J Head Trauma Rehabil

Vol. 29, No. 4, pp. 321–337

c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright 

INCOG Recommendations for

Management of Cognition Following
Traumatic Brain Injury, Part II: Attention
and Information Processing Speed
Jennie Ponsford, MA, PhD; Mark Bayley, MD; Catherine Wiseman-Hakes, PhD;
Leanne Togher, BAppSc, PhD; Diana Velikonja, PhD; Amanda McIntyre, MSc;
Shannon Janzen, MSc; Robyn Tate, PhD, On Behalf of the INCOG Expert Panel

Introduction: Traumatic brain injury, due to its diffuse nature and high frequency of injury to frontotemporal and
midbrain reticular activating systems, may cause disruption in many aspects of attention: arousal, selective atten-
tion, speed of information processing, and strategic control of attention, including sustained attention, shifting and
dividing of attention, and working memory. An international team of researchers and clinicians (known as INCOG)
convened to develop recommendations for the management of attentional problems. Methods: The experts se-
lected recommendations from published guidelines and then reviewed literature to ensure that recommendations
were current. Decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of
published trials were developed. The team then prioritized recommendations for implementation and developed
audit criteria to evaluate adherence to these best practices. Results: The recommendations and discussion highlight
that metacognitive strategy training focused on functional everyday activities is appropriate. Appropriate use of dual
task training, environmental modifications, and cognitive behavioral therapy is also discussed. There is insufficient
evidence to support mindfulness meditation and practice on de-contextualized computer-based tasks for attention.
Administration of the medication methylphenidate should be considered to improve information-processing speed.
Conclusion: The INCOG recommendations for rehabilitation of attention provide up-to-date guidance for clini-
cians treating people with traumatic brain injury. Key words: attention, cognitive rehabilitation, information processing,
traumatic brain injury

Author Affiliations: NHMRC Centre of Research Excellence in

Traumatic Brain Injury Psychosocial Rehabilitation, Canberra, Australia
(Drs Ponsford, Togher, and Tate); School of Psychological Sciences,
Monash University and Epworth Hospital, Melbourne, Australia
(Dr Ponsford); National Trauma Research Institute, Monash University
and the Alfred Hospital, Melbourne, Australia (Dr Ponsford); Neuro
Rehabilitation Program, Toronto Rehabilitation Institute, University of
Toronto, Toronto, Canada (Dr Bayley); Bloorview Research Institute,
Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
(Dr Wiseman-Hakes); Speech Pathology, Faculty of Health Sciences, The
University of Sydney, New South Wales, Australia (Dr Togher);
Neuropsychology, Acquired Brain Injury Program, Hamilton Health
Sciences, Hamilton, Ontario, Canada (Dr Velikonja); Department of
Psychiatry and Behavioural Neurosciences, DeGroote School of Medicine,
McMaster University, Hamilton, Ontario, Canada (Ms Velikonja);
Lawson Health Research Institute, London, Canada (Mss McIntyre and
Janzen); Royal Rehabilitation Centre Sydney, New South Wales,
Australia (Dr Tate); and Centre for Rehabilitation Research, Kolling
Institute, Sydney Medical School—Northern, University of Sydney,
Australia (Dr Tate).
The authors gratefully acknowledge the support of the Victorian Transport
Accident Commission (TAC) through its Victorian Neurotrauma Initia-
tive (VNI), Monash University, and the Ontario Neurotrauma Foundation
(ONF) for their support of this project.
I N 1890, William James1 defined attention as, “the
taking possession of the mind, in clear and vivid
form, of one out of what may seem several simulta-
neously possible objects or trains of thought . . . . It
implies withdrawal from some things in order to deal
effectively with others.”(pp403–404) Attention is clearly a
multifaceted construct.2 Attentional processes are me-
diated by diffuse networks, including the dopaminergic
and noradrenergic afferent pathways to the dorsolateral
prefrontal cortex, parietal lobes, and thalamic projec-
tion system.3,4 Theoretical models of attention suggest
that attentional functions are mediated by several
The authors declare no conflicts of interest.
Corresponding Author: Jennie Ponsford, MA, PhD, School of Psycho-
logical Sciences, Monash University, Clayton, 3800, Victoria, Aistralia
(jennie.ponsford@monash.edu).
DOI: 10.1097/HTR.0000000000000072

