Rehabilitation with intensive attention training early after acquired brain injury promotes better long-term status on health-related quality of life, daily activities, work ability and return to work.

OBJECTIVE: To describe long-term effects on activity, participation, and quality of life (i) at different post-injury starting time points of attention training and (ii) of two different types of rehabilitation with attention training in patients after stroke or traumatic brain injury; and to describe their functioning level. DESIGN: 2 years after rehabilitation intervention, comparisons were made in one cohort receiving attention training subacute (< 4 months) or post-acute (4-12 months) and in one cohort with two different training methods, a process-based and an activity-based method respectively. PATIENTS: 100 patients were recruited from our earlier RCT study. They had mild to moderate stroke or traumatic brain injury with relatively limited symptomatology, and all had moderate to severe attention impairment. METHODS: A questionnaire-based interview: EuroQol 5 dimensions, Occupational Gaps Questionnaire, Work Ability Index, self-assessed work status, self-reported employment conditions, sick leave, and experienced cognitive limitations in work performance. RESULTS: An advantage for patients receiving subacute attention training regarding daily activities, work ability and returning to work. CONCLUSION: The results indicate that subacute rehabilitation with attention training (< 4 months) is preferable compared to post-acute intervention (4-12 months). There were only minor differences between the training methods.

CHANGES IN FUNCTIONAL CONNECTIVITY FOLLOWING INTENSIVE ATTENTION TRAINING IN PATIENTS WITH TRAUMATIC BRAIN INJURY. A PILOT STUDY.

Objective: To explore functional connectivity after intensive attention training in the chronic phase after traumatic brain injury as clinical evidence indicates that intensive attention training improves attention dysfunction in persons with traumatic brain injury. Design and subjects: A case series study. Two young adults, 13- and 18-months post traumatic brain injury, with traumatic brain injury induced attention deficits were assigned to 20 h of intensive attention training and neuroimaging. Methods: Functional magnetic resonance imaging during a psychomotor vigilance test was conducted pre- and post-intervention. Results: The neuroimaging indicated both increased and decreased connectivity density in frontal, posterior and subcortical brain regions, for some regions with separate change patterns for left and right hemisphere respectively, and an overall reduction in variability in functional connectivity. Conclusion: The changed and decreased variability of functional connectivity in various brain regions, captured by fMRI during a psychomotor vigilance test after direct attention training in a small sample of persons with traumatic brain injury, suggests further studies of functional connectivity changes in neural networks.

Vision impairment is common in non-hospitalised patients with post-COVID-19 syndrome.

CLINICAL RELEVANCE: Vision-related problems can be part of longstanding sequelae after COVID-19 and hamper the return to work and daily activities. Knowledge about symptoms, visual, and oculomotor dysfunctions is however scarce, particularly for non-hospitalised patients. Clinically applicable tools are needed as support in the assessment and determination of intervention needs. BACKGROUND: The purpose of this study was to evaluate vision-related symptoms, assess visual and oculomotor function, and to test the clinical assessment of saccadic eye movements and sensitivity to visual motion in non-hospitalised post-COVID-19 outpatients. The patients (n = 38) in this observational cohort study were recruited from a post-COVID-19 clinic and had been referred for neurocognitive assessment. METHODS: Patients who reported vision-related symptoms reading problems and intolerance to movement in the environment were examined. A structured symptom assessment and a comprehensive vision examination were undertaken, and saccadic eye movements and visual motion sensitivity were assessed. RESULTS: High symptom scores (26-60%) and prevalence of visual function impairments were observed. An increased symptom score when reading was associated with less efficient saccadic eye movement behaviour (p < 0.001) and binocular dysfunction (p = 0.029). Patients with severe symptoms in visually busy places scored significantly higher on the Visual Motion Sensitivity Clinical Test Protocol (p = 0.029). CONCLUSION: Vision-related symptoms and impairments were prevalent in the study group. The Developmental Eye Movement Test and the Visual Motion Sensitivity Clinical Test Protocol showed promise for clinical assessment of saccadic performance and sensitivity to movement in the environment. Further study will be required to explore the utility of these tools.

Preliminary Findings on Cognitive Dysfunction in University-Educated Patients After Mild COVID-19 Disease.

Objective: To investigate cognitive functioning in patients with higher education having post COVID-19 condition. Design: Prospective cohort study. Setting: Outpatient rehabilitation clinic. Participants: Patients (N=38; mean age, 48.5y; 71% women) at the Cognitive Post COVID-19 Clinic at Danderyd University Hospital in Stockholm, Sweden, who sought health care because of self-experienced cognitive problems. All had at least 4 years of university education and an initially mild infection (ie, most were not hospital admitted, none were admitted to intensive care). Interventions: Not applicable. Main Outcome Measures: Cognitive test performance assessed with a comprehensive neuropsychological test battery including Information, Matrix Reasoning, Coding, and Digit Span from Wechsler's Adult Intelligence Scale-IV, Buschke Selective Reminding Test, Rey Complex Figure Test, Ruff 2&7, Color-Word Interference Test, Verbal Fluency, and Trail Making Test. The mean time between the infection and the assessment was 18 months. Results: Cognitive deficits were evident on tests of verbal learning and memory (Buschke Selective Reminding Test) and selective attention (Ruff 2&7). Approximately 50% of the participants had scores lower than 1 SD below the mean in the norm group on the measures of verbal learning and memory. When estimated premorbid cognitive functioning was accounted for, deficits were suggested in most cognitive domains. Conclusions: Post COVID-19 condition seems to be associated with cognitive deficits, even in patients with high education and an initially mild infection.

