Attention
Attention deficits are among the most frequent damages in the cognitive sphere, of which, however, the exact frequency has not yet been unanimously determined. A study of the 2013 (Loetscher T et all, 2013) reports a percentage that varies in a range between 46 e 92% in the acute phase (Stapleton T et all, 2001) is between 24 e 51% upon discharge from the hospital (Hyndman D et all, 2008). However, what we can say with certainty is the fact that the incidence of attention deficit resulting from stroke is very high, and Goldberg convincingly illustrates the reasons. "Attention can well be described as a circuit that involves complex interactions between the prefrontal cortex, ventral regions of the brain stem, and posterior cortex. A collapse, at any level in this circuit, it can interfere with attention, thus producing a form of deficit. The first consequence of the previous analysis is that attention deficit is one of the most common repercussions of brain injuries” (Goldberg, E, 2004. Pag. 198).
Attention deficits manifest themselves with anwide variety of symptoms, such as reduced ability to concentrate, distractibility, reduced error checking, difficulty doing more than one thing at the same time, mental slowness and fatigue (Loetscher T et all, 2013).
These are limitations that seriously affect the daily life of those affected. It has been demonstrated, for example, that attention deficits in the different components they can help generate behavior prone to cause accidents, with particular regard to accidental falls (Hyndman, D. et all, 2003) and are also associated with the control of the’Balance and functional impairment (Stapleton T et all, 2001).
In particular McDowd (McDowd, J and all, 2003) et al. they suggest alternating attention and divided attention as a deficit, often compromised in stroke, seriously hinder social participation and that even a slight deficit of these functions has a major negative impact and therefore suggests that these deficits be treated specifically in the context of post-stroke rehabilitation.
We also know that, attention being involved in many mental processes, its deficit can have a negative impact on other cognitive functions such as language, the memory (Lezak M et all, 2004) and in all forms of learning (Roberson IH et all, 1997.
In particular, it seems that a preponderant role is played by’sustained attention, which appears to be largely a function of the right hemisphere (Bench C. J. Et all, 1993) and it is an important one predictive factor for functional recovery (Ben-Yishay et all, 1968). Although the literature shows that attention deficit in some cases (Hochstenbach, J. B. et all, 2003) they can regress over time, in fact l’importance of attention for the purpose of functional recovery suggests the need for early intervention on its rehabilitation. Among other things in the 20-50% of cases, these deficits seem to persist for years in stroke survivors (Barker-Collo S et all, 2010).
L'Early identification and rehabilitation of attention deficit disorders after stroke are vigorously supported by the American Heart Association (Duncan PW et al, 2005).
ATTENTION
Attention, which intuitively seems to be a very clear process, it is actually a very complex phenomenon. In 1890 William James wrote:
"Everyone knows what attention is. It is the taking of possession by the mind, in clear and vivid form, of one of what appear to be multiple simultaneous objects or streams of thought. Focus, concentration of consciousness are its essence. This involves withdrawing from some things in order to deal effectively with others, and it is a condition that finds its real opposite in the confused state, stunned and straggling which in French is called distraction and in German Zerstreutheit ".
E’ It is remarkable that James had sensed that attention operates not only in the sensory flow, but also in the flow of thoughts (Once, A and all, 2004). We can roughly say that attention is a process through which aspects of the environment or ideas stored in our mind are selected in order to reserve them, and to these only, computational resources. The selection process is essential for the limitation of our computational resources (Broadbent DE, 1958).
We often use to define attention metaphors drawn from the visual experience, which is by far the most important and the most studied in man; we therefore speak of a light beam, reflector, zoom, fire, all metaphors that provide intuitive insight. In fact, it is possible to choose whether to examine an environment in a panoramic way or whether to zoom in on particular aspects or move the gaze from one object to another.
On the other hand, analogous attentional mechanisms can also operate in the auditory modality: in Cocktail party, for example, we can comprehensively perceive the chatter in a room where several conversations take place or we can concentrate on our interlocutor, leaving everything else in the background. E’ It is also possible to shift attention from one auditory stimulus to another, changing interlocutor. In the case of hearing, we can also shift attention from one ear to the other as happens in dichotic listening.
(…) The first formulation of the complexity of the attentional system dates back to Posner's article of 1971(Posner M. I., 1971) (…). (…). In a key article of the 1990 Posner and Petersen (Posner, M. I. et all, 1989) established (that) (…) attention is activated by a network of anatomical areas, (…). The authors identified three distinct functions, (..)connected to three distinct neural networks. The proposed model has since been corrected and refined, but still retains the original layout: three networks for three distinct functions, which today we usually refer to as alerting, orienting e executive:
· alerting (vigilance), whose function consists in activating and maintaining the alert state
· orienting, which is the process by which the information in the sensory flow is selected
· executive, which is the mechanism for monitoring and resolving conflicts between thoughts, feelings and responses.
