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Executive Function and Rehabilitation
We have been active in the development of new assessment tools to assess executive or frontal lobe functions. We have been especially interested in self-regulation, commonly affected by damage to ventral frontal regions, as well as diffuse injury. The Strategy Application Test (Levine et al., 1998; Levine et al., 2000), is a tabletop measure that simulates the uncertainty inherent in real life situations and shows strong relationships to real-life outcome in patients with TBI. This work has been supplemented by studies exploring the relationship of novel and standard “frontal” tests to type and location of brain damage in patients with TBI (Fujiwara et al., 2008, Levine et al., 2005). The theoretical framework for this research, including the importance of process analysis and intra-frontal localization, was described in (Stuss and Levine, 2002). An article in Scientific American: Mind concerns the effects of serious mental illness on executive and prefrontal function, using the singer Brian Wilson as a case study (Levine, 2005). |
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In a separate line of research, lifelong occupation is treated as a naturally occurring method of practice to build specific foci of brain reserve that is in turn related to patterns of neurodegeneration in patients with frontotemporal lobar degeneration (FTLD; Spreng et al., 2010, 2011). We demonstrated that specific occupational practices are associated with specific volumetric or brain metabolic patterns, either due to buildup of brain reserve through repeated practice or pre-existing functional capacity differences.
Model of cerebral small vessel disease effects on distributed brain systems, as measured by functional MRI and EEG.
Cerebral small vessel disease
Cerebral small vessel disease is a major contributor to age-related cognitive decline. It is enhanced by vascular risk factors (e.g., obesity, hypertension, diabetes, high cholesterol) and it can progress to vascular cognitive impairment, a common cause of dementia. Furthermore, cerebral small vessel disease can exacerbate the effects of dementia due to other causes, including Alzheimer's disease.
Dey et al., (2016) reviewed neuroimaging research demonstrating the effects of these conditions on the functioning of distributed brain networks, as measured by functional MRI and electroencephalography (including both event-related potentials (ERPs) and spectral analyses). These brain changes affect the ability to focus attention and keep goals active in consciousness. We are currently studying novel neuroimaging assessment of cerebral small vessel disease and treatment methods to compensate for its effects on behaviour. For information on participating in this research, click here.
Cerebral small vessel disease is a major contributor to age-related cognitive decline. It is enhanced by vascular risk factors (e.g., obesity, hypertension, diabetes, high cholesterol) and it can progress to vascular cognitive impairment, a common cause of dementia. Furthermore, cerebral small vessel disease can exacerbate the effects of dementia due to other causes, including Alzheimer's disease.
Dey et al., (2016) reviewed neuroimaging research demonstrating the effects of these conditions on the functioning of distributed brain networks, as measured by functional MRI and electroencephalography (including both event-related potentials (ERPs) and spectral analyses). These brain changes affect the ability to focus attention and keep goals active in consciousness. We are currently studying novel neuroimaging assessment of cerebral small vessel disease and treatment methods to compensate for its effects on behaviour. For information on participating in this research, click here.
Goal Management Training™
Many patients with brain disease affecting the frontal lobes or distributed brain networks suffer from significant daily life disruption due to executive dysfunction, concentration, impulse control, planning, and use of feedback. Goal Management Training ™ , developed in collaboration with Ian Robertson and Tom Manly, is a practical, manualized intervention that addresses these deficits through education, task practice, narrative structure, and mindfulness practice.
GMT is centered on a simple instruction, to “STOP!" the automatic pilot and state one’s goals periodically before and during task execution. The theoretical framework for this intervention is derived from the hypothesis that the brain’s sustained attention network supports executive function. Lapses in sustained attention associated with slips of intention can be avoided through periodic alerting of the sustained attention system (for neuroimaging support, see O'Connor et al., 2011). This program has been validated in healthy aging, traumatic brain injury, spina bifida, multiple sclerosis, stroke, abstinent polysubstance abuse, and post-critical care patients (for review and meta-analysis, see Stamenova et al., 2018) For more information on GMT, check out GoalManagementTraining.com.
Many patients with brain disease affecting the frontal lobes or distributed brain networks suffer from significant daily life disruption due to executive dysfunction, concentration, impulse control, planning, and use of feedback. Goal Management Training ™ , developed in collaboration with Ian Robertson and Tom Manly, is a practical, manualized intervention that addresses these deficits through education, task practice, narrative structure, and mindfulness practice.
