Gabriela Markovic, Marie-Louise Schult, Mattias Elg, Aniko Bartfai
Karolinska Institutet, Department of Clinical Sciences, Division of Rehabilitation Medicine, Danderyd Hospital, 182 88 Stockholm, Sweden.
DOI: 10.2340/16501977-2628

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.

One of the most common and lasting cognitive symptoms after ABI is attention dysfunction. Although there are interventions that can improve attention, the intervention recommendations are based on studies in the chronic phase after the injury. However, most improvement occurs naturally in the early phase. The cognitive recovery process early after a brain injury is complex and rich in individual variation. Therefore, when evaluating intervention effects early on, one must consider both improvements due to treatment and individual variations in performance. This study compares two attention training interventions provided during the first four months after injury; Attention Process Training and activity-based attention training. In order to capture both improvement and individual variability, we applied process analysis using the method of statistical process control. The study identified three different trajectories for recovery: improvement at a steady or a rapid pace and no identified improvement. Both interventions led to improvement, as expected in this early stage. However, for the Attention Process Training group, performance became more stable and more predictable. The Attention Process Training method resulted in improved attention for significantly more patients and decreased day-to day variations. Differences in treatment effects were maintained at 6-month follow-up. These results emphasize the clinical benefit of the Attention Process Training method over the activity-based attention training.