321

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
322 JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2014
interconnected networks, including a sensory selective
attentional system, mediated by the parieto-temporo-
occipital area, responsible for orienting, engaging, and
disengaging attention and object recognition; a system
controlling arousal, sustained attention, and vigilance, also
regulating mood, motivation, the salience of stimuli and
readiness to respond, mediated by the midbrain reticular
activating system, and limbic structures; and an anterior
system for selection and control of responses, involving inten-
tional and strategic control, switching and inhibition,
mediated by the frontal lobes, anterior cingulate gyrus,
and basal ganglia, with the thalamus relaying incoming
information and outgoing responses.5–7
There is debate as to how to describe the component
processes of attention; Whyte et al2 suggests that they
include arousal, selection, strategic control, and processing
speed. A number of theoretical models have contributed
to the characterization of components of attention. Ac-
cording to van Zomeren and Brouwer,8 intensity in-
volves arousal, alertness, attentional capacity, and vigi-
lance, whereas selectivity involves the process of filtering
relevant sensory information from irrelevant material,
sometimes on spatial grounds. Shiffrin and Schneider9
proposed that attention was mediated by 2 parallel pro-
cesses: automatic processing, which is parallel in nature,
and unaffected by load, and controlled processing, which
is serial in nature and, therefore, has a limited rate and ca-
pacity. The duration of controlled processing is affected
by the cognitive steps required by a task8 and the speed
of information processing. Baddeley’s10 process of working
memory allows for temporary storage and manipulation
during controlled information processing. Allocation of
attentional resources when performing complex tasks
is said to be controlled by a “central executive,” akin
to Shallice’s11 concept of supervisory attentional control.
These executive processes exercise what Whyte et al2
term strategic control over controlled processing includ-
ing the ability to maintain attention to a task; inhibit
disruption by distracting influences; shift attention in
line with changing goals and priorities; manipulate in-
formation currently held in mind (referred to as working
memory); and divide attention between 2 or more task
demands. Thus, the components of attention consid-
ered “in scope” for this review include arousal, selective
attention, speed of information processing, and strategic con-
trol of attention, including sustained attention, shifting and
dividing of attention, and working memory.
Arguably, traumatic brain injury (TBI) may disrupt
any or all of these processes, given its diffuse nature
and high frequency of injury to frontotemporal and
midbrain reticular activating systems. Diffuse axonal
injury potentially disrupts attentional neural networks,
including ascending noradrenergic, dopaminergic,
and serotonergic pathways.12 Experimental studies
have confirmed the presence of slowed information
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
processing,13–15 working memory difficulties,16 im-
paired levels of vigilance or sustained attention
performance,17,18 difficulty dividing attention under
conditions of high working memory load,14,19,20 be-
havioral distraction,21 and problems with goal-directed
allocation of attention on tasks with multiple steps or
changing demands.22,23
It is, therefore, not surprising, based on subjective re-
ports, that attentional difficulties are among the most
common cognitive sequelae of TBI, being reported by
more than 60% of individuals with moderate to severe
injuries as long as 10 years postinjury.24–26 They may
also be associated with mild TBI.27,28 When completing
a Rating Scale of Attentional Behavior, clinicians and
relatives most commonly endorse problems in the do-
mains of processing speed, sustaining attention, paying
attention to more than 1 thing at a time, ignoring distrac-
tions, and missing details.29 Attentional impairments
contribute to difficulty engaging in important life roles
such as work or study and also affect social interaction.24
They may also be associated with anxiety after TBI,30 as
well as fatigue31 and sleep-wake disturbances.32 There-
fore, improving or maximizing attention represents an
important goal of the rehabilitation process. However,
despite a plethora of studies, the evidence supporting
specific intervention strategies remains limited.
METHODS
The Guidelines Adaptation and Development
(ADAPTE) process was used to develop the INCOG
guidelines,33,34 with INCOG being an acronym stand-
ing for “International Cognitive.” An international ex-
pert panel was formed through invitations of authors of
previously published cognitive rehabilitation guidelines
