Evaluating the impact of Attention Process Training (APT) on attention deficit in the early stages of recovery from stroke

Attention deficits are a prominent sequel of stroke and impact negatively on rehabilitation outcomes. However, rehabilitation efforts are almost entirely concerned with the remediation of physical impairments that result from the stroke despite the involvement of attention in physical functioning. Attention Process Training (APT) is a cognitive retraining programme originally designed for the remediation of attention deficit following traumatic brain injury. However, the efficacy of APT post-stroke is not yet known, as to date, few studies have been conducted with small sample sizes. This study evaluated the effectiveness of APT in improving attention in stroke survivors within the 5 to 8 week period post-stroke. Seventy eight patients admitted to hospital with first-ever-stroke were identified as having an attention deficit by obtaining a score of 1 standard deviation below the normative mean on any of the following widely-used neuropsychological measures of attention; the Auditory Attention Quotient (AAQ) or Visual Attention Quotient (VAQ) of the Integrated Visual and Auditory Continuous Performance Test, (IVA-CPT), either trial of the Trail Making Test (TMT), the Paced Auditory Serial Addition Test (PASAT), or by 3 or more errors made on the left or right side of the Bells Cancellation Test. These measures were re-administered on completion of treatment. Participants were randomised to either the experimental group who received standard care and up to 30 hours of APT or to a control group that received standard care only. The primary outcome measure was the Full Scale Attention Quotient (FSAQ) of the IVA-CPT which is a measure of attention derived from both auditory and visual attention quotients. The secondary outcome measure was a health-related quality of life measure, the SF-36, (Short-Form-36). Both measures were administered before treatment and again on the completion of treatment. The results showed that on the primary outcome, the APT group showed improvement from baseline to post-treatment whereas the SC group had not. Significant improvement by the APT group was also demonstrated on two other measures of the IVA-CPT including the Auditory Attention Quotient and the Full Scale Response Quotient (a measure of impulsivity). On the quality of life measure neither the APT group nor the SC group demonstrated a significant change in scores. The results of this study provide further support for the efficacy of cognitive rehabilitation and in particular that APT is an effective cognitive treatment option for the remediation of attention deficit in the early stages of stroke recovery. The characteristics of stroke survivors who might benefit most from APT are identified as well as those factors that possibly influence the subjective experience of this particular intervention. The appropriateness of some measures such as the PASAT, the TMT, cancellation tests as well as continuous performance tests that are often used in research of attention deficit, are also discussed in the context of a stroke population. It is hopeful that the optimistic outcomes of this study will encourage further needed research in this area in order to inform stroke rehabilitation specialists to incorporate cognitive rehabilitation into predominantly physically-focussed programmes