Acquired brain injury and evaluation of intensive training of attention in early neurorehabilitation : statistical evaluation and qualitative perspectives

Attention dysfunction is a cardinal symptom after an acquired brain injury (ABI) sometimes leading to life-long consequences that affect learning skills, daily functioning and social and emotional life. Attention may be successfully improved by structured training within rehabilitation programs, with the Attention Process Training (APT) as practice standard in the chronic stage after ABI. Practice recommendations in an earlier stage after ABI are less conclusive, possibly due to difficulties in distinguishing treatment effect from individual trajectories of spontaneous recovery. A randomized controlled trial (RCT) was performed at a university department of rehabilitation medicine. Patients with attention dysfunction after stroke or traumatic brain injury received 20 hours of attention training added to their individual rehabilitation program. The patients were randomized to one of two interventions of attention training: APT or activity-based attention training. The thesis focuses on the effect of attention training within four months post-injury.

In Study I, the strict inclusion and exclusion criteria common to interventions trials in clinical research decimated patient recruitment, ultimately leading to an inclusion of < 10 % of admitted patients with stroke or TBI. Sampling bias was identified within the group of patients meeting all criteria. Eligible patients participating in the intervention study were more likely to be in a relationship and had a higher education. Strict inclusion and exclusion criteria prolonged data collection rendering the study group potentially less representative. We advocate the use of broader inclusion criteria and common data elements in future studies.

Study II evaluated the feasibility of time-series measurements using statistical process control (SPC) for detecting change in an evolving process. SPC identified if, and when change occurred and the results described three patterns of performance: rapid improvement, steady improvement and stationary performance showing no improvement. By providing information about when change occurs, SPC enables adjustment of individual treatment response in early cognitive rehabilitation.

In Study III, we applied SPC to explore the intervention effect of two methods of attention training: APT and activity-based attention training, within four months post injury. Although substantial improvement of attention was confirmed for both intervention groups, APT lead to an increased robustness of improvement, and resulted in a higher number of improved patients reaching change in performance at a faster rate.

Study IV explored the experience of managing attention difficulties in daily life 2-4 years after brain injury and APT. Fourteen interviews were analyzed according to grounded theory and lead to the development of a model of attention management. The attention management emerged as a dynamic process where adjustment and refinement of management strategies increased with awareness and deepened application of applied knowledge, regulated by situation-dependent factors. Self-awareness and the detailed identification of dysfunction derived problem areas, including tenacious self-training with specific goal-setting, were promoted by APT.

In conclusion, attention training is a promising intervention in the early stage after ABI with APT potentially boosting the improvement process as seen both during intervention and in the experience of attention management over time. SPC enables us to identify if, when and how change occurs in an evolving process. It may be used on both individual and group level.

List of scientific papers

I. Markovic G, Schult M-L & Bartfai A. (2016). The effect of sampling bias on generalizability in intervention trials after brain injury. Brain Injury.
https://doi.org/10.1080/02699052.2016.1206213

II. Markovic G, Schult M-L, Bartfai A, Elg M. (2017). Statistical process control: a feasibility study of the application of time-series measurement in early neurorehabilitation after acquired brain injury. J Rehabil Med. 2017 Jan 31;49(2):128-135.
https://doi.org/10.2340/16501977-2172

III. Markovic G, Schult M-L, Elg M, A Bartfai. Attention process training is beneficial during early intervention after acquired brain injury. A randomized controlled trial. [Manuscript]

IV. Markovic G, Bartfai A, Ekholm J, Nilsson C, Schult M-L, Löfgren M. Daily management of attention dysfunction 2-4 years after brain injury and early cognitive rehabilitation with Attention Process Training - A qualitative study. [Submitted]