and contacts of the team. In preparation, a detailed In-
ternet and Medline search was conducted to identify
published TBI and cognitive rehabilitation evidence-
based guidelines.35 The quality of the development pro-
cess for each eligible clinical practice guideline (CPG)
was evaluated using the Appraisal of Guidelines for Re-
search and Evaluation (AGREE II) instrument.36,37 The
ADAPTE process involves extracting recommendations
from these CPGs to allow easy comparison, for exam-
ple, all recommendations about executive function were
tabulated together. The Evidence-Based Review of Ac-
quired Brain Injury (ERABI: http://www.abiebr.com/)
synopses of evidence for each topic area were also dis-
tributed to the panel.38
The initial expert panel meeting was scheduled for
convenience just prior to the World Congress of Neu-
rorehabilitation in Melbourne, Australia, in May of
2012. Some members attended via Web conferencing
from the United States and Canada. This panel exam-
ined the recommendations matrix and selected suitable
 INCOG Recommendations for Management of Cognition Following TBI
recommendations from existing guidelines or articu-
lated novel recommendations on the basis of the evi-
dence available and giving consideration to the clini-
cal applicability of recommendations to achieve mean-
ingful outcomes for individuals with TBI. This yielded
an initial draft set of recommendations; however, to
ensure that the recommendations were updated ac-
cording to the most current evidence, the research
team prepared synopses of large systematic reviews, the
Global Evidence Mapping Initiative,39 based in Aus-
tralia (www.evidencemap.org), the Acquired Brain In-
jury Evidence-Based Review38 and PsycBITE (http://
www.psycbite.com).40 Furthermore, the reference sec-
tions of all eligible cognitive rehabilitation CPGs were
also extracted. All relevant references were consolidated
into a reference library that was made available to the au-
thor teams as they drafted the manuscripts and finalized
the recommendations accordingly.
By the end, the team completed the evidence review
of more than 600 references found in this search process.
Only studies in which more than half of the participants
had TBI were included. This task has resulted in a com-
prehensive mapping of evidence to all previously and
newly developed recommendations. The tables will be
made available in on online content on the Web site of
the Journal of Head Trauma Rehabilitation. With the up-
dated literature search in mind, the experts graded the
evidence. As various systems for determining the level
of evidence were used across the CPGs, the INCOG
team standardized this by using the grading system out-
lined later (see Table 1), which was based upon that used
in previous guideline development projects.41 These fi-
nal recommendations were then presented to the entire
team for approval and then the expert panel used Mod-
ified Delphi Voting Technique to prioritize the recom-
mendations from the INCOG guideline for audit. Each
TABLE 1 INCOG level of evidence-
grading system
A: Recommendation supported by at least 1
meta-analysis, systematic review, or randomized
controlled trial of appropriate size with relevant
control group.
B: Recommendation supported by cohort studies
that at minimum have a comparison group,
well-designed single subject experimental
designs, or small sample size randomized
controlled trials.
C: Recommendation supported primarily by expert
opinion on the basis of their experience through
uncontrolled case series without comparison
groups that support the recommendations are
also classified here.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
323
of the experts was asked in this exercise to vote for his
or her top 15 recommendations considering both the
importance to practice and feasibility of auditing the
recommendations.
For each domain of posttraumatic amnesia, attention,
memory, executive function, and cognitive communi-
cation, a clinical algorithm was developed to help clin-
icians decide to whom the recommendations applied.
To finalize the algorithm, evidence tables were reviewed
to find the inclusion and exclusion criteria for the study
populations that were used. By understanding the sub-
populations of patients with TBI to whom the evidence
applies, it is possible to understand what treatments are
appropriate for each patient. In contrast to other guide-
lines, the INCOG team has identified recommendations
that could be audited from clinical charts to determine
adherence to the best practice guidelines in each sec-
tion. This is known as the INCOG audit tool. A more
detailed version of the “Methods” section is available in
the third article of the series.42
LIMITATIONS OF USE AND DISCLAIMER
These recommendations are informed by evidence
for TBI cognitive rehabilitation interventions that was
current at the time of publication. Relevant evidence
published after the INCOG guideline could influence
