@2024 Afarand., IRAN

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ISSN: 2008-2630    Iranian Journal of War & Public Health 2018;10(4):187-193

Background
Post-traumatic stress disorder (PTSD) is a set of continuous and frequent symptoms that occur following witnessing or exposure to a traumatic event, for example, being involved in the war, sexual abuse or various types of physical assaults, child abuse, car and aviation accidents, and natural or man-made disasters. ... [1].
Previous Studies
... [2, 3]. According to studies, 50-60% of the people have experienced traumatic events. However, only 5-10% of these people develop symptoms that can be diagnosed with PTSD. According to such statistics, the researchers have concluded that other factors are responsible for PTSD symptoms and its maintenance. Neuropsychological approaches may provide an important perspective on the underlying factors for determining the pre-injury cognitive functions that are associated with PTSD. Understanding these processes can lead to the emergence of new approaches to treat and improve long-term complications in people with PTSD [4]. ... [5-18]. Neurocognitive rehabilitation is one of the newest cognitive-behavioral approaches to treat psychological disorders. ... [19, 20]. Recent studies have shown that neurocognitive rehabilitation is effective in improving cognitive impairments [19, 21-23]. ... [24]. Neurofeedback training to improve the symptoms of the people with mental disorders is one of the methods that has been considered in recent years. ... [25-28]. Several studies have reported the effectiveness of this method on improving brain processes, brain function and executive functions, attention, and memory [29, 30].
Aim(s)
The aim of this study was to evaluate the effectiveness of the Powell’s cognitive rehabilitation with neurofeedback in improving executive functions, memory, and attention in the veterans with PTSD.
Research type
This research is a semi-experimental study, with pre-test post-test design.
Research society, place and time
This research was conducted on veterans referred to a consulting center of the Tehran Foundation of Martyrs and Veterans Affairs in 2017.
Sampling method and number
Twenty-four subjects were selected by purposeful sampling method [31] and were divided into two experimental and control groups. The inclusion criteria included the veterans with PTSD symptoms (a score higher than 10 on the PSSI scale), defects in executive functions, attention, and memory [4], the possibility to sustain the type and amount of the medication through the study (if used), the consent to participate in research and signing the written consent. The lack of regular attendance at treatment sessions and the lack of doing assignments regularly were the most important exclusion criteria.
Used devices&materials
The Wisconsin Card Sorting Test (WCST) [32, 33], Stroop test [9], and Active Memory index [34] were used. The Powell’s cognitive rehabilitation with neurofeedback was performed for 12 sessions in three months as the independent variable. The cognitive rehabilitation program for the experimental group was presented in twelve 45-minute sessions. The Powell's cognitive rehabilitation protocol was used for cognitive rehabilitation. This protocol has different exercises with different aspects, of which three sections focused on the executive functions, attention, and memory, were selected. The first section is memory-related exercises, which was done through four sessions, including recalling daily activities, memorizing the sequences, memorizing images (two sections), memorizing people’s names from their faces (two sections), segmentation (three sections), news reports (two sections), memorizing the numbers, and using auxiliary memory equipment. The second section is attention-related exercises, which was done through four sessions, including latent words (two sections), counting “of” (two sections), memorizing, dividing and changing the attentions and training previous stimuli (N-back). The third part was the executive functions-related exercises, which was done in four sessions, including examining the main ideas (three sections), sorting, simultaneous questions, thinking beyond the obvious situation, the entertainment park, planning for a day with fun, answering questions, setting a one-minute lecture, examination of the feelings and emotions, emotion recognition, doing activities (four sections), operational programs, sentence sequences, planning courses, problem solving, sorting images (three sections), and title recognition. Neurofeedback training was performed after cognitive rehabilitation intervention once a week and in 12 sessions. At the beginning of each session, a three-minute evaluation of the baseline was done with open eyes as a threshold for the training period. The ProComp2 infiniti (6.0) apparatus was used. The electrodes were placed in the frontal area (Fz), the reference electrode in the left region, and the ground electrode in the right region of the temporal lobe, according to the international 10-20 system. All signals were kept at less than 5 kHz. The errors were eliminated to prevent amplification of the signals by fake errors such as blinking, coughing, teeth and jaw grinding. The inhibition bands were scanned using a horizontal scale in the EEG