GMT is centered on a simple instruction, to “STOP!" the automatic pilot and state one’s goals periodically before and during task execution. The theoretical framework for this intervention is derived from the hypothesis that the brain’s sustained attention network supports executive function. Lapses in sustained attention associated with slips of intention can be avoided through periodic alerting of the sustained attention system (for neuroimaging support, see O'Connor et al., 2011). This program has been validated in healthy aging, traumatic brain injury, spina bifida, multiple sclerosis, stroke, abstinent polysubstance abuse, and post-critical care patients (for review and meta-analysis, see Stamenova et al., 2018) For more information on GMT, check out GoalManagementTraining.com.
Selected publications
For full publication list, see Google Scholar; articles may be downloaded from the Rotman Research Institute article database
1. Armson, M., Ryan, J., Levine, B. (2019). Maintaining fixation does not increase demands on working memory relative to free viewing. PeerJ. 7: e6839. DOI: 10.7717/peerj.6839
2. Dey, A.K., Stamenova, V., Bacopulos, A., Jeyakumar, N., Turner, G., Black, S.E., Levine, B. (2019). Cognitive heterogeneity among community dwelling older adults with cerebral small vessel disease. Neurobiology of Aging. 77:183-193. DOI: 10.1016/j.neurobiolaging.2018.12.011
3. Stamenova, V., & Levine, B. (2018). Effectiveness of Goal Management Training® in improving executive functions: A meta-analysis. Neuropsychological Rehabilitation. 14:1-31. DOI: 10.1080/09602011.2018.1438294
4. Lam, T., Dawson, D., Honjo, K., Ross, B., Binns, M., Stuss, D., Black, S., Chen, J., Levine, B., Fujioka, T., & Chen, J. (2018). Neural coupling between contralesional motor and frontoparietal networks correlates with motor ability in individuals with chronic stroke. Journal of the Neurological Sciences. 384:21-29. DOI: 10.1016/j.jns.2017.11.007
5. Feng, J., Craik, F.I.M., Levine, B., Moreno, S., Naglie, G., & Choi,H.(2016). Differential age-related changes in localizing a target among distractors across an extended visual field. European Journal of Aging. 14(2):167-177. DOI: 10.1007/s10433-016-0399-7
6. Feng, J., Choi, H., Craik, F.M., Levine, B., Moreno, S. Naglie, G., Zhu, M. (2018). Adaptive response criteria in road hazard detection among older drivers. Traffic Injury Prevention. 19(2):141-146. DOI: 10.1080/15389588.2017.1373190
7. Dey, A.K., Stamenova, V., Turner, G., Black, S.E., & Levine, B. (2016). Pathoconnectomics of cognitive impairment in cerebral small vessel disease: a systematic review. Journal of Alzheimer’s Disease. 12(7), 831-845. DOI: 10.1016/j.jalz.2016.01.007
8. Stubberud, J., Langenbahn, D., Levine, B., Stanghelle, J., Schanke, A.-K. (2014). Goal Management Training improves real-life executive functioning for persons with spina bifida: Self-and informant reports 6 months post-training. Neuropsychological Rehabilitation, 24(1), 26-60.
9. 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 Trial. Journal of the International Neuropsychological Society. DOI: 10.1017/S1355617713000209.
10. Mind and the frontal lobes: cognition, behavior, and brain imaging. Levine, B. & Craik, F.I.M., New York: Oxford University Press (2012).
11. Levine, B. Understanding the effects of focal and diffuse injury on behavior: assessing “a slice of life” with neuropsychology and multimodal neuroimaging (2012). In Levine, B. & Craik, F.I.M. (Eds.) Mind and the frontal lobes: cognition, behavior, and brain imaging, (pp. 235-247). New York: Oxford University Press.
12. Levine, B. and Craik, F.I.M. Unifying clinical, experimental, and neuroimaging studies of the human frontal lobes (2012). In Levine, B. & Craik, F.I.M. (Eds.) Mind and the frontal lobes: cognition, behavior, and brain imaging (pp. 3-15). New York: Oxford University Press.
