The efficacy of VTS forpatients with executivefunction deficits afteracquired brain injuryRené ter Horst & Suzanne Kruiper

Executive functions

“The functions that regulate and control cognitive processes.”

Especially important when behavior is not automatic and routine, in new and complex situations (Shallice1988)

Executive function deficits: examples

impulsive

difficulty in grasping the whole picture

difficulty generating thoughts / ideas /solutions to problems

get caught in a thinking rut, 

cannot easily shift frames of mind

In social communication:

not listening 

jumping to conclusions

inappropriate comments 

Critical Thinking

“the purposeful and reflective judgment about what to believe or what to do in response to observations, experience, verbal or written expressions, orarguments. It involves determining the meaning and significance of what is observed or expressed.”

Facione (2007)Dauer, Francis Watanabe

executive function deficits trouble with critical thinking

Fluid intelligence

“the capacity to think logically and solve problems in novel situations, independent of acquired knowledge. It is the ability to analyze novel problems, identify patterns and relationships that underlie these problems, and the extrapolation of these using logic”

Executive function deficits trouble with fluid intelligence

Rehabilitation of executive function deficits

protocol for disexecutive syndrome, Spikman (2010) Goal Management training Problem Solving training Algemene Plannings Aanpak

PCR (Policlinic Cognitive Rehabilitation)INR (Intensive Neuro Rehabilitation)

How?

The group‐setting: Different perspectives (shift between points of view) Discuss and compare different points of view Highlight agreement or contrasts Invite explanations Ongoing process of exploration and elaboration

Art as a medium to practice critical thinking

Accessible: no prior knowledge necessary No fixed meaning (therefore no wrong answers) Many layers of interpretation

Inclusion Criteria

No current cognitive rehabilitationExecutive function deficits (DEX > 27)Acquired brain injury, at least 1 year post onsetAge 18‐65Informed consent

Design

Group A T1 VTSTwice a weekfor 4 weeks

T2  no intervention T3

Group B no intervention VTSTwice a weekfor 4 weeks

Randomisation

Rappid Assessment of Problem Solving

WAIS‐III Picture Arrangement

WAIS‐III Comprehension

Explain social conventions, rules or expressions

Dysexecutive Questionnaire (DEX)

(Burgess et al., 1996)

Examples

Does or says embarrassing things when in the company of others.

Loses his/her temper at the slightest thing. Finds it hard to stop repeating saying or doing things once started.

Social Communication Skills Q.

Examples

Thinks of new topics to discuss and questions to ask Allows others to express themselves without interruptionsReads and responds to clues the other person givesSupports opinions with facts 

ADI and MOI

Aesthetic Development Interview (ADI) (Housen, 1983) 2 paintings (3 parallel versions) No aid of facilitator or groupmembers

Material Object Interview (MOI) (Housen, 2002)  2 objects: generalisation to different context No aid of facilitator or groupmembers

Analysing the ADI and MOI

CADRE = Framework

- Context

- Association

- Divergent thinking 

- Revision

- Explanation

Context

Examples Context“That looks like a Monet!”“I think it is an Italian painter out of Rembrandts time!”“A Greek nose from the Hellenistic era”

Association

Example Association

“Oh I love sunflowers, they are such cheerfull flowers. I always bought them for my grandmother. She diedseven years ago, her nose was always so red… etc.”

ADI

ADI

“….It seems like that is the edge of a bath, and on top there is something made of fabric….I do not knowwhether it is something she had wrapped aroundherself, or if it’s her clothes (divergent thinking) …No, I do not think it’s her clothes (revision), because if thiswas the case, she would’nt have put them aside socarelessly; you can see the fabric almost hanging in the water (explanation).”