Predicting Outcome for Early Attention Training After Acquired Brain Injury.

Background: The training of impaired attention after acquired brain injury is central for successful reintegration in daily living, social, and working life. Using statistical process control, we found different improvement trajectories following attention training in a group of relatively homogeneous patients early after acquired brain injury (ABI). Objective: To examine the contribution of pre-injury factors and clinical characteristics to differences in outcome after early attention training. Materials and Methods: Data collected in a clinical trial comparing systematic attention training (APT) with activity-based attention training (ABAT) early after brain injury were reanalyzed. Results: Stroke patients (p = 0.004) with unifocal (p = 0.002) and right hemisphere lesions (p = 0.045), and those with higher mental flexibility (TMT 4) (p = 0.048) benefitted most from APT training. Cognitive reserve (p = 0.030) was associated with CHANGE and APT as the sole pre-injury factor. For TBI patients, there was no statistical difference between the two treatments. Conclusion: Our study identifies indiscernible factors predicting improvement after early attention training. APT is beneficial for patients with right-hemispheric stroke in an early recovery phase. Knowledge of prognostic factors, including the level of attention deficit, diagnosis, and injury characteristics, is vital to maximizing the efficiency of resource allocation and the effectiveness of rehabilitative interventions to enhance outcomes following stroke and TBI.

Does Intensive Training of Attention Influence Cognitive Fatigability in Patients With Acquired Brain Injury?

RESEARCH OBJECTIVES: Impairments in attention and the speed of information processing are central to the experience of cognitive fatigue in patients with acquired brain injury (ABI). Attention may be improved through intensive training in a rehabilitation setting. The aim of the study was to investigate the feasibility of reducing cognitive fatigability (CF) using attention training and to explore the effect of two different approaches to attention training. DESIGN: Randomised controlled study in a rehabilitation setting. PARTICIPANTS: 59 patients (age 19-59 years) with mild to moderate stroke or traumatic brain injury in the early (<4 month) phase. INTERVENTIONS: Patients were randomly assigned to intensive specific training with Attention Process Training (APT) or Activity-Based Attention Training (ABAT) for 3-5 days per week for a period of 5-6 weeks with a total of 20 h, in addition to traditional interdisciplinary rehabilitation. MAIN OUTCOME MEASURE: CF was conceptualised as performance decline in terms of an increased number of incorrect responses between the first and the last quintiles of the Paced Auditory Serial Addition Test (PASAT). A negative result was defined as fatigability. The evaluator of fatigability was blinded to treatment. RESULTS: At baseline, there were no differences between the groups in age, education, reasoning, anxiety or depression. After training, a significant treatment effect was found (p = 0.020), as the APT-group, but not the ABAT-group, had improved. However, after controlling for baseline differences regarding CF on the PASAT-f, the difference was no longer significant. CONCLUSION: The results indicate that cognitive training might be a feasible method for reducing CF through attention training and that patients with high levels of CF benefit most from attention training. The type of intervention provided, whether specific or activity-based attention training, appears to be of less importance, as there was no treatment effect after controlling for the baseline level of CF. Future studies are required to confirm the validity of the findings.

Daily management of attention dysfunction two-four years after brain injury and early cognitive rehabilitation with attention process training: a qualitative study.

The evaluation of intensive cognitive training is usually based on neuropsychological tests and questionnaires. A study of the subjective experience of cognitive training would provide another type of valuable information concerning the effects of rehabilitation. We used grounded theory methods to explore the experience and management of attention dysfunction in daily life two-four years after brain injury. Data were collected by in-depth interviews of 14 adults with moderate-to-mild attention dysfunction after stroke or traumatic brain injury, and working part time or full time at the time of the interviews. The group received 20 hours of attention process training within the context of multidisciplinary rehabilitation early after brain injury. Data were analysed by open coding with constant comparison. The management of attention dysfunction was described by the informants as a dynamic process where strategies are continuously refined and flexibly adjusted as awareness and metacognitive knowledge increases. This process is regulated by situation-dependent factors. Attention process training might provide a suitable starting point for the identification of problem areas, improved specific goalsetting and stimulated self-training. The model describes the dynamic nature of the process, the ongoing struggle, self-training and search for feedback.

Beneficial effects of early attention process training after acquired brain injury: A randomized controlled trial.