13. Jackson, J. C., Ely, E. W., Morey, M. C., Anderson, V. M., Denne, L. B., Clune, J., Siebert, C. S., Archer, K. R., Torres, R., Janz, D., Schiro, E., Jones, J., Shintani, A. K., Levine, B., Pun, B. T., Thompson, J., Brummel, N. E., & Hoenig, H. (2012). Cognitive and physical rehabilitation of intensive care unit survivors: Results of the RETURN randomized controlled pilot investigation*. Critical Care Medicine, 40(4), 1088-1097.
14. Robertson, I.H. & Levine, B., Attention and arousal in rehabilitation (2012). In Stuss, D.T. & Knight, R.T. (Eds.), Principles of Frontal Lobe Function, 2nd Ed., New York, Oxford University Press.
15. O’Connor, C., Robertson, I.H., & Levine, B. (2011). The prosthetics of vigilant attention: random cuing cuts processing demands. Neuropsychology, 25, 535-543.
16. Levine, B., Schweizer, T. A., O’Connor, C., Turner, G. R., Gillingham, S., Stuss, D. T., Manly, T., & Robertson, I.H. (2011). Rehabilitation of executive functioning in patients with frontal lobe brain damage with goal management training. Frontiers in Human Neuroscience, 5:9. doi: 10.3389/fnhum.2011.00009.
17. Spreng, R.N., Drzezga A., Diehl-Schmid, J., Kurz, A., Levine, B., Perneczky, R. (2011). Relationship between occupation attributes and brain metabolism in frontotemporal dementia. Neuropsychologia, 49, 3699-3703.
18. Spreng, R.N., Rosen, H., Strother, S., Black, S., Chow, T., Diehl-Schmid, J., Freedman, M., Graff-Radford, N., Hodges, J., Lipton, A., Mendez, M., Morelli, S., Miller, B., Levine, B. (2010). Occupation attributes relate to location of atrophy in frontotemporal lobar degeneration. Neuropsychologia, 48, 3634-3641.
19. Schweizer, T.A., Levine, B., Rewilak, D., O'Connor, C., Turner, G.R., Alexander, M.P., Cusimano, M. Manly, T., Robertson, I., & Stuss, D.T. (2008). Rehabilitation of executive functioning after focal damage to the cerebellum. Neurorehabilitation and Neural Repair, 22, 72-77.
20. Levine, B., Turner, G.R., and Stuss, D.T. (2008). Rehabilitation of frontal lobe functions. In Stuss, D.T., Winocur, G., and Robertson, I.H. (Eds.). Cognitive Neurorehabilitation, Evidence and Application, 2nd Edition, Cambridge University Press.
21. Levine, B., Stuss, D. T., Winocur, G., Binns, M. A., Fahy, L., Mandic, M., Bridges, K., & Robertson, I. H. (2007). Cognitive rehabilitation in the elderly: Effects on strategic behavior in relation to goal management. Journal of the International Neuropsychological Society, 13, 143-152.
22. Levine, B. (2005). A Cork on the Ocean: The rise and fall of The Beach Boys leader Brian Wilson shows how crucial the brain’s executive function is to creativity. Scientific American: Mind, 16, 36-42. Reprinted in Scientific American: Mind, 23, 40-47 (special edition on creativity, Winter, 2014).
23. Stuss, D.T. and Levine, B. (2002). Adult clinical neuropsychology: lessons from studies of the frontal lobes. Annual Review of Psychology, 43, 401-433.
24. Levine, B., Robertson I, Clare, L., Carter, G., Wilson, B.A., Duncan, J., & Stuss, D.T. (2000). Rehabilitation of executive functioning: An experimental-clinical validation of Goal Management Training. Journal of the International Neuropsychological Society, 6, 299-312.
25. Levine, B., Dawson, D.R., Boutet, I., Schwartz, M., & Stuss, D.T. (2000). Assessment of strategic self-regulation in traumatic brain injury: its relationship to injury severity and psychosocial outcome. Neuropsychology, 14, 491-500.
26. Stuss, D.T., Levine, B., Alexander, M.P., Hong, J., Palumbo, C., Hamer, L., Murphy, K., & Izukawa, D. (2000). Wisconsin Card Sorting Test performance in patients with focal frontal and posterior brain damage: Effects of lesion location and test structure on separable cognitive process. Neuropsychologia, 38, 388-402.