the recommendations contained herein. Clinicians must
also consider their own clinical judgment, patient pref-
erences, and contextual factors such as resource avail-
ability in their decision-making processes about imple-
mentation of these recommendations.
(Note: The INCOG developers, contributors, and sup-
porting partners shall not be liable for any damages,
claims, liabilities, costs, or obligations arising from the
use or misuse of this material, including loss or damage
arising from any claims made by a third party.)
RECOMMENDATIONS AND LITERATURE
REVIEW
The reader is referred to the “Methods” article42 of
this series for a complete review of the strategies used
for the literature review and development of the rec-
ommendations and other tools. The INCOG guidelines
include recommendations relating to best practice in
the remediation of attentional problems following brain
injury. There have been several previous published re-
views from which guidelines for the rehabilitation of at-
tentional impairments following brain injury have been
recommended. Rees et al43 completed a comprehensive
database search of evidence relating to cognitive reha-
bilitation for acquired brain injury (ie, cerebrovascular
accident [CVA], TBI) published 1980–2006, grading ev-
idence as Strong if based on 2 or more randomized con-
trolled trials (RCTs), Moderate if based on 1 RCT, Limited
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324 JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2014
if based on prospective or retrospective controlled trials
or single-group interventions, or Consensus Opinion. In
the domain of attention, they concluded that there was
Strong evidence supporting use of methylphenidate to
increase speed of information processing, Moderate evi-
dence that specific structured training programs had no
significant effect on attention in people with moderate
to severe brain injury, and that there was Moderate evi-
dence that dual-task training in speed of processing was
an effective intervention for patients with brain injury.
A series of reviews led by Cicerone et al44–46 on the
basis of studies published up to 1997,44 from 1998 to
2002,45 and from 2003 to 2008,46 respectively, graded
evidence for rehabilitation following acquired brain in-
jury (ie, including both CVA and TBI). Studies rated
as level/class I were based on well-designed prospective
RCTs and level/class II were prospective nonrandom-
ized cohort or retrospective case-control or multiple
baseline studies. Level/class III included case series with
no controls or single subject designs. While the strengths
and weaknesses of studies are appropriately noted, the
guidelines in the domain of attention do not separate
the effects of attention training, in the sense of repeated
drill or practice, from studies in which development of
metacognitive strategies are encouraged. Cicerone et al44
concluded that evidence was insufficient to distinguish
effects of specific attention training from spontaneous
recovery for people with moderate to severe TBI and
stroke during the acute stages of recovery and inpatient
rehabilitation, but that that evidence did support “at-
tention training” during the postacute phase of recov-
ery from TBI or stroke, provided it involved therapist
monitoring and feedback, teaching of strategies, and was
directed at performance on more complex functional
tasks. The manner in which this “Practice Guideline” was
arrived at was, however, not entirely clear. Following the
2005 update, which added 2 class 1 and 1 small class II
study, Cicerone et al45 recommended as a practice stan-
dard, attention training with emphasis on development
of strategies to compensate for attentional difficulties
in functional situations in the postacute recovery pe-
riod. Adding 2 class I and 6 class III studies, Cicerone
et al46 confirmed their practice standard as follows: “Re-
mediation of attention deficits after TBI should include
direct attention training and metacognitive training to
promote development of compensatory strategies and
foster generalization to real world tasks.” A practice op-
tion stated that:
Computer based interventions may be considered as an ad-
junct to clinician-guided treatment for the remediation of
attention deficits after TBI or stroke. Sole reliance on re-
peated exposure and practice on computer-based tasks with-
out some involvement and intervention by a therapist is not
recommended.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Following almost directly from the methods and
evidence reviewed by Cicerone et al,44 a European Fed-
eration of Neurological Societies taskforce47 made the
same practice guideline recommendations for rehabili-
tation of attention. Another review conducted by the
Academy of Neurologic Communication Disorders by
Sohlberg et al48 also similarly recommended that re-
peated stimulation of attention via graded exercises in