BACKGROUND: Evaluation of outcome after intensive cognitive rehabilitation early after brain injury is complicated due to the ongoing biological recovery process. OBJECTIVE: To evaluate the efficacy of Attention Process Training early after acquired brain injury through time-series measurement with statistical process control. DESIGN: Randomized controlled trial. METHOD: Patients with acquired brain injury (n = 59) within 4 months' post-injury in interdisciplinary rehabilitation received an additional 20 h of attention training with Attention Process Training or with activity-based attention training. The primary outcome variable was Paced Auditory Serial Attention Test (PASAT) evaluated using statistical process control. RESULTS: Both groups improved (p < 0.001), although a higher number of patients improved with attention process training (χ2 (1, n = 59) = 5.93, p = 0.015) and the variability was significantly decreased. The Attention Process Training group maintained or improved performance at 6 months follow-up (χ2 (1, n = 51) = 6,847, p = 0.033). Attention Process Training required fewer intervention hours for improvement. Based on individual performance, 3 improvement trajectories were identified: stationary, steady, and rapid improvers. CONCLUSION: The results indicate that attention training is promising early after acquired brain injury and that Attention Process Training boosts functional improvement. Notably, in the present group of relatively homogeneous patients, 3 different trajectories were identified for recovery after acquired brain injury regardless of intervention.

Statistical process control: A feasibility study of the application of time-series measurement in early neurorehabilitation after acquired brain injury.

BACKGROUND: Progress in early cognitive recovery after acquired brain injury is uneven and unpredictable, and thus the evaluation of rehabilitation is complex. The use of time-series measurements is susceptible to statistical change due to process variation. OBJECTIVE: To evaluate the feasibility of using a time-series method, statistical process control, in early cognitive rehabilitation. METHOD: Participants were 27 patients with acquired brain injury undergoing interdisciplinary rehabilitation of attention within 4 months post-injury. The outcome measure, the Paced Auditory Serial Addition Test, was analysed using statistical process control. RESULTS: Statistical process control identifies if and when change occurs in the process according to 3 patterns: rapid, steady or stationary performers. The statistical process control method was adjusted, in terms of constructing the baseline and the total number of measurement points, in order to measure a process in change. CONCLUSION: Statistical process control methodology is feasible for use in early cognitive rehabilitation, since it provides information about change in a process, thus enabling adjustment of the individual treatment response. Together with the results indicating discernible subgroups that respond differently to rehabilitation, statistical process control could be a valid tool in clinical decision-making. This study is a starting-point in understanding the rehabilitation process using a real-time-measurements approach.

The effect of sampling bias on generalizability in intervention trials after brain injury.

OBJECTIVE AND DESIGN: The first objective of this descriptive study was to explore the effect of strict inclusion and exclusion criteria on patient recruitment in cognitive rehabilitation; the second was to analyse the representativeness of study patients for all eligible stroke and traumatic brain injury patients referred to the department from September 2011 to November 2014. METHODS: The setting was multi-professional in- and outpatient brain injury rehabilitation in a university hospital. Participants were enrolled consecutively in acute (< 4 months) or sub-acute (4-12 months) phases of rehabilitation after injury. RESULTS: Nine-hundred-and-forty-four patients were screened. Many failed to meet the inclusion and exclusion criteria (acute phase = 90.5%; sub-acute phase = 85.3% excluded). The most frequent exclusion criteria were age and multiple co-morbidity. The most striking differences between eligible participants and non-participants were the latter's lower educational and occupational levels. CONCLUSION: Results indicate the need for a closer connection between selection criteria and study aims. Strict inclusion and exclusion criteria render the study population less representative and, thus, reduces generalizability. Data collection is prolonged. This study, instead, advocates the use of broad inclusion criteria and common data elements and the need to report data from the total patient population. Increased awareness of the participants' socioeconomic backgrounds is also needed when recruiting to research studies.

The protocol and design of a randomised controlled study on training of attention within the first year after acquired brain injury.

BACKGROUND: To describe the design of the study aiming to examine intensive targeted cognitive rehabilitation of attention in the acute (<4 months) and subacute rehabilitation phases (4-12 months) after acquired brain injury and to evaluate the effects on function, activity and participation (return to work). METHODS/DESIGN: Within a prospective, randomised, controlled study 120 consecutive patients with stroke or traumatic brain injury were randomised to 20 hours of intensive attention training by Attention Process Training or by standard, activity based training. Progress was evaluated by Statistical Process Control and by pre and post measurement of functional and activity levels. Return to work was also evaluated in the post-acute phase. Primary endpoints were the changes in the attention measure, Paced Auditory Serial Addition Test and changes in work ability. Secondary endpoints included measurement of cognitive functions, activity and work return. There were 3, 6 and 12-month follow ups focussing on health economics. DISCUSSION: The study will provide information on rehabilitation of attention in the early phases after ABI; effects on function, activity and return to work. Further, the application of Statistical Process Control might enable closer investigation of the cognitive changes after acquired brain injury and demonstrate the usefulness of process measures in rehabilitation. The study was registered at ClinicalTrials.gov Protocol. TRIAL REGISTRATION: NCT02091453, registered: 19 March 2014.