27. Levine, B., Stuss., D.T., Milberg, W.P., Alexander, M.P., Schwartz, M., & Macdonald, R. (1998). The effects of focal and diffuse brain damage on strategy application: Evidence from focal lesions, traumatic brain injury, and normal aging. Journal of the International Neuropsychological Society, 4, 247-264.
For full publication list, see Google Scholar; articles may be downloaded from the Rotman Research Institute article database
1. Armson, M., Ryan, J., Levine, B. (2019). Maintaining fixation does not increase demands on working memory relative to free viewing. PeerJ. 7: e6839. DOI: 10.7717/peerj.6839
2. Dey, A.K., Stamenova, V., Bacopulos, A., Jeyakumar, N., Turner, G., Black, S.E., Levine, B. (2019). Cognitive heterogeneity among community dwelling older adults with cerebral small vessel disease. Neurobiology of Aging. 77:183-193. DOI: 10.1016/j.neurobiolaging.2018.12.011
3. Stamenova, V., & Levine, B. (2018). Effectiveness of Goal Management Training® in improving executive functions: A meta-analysis. Neuropsychological Rehabilitation. 14:1-31. DOI: 10.1080/09602011.2018.1438294
4. Lam, T., Dawson, D., Honjo, K., Ross, B., Binns, M., Stuss, D., Black, S., Chen, J., Levine, B., Fujioka, T., & Chen, J. (2018). Neural coupling between contralesional motor and frontoparietal networks correlates with motor ability in individuals with chronic stroke. Journal of the Neurological Sciences. 384:21-29. DOI: 10.1016/j.jns.2017.11.007
5. Feng, J., Craik, F.I.M., Levine, B., Moreno, S., Naglie, G., & Choi,H.(2016). Differential age-related changes in localizing a target among distractors across an extended visual field. European Journal of Aging. 14(2):167-177. DOI: 10.1007/s10433-016-0399-7
6. Feng, J., Choi, H., Craik, F.M., Levine, B., Moreno, S. Naglie, G., Zhu, M. (2018). Adaptive response criteria in road hazard detection among older drivers. Traffic Injury Prevention. 19(2):141-146. DOI: 10.1080/15389588.2017.1373190
7. Dey, A.K., Stamenova, V., Turner, G., Black, S.E., & Levine, B. (2016). Pathoconnectomics of cognitive impairment in cerebral small vessel disease: a systematic review. Journal of Alzheimer’s Disease. 12(7), 831-845. DOI: 10.1016/j.jalz.2016.01.007
8. Stubberud, J., Langenbahn, D., Levine, B., Stanghelle, J., Schanke, A.-K. (2014). Goal Management Training improves real-life executive functioning for persons with spina bifida: Self-and informant reports 6 months post-training. Neuropsychological Rehabilitation, 24(1), 26-60.
9. 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 Trial. Journal of the International Neuropsychological Society. DOI: 10.1017/S1355617713000209.
10. Mind and the frontal lobes: cognition, behavior, and brain imaging. Levine, B. & Craik, F.I.M., New York: Oxford University Press (2012).
11. Levine, B. Understanding the effects of focal and diffuse injury on behavior: assessing “a slice of life” with neuropsychology and multimodal neuroimaging (2012). In Levine, B. & Craik, F.I.M. (Eds.) Mind and the frontal lobes: cognition, behavior, and brain imaging, (pp. 235-247). New York: Oxford University Press.
12. Levine, B. and Craik, F.I.M. Unifying clinical, experimental, and neuroimaging studies of the human frontal lobes (2012). In Levine, B. & Craik, F.I.M. (Eds.) Mind and the frontal lobes: cognition, behavior, and brain imaging (pp. 3-15). New York: Oxford University Press.
13. Jackson, J. C., Ely, E. W., Morey, M. C., Anderson, V. M., Denne, L. B., Clune, J., Siebert, C. S., Archer, K. R., Torres, R., Janz, D., Schiro, E., Jones, J., Shintani, A. K., Levine, B., Pun, B. T., Thompson, J., Brummel, N. E., & Hoenig, H. (2012). Cognitive and physical rehabilitation of intensive care unit survivors: Results of the RETURN randomized controlled pilot investigation*. Critical Care Medicine, 40(4), 1088-1097.