MAIN REHABILITATION METHODS
The various standardized methodologies are indispensable for a serious approach to the problem of rehabilitation, but their function is only to provide a framework, within which the therapist is fully responsible outline a highly personalized rehabilitation path for each patient (Michel, J. A. et all, 2006).
The main methodologies for the rehabilitation of attention deficits are l’ Attention Process Training (APT), Time Pressure Management (TPM), the Training of specific skills and the Working Memory Training (VMT).
ATTENTION PROCESS TRAINING (APT)
L’A.P.T (Haskins EC et all, 2012) is a structured attention training program developed by McKay Moore Sohlberg and Catherine A. Mateer.
It is based on a clinical model of attention, which identifies five distinct types of attention : focused attention, sustained, selective, alternating and divided.
· L’focused attention it is the ability to respond distinctly to specific sensory stimuli (visual, auditivi, tactile). (…)
· L’sustained attention is the ability to maintain a consistent behavioral response during a continuous and repetitive activity. There are two distinct components in it: vigilance and working memory. Loss of vigilance involves the inability to maintain consistency of responses for more than a short period of minutes or seconds. The deficit in working memory implies the inability to manipulate information and keep it in the mind.
· L’selective attention is the ability to (carry out a task), despite the presence of distracting or competitive stimuli, external (sensory) or interior.
· L’alternating attention (…) (is the possibility) to focus from time to time on distinct tasks that require different cognitive skills.
· L’divided attention (…) (it allows to) respond simultaneously to multiple tasks. (…).
Nell’Attention Process Training:
· Training tasks must follow a hierarchical order. When and only when a patient has acquired the ability to perform a certain exercise, the treatment passes to higher levels of complexity.
· Repetition of the task and intensive exercise they are essential requirements for the patient to acquire the ability to perform it correctly.
· Attention training should include tasks that promote the generalization of strategies. Putting them into practice in other contexts is a fundamental step towards generalization.
TIME PRESSURE MANAGEMENT
Patients who have had a stroke or head injury often experience slowed information processing, in particular when they are under pressure or have limited time to carry out an activity. There is an overload for cognitive functions.
It T.P.M. (Haskins et all, 2012) proposes structured problem-solving strategies that allow a control and regulation of the information inputs (Fasotti et al, 2000). It TPM trains patients to make the necessary decisions in time both before and during the performance of a task. The authors identified three levels of approach:
Strategic decisions. A preventive planning of the task to be performed helps to balance and minimize the problems that this can entail. It is essential to avoid an overload in information processing.I
Tactical decisions. Needed when planning changes need to be made while the task is being performed.
Actions at the operational level. There may be a need to make very quick decisions, above the patient's time limits (because the situation requires an immediate response to a stimulus).
TRAINING OF SPECIFIC SKILLS
This approach is aimed at training or retraining meaningful skills from a functional point of view such as driving a car, o specific professional activities. Nello specific skill training, unlike the APT, there is no expectation that the patient will be able to generalize the skills (the skills) learned and find benefit even in tasks that have not been subject to rehabilitation.
WORKING MEMORY TRAINING (VMT)
Working memory training is used in VMT to indirectly rehabilitate attention in patients with subacute stroke.
ATTENTION AS A PREREQUISITE FOR REHABILITATION
The importance of attention to recovery and maintenance emerges from the literature, not just cognitive functions, but also of the motor ones. In fact, there is little possibility of effectively intervening on cognitive deficits as a whole regardless of attention (McDowd J. M., 2003), and also attention deficits, when associated, as it often happens, to a compromised communicative function caused by language deficit, they induce a high risk of cognitive decline (Ballard C, 2003).
Also the recovery of motor deficits resulting from stroke strongly depends on the integrity of attention, in particular of the one sustained, as Robertson et all have shown (Robertson, I. H. et all, 1997).
Considering that attention is very frequently compromised (Goldberg, E., 2004) in stroke, as well as in head trauma , the problem of its rehabilitation arises almost invariably in every neuro-rehabilitative intervention. The rehabilitation process must be cut to size (tailored) so that it can answer to the individuality of the patient, and therefore a comprehensive approach must be proposed (Michel, J. A. et all, 2006).
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