This paper reviews a quantitative research study by Baum et al. (2008) examining the reliability and validity of the Executive Function Performance Test (EFPT) as applied to patients with mild to moderate stroke. The paper summarizes the study's design, including its use of simulated real-world tasks — cooking, telephoning, managing medications, and paying bills — to assess five executive cognitive functions: initiation, organization, sequencing, safety judgment, and task completion. It discusses how the independent variable (stroke severity) and dependent variables (EFPT scores) were classified and operationalized, evaluates the study's reliability and validity testing methods, and summarizes key findings showing that stroke severity correlated strongly with impaired executive functioning in daily life activities.
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The paper demonstrates the technique of structured study critique, moving methodically through the components of a quantitative research design. By defining key terms — reliability, validity, independent and dependent variables — before applying them to the specific study, the paper shows how to evaluate empirical research against established methodological standards.
The paper opens with a brief background establishing the gap in the literature that motivated the study. It then addresses research design, instrument distinctiveness, variable classification, reliability, validity, and results in separate labeled sections, before closing with a balanced strengths-and-limitations assessment. This organization mirrors the IMRaD (Introduction, Methods, Results, and Discussion) logic common in health sciences research reviews.
This paper reviews a study by Baum et al. (2008) that was motivated by a recognized absence within the neurological community of executive function performance testing for various real-world activities — including multi-tasking — in subjects who have suffered brain damage. By testing real-world functioning via the Executive Function Performance Test (EFPT), the researchers, as occupational therapists, hoped to provide more accurate information on subjects' ability to function independently in their day-to-day existence and to perform tasks within society (Baum et al., 2008). This study served as a test of the validity and reliability of the EFPT model on patients with mild to moderate stroke, as a follow-up to previous studies of EFPT validity and reliability conducted on subjects with multiple sclerosis and schizophrenia (Baum et al., 2008).
Hypothesis: Stroke will have a negative effect on executive functioning in real-world tasks.
This was an empirical, quantitative, conclusion-oriented, lab/simulation research study using the EFPT. The EFPT measures executive cognitive functions — initiation, organization, sequencing, safety judgment, and task completion — via a "structured cueing and scoring system" (Baum et al., 2008, p. 446). The five specific cognitive functions are assessed as participants complete four separate tasks: "cooking, using the telephone, managing medications, and paying bills" (Baum et al., 2008, p. 446). These activities were structured based on the existing Kitchen Task Assessment, using simple instructions and materials in a simulated laboratory environment (Baum et al., 2008).
The EFPT was administered to 73 subjects who had previously suffered a mild to moderate stroke, and to 22 healthy control-group volunteers matched for age and education level and tested for physical and cognitive health (Baum et al., 2008). The experimental group consisted of participants in a research program at a nearby hospital, and each participant's stroke diagnosis was verified by a neurologist (Baum et al., 2008). Testing was conducted six months after stroke onset, while none of the patients were undergoing rehabilitative care (Baum et al., 2008). Dependent variables were measured using a "standardized cueing system" based on "the progressive need for assistance associated with increasing levels of cognitive impairment," and were analyzed statistically using ANOVA and chi-square analyses, resulting in a concise table of data and results (Baum et al., 2008).
The EFPT differs from existing performance assessments in several important ways. First, it is easy for occupational therapists to learn, conduct, and score (Baum et al., 2008). Second, it measures the amount of support a subject will need in order to successfully carry out four daily activities essential to "daily community life" (Baum et al., 2008). Third, during the four activities, the instrument measures key executive functions in terms of their cognitive components, allowing for the development of effective treatment plans (Baum et al., 2008).
Finally, the EFPT "uses a top-down approach that allows the practitioner to objectively assess the client during the performance of a task, and unlike many other instruments assessing instrumental activities of daily living (IADLs), it assesses actual performance rather than rely on proxy or self-report" (Baum et al., 2008, p. 447). This direct performance-based approach is a significant distinguishing feature within the broader field of occupational therapy assessment.
The independent variable in this study was stroke, classified as either mild or moderate based on the NIHSS (National Institutes of Health Stroke Scale), and controlled with a group of healthy individuals also tested for cognitive and physical health functions (Baum et al., 2008). These variables were further classified based on age, gender, race, and education level (Baum et al., 2008).
The dependent variables were classified under five categories: "initiation, organization, sequencing, safety judgment, and task completion" (Baum et al., 2008, p. 446). These variables were operationalized in terms of their role in the successful completion of four daily tasks — cooking, using the telephone, managing medications, and paying bills — and measured via a "standardized cueing system" (Baum et al., 2008, p. 446). The cueing system rates the subject on a scale of 0 to 5, with 0 being "no assistance needed" and 5 being "tester must complete the task for the participant" (Baum et al., 2008).
This cueing system produces three quantitative scores:
"(1) the executive function (EF) component score, (2) the task score, and (3) a total score. The EF component score is calculated by summing the numbers recorded on each of the four tasks for initiation, organization, sequencing, safety and judgment, and completion. Scores on each EF component can range from 0 to 5, and the total for all four tasks can range from 0 to 20. The task score is calculated by summing the five scores for each task. The range for each task is 0 to 25. The total score is the sum of the performance on all four tasks; the total score of performance on all four tasks can range from 0 to 100." (Baum et al., 2008, p. 449)
Based on this score, testers can determine quantitatively how much support the subject will require in everyday life (Baum et al., 2008).
Reliability is the opposite of random error; it indicates how consistently a test produces valid results. In this study, reliability was determined in two ways: by measuring test result consistencies via intraclass correlation coefficient (ICC) scores on the four tasks across different raters — accomplished by having three trained raters simultaneously test participants from both the stroke and control groups — and by measuring the internal consistency of the EFPT via Cronbach's alpha coefficients for each task, correlated to the five test domains (Baum et al., 2008).
In scientific research, validity refers to the degree to which the measurements taken or results concluded in a study correspond to reality. The instruments in this study were tested for validity in two ways: for construct validity, based on one-way ANOVA testing across the three groups (control, mild stroke, and moderate stroke), to ensure that the test could discriminate between subjects "with and without a known trait"; and for criterion validity — in the form of concurrent validity — by comparing scores from various neuropsychological tests to EFPT scores (Baum et al., 2008). This concurrent validity testing was conducted only on participants with stroke, in order to verify that EFPT scores corresponded reasonably with other established cognitive performance tests (Baum et al., 2008).
The data presented in Table 1 of the original study validates the researchers' hypothesis: that the EFPT would detect executive function impairments in stroke victims, and that those with moderate stroke would be more impaired than those with mild stroke when compared to healthy controls. The table also demonstrates that EFPT scores allow therapists to determine the degree of impairment and the degree of support needed for subjects to function in daily life (Baum et al., 2008).
In summary, the EFPT total average scores for each group — which can range from 0 to 100, with 100 indicating total impairment in functioning — were only 1.51 for the control group, more than five times that figure for the mild stroke group (7.87), and approximately 16 times higher than the control scores for the moderate stroke group (24.21) (Baum et al., 2008). The table thus shows a clear correlation between the degree of impairment in executive functioning during real-world activities and the degree of cognitive damage resulting from stroke. Further information on stroke-related cognitive outcomes is available through the CDC's stroke resources.
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