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15 EXECUTIVE FUNCTIONS Rochette Et Al., 2007) 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 behavioral/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 ac tive 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 executive functions) 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 Brain (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 function shares characteristics with, but need not be Neural Brain Behavior Behavioral Daily Life Tasks In general, cognitive psychologists describe executive and discuss some of the difficulties with assessing cogni­ identical to, neuropsychological tasks primarily reliant on Constructs Relationship Consequences 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 • Attention • 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 • 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 • Judgment/ • Failure to • Multimodal safety • Automaticity (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 inhibit • Impulsivity • 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 the term executive functions also derives in part from the prising that 85% of people who survive a stroke return Dosenbach, 2008; Pessoa, 2008). specializations • Fatigue 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
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