Combining attention and metacognitive training to improve goal directed behavior in Veterans with TBI

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Background: TBI can be the beginning of a disease process that produces change that continue years after injury resulting in debilitating chronic TBI symptomatology. Some studies find that up to 30% of people that have sustained mTBI have persistent symptoms. Enduring cognitive deficits after mTBI present barriers to full functional recovery and re-entry into societal roles. Executive dysfunction, poor attention-concentration, and memory difficulties are the most persistent disabilities faced by mTBI survivors. An estimate 44% of Veterans with mTBI also have PTSD with overlapping symptoms. Attention problems are reported by 50% of combat Veterans which are requisite for other cognitive processes that are vital to everyday functioning such as memory, problem solving, language skills, and the cognitive control of behavior. Effective interventions are needed to address the cognitive deficits resulting from chronic mTBI. Of the attention and executive function treatments currently used in clinical practice, there is a dearth of those with substantial evidence to support effectiveness. Current cognitive interventions for Veterans with mTBI did not include specific attention training, lacked rigorous training or found improvement only on self-reported symptoms. In order to improve translation, strategy training has been recommended to accompany attention training. Goal Management Training (GMT) is such a strategy training and has been found to be improve executive function skills in Veterans with mTBI. However, GMT lacks specific attention training, which is a limitation in that attention is a component of the normal executive function used in goal management. Given the need in mTBI lack of rigor in attention training, the relationship of attention to goal management, and the promise of combined attention training and goal management training, we will innovatively combine the metacognitive intervention, GMT, with a drill method of attention training that also includes individual functional goals for attention recovery. Method: This is a randomized control pilot study to determine effectiveness of GMT plus Attention Training in 50 Veterans with 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. 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.