14. Robertson, I.H. & Levine, B., Attention and arousal in rehabilitation (2012). In Stuss, D.T. & Knight, R.T. (Eds.), Principles of Frontal Lobe Function, 2nd Ed., New York, Oxford University Press.
15. O’Connor, C., Robertson, I.H., & Levine, B. (2011). The prosthetics of vigilant attention: random cuing cuts processing demands. Neuropsychology, 25, 535-543.
16. Levine, B., Schweizer, T. A., O’Connor, C., Turner, G. R., Gillingham, S., Stuss, D. T., Manly, T., & Robertson, I.H. (2011). Rehabilitation of executive functioning in patients with frontal lobe brain damage with goal management training. Frontiers in Human Neuroscience, 5:9. doi: 10.3389/fnhum.2011.00009.
17. Spreng, R.N., Drzezga A., Diehl-Schmid, J., Kurz, A., Levine, B., Perneczky, R. (2011). Relationship between occupation attributes and brain metabolism in frontotemporal dementia. Neuropsychologia, 49, 3699-3703.
18. Spreng, R.N., Rosen, H., Strother, S., Black, S., Chow, T., Diehl-Schmid, J., Freedman, M., Graff-Radford, N., Hodges, J., Lipton, A., Mendez, M., Morelli, S., Miller, B., Levine, B. (2010). Occupation attributes relate to location of atrophy in frontotemporal lobar degeneration. Neuropsychologia, 48, 3634-3641.
19. Schweizer, T.A., Levine, B., Rewilak, D., O'Connor, C., Turner, G.R., Alexander, M.P., Cusimano, M. Manly, T., Robertson, I., & Stuss, D.T. (2008). Rehabilitation of executive functioning after focal damage to the cerebellum. Neurorehabilitation and Neural Repair, 22, 72-77.
20. Levine, B., Turner, G.R., and Stuss, D.T. (2008). Rehabilitation of frontal lobe functions. In Stuss, D.T., Winocur, G., and Robertson, I.H. (Eds.). Cognitive Neurorehabilitation, Evidence and Application, 2nd Edition, Cambridge University Press.
21. Levine, B., Stuss, D. T., Winocur, G., Binns, M. A., Fahy, L., Mandic, M., Bridges, K., & Robertson, I. H. (2007). Cognitive rehabilitation in the elderly: Effects on strategic behavior in relation to goal management. Journal of the International Neuropsychological Society, 13, 143-152.
22. Levine, B. (2005). A Cork on the Ocean: The rise and fall of The Beach Boys leader Brian Wilson shows how crucial the brain’s executive function is to creativity. Scientific American: Mind, 16, 36-42. Reprinted in Scientific American: Mind, 23, 40-47 (special edition on creativity, Winter, 2014).
23. Stuss, D.T. and Levine, B. (2002). Adult clinical neuropsychology: lessons from studies of the frontal lobes. Annual Review of Psychology, 43, 401-433.
24. Levine, B., Robertson I, Clare, L., Carter, G., Wilson, B.A., Duncan, J., & Stuss, D.T. (2000). Rehabilitation of executive functioning: An experimental-clinical validation of Goal Management Training. Journal of the International Neuropsychological Society, 6, 299-312.
25. Levine, B., Dawson, D.R., Boutet, I., Schwartz, M., & Stuss, D.T. (2000). Assessment of strategic self-regulation in traumatic brain injury: its relationship to injury severity and psychosocial outcome. Neuropsychology, 14, 491-500.
26. Stuss, D.T., Levine, B., Alexander, M.P., Hong, J., Palumbo, C., Hamer, L., Murphy, K., & Izukawa, D. (2000). Wisconsin Card Sorting Test performance in patients with focal frontal and posterior brain damage: Effects of lesion location and test structure on separable cognitive process. Neuropsychologia, 38, 388-402.
27. Levine, B., Stuss., D.T., Milberg, W.P., Alexander, M.P., Schwartz, M., & Macdonald, R. (1998). The effects of focal and diffuse brain damage on strategy application: Evidence from focal lesions, traumatic brain injury, and normal aging. Journal of the International Neuropsychological Society, 4, 247-264.