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Training of attention. What have we learned?

Aniko BartfaiSenior professorDepartment of Clinical Sciences Danderyd HospitalKarolinska institutet

26 augusti 2018A n iko B artfa i 2

J Head Trauma RehabilVol. 29, No. 4, pp. 277–289

Copyright c⃝ 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Quality of Guidelines for CognitiveRehabilitation Following TraumaticBrain Injury

Peter Bragge, PhD; Loyal Pattuwage, MPH; Shawn Marshall, MD, FRCPC;Veronica Pitt, PhD; Loretta Piccenna, PhD; Mary Stergiou-Kita, PhD; Robyn L. Tate, PhD;Robert Teasell, MD, FRCPC; Catherine Wiseman-Hakes, PhD; Ailene Kua, MSc;Jennie Ponsford, PhD; Diana Velikonja, PhD; Mark Bayley, MD, FRCPC

Introduction: Cognitive rehabilitation following traumatic brain injury can aid in optimizing function, indepen-dence, and quality of life by addressing impairments in attention, executive function, cognitive communication,and memory. This study aimed to identify and evaluate the methodological quality of clinical practice guidelinesfor cognitive rehabilitation following traumatic brain injury. Methods: Systematic searching of databases and Websites was undertaken between January and March 2012 to identify freely available, English language clinical practiceguidelines from 2002 onward. Eligible guidelines were evaluated using the validated Appraisal of Guidelines forResearch and Evaluation II instrument. Results: The 11 guidelines that met inclusion criteria were independentlyrated by 4 raters. Results of quality appraisal indicated that guidelines generally employed systematic search andappraisal methods and produced unambiguous, clearly identifiable recommendations. Conversely, only 1 guidelineincorporated implementation and audit information, and there was poor reporting of processes for formulating,reviewing, and ensuring currency of recommendations and incorporating patient preferences. Intraclass correla-tion coefficients for agreement between raters showed high agreement (intraclass correlation coefficient > 0.80)for all guidelines except for 1 (moderate agreement; intraclass correlation coefficient = 0.76). Conclusion: Futureguidelines should address identified limitations by providing implementation information and audit criteria, alongwith better reporting of guideline development processes and stakeholder engagement. Key words: clinical practiceguidelines, cognitive rehabilitation, traumatic brain injury

EACH YEAR, more than 10 million people world-wide, or 100 to 300 per 100 000 population, sustain

a traumatic brain injury (TBI).1,2 Moderate to severe TBIcan result in a range of ongoing physical and psycholog-ical impairments. Individuals with TBI often have diffi-culties with memory; attention and concentration; plan-ning, organizing, and decision making; and cognitive as-

Author Affiliations: National Trauma Research Institute, MonashUniversity and The Alfred Hospital, Melbourne, Victoria, Australia(Drs Bragge, Pitt, and Piccenna and Mr Pattuwage); The OttawaHospital Rehabilitation Center, University of Ottawa, Ottawa, Ontario,Canada (Dr Marshall); University of Toronto and Toronto RehabilitationInstitute, Toronto, Ontario, Canada (Dr Stergiou-Kita); UHN-TorontoRehabilitation Institute and Division of Physiatry, Department ofMedicine, University of Toronto, Toronto, Ontario, Canada (Dr Bayley);Rehabilitation Studies Unit, Sydney Medical School - Northern, TheUniversity of Sydney, New South Wales, Australia (Professor Tate);Lawson Research Institute and Western University, London, Ontario,Canada (Dr Teasell); Bloorview Research Institute, Holland, BloorviewKids Rehabilitation Hospital, Toronto, Ontario, Canada (DrWiseman-Hakes); Toronto Rehabilitation Institute, Toronto, Ontario,Canada (Ms Kua); Monash-Epworth Rehabilitation Research Centre,Epworth Hospital and School of Psychological Sciences, MonashUniversity, Victoria, Australia (Professor Ponsford); and Acquired BrainInjury Program, Hamilton Health Sciences, DeGroote School of Medicine,McMaster University, Hamilton, Ontario, Canada (Dr Velikonja).