activity at a range of 0.5-2 Hz and 43-59 Hz, due to the interventions. The audio-visual feedback was used as short films. The short film was displayed as a reward, for those who met the expectation, and the film and music were stopped for those who failed. In general, in this study, there was no limitation on the type of feedback (visual, audio, or visual-audio), and the combination method was used as other studies. In order to improve the executive functions, memory, and attention of the participants, the theta wave range (4-7 Hz) higher than the mean theta wave was considered, while increasing the activity of the low beta band (12-15 Hz) in the C4 region of the cerebellum. The electrodes were placed at the C3 and C4 regions of the cortex of the participants. For each participant in the intervention group, an approximately 30-minute training session was performed. The protocol was completely performed through the sessions, including the introducing the Powell's cognitive rehabilitation techniques, followed by neurofeedback training for 3 minutes on the baseline, followed by seven 3-minute specific interventions. The neurofeedback interventions were separated with one-minute intervals. There was also no training participant on how to increase or decrease the wavelength range, and all the subjects found an effective strategy to reach the target with no aid. Data was analyzed using SPSS 24. The univariate covariance analysis was used to study the effect of independent variable on dependent variables, as well as to calculate the modulation of pre-test effect on the post-test values. The Leven test was used to assess the homogeneity of the variance of the groups and the Mauchly's test was used to evaluate the homogeneity of the linear coefficients.
Findings by Text
The mean age of the experimental group and the control group were 46.26±3.12 and 46.14±3.26 years, respectively. One subject in the experimental group and two subjects in the control group were women. Controlling the effects of pre-test, there was a significant difference between the experimental and the control groups in overall score of the executive functions, memory, and attention and their sub-components (p=0.001; Table 1).
Main comparison to the similar studies
The results of present study were consistent with the results of other studies on cognitive rehabilitation [35-38]. In addition, the results were also consistent with the results of other studies on the effectiveness of neurofeedback on improving executive functions, attention, and memory [22]. The results of this study on the improved executive functions of the veterans with PTSD showed a significant difference in perseveration error and the number of completed categories between the experimental and the control groups, which was consistent with other studies [38-41]. The effectiveness of cognitive rehabilitation on various patients has been confirmed in the studies by Miller and Radford [40] and Radford et al. [42], Das Nair & Lincoln and Doornhein & De Haan [43]. According to the Das Nair & Lincoln [41] study on the effect of the two rehabilitation methods in people with neurological disorders, participation in rehabilitation sessions led to improvement in the memory impairments and neurological conditions, knowledge and skills on memory use and also the improved cognitive functions. The third hypothesis was the effectiveness of the Powell's rehabilitation with neurofeedback on improving the attention of veterans with PTSD, which was confirmed. There was a significant difference between the experimental and the control groups in the amount of attention following the Powell's rehabilitation method and these results were consistent with previous studies [38-41].
Suggestions
The studies with different samples and the future studies to examine the effectiveness of the Powell's cognitive rehabilitation approach to treat PTSD are suggested, comparatively and concurrent with other therapeutic approaches. The difference between therapeutic patterns at the same time and on the same samples can better indicate the differences and efficacy. It is suggested to perform this study as two distinct independent variables (cognitive rehabilitation and neurofeedback) as well as on other people with PTSD.
Limitations
In this study, the veterans with PTSD in Tehran were used as the sample, which caution should be taken in generalizing the results to the other people with PTSD and it can be considered as one of the limitations of this study. Moreover, due to the lack of PTSD veterans who have the inclusion criteria, the small sample size, was another limitation of this study.
Conclusions
Powell's rehabilitation method with neurofeedback is effective on improving the symptoms of executive functions, memory, and attention of the veterans with PTSD.
Acknowledgments
The authors sincerely thank the cooperation of all veterans and employees of the Foundation of Martyrs and Veterans Affairs of the Tehran city who have contributed to this research.
Conflict of interest
None declared.
Ethical Permissions
The participants were assured about the confidentiality of information, and the subjects were psychologically prepared to participate.
Funding Sources
The funding of this research was provided by the authors.

TABLES and CHARTS

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