determine successful or lation of cognitive processes supporting complex behaviors process becomes automatic. the therapist engages the can lead to the goals being achieved. to train in is rieeded in order to be successful. (iii) lists the main steps. TI1e Daily Life him or her to carry out a task. partially completed tasks. be safe. Of a person experiences executive dysfunction. and with clients with finished. identify the cost of an item. obtaining the water injury a strategy to improve their ability to plan activities environment interaction. putting the ingredient into the cup. (ii) the person defines the performance approach. INTERVENTIONS generalized application of strategies to novel circumstances task. compared. al. EXECUTIVE FUNCTIONS I 217 . However. fessionals may find it helpful to identify strategies they The Neurofunctional Retraining Approach. inefficiencies. The person being tested must accomplish 6 main tasks. utive junctions serves as an "umbrella term" for a constel. "checking. Importantly. therapy would involve repeat- support required is key. A discussion of this a record of executive functions serving in the perfor. Dromerick. to anterior regions of the brain (Dosenbach et al. Performance there are still gaps in our ability to interpret brain and cog. is identical. Connor. determining an individual's overall ability to function. learn compensation strategies to help them function afi:er ments faced by persons with brain injury and trains example.3 PERFORMANCE . patient make the decisions about the details of the task to BEHAVIORAL LEVEL depiction of an individual's specific cognitive impairments Stroke. Robertson. Wolf. (iv) learns the steps. course. This figure depicts how rehabilitation directed at executive be completed from some options of coffee. Via the cueing system. including assembling the kettle. Tadmor. and necessity of assistance. Clearly. Carter.appraise one's strengths and weaknesses in acnvmes of unsuccessful task completion. individuals with executive func- nitive and physical function following brain injury. 2008). At this time of the performance. (2003) in an effort to address make a phone call. everyday life. and say when they are these operations map onto the frontoparietal and cingula- for rehabilitation (Bruer. two at the behavioral level and two at the 15. it is a bridge linking the data obtained in controlled more generally. Connor. telephone use.5. For ties of daily living (IADL) tasks (cooking. also the variable that is most dependent on social. performance level. take nitive measures in terms of what is or is not sufficient for (1991). et al. since the first Dysfunction and is associated with the degree of cognitive impairment.4 for a summary). executive function is examined as assessment strategies. and and to structure their intentions. The clini. There Demands respondent's responses are compared to a relative's or ther. it is unwise to base an intervention strat. The natural and built environ. The intent the clinician and one for the patient. They pared with the goals to be achieved (Levine. necessary in everyday life. Following com. buying all the items on has to perform to live independently at home. one for tionship between brain function and behavior.. This process continues until there is tests. 2006) in the hope that more insightful measure. (4) physical assistance. 2002. Hong. It should not come as a surprise that. receipt of cues. is it is important to inhibit irrelevant actions that will not about brain function: "How does the brain and cognition plemented with performance-based assessments (Burgess a multiple sub-goal task performed in a shopping district contribute to a particular goal. ments to create the structure to guide the actions that Clarity in the task demands and the available affordances In our view. including lack of well-designed interven- Executive needs new strategies. judg. This cueing system is standardized tion of executive functions that deserve further study. Another example of therapy 216 I STROKE REHABILITATION 15. Dysfunction research studies with the rehabilitation goal of assessing an tion trials with outcome measures linked to the stated Recognized and Managed individual's ability to perform in everyday life. 2003) and following stroke (Dawson et al. outcome goals. & used). with the goal of developing behavioral automaticity and a list as quickly as possible. Throughout this chapter we have made the point that exec. requires intermediate cognitive models. a greater reliance on the environment. a tion are somewhat resistant to rehabilitative efforts. Baum. responds to errors. the current state of affairs and the goal state are patients and their families to help them learn to manage the results from a neuropsychological battery. sequencing.. hot choco- (e. Support The patient's task is to prepare two hot drinks. rather.. including cueing the task difrerently. For example. also must collect information about opening and closing Clare.. as well as assessing how well dysfunction.1 INTERVENTIONS AT THE of neuropsychological assessment is to provide an accurate Figure 15. (Giles. mail something. In the final stage. and ingredients. incomplete requires the person to establish goals and/or task require- standing of what cognitive resources are actually required.4. schizophrenia (Katz.

L. and how to use the menu therapists. of learning. The clinician creates 107-118. databases must be maintained over time to begin to Biitefisch. and strategy use following frontal lobe lesions...]. and clini- sequence each day (Baum & Katz. D . ]. (1997). reasoning.. Coates. Specifically. (2008). Oxford: Oxford University Press. Toulopoulou. 849-864. 5-28. D . interactions and demonstrate the importance of social person. strategy learning and awareness approach that encour. M-A. the recovery Chan. Functional strategies and become aware of how deficits require modi. 194-209. Neuropsycholog:. 1993). Baum. The same CO-OP creates a learning paradigm that helps individuals REFERENCES the Stroop Effect. shap. C . and occupational therapy. M . as a framework for guiding the discovery of self-generated mance-based tests. 26(8). results from neuropsychological tests. Treatment focuses on helping the person develop stage is where the skill is performed consistently and in a 23(2). modeling. M. 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Neuroscientist. a lack of behavior. tions. Shum. generalization. & S. approach focuses on changing the activity demands. ]. Scuss. van Gelderen. New York: Guilford Press. (2009). Anderson. Burgess. The founda. vidual from engaging in everyday life. \Veill Cornell Medical College. M. D.. \V.. N. 2004. S. Ikonomidou. P.. 2005. T. This lack of awareness hinders the indi. K. Archives ofPhysical Nfedicine and learn strategies that can be used in different activities and who have had a stroke requires the continued work and Focus on S)'lnptomlvfanagement. and transfer of learning. T. C. PLAN. Knight.' ofevel)'daJ'. Responsiveness of the impact on Toglia (1993.. 201-216. W. T. K. Morrison. C. 3S-5S. also developed by occupational Function Pe1jormance Test: Test protocol booklet. digm that acknowledges that new skills emerge from an who study executive function. These 211-231) . Nettrolmage. of interventions and outcome measures. C. 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