pects of communication. These deficits, along with be-havior and personality changes, have a greater impact onpost-TBI quality of life than do physical disabilities.3 In-ability to return to preinjury employment,4 poor every-day functioning,5,6 relationship difficulties, and loss ofindependence3,4,6,7 are estimated to contribute to morethan 80% of the lifetime cost of TBI to society becauseof their impact on burden of disease, lost productivity,and long-term care needs.8,9 Cognitive rehabilitation—defined herein as interventions addressing deficits in at-tention, executive function, cognitive communication,

This project was funded through Monash University’s Strategic Grants Scheme(Lead CI: Peter Bragge) and the Ontario Neurotrauma Foundation (Lead CI:Mark Bayley).The authors gratefully acknowledge Lyn Turkstra for her editorial input to thisarticle.The authors declare no conflicts of interest.Corresponding Author: Peter Bragge, PhD, National Trauma Research In-stitute, Monash University and The Alfred Hospital, Level 4, 89 CommercialRoad, Melbourne, Australia 3004 ([email protected]).DOI: 10.1097/HTR.0000000000000066

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

277

© 2007 The Authors. Journal compilation © 2007 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice

13

(2007) 657–664

657

Journal of Evaluation in Clinical Practice ISSN 1356-1294

Blackwell Publishing LtdOxford, UKJEPJournal of Evaluation in Clinical Practice1356 1294© 2006 The Authors; Journal compilation © 2006 Society/Blackwell Publishing Ltd2006134657664Original Article Quality of stroke care clini

cal guidelinesA. Hurdowar et al

.

Quality of stroke rehabilitation clinical practice guidelines

Amanda Hurdowar MSc,

1

Ian D. Graham PhD,

2

Mark Bayley MD FRCPC,

3

Margaret Harrison RN PhD,

4

Sharon Wood-Dauphinee PhD PT

5

and Sanjit Bhogal MSc

6

1

Project Coordinator, Toronto Rehabilitation Institute, Toronto, ON, Canada

2

Associate Professor, School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, and Associate Director and Senior Social Scientist, Clinical Epidemiology, Ottawa Health Research Institute, The Ottawa Hospital, Ottawa, ON, Canada

3

NeuroRehabilitation Program Medical Director, Toronto Rehabilitation Institute, Toronto, and Associate Professor, Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada

4

Associate Professor, Queen’s University School of Nursing, Community Health and Epidemiology, Kingston, ON, Canada

5

Professor, School of Physical and Occupational Therapy, McGill University, Montreal, PQ, Canada

6

Department of Epidemiology and Biostatistics, McGill University, Montreal, PQ, Canada

Abstract

Background and purpose

Clinical practice guidelines (CPGs) are systematically devel-oped statements that assist practitioners to provide appropriate evidence-based care. Thepurpose of this study was to evaluate the quality of currently published CPGs for strokecare and to examine the reliability and validity of the appraisal of guidelines, research andevaluation (AGREE) instrument.

Methods

Multiple databases and Internet resources were searched for stroke care CPGs.Guidelines included were published in English or French from 1998 to 2004 and developedby a group process. Four appraisers evaluated each CPG using the AGREE instrument. TheAGREE consists of 23 items, ranked on a 4-point Likert scale, that is organized into sixdomains. A standardized score is calculated separately for each domain and ranges from 0to 100.

Results

Eight guidelines were identified. The AGREE quality scores were high for the‘scope and purpose’ domain (mean

±

SE

=

71.2

±

5.48, intra-class correlation (ICC)

=

0.66), and ‘clarity and presentation’ (mean

±

SE

=

70.6

±

4.43, ICC

=

0.66). There waswide variation in ratings of ‘rigour of development’ (mean

±

SE

=

60.7

±

7.1, ICC

=

0.75)and ‘stakeholder involvement’ (mean

±

SE

=

52.6

±

7.14, ICC

=

0.89). The ‘editorial inde-pendence’ (mean

±

SE

=

38.1

±

8.72, ICC

=

0.88) and ‘applicability’ (mean

±

SE

=

35.1

±

4.93, ICC

=

0.75) had the lowest scores.

Conclusions

There is considerable variability in quality of stroke care guidelines butstroke guidelines score higher on the AGREE rigour of development domain than CPGsfrom other medical fields. The Scottish Intercollegiate Guideline Network, VeteransAffairs/Department of Defence, Royal College of Physicians, and the New Zealand Guide-lines Group consistently scored the highest across the domains. Stroke rehabilitationclinicians should consider these results in selecting a guideline. CPG development groupscan improve their AGREE scores by considering the cost of implementing their CPGs, pilottesting their CPGs, recording conflict of interest of development panel members andproviding tools supporting application of the their CPGs.

