Cognitive Rehabilitation of Executive Dysfunction With the Goal Management Training (GMT) - Exploring Variations in Mode of Administration, Frequency and Intensity. (GMT)

Goal Management Training (GMT) is a group-based intervention for executive dysfunction intended to promote cognitive control when behaviour is incompatible with stated goals. It comprises self-instruction strategies, self-monitoring exercises and homework assignments. Arm 1 comprises 10 hrs (2 hrs weekly, 5 weeks), led by a neuropsychologist and an occupational therapist specialized in brain injury rehabilitation. The GMT is administered within outpatient rehabilitation services.

Goal Management Training (GMT; Levine et al., 2011) is an evidence-based, module-based metacognitive program designed to treat executive dysfunction and goal neglect by fostering deliberate, goal-directed behavior. The protocol utilizes a five-step, mindfulness-integrated cognitive algorithm-Stop, Define, List, Learn, Check-combined with interactive tasks and real-world homework to facilitate improved attention and task management.

Goal Management Training (GMT) is a group-based intervention for executive dysfunction intended to promote cognitive control when behaviour is incompatible with stated goals. It comprises self-instruction strategies, self-monitoring exercises and homework assignments. Arm 1 comprises 14 hrs (2 hrs weekly, 7 weeks), led by a neuropsychologist and an occupational therapist specialized in brain injury rehabilitation. The GMT is administered within outpatient rehabilitation services.

Goal Management Training (GMT; Levine et al., 2011) is an evidence-based, module-based metacognitive program designed to treat executive dysfunction and goal neglect by fostering deliberate, goal-directed behavior. The protocol utilizes a five-step, mindfulness-integrated cognitive algorithm-Stop, Define, List, Learn, Check-combined with interactive tasks and real-world homework to facilitate improved attention and task management.

Goal Management Training (GMT) is a group-based intervention for executive dysfunction intended to promote cognitive control when behaviour is incompatible with stated goals. It comprises self-instruction strategies, self-monitoring exercises and homework assignments. Arm 1 comprises 18 hrs (2 hrs weekly, 9 weeks), led by a neuropsychologist and an occupational therapist specialized in brain injury rehabilitation. The GMT is administered within outpatient rehabilitation services.

Goal Management Training (GMT; Levine et al., 2011) is an evidence-based, module-based metacognitive program designed to treat executive dysfunction and goal neglect by fostering deliberate, goal-directed behavior. The protocol utilizes a five-step, mindfulness-integrated cognitive algorithm-Stop, Define, List, Learn, Check-combined with interactive tasks and real-world homework to facilitate improved attention and task management.

Everyday executive difficulties are assessed using the participant-reported Dysexecutive Questionnaire from the Behavioural Assessment of the Dysexecutive Syndrome. The 20-item questionnaire assesses cognitive, behavioral, and emotional manifestations of executive dysfunction in everyday life. The total score ranges from 0 to 60, with higher scores indicating greater executive difficulties.

Attainment of individually defined rehabilitation goals is assessed using Goal Attainment Scaling. Before the intervention, individualized goals and levels of expected attainment are defined using a five-level scale ranging from -2 to +2, where 0 represents the expected level of goal attainment, negative values represent outcomes below the expected level, and positive values represent outcomes above the expected level. The primary GAS metric reported will be iterative GAS T-score. Higher scores indicate greater attainment of the predefined rehabilitation goals.

Functional outcome is assessed using the Mayo-Portland Adaptability Inventory-4, total score. The inventory assesses ability, adjustment, and participation following acquired brain injury. The total score will be calculated and transformed according to the standardized scoring procedure, with higher scores indicating greater limitations.

Everyday executive difficulties are assessed using the informant-reported Dysexecutive Questionnaire from the Behavioural Assessment of the Dysexecutive Syndrome. The 20-item questionnaire assesses cognitive, behavioral, and emotional manifestations of executive dysfunction in everyday life. The total score ranges from 0 to 60, with higher scores indicating greater executive difficulties.

The Assessment of Work Performance (AWP) is a standardized observation-based instrument used to assess an individual's work skills during the performance of a work activity. It evaluates 14 items divided into three subdomains (motor skills, process skills, communication/interaction skills). Items are scored on a 4-point ordinal scale ranging from 1 (Incompetent performance) to 4 (Competent performance), thus ranging from 14 to 56, with higher scores indicating better observed work performance. To allow for precise linear measurement and to demonstrate a targeted intervention effect, raw ordinal scores are converted into interval-scale Logit values using Rasch analysis.

The intervention effect will be evaluated on two levels:

1. Total Score Change (increase in overall Logit value indicates improvement)
2. Subdomain Profile Changes

Self-rated occupational performance is assessed using the Canadian Occupational Performance Measure. Participants identify activities that are important to them and rate their current performance and satisfaction of performance of the selected activities on a scale from 1 to 10, with higher scores indicating better perceived performance nad satisfaction with perfomrance respectively. The outcome is the mean performance rating across the activities selected for reassessment.

Executive attention and working memory are assessed using the Paced Auditory Serial Addition Test. The prespecified outcome is number of correct responses and standardized score for the PASAT version A (presentation rate 2,4 sec) and version C (presentation rate 1,8 sec). Scores range from 0 to 60, with higher scores indicating better performance.

