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INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part II: Attention and
Jennie Ponsford1, Diana Velikonja, Shannon Janzen
1Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia, and Epworth Healthcare, Melbourne Australia (Dr Ponsford); Acquired Brain Injury Program, Hamilton Health Sciences, Hamilton, Ontario, Canada, and Department of Psychiatry and Behavioural Neurosciences, DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada (Dr Velikonja); Lawson Health Research Institute, Parkwood Institute, London, Ontario, Canada (Mss Janzen, Harnett, and McIntyre and Dr Teasell); Speech Language Pathology Program, School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada, and KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada (Drs Wiseman-Hakes and Bayley and Mss Patsakos and Kua); Faculty of Health Sciences, The University of Sydney, New South Wales, Australia, and NHMRC Centre of Research Excellence in Aphasia Rehabilitation, Australia (Dr Togher); Department of Physical Medicine and Rehabilitation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada (Dr Teasell); Parkwood Institute, St Joseph's Health Care, and School of Communication Sciences and Disorders, University of Western Ontario, London, Ontario, Canada (Ms Welch-West); and Temerty Faculty of Medicine, University of Toronto, Ontario, Canada (Dr Bayley); on behalf of the INCOG Expert Panel.
Introduction:
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.
Methods:
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.
Results:
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.
Conclusion:
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.
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