Introduction

Stroke is the leading cause of long-term adult disability in Canadawith over 300 000 people living with the after-effects of strokeeach year [1]. Organized post-stroke care has been shown toreduce mortality and the burden of disability when it is provided in

a multidisciplinary acute stroke unit [2]. However, large variationsin service provided by teams, rising health care costs, increaseddemand for care, and the ageing population have fuelled interest indeveloping and using clinical practice guidelines (CPGs) to facili-tate organized care [3]. CPGs are ‘systematically developed state-ments used to assist practitioners to make patient decisions about

Keywords

AGREE, clinical practice guidelines, evidence-based practice, rehabilitation, stroke

Correspondence

Amanda HurdowarQuality & Risk ManagementThe Hospital for Sick Children555 University AvenueRoom 2206TorontoON M5G 1X8CanadaE-mail: [email protected]

Accepted for publication: 23 January 2006

Remediation of Attention

Intervention Level of Recommendation

Recommended during postacuterehabilitation after TBI, including directattention training and metacognitivetraining, development of compensatorystrategies and foster generalizationInsufficient evidence exists to distinguishthe effects during acute recovery

Practice Standard

Computer-based interventions may be an adjunct to clinician-guided treatment afterTBI or stroke. Sole reliance on repeatedexposure on computer-based tasks withoutsome involvement and intervention by a therapist is not recommended.

Practice Option


Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008.Cicerone KD, Langenbahn DM, Braden C, et al. Arch Phys Med Rehabil. 2011 Apr;92(4):519-30

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26 augusti 2018A n iko B artfa i 426 augusti 2018 4

Background for attention training in the early stage after ABI§ Evidence for the affectivity of attention training in the chronic

stage after ABI (Cicerone et al 2000, 2006, 2011)

§ Experiential factors in animal studies are among the major driving forces in cortical reorganization (Johansson, 2000)and the reorganisation of brain function after ABI is most intensive during year 1 (Allred R P & Jones T A (2008)

§ Results in the acute stage conflicting (Cicerone et al 2000)• (Sturm & Wilmes, 1991, Ponsford & Kinsella, 1992, Novack, et al,

1996)• Barker-Collo et al, 2009

Attention Process Training; APT

Meta-cognitivestrategies

Generalisation

HierarchicalIntensity

Repetition

5

APT II:Light

APT I: Moderate/light

Diagnostic test – level and type of impairment

Sohlberg & Mateer, 1987; Sohlberg, McLaughlin, et al 2000.

The protocol and design of a randomised controlled study on training of attention within the first year after acquired brain injuryBartfai A, Markovic G, Sargenius Landahl K & Schult MLBMC Neurology 2014 14:102


ClinicalTrials.gov protocol NCT02091453

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Study schedule and study measures


§ Most studies use pre and post measurement design

§ Some use single case studies

§ Are there other statistical methods capturing the process ofrehabilitation in a better way?


Is this a measurement problem?

Statistical Process Control (SPC)

§ Control charts to monitor the targeted process§ Discriminates between two kinds of variation:

- random(noise)- discernible(signal)

§ Additional rules to evaluate significant variations

Markovic G, Schult M-L, Bartfai A & Elg M. J of Rehabil Med 2017;49:128-135

U C L=41,093

LC L=5,157

C E N =23,125

05

1015202530354045

1 2 3 4 5 6 7 8

R C hart


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Modified SPC procedure by Matthias Elg

§ Estimate of baseline as mean of the first two measurementsà Montgomery DC. Introduction to statistical quality control: John Wiley & Sons; 2007

§ Valid for both individual and group chartsà X charts (for mean values)à S charts (for variance)

§ 11 patients in each group are sufficient


Results on group levelPASAT scores(Markovic, 2017, PhD thesis)


P-value for within-group variability is computed with Leven’s test for homogeneity in variance, Sig. (2-tailed).