MOI

MOI

Baseline characteristics

Group A 

(n=7)

Group B

(n=6)

Age 46.14  (14.29) 46.83  (14.00)

Sex male: 4

female: 3

male: 5

female: 1 

Time sinceonset (years)

6.89 (3.83) 9.53 (7.32)

Education 5.57  (0.98) 5.00  (1.27)

Baseline (cognitive screening)

Group A Group B

TMT‐A 50.57 (6.48) 42.50 (17.82)

TMT‐B / A 54.29 (7.80) 49.67 (7.39)

Stroop I 35.29 (9.96) 28.17 (13.57)

Stroop II 43.00 (9.61) 25.67 (12.77)*

Stroop III / II 57.14 (8.95) 49.17 (8.31)

RBMT immediate 47.71 (12.42) 32.83 (4.36)*

RBMT delayed 47.00 (12.56) 34.50 (6.78)

Results group A

T1 T2 T3

Picture Arrangement 9.43 (3.8) 11.57 (4.4) 12.83 (4.22)

Comprehension 13.00 (2.3) 14.71 (2.8) 15.67 (2.34)

DEX 37.67 (18.0) 32.14 (12.0) 27.67 (16.4)

SCSQ self 91.00 (9.90) 96.71 (10.3) 99.00 (14.38)

SCSQ proxy 97.00 (11.3) 99.50 (12.4) 100.50 (10.29)

RAPS % constraint q. 88.98 (7.3) 92.52 (8.4) 89.37 (9.4)

RAPS efficiency q.1 48.81 (10.2) 53.87 (23.8) 50.70 (13.6)

RAPS efficiency q.2 59.35 (11.2) 58.45 (9.5) 64.67 (13.8)

VTS

Results group A

T1 T2 T3

ADI Divergent th 2.00 (1.61) 4.21 (3.88) 4.42 (3.64)

MOI Divergent th 3.57 (2.88) 5.21 (4.11) 4.17 (2.44)

ADI Revision 0.79 (1.47) 1.36 (1.89) 0.92 (1.56)

MOI Revision 1.43 (2.73) 2.21 (1.63) 2.00 (2.12)

ADI Explanation 2.71 (2.63) 14.00 (8.36) 14.25 (11.07)

MOI Explanation 2.21 (2.06) 6.29 (3.97) 6.58 (5.32)

VTS

Results group B

T1 T2 T3

Picture Arrangement 7.67 (2.25) 9.33 (4.13) 10.67 (4.27)

Comprehension 9.50 (2.88) 9.83 (2.64) 10.83 (2.48)

DEX 35.50 (8.12) 28.17 (13.7) 28.33 (8.29)

SCSQ self 93.33 (7.17) 92.17 (11.27) 96.00 (5.44)

SCSQ proxy 93.67 (13.03) 93.33 (9.71) 96.00 (11.31)

RAPS % constraint q. 77.88 (21.35) 82.59 (18.01) 82.14 (12.82)

RAPS efficiency q.1 38.94 (18.33) 51.04 (24.21) 60.76 (30.97)

RAPS efficiency q.2 46.77 (14.7) 50.53 (15.9) 51.71 (18.6)

VTS

Results group B

T1 T2 T3

ADI Divergent th 0.50 (0.63) 0.58 (1.02) 1.42 (1.50)

ADI Explanation 2.25 (2.66) 3.17 (3.80) 5.42 (4.41)

ADI Revision 0.17 (0.26) 0.42 (0.49) 0.33 (0.41)

MOI Divergent th 2.25 (2.56) 2.08 (2.40) 1.17 (1.75)

MOI Explanation 0.58 (0.38) 1.58 (1.59) 1.00 (1.76)

MOI Revision 0.75 (0.99) 0.42 (0.49) 0.58 (0.80)

VTS

Evaluation: what have you learned?

observe in a different manner (more consciously, from a broader perspective) (n=8) 

revise opinion more easily making it easier to choosebetween alternatives (n=5) 

less inclined to jump to conclusions and respondpremature (agressively)  (n= 5) 

More inclined to listen to others (n= 4) 

more awareness (n= 3) 

Summary

Group A improved after VTS: ADI Explanation, MOI Explanation, WAIS‐III Comprehension

Group B did not improve on the tests after VTS: cognitive deficits?

Questionnaires (DEX, SCSQ) did not show improvement: better awareness / not all questions applicable

Future research

Effect of deficits in attention and memory on efficacyof VTS

MOI and ADI as outcome measures Goal Attainment Scaling in stead of questionnaires

Conclusions

VTS seems to improve critical thinking in patients withdeficits in executive functioning. 

Top down & bottom up Compensation and/or new routines