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 Table of Contents  
Year : 2018  |  Volume : 4  |  Issue : 4  |  Page : 191-196

Computerized neuropsychological rehabilitation of a frontal lobe stroke: Hierarchical attention training

Prosperius Institute, Neurorehabilitation and Robotic Area, University of Perugia, Umbertide, Italy

Date of Web Publication28-Dec-2018

Correspondence Address:
Paolo Milia
Prosperius Institute, Neurorehabilitation and Robotic Area, Umbertide
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/digm.digm_15_18

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The prefrontal cortex (PFC) has extensive reciprocal connections with nearly all cortical and subcortical structures, placing it in a unique position to orchestrate a wide range of cognitive and affective neural functions. Damage of PFC in humans is associated with profound changes in social and affective behavior. The development of new technologies in the field of cognitive rehabilitation is giving us the opportunity to use computer-based cognitive tools to improve the recovery of patients affected by acquired brain injury.

Keywords: Digital, frontal, stroke

How to cite this article:
De Salvo F, Milia P, Peccini MC, Sfaldaroli A, Cadri S, Caserio M, Bigazzi B, Bigazzi M. Computerized neuropsychological rehabilitation of a frontal lobe stroke: Hierarchical attention training. Digit Med 2018;4:191-6

How to cite this URL:
De Salvo F, Milia P, Peccini MC, Sfaldaroli A, Cadri S, Caserio M, Bigazzi B, Bigazzi M. Computerized neuropsychological rehabilitation of a frontal lobe stroke: Hierarchical attention training. Digit Med [serial online] 2018 [cited 2023 Jun 8];4:191-6. Available from: http://www.digitmedicine.com/text.asp?2018/4/4/191/248977

  Introduction Top

The prefrontal cortex (PFC) has extensive reciprocal connections with nearly all cortical and subcortical structures, placing it in a unique position to orchestrate a wide range of cognitive and affective neural functions.[1]

The PFC's functions are often collectively referred to as cognition, or executive control, and can be broadly divided into several core cognitive components, including mental set-shifting, inhibition, information updating, working memory, response monitoring, and temporal coding.[2] Literature suggests that major divisions of the PFC control different aspects of executive functions (EF) and, in turn, make different contributions to goal-directed behavior. The lateral PFC is critical for the selection, monitoring, and manipulation of cognitive task sets. In addition, the dorsolateral aspect of the PFC is thought to be particularly important for the monitoring and control of memory processes – both at the time of encoding and at the time of retrieval.[3] The medial PFC is critical for the updating of cognitive task sets, and the orbitofrontal cortex is critical for assigning social and emotional meaning to these task sets in order to better guide goal-directed behavior.[2] Damage restricted primarily to the medial orbital and ventromedial PFC in humans is associated with profound changes in social and affective behavior.[4],[5],[6] This includes lack of affect or poorly modulated emotional reactions and disinhibited or socially inappropriate behavior and decision-making.[7] Although specific function is usually linked to specific PFC subregion, there is substantial overlapping of interactive functions across these regions.[8]

Numerous direct intervention techniques have focused on various forms of cognitive training to help patients with PFC injuries regain some of their lost cognitive abilities (such as attentional focus, working memory, and goal-directed behavior). The hope for using these techniques is that training will transfer to behavioral and cognitive improvement in day-to-day life situations.[2]

In recent years, the development of new technologies in the field of cognitive rehabilitation has led to a growing use of computer-based cognitive tools in patients with acquired brain injury.[9] Examples for such computer-based tools include the attention process training (APT)[10] and the Paced Auditory Serial Addition Test (PASAT).[11] Brief descriptions of these cognitive training tools are as follows:

APT[12] is a rehabilitation program for attention built according to a specific functional approach.[13] It is based on the assumption that attention is not unitary, but consists of a number of distinct components.[14] APT includes hierarchically organized tasks requiring different types of attention (sustained, selective, alternating, and divided).[12] The program tasks place an increasing demand on complex attentional control and the working memory system.[10] Efficacy studies have demonstrated consistent attentional improvements (measured through the PASAT and the Consonant Trigrams) in patients with brain injury.[15] Other studies, comparing APT to an educational support method, have demonstrated that APT resulted in more significantly improved attentional skills, which generalized to measures that were different from the training tasks.[13] Several reports indicate that APT improves real-world outcomes,[16] independent living, and return to work.[17] The effectiveness of APT has also been demonstrated in a large sample of individuals poststroke.[18]

The pasat has been used in distinct ways such as an assessment tool or as a rehabilitative task.[11] Research has shown that the PASAT has clinical utility for detecting cognitive processing impairments in a wide variety of neuropsychological syndromes. The PASAT was originally assumed to measure the rate of information processing.[11] More recently, however, the PASAT has been conceptualized as multifactorial because it requires successful application of numerous cognitive functions including executive control, sustained attention and working memory,[19] and simultaneously performing several cognitive tasks under specific time constraints.[20] Administration of the PASAT involves presenting a series of single-digit numbers where the two most recent digits must be summed. The participant must respond prior to the presentation of the next digit for a response to be scored as correct. The vast majority of applications have presented the digits aurally rather than visually. To increase the difficulty of the task, the interstimulus interval is progressively decreased (2.4 s, 2.0 s, 1.6 s, 1.2 s, and 0.8 s).[11] Computerized versions of the PASAT permit measuring the speed at which a person responds as well as recording the number of correct responses.[20],[21],[22] Gronwall[23],[24] described a rehabilitation program in which the PASAT played a central role as a guide to return to work. More recently, the efficacy of a rehabilitative program (working memory training [WMT]) based on the PASAT targeting the central executive system (CES) in improving working and other functions dependent on this system has been investigated. The WMT was preceded by a general stimulation training (GST: control training), where the GST had no effect on patient's performance; patients improved in working memory and in the cognitive function controller by CES (divided attention, EFs, and long-term memory) after the WMT. Importantly, a beneficial WMT effect was found on patients' day-to-day life functioning.[25] This result was based on the evidence that working memory, divided attention, EFs, and long-term memory are associated with each other and depend on CES functioning.[26]

In the present study, an attempt has been made to develop a computerized cognitive training program and to explore its usefulness in improving cognitive functioning in a patient with acquired brain injury: hierarchical attention training (HAT) which resulted by a fusion of APT and PASAT-like tasks. It is composed of tasks regarding three domains of cognitive functions, attention EFs, and working memory. These tasks are hierarchically organized requiring different cognitive functions and increasing demand (from lower to higher cognitive functions).

Case Report

The patient is a 54-year-old female, right handed, with 11 years of education. She underwent removal of a right temporal frontal parietal meningioma and subsequent ischemic stroke of the left anterior communicating artery. She was admitted to the neuropsychological assessment and rehabilitation course at the Prosperius Tiberino Institute. An extensive neuropsychological examination of the patient was performed before and after the cognitive training.

Neuropsychological assessment pre cognitive rehabilitation

The assessment was conducted through standardized tests that investigate cognitive functions such as memory, attention, EFs, logical-deductive reasoning skills, and praxis-constructive skills [Table 1] shows test scores in detail]. The patient was disoriented to time and place. The patient's performances in the following tests were normal: the short-term memory, both verbal and visuospatial (Digit Span and Corsi Test); visuospatial long-term memory (Rey Complex Figure); and performance in the digit span backward, indicating adequate functioning of working memory. There were no deficits of sustained and selective attention (attentional matrices), or of mental flexibility and EFs (Trial Making Test Part B). Performance in the Verbal Fluency Test for phonemic cues was unimpaired, indicating adequate lexical access and executive control ability. Constructional apraxia (Rey Complex Figure-copy) fell in the normal range, as did logical-deductive reasoning (verbal judgments). The preassessment revealed pathologic score on the Mini–Mental State Examination and on the Rey Auditory Verbal Learning Test (AVLT), indicating a severe impairment of long-term memory, with the presence of confabulations. Her behavioral status was characterized by inadequate behavior due to the excessive prevalence of disinhibition and poor social cognition.
Table 1: Profile of scores in neuropsychological assessment pre- and post-cognitive training