Inhibitory control and Cognitve Flexibility is assessed using the Color-Word Interference Test from the Delis-Kaplan Executive Function System. The prespecified outcome is completion time including scaled and error score for conditions 3 (Inhibition) and 4 (Inhibition-Switching). Performance is measured by completion time (in seconds) and error rates. Raw scores are converted to standardized scaled scores (normative mean = 10, SD = 3). Higher scaled scores indicate better executive functioning, whereas higher raw scores (more seconds used) indicate poorer performance.

The D-KEFS Trail Making Test evaluates visual scanning, motor speed, and executive set-shifting across 5 conditions (Visual Scanning, Number Sequencing, Letter Sequencing, Number-Letter Switching, and Motor Speed). Raw scores (completion time in seconds) for each condition, as well as contrast scores, are converted into age-corrected scaled scores based on normative data. Scaled scores range from 1 to 19, with higher scores indicating better performance (i.e., faster processing speed and superior set-shifting flexibility).

The D-KEFS Verbal Fluency Test assesses fluent productivity in the verbal domain under specific executive constraints. It consists of 3 conditions: Letter Fluency (phonemic), Category Fluency (semantic), and Category Switching. Performance is measured by the total number of correct words generated within designated time limits (typically 60 seconds per trial). Raw counts are converted into age-corrected scaled scores. Scaled scores range from 1 to 19, with higher scores indicating better verbal fluency and cognitive flexibility.

Processing speed and sustained visual attention are assessed using the Coding subtest from the Wechsler Adult Intelligence Scale-Fourth Edition Neuropsychological Instrument. The prespecified outcome is raw and scaled total score, ranging from 0-135, with higher scores indicating better performance, Incidental Learning (Free Recall) (0-9), Incidental Learning (Pairing) (0-18), and Interval Discrepancy (raw difference in correct stimuli between the first 30 seconds and the last 30 seconds of the test (ranging from -15 to +15; negative scores indicate fatigue, while positive scores indicate a beneficial learning curve).

Mental fatigue is assessed using the Mental Fatigue subscale of the 20-item Multidimensional Fatigue Inventory. The subscale consists of five items and has a mean score ranging from 4 to 20 per subscale, with higher scores indicating greater mental fatigue.

Mental fatigue is rated immediately before and immediately after each Goal Management Training session using a visual analogue scale ranging from 0 to 100, where 0 represents no fatigue and 100 mm represents excruciating fatigue. The prespecified outcome is mean within-session change across completed sessions and change in pre-session ratings across the treatment period.

Pain-related discomfort is rated immediately before and immediately after each Goal Management Training session by participants in the long-term pain cohort using a visual analogue scale ranging from 0 to 100 mm, where 0 represents no pain and 100 represents extreme pain. The prespecified outcome is mean within-session change across completed sessions and change in pre-session ratings across the intervention period.

Symptoms are assessed using the Anxiety and Depression subscale of the Hospital Anxiety and Depression Scale. The scale consists of forteen items (seven items for anxiety, seven items for derpession)and has a total score ranging from 0 to 42, with higher scores indicating more severe symptoms.

Global life satisfaction is assessed using global and domain-specific items (covering Vocation, Financial situation, Leisure, Contact with friends/acquaintances, Sexual life, Activities of daily living (ADL), Family life, Partnership, Physical health, and Psychological health) from the Life Satisfaction Questionnaire-11. The items are rated on a six-point scale ranging from 1 to 6, with higher scores indicating greater life satisfaction. Median Scores (Evaluation of changes in central tendency) and Dichotomized Proportions for Satisfaction Rates (Calculation of the percentage of participants classified as "satisfied" (scores 5-6) versus "not satisfied" (scores 1-4) will be used to track the clinical rate of satisfaction over time.

The EQ-5D-3L index score is used to evaluate generic health-related quality of life across 5 dimensions (Mobility, Self-Care, Usual Activities, Pain/Discomfort, and Anxiety/Depression). The index score is derived by applying the Swedish experience-based Time Trade-Off (TTO) value set to the descriptive profile. The Swedish index scores range from 0.340 to 1.00, where 1.00 represents full health and 0.340 represents the worst possible health state. Higher scores indicate a better health-related quality of life.

Self-rated health is assessed using the EQ Visual Analogue Scale. Scores range from 0 to 100, with 0 representing the worst imaginable health and 100 representing the best imaginable health.

Sense of coherence is assessed using the 13-item Sense of Coherence Scale. A total score is calculated by summing the item scores after reverse scoring the applicable items. The total score ranges from 13 to 91, with higher scores indicating a stronger sense of coherence.

Mental fatigue is rated immediately before and immediately after each neuropsychological assessment using a visual analogue scale ranging from 0 to 100, where 0 represents no fatigue and 100 mm represents excruciating fatigue. The prespecified outcome is the within-assessment change from the pre-assessment rating to the post-assessment rating.

Pain-related discomfort is rated immediately before and immediately after each neuropsychological assessment by participants in the long-term pain cohort using a visual analogue scale ranging from 0 to 100 mm, where 0 represents no pain and 100 represents extreme pain. The prespecified outcome is the within-assessment change from the pre-assessment rating to the post-assessment rating.