Measurement LeveneStatistic

df (1) df (2) p (Sig)

1 3,627 1 57 0,0622 0,693 1 57 0,4093 1,894 1 57 0,1744 5,045 1 57 0,0295 2,337 1 57 0,1326 4,924 1 57 0,037 7,972 1 57 0,0078 5,163 1 57 0,0279 2,059 1 57 0,157In

omgr

upps

var

iatio

n; P

ASA

T

Differences in within group variance ofPASAT scores (Markovic, 2017, PhD thesis)


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Cluster and pattern analysis of individual data(Markovic, 2017, PhD thesis)§ Clustering patients into major groups depending on

common features. § Looking for specific patterns over time:

à Trendsà Stationary, white noise behavior

§ Three distinct patterns were detected both on groupand individual level: 1. Steady improvement2. Rapid improvement3. Stationary performance


0102030405060

1 2 3 4 5 6 7 8

PASA

T sc

ore

Rapid Improvers

0102030405060

1 2 3 4 5 6 7 8

PASA

T sc

ore

Stationary performers

0102030405060

1 2 3 4 5 6 7 8

PASA

T sc

ore

Steady improvers

0102030405060

1 2 3 4 5 6 7 8

PASA

T Sc

ore

Steady improvers

0102030405060

1 2 3 4 5 6 7 8

PASA

T Sc

ore

Rapid improvers

0102030405060

1 2 3 4 5 6 7 8

PASA

T Sc

ore

Stationary performers

ABAT APT


Individual data – PASAT scores

Distribution of patients per identified improvement patterns, including number of patients with maintained improvement at six months follow-up (Markovic, 2017, PhD thesis)

1526 augusti 2018A n iko B artfa i

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Do we get changes on activity level?


Primary outcome measure: WAISecondary outcome measures: COPM

RSABAWPAWP-rev

Effects on activity levelWork Ability Index


0

2

4

6

8

10

12

14

16

poor moderate goodAPT ABAT

Pre-tra

ining

Post-tra

ining

Follow

-up

Pre-tra

ining

Post-tra

ining

Follow

-upNr ofpatients

WAIgroups

Pre-tra

ining

Post-tra

ining

Follow

-up

Pre-tra

ining

Post-tra

ining

Follow

-up

Pre-tra

ining

Post-tra

ining

Follow

-up

Pre-tra

ining

Post-tra

ining

Follow

-up

Effects on activity level, cont’d

0

5

10

15

20

25

Total Alertn ess Sustained SelectiveAPT ABAT

COPM – no differences

RSAB – no differences


Pre-tra

ining

Post-tra

ining

Pre-tra

ining

Post-tra

ining

RSABsubscales

Nr ofpatients

Pre-tra

ining

Post-tra

ining

Pre-tra

ining

Post-tra

ining

Pre-tra

ining

Post-tra

ining

Pre-tra

ining

Post-tra

ining

Pre-tra

ining

Post-tra

ining

Pre-tra

ining

Post-tra

ining

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Effects on Assessment of Work Performance (AWP)


APT

ABAT

Mentalenergy Knowledge Adaptation

Before

Deficient

Inefficient

Uncertain

Competent



APT

ABAT


After

Deficient

Inefficient

Uncertain

Competent



APT

ABAT


Follow-up

Deficient

Inefficient

Uncertain

Competent

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Significant differences in ratings in WAI 2–4 years later between APT and ABAT


general work sitfatigueconc diff diff in multitaskingpainforgetting important tasksuse of memory aidscommunicationproblem solvingsocial contactskeeping schedulesminor missesstructuringorganizingmood issues

APT

ABAT

forgetting structuring organising

NoNo No

NoNoNo

Yes

YesYes

YesYes

Some-times

Some-times

Some-times

Some-times

Conclusions

§ Statistical Process Control - a promising method à Progress can be monitored in real time during rehabilitation

§ There are differential patterns of recovery during the first 4 months after ABI –relevance for rehabilitation programs§ Change patterns can be used as variable of prognosis

§ Initial performance in PASAT has prognostic value for rehabilitation planning à Patients with low performance benefit only of systematic, targeted intensive cognitive

training

à Patients with high performance need more challenges in attention training.

§ Results on activity level are mixedà Relevant behaviors show improvement over timeà Need for improved methodology to define and measure activities


Grant support:

§ The APT-group

The Swedish Research CouncilPromobilia foundationSwedish Stroke Association

RTP

Thanks to all participants!


And many others

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Thank you all for your attention!


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