Training Improves Cognitive Functioning for Patients with Brain Injury

By Steve Tokar

Tatjana Novakovic-Agopian, PhD and Anthony Chen, MDTatjana Novakovic-Agopian, PhD and Anthony Chen, MD

In a study led by researchers at the San Francisco VA Medical Center and the University of California, San Francisco, a new cognitive training method significantly improved the ability of patients with chronic brain injury to maintain attention on goals and execute tasks – skills that these patients often lack as a result of their injuries.

“In the past, it hasn’t been clear what the best approaches to treatment are, and it’s sometimes even been assumed that people with chronic brain injury don’t get better,” said co-lead authors, neuropsychologist Tatjana Novakovic-Agopian, PhD, and neurologist Anthony Chen, MD. “We have demonstrated that cognitive functioning can improve with training, even years after injury. This is a significant step forward in the field of brain injury rehabilitation.” Both Chen and Novakovic-Agopian are affiliated with SFVAMC and the Martinez VA Northern California Health Care System, and are assistant professors of neurology at UCSF.

Chronic brain injury can result from external causes such as falls, vehicle accidents, and the violence of war, and internal causes such as stroke.

The researchers said the intervention, termed goal-oriented attentional self-regulation (GOALS), is designed to address underlying neurocognitive problems commonly experienced by people with chronic brain injury, giving them skills and strategies that they can apply in their everyday lives.

“This is a group that, because of their injuries, often has serious problems with regulating attention and with organizing, planning, and carrying out daily tasks and complex goals,” noted Novakovic-Agopian, who co-directs Program in Rehabilitation Neuroscience at San Francisco and Martinez VA with Chen.

“Developing interventions for these problems is extremely important, given the large number of young men and women coming back from active duty deployment in Iraq and Afghanistan with traumatic brain injury and persistent symptoms of cognitive dysfunction,” said Chen, who co-directs the Center for Brain Injury Treatment and Research at the Martinez VA.

The study appears in the on-line “Published Ahead-of-Print” section of the Journal of Head Trauma Rehabilitation.

Novakovic-Agopian and Chen explained that GOALS is designed to train participants in skills to improve their ability to regulate attention, focus on and hold relevant information in mind while managing distractions, and then actively apply those techniques to managing and achieving real-life goals.

Chen described one of the basic GOALS strategies, called “Stop-Relax–Refocus,” as: “Stop, relax, refocus on the goal to be accomplished, and when your mind wanders, practice redirecting your attention back to the central goal. This is inspired by mindfulness training that’s been taught for thousands of years. The difference is that we have put a rehabilitation twist to it. This is not traditional meditation, but goal-oriented applied mindfulness.”

Over the course of the 10-week study, 16 participants were divided into two groups. The first group received GOALS training for five weeks and a brief educational instruction session about brain injury during the second five weeks. The second group received the identical course of training and instruction, but in reverse order.

At the end of the first five weeks, the GOALS training group showed significant improvement on tests of complex attention and executive function, with effects that seemed to extend to long-term learning and memory. They also exhibited improvement on a complex functional task performed in a real-life setting, reported that they had incorporated the training into their daily lives, and reported subjective improvements in personal functioning. Such changes did not occur in the group that received educational instruction.

At the end of 10 weeks, participants in the second group who were switched from education to GOALS training also showed similar significant improvements. Participants in the first group maintained the cognitive and behavioral gains they had shown after the first five weeks.

“We did not expect the degree of improvement that we found,” said Novakovic-Agopian. “My strong belief is that the training was successful because the study participants saw it as personally relevant and practiced it in their own lives.”

She noted that, in follow-up research completed since the study was accepted for publication, 14 out of 16 participants reported using some of the GOALS strategies for up to two years after the end of study.

Novakovic-Agopian and Chen said that the training protocol, which they developed with study co-author Scott Rome, MD, of the California Pacific Regional Rehabilitation Center and the California Pacific Medical Center, provides a set of tools that can be used for further research to advance treatment development. Currently, the researchers are conducting a larger follow-up study among veterans with brain injuries.

Co-authors of the study are Gary Abrams, MD, of SFVAMC and UCSF; Holli Castelli, OTR/L, of CPRRC; Annemarie Rossi, OTR/L, of SFVAMC and CPRRC; Ryan McKim, PsyD, of SFVAMC; Nancy Hills, PhD, of UCSF; and Mark D’Esposito, MD, of VA Northern California Health Care System and UC Berkeley.

The research was supported by funds from the Department of Veterans Affairs and the California Pacific Medical Center Foundation.

SFVAMC has the largest medical research program in the national VA system, with more than 200 research scientists, all of whom are faculty members at UCSF.

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.