背景:中度至重度创伤性脑损伤(MS-TBI)通常由于其弥漫性和对额颞叶和中脑网状激活系统的损伤而导致注意力方面的破坏。注意障碍是认知康复的共同焦点,需要提高对证据的认识,以促进知情的临床实践。
方法:一个由临床医生/研究人员组成的专家小组(称为INCOG)审查了2014年发表的证据,并制定了成人注意力管理的最新指南。以及决策算法,以及用于审查临床实践的审计工具。
结果:本次更新纳入了27项研究,提出了11项建议。提出了两项有关经颅刺激和草药补充剂的新建议。5个从INCOG2014更新,4个保持不变。该小组建议筛查和解决导致注意力问题的因素,包括听力,愿景,疲劳,睡眠-觉醒障碍,焦虑,抑郁症,疼痛,物质使用,和药物。对于轻度-中度注意障碍的个体,建议进行以日常活动为重点的元认知策略训练。由于缺乏泛化的证据,因此不建议对基于计算机的去情境化注意任务进行练习,但是直接训练日常任务,包括双重任务或处理背景噪音,可能会为执行这些任务带来收益。还讨论了环境改变的潜在用途。没有足够的证据支持基于正念的冥想,定期警报,或非侵入性脑刺激以减轻注意力障碍。在药理干预中,哌醋甲酯建议提高信息处理速度。金刚烷胺可以促进昏迷或植物人患者的唤醒,但从长远来看不会提高注意措施的表现。抗氧化剂中草药补充剂MLC901(NeuroAiDIITM)可以增强轻度-中度TBI个体的选择性注意力。
结论:TBI后改善注意力的干预措施的证据正在缓慢增长。然而,需要更多的对照试验,特别是评估行为或非药物干预措施的注意力。
Moderate to severe traumatic brain injury (MS-TBI) commonly causes disruption in aspects of attention due to its diffuse nature and injury to frontotemporal and midbrain reticular activating systems. Attentional impairments are a common focus of cognitive rehabilitation, and increased awareness of evidence is needed to facilitate informed clinical practice.
An expert panel of clinicians/researchers (known as INCOG) reviewed evidence published from 2014 and developed updated
guidelines for the management of attention in adults, as well as a decision-making algorithm, and an audit tool for review of clinical practice.
This update incorporated 27 studies and made 11 recommendations. Two new recommendations regarding transcranial stimulation and an herbal supplement were made. Five were updated from INCOG 2014 and 4 were unchanged. The team recommends screening for and addressing factors contributing to attentional problems, including hearing, vision, fatigue, sleep-wake disturbance, anxiety, depression, pain, substance use, and medication. Metacognitive strategy training focused on everyday activities is recommended for individuals with mild-moderate attentional impairments. Practice on de-contextualized computer-based attentional tasks is not recommended because of lack of evidence of generalization, but direct training on everyday tasks, including dual tasks or dealing with background noise, may lead to gains for performance of those tasks. Potential usefulness of environmental modifications is also discussed. There is insufficient evidence to support mindfulness-based meditation, periodic alerting, or noninvasive brain stimulation for alleviating attentional impairments. Of pharmacological interventions, methylphenidate is recommended to improve information processing speed. Amantadine may facilitate arousal in comatose or vegetative patients but does not enhance performance on attentional measures over the longer term. The antioxidant Chinese herbal supplement MLC901 (NeuroAiD IITM) may enhance selective attention in individuals with mild-moderate TBI.
Evidence for interventions to improve attention after TBI is slowly growing. However, more controlled trials are needed, especially evaluating behavioral or nonpharmacological interventions for attention.