Combining Attention and Metacognitive Training to Improve Goal Directed Behavior in Veterans With TBI
Condition: Mild Traumatic Brain Injury
MeSH terms: Brain Injuries; Brain Injuries, Traumatic; Brain Concussion
Study type: Interventional

Summary: 
      Veterans with mild traumatic brain injury continue to deal with symptoms that interfere with
      their ability to engage in productive activities. In combination with other psychosocial
      difficulties, impairments are found in cognition, such as attention and executive function.
      Few interventions are available to treat attention in Veterans with mTBI. Of the
      interventions available, none rigorously train attention combined with strategy training.
      This project will innovatively combine a strategy training called Goal Management Training
      with computerized attention training to improve tests of problem solving, attention and
      functional tasks compared to a control group.
    

Detailed description: 
      This is a pilot study to test the effect of GMT plus Attention Training for Veterans with
      chronic mTBI. The research design is a parallel study with randomization to treatment or
      control with test administration at pre/post and six months following treatment. The
      investigators will enroll 50 Veterans with a diagnosis mTBI between the ages of 18 to 55,
      that demonstrate a deficit in attention, pass effort testing and have not changed
      psychotropic medication within the past two weeks. Treatment utilizes GMT for 10-weekly
      two-hour sessions and Brain HQ/Attention Process Training III for 10-weekly two-hour
      sessions. Control utilizes a complimentary Brain Health Workshop for 10-weely two-hour
      sessions and National Geographic movies for 10-weekly two-hour sessions.

      Aim 1: Determine the treatment effect of attention training combined with GMT in Veterans
      with mTBI.

      Hypothesis 1: GMT plus attention training will significantly improve performance on tests of
      cognition compared to the control group.

      Primary measure: Computerized Tower of London (cTOL) total time, time to first move and
      optimal moves). The investigators have found significant improvement in cTOL following GMT in
      previous cohorts of Veterans with blast-related mTBI and anticipate improvement following a
      combined intervention.

      Secondary measure: Attention Network Task (ANT) reaction time and errors for one or all
      dissociable components of three attentional systems (orienting, alerting, executive control)
      following intervention. There is little understanding of components of impaired attention and
      how it impacts executive function; therefore, there is limited guidance in shaping cognitive
      training. The investigators will conduct an experimental task (attention network task) that
      disassociates three attentional components (alerting, orienting, and executive control). The
      investigators will specifically target the orienting component of attention that is
      problematic for Veterans with mTBI and PTSD24, 26. Attentional processes are vital to
      goal-directed behavior. There is great potential in the use of these measures to identify
      individual differences (type of attention deficit) that could moderate treatment-related
      improvement and inform targeted interventions.

      Hypothesis 2: Treatment gains will translate to functional activities compared to controls.

      Primary measure of functional performance: test of grocery shopping skills (TOGSS) total time
      and optimal strategy use. The TOGSS captures efficiency in completing a real-world task and
      aligns with the strategy skills learned in GMT.

      Secondary measure of community participation, the Community Reintegration of Servicemembers
      (CRIS) extent of participation. The CRIS demonstrated significant GMT treatment effect
      compared to controls in Veterans with mTBI. The combined treatment of attention training
      using drill training and implementing strategies to improve attention in a functional setting
      through GMT will potentiate treatment effect to functional activities. Measuring functional
      improvement through performance-based measures and self-report of engagement in activities
      will demonstrate treatment translation.

      Tertiary analysis will be conducted on moderator variables: PTSD symptoms, Pain, History of
      Substance Abuse, Depression, number of concussions and combat exposure.

      Successful completion of the proposed study will provide insight into the effectiveness of
      the innovative combined treatment of attention and executive function in Veterans with mTBI
      and PTSD. Use of the ANT could better target treatment and lead to future examination of
      attention treatment on neuroplasticity.

      A multiple linear regression model will be used to determine if there is a significant
      association between treatment effect and comorbidities such as PTSD, depression, anxiety,
      pain, sleep, substance abuse, etc.
    

Intervention name(s): Goal Management Training; Attention Training; Brain Health Workshop; National geographic movies
Intervention type(s): Behavioral; Behavioral; Behavioral; Behavioral
Intervention description(s): GMT: is a 10-session intervention to improve planning and problem solving. Interactive Power Point modules are administered by a cognitive therapist. Each session builds on the steps of a five-stage planning and problem-solving strategy. Veterans will be taught to generate and verbalize the following five-steps: "stop-what am I doing?", "define the goal", "list the steps", "learn the steps"; then, "check-am I doing what I planned?" The five-stage strategy is then incorporated into a variety of activities in the laboratory and in-home assignments.; Attention Process Training (APT-III) will be administered for a second weekly session in addition to the GMT session. Each session will be 2 hours/ week for 10 weeks. Veterans will also engage in BrainHQTM attention training at home for one-hour, five days/ week comprised of selected components of BrainHQ from Posit Science Corporation. This web-based computerized CRT modality of cognitive training is a restorative or "bottom-up" approach that targets basic cognitive skills such as arousal and vigilance processes, attention and information processing, and directly engages fundamental attention-control skills through repetitive graded exercises.; . BHW was developed specifically for consistency with GMT session length and contact with the facilitator49. BHW is an education presentation on brain function and cognitive principles of learning with homework and quizzes on information covered. To match time and contact of attention training, control participants will meet with the therapist for a separate two-hour session from BHW; participants will select movies to watch and answer a few questions about to equate the time and therapist interaction to attention training in arm 1.
Other intervention name(s): GMT; APT III, Brain HQ; BHW; movies
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: participants meeting inclusion criteria will be randomized to either treatment (Goal management training and attention training) or control (Brain Health Workshop and national geographic movies).
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Brain Injury; Cognition; Veteran; Attention; Metacognition