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Neuropsychological rehabilitation

Based on the obtained profile (preassessment) and literature evidence of the existing cognitive rehabilitation training (APT-PASAT), a computerized cognitive training was developed: HAT that is a fusion of the two computerized rehabilitation program described before. The underlying rationale for our rehabilitative approach is as follows:

  1. The most evident deficit of the patient's EF is severe memory impairment. Research has shown that repetitive practice and drills focusing on the direct restoration of memory have been ineffective, even after extensive training periods. The use of techniques has also demonstrated limited efficacy when focusing solely on a restorative memory approach. There is a strong indication that memory strategy training combined with EF training is more successful than isolated memory training[27]
  2. A rehabilitative program based on PASAT improved patient's performance in working memory and in other functions not directly treated such as divided attention, EFs, and long-term memory[25]
  3. PASAT-like tasks to be performed require a variety of cognitive functions, especially those related to attention.[28] It is, therefore, necessary to strengthen the patient's attentive abilities
  4. Computerized cognitive training function specific such as APT improves attention.[10],[15],[18]

Our cognitive training is designed to simplify the cognitive mechanism based on APT and PASAT by using different aspect of two major scales, providing a hierarchically attention training.

The key characteristic of the training is to use a broad spectrum of tasks that aim to cover the entire range of attentional processes. Our training is divided into two sections. The first one aims to enhance the patient's attentive abilities through tasks targeted in particular to the following four components of attention: sustained, selective, alternating, and divided. For each of the components of the attention, hierarchically ordered tasks are developed, so as to allow the stimulation of the functions already treated. In the second section, intensive and repeated sessions of exercises are performed in order to obtain generalized functions not directly treated, such as long-term memory, impaired in our patient. All the tasks were presented in a graded fashion; the difficulty level and the complexity of the tasks were gradually increased. An advantage to the use of computerized program is that it can be used in an adaptive mode adjusting the task difficulty level to the individual patient's performance. For each proposed exercise, there are parallel forms, and the presentation of the stimuli takes place both in visual and auditory modalities.

The cognitive training was performed for 60 days, five times per week for 30 min per session. During the rehabilitation process, the patient's performance progressively improved, even though it was necessary to repeat the instructions of the task to be performed. In addition, psychotherapy sessions with neuropsychologic-cognitive-orientation were performed (one time a week).

Neuropsychological assessment post cognitive rehabilitation

The neuropsychological assessment was repeated after the ending of cognitive training for 2 months. [Table 1] shows the test scores in detail. The patient showed a great improvement in all of the cognitive domains investigated. Especially, after rehabilitation, the score on the Mini–Mental State Examination improved to within normal limits, indicating a recovery of general intellectual level. The patient's performance in memory tasks (Rey AVLT and Memory of Prose Test) showed great improvement (from equivalent scores of 0 to equivalent scores of 2 and from equivalent score of 0 to equivalent scores of 1, respectively). Confabulations were reduced. In remission behavioral symptoms, the patient was more appropriate to the context, despite still needing supervision in the activities of daily life. She did not return to her prior employment.

  Discussion Top

The aim of the present study was to examine the usefulness of a computerized rehabilitation training program (HAT) in a patient with severe memory impairment due to frontal lobe stroke. The fusion of APT and WMT based on PASAT has allowed us to design HAT.

Neuropsychological rehabilitation is based on the concept of neural plasticity, involving the principles of reestablishment and reorganization of the lost functions of the brain.[29] It uses a systematically organized procedure that focuses on specific core processing abilities which in turn enhance the cognitive competency of the affected patients. It involves the assessment of cognitive functions, goal setting, and applying appropriate cognitive exercise to improve cognitive functions.[30] Cognitive training utilizes this mechanism, thereby allowing the brain to restore or compensate for the impaired cognitive functions that are lost due to trauma. Studies have shown neuropsychological rehabilitation to be useful in improving the cognitive functions and day-to-day functioning.[31] HAT acts on the mechanisms underlying the functioning of attention, EF, and working memory.

Memory impairment was the target of our rehabilitation program. For the entire duration of the admission (60 days), our patient underwent intensive and repeated sessions of a computerized rehabilitative training aimed at enhancing the basic attentive skills prior to performing task that requires the completion of numerous cognitive functions including executive control, sustained attention, and working memory. The difficulty of the tasks was gradually increased as the patient's performance improved. In this study, the training of cognitive process was adopted involving repetitive stimulation of distinct components of cognitive functions with an expectation of improvement of the specific tasks and generalization to functions not directly treated because the goal of our rehabilitation was the recovery of memory impairment. After the cognitive rehabilitation, the patient's performance in memory tasks showed a great improvement. Similar findings are shown in a study by Serino et al.[25] which show how a treatment with PASAT, which is based on functions that depend on the CES, not only improve working memory, but also improve other functions depending on CES functioning, for example, divided attention, EF, and long-term memory.

There is a consensus that cognitive rehabilitation should not only be focused exclusively on the remediation of impairments, but should also reduce disability and help to restore social role functioning.[32] Although the results are encouraging, our study is only a case report, and further studies are needed to reduce methodological issues (small sample size and lack of control group) and to develop standardized protocols. However, whether the gains obtained are maintained and generalized to everyday tasks is yet to be seen. Furthermore, it is difficult ascertaining whether the improvement in the patient's cognitive performance was due to the natural or spontaneous recovery or was due to the cognitive program.

However, when considering the severity and characteristics of the initial deficits, it is highly improbable that such restoration would have been obtained in the absence of intensive training. A follow-up neuropsychological assessment is needed to ascertain if the recovery of memory impairment is maintained and generalized to day-to-day functioning.

Despite several limitations, our computerized cognitive rehabilitation program may be effective in treating memory impairment due to frontal lobe lesion. Moreover, compared to traditional rehabilitation approaches that are often considered repetitive and boring by patients, resulting in difficulties to maintain their continued interest and their motivation, the use of computer programs could be the key solution. This is because they present a more dynamic and motivating design and layout, also due to the presence of immediate feedback, allowing concentration only on the activities to be carried out, and designed in a way so that they are more similar to real-life situations. In addition, these programs can be used in an adaptive mode, adjusting the task difficulty level to the individual patient's performance. In recent years, a growing body of research has examined the feasibility and efficacy of alternative mode of rehabilitation, such as telerehabilitation, defined as the ability to provide distant support, evaluation, and intervention to patients via telecommunication[33] and serious games that can be used in the rehabilitation area to increase patient motivation in the rehabilitation sessions.[34] Another field of research is virtual reality (VR) for neuropsychological rehabilitation after brain injury.[35],[36] VR-based rehabilitation methods have important benefits: VR settings, although involve controlled environments, are more ecologically valid. VR environments replicate real-life situation; patients receive dynamic and real-time feedback and training involves task customization according to user's requirements.[37] Further research is needed. In the future, we may use VR, serious games, and telerehabilitation to improve the efficacy of cognitive rehabilitation.

  Conclusion Top

This study emphasizes the role of computerized neuropsychological rehabilitation of patients with acquired brain injury. We can conclude that computerized cognitive rehabilitation can produce satisfying results in patients with acquired brain injury.

The novelty of our study is HAT, a new computerized cognitive training that exploits the same rationale underlying the most standardized and effective tools that are present in the literature (APT and PASAT) in a single rehabilitative program.

It was revealed through our study that computerized cognitive rehabilitation with HAT results in improvement in memory abilities and EF in patients with memory impairment due to frontal lesion. In the near future, it can be used as a treatment tool beneficial to a wide stroke population to discover the real effect on cognitive deficit and on the daily life.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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