conjunction with metacognitive strategy training was
effective for postacute or mildly impaired clients with
intact vigilance.
The current guidelines, developed as a basis for an
audit tool to examine clinical practice, differ from the
aforementioned studies in that they are focused on TBI
only, such that studies including only a majority of
participants with TBI were included. Unlike the guide-
lines by Cicerone et al,44–46 Sohlberg et al,48 and Cappa
et al,47 they also included review of pharmacologic inter-
ventions. Moreover, the aforementioned reviews cover
studies published up to 2008 only. The current guide-
lines are based on literature published up to 2012. Four
recommendations are based on level A evidence, 6 rec-
ommendations are based on level B and/or level C evi-
dence, and 1 guideline is proposed without supporting
evidence. The evidence relating to each guideline is out-
lined later.
NONPHARMACOLOGICAL STRATEGIES TO
ENHANCE ATTENTION
Attention #1. Metacognitive strategy training using functional
everyday activities should be considered, especially in pa-
tients with mild-moderate attention deficits. (Adapted from
Cicerone et al,
46(p521)
; Sohlberg et al48 ; INCOG Expert Panel42 )
There is level A evidence that strategies may be devel-
oped, practised, and applied to compensate for atten-
tional problems, including speed of information pro-
cessing and working memory.
Fasotti et al49 designed a form of strategy training,
termed Time Pressure Management (TPM), to enhance
coping with slowed information processing in individu-
als with brain injury. This RCT provides level A evidence
in support of the use of strategies to prevent or man-
age time pressure in individuals with TBI and slowed
processing speed. The 3-step training facilitates aware-
ness of the effects of mental slowness on daily activities,
supports the individual not only in accepting that this
may be a persisting problem but also in realizing that
it is possible to develop and use self-instructional tech-
niques, or managing steps prior to or during task per-
formance to reduce time pressure. These might involve,
for example, asking for repetition, reducing background
noise, or tape-recording and replaying interactions. The
implementation of steps is demonstrated, followed by
overt self-instruction with written prompts that are
 INCOG Recommendations for Management of Cognition Following TBI
gradually withdrawn and then the strategies are applied
in a range of situations and conditions of increasing
complexity to encourage generalization. In the RCT,
22 individuals with severe to very severe TBI were ran-
domly assigned to receive TPM or concentration train-
ing, in which verbal instruction was the key element. The
TPM produced greater gains than concentration training
for an information intake task and appeared to general-
ize to other measures of speed and memory function.49
Winkens et al,50,51 who also demonstrated that these
strategies can be learned and applied by patients who
had a stroke, highlighted a number of factors that in-
creased chances of successful intervention: some degree
of self-awareness, together with an ability to identify sit-
uations in which time pressure would cause problems
and to set appropriate goals. Other factors included the
potential for the therapist to apply the training directly
to situations of relevance to the injured individual, as
well as monitor the use of the strategies over time.
There is level C evidence to suggest that training and
guidance in strategy use may be used to compensate for
problems with divided attention and working memory.
Cicerone52 provided training in metacognitive strategies
for increasing efficiency of allocation of attentional re-
sources and management of rate of flow of information
on tasks that demanded divided attention to 4 single
cases with mild TBI. This therapy was provided once a
week for 11 to 27 weeks. It also included explicit dis-
cussion of how to apply the strategies to everyday ac-
tivities. There was greater improvement in the treated
participants on the Paced Auditory Serial Addition Task
(PASAT) and reduction in self-rated everyday attentional
difficulties. Vallat-Azouvi et al53 also reported success
in training working memory in 2 single cases with se-
vere TBI undertaking 2 hourly sessions per week over
6 to 8 months. They showed high levels of motivation.
Variability in the nature and severity of cognitive im-
pairments, the level of self-awareness, and capacity to
develop and implement compensatory strategies may
underpin the success, or otherwise, of any rehabilitative
intervention for attention. However, the influence of
these factors has not been systematically studied. There
is also a need for studies examining the extent to which
the frequency and duration of therapy may influence
outcome.
Attention #2. Training in dual-tasking should be used to im-
prove dual task performance on tasks similar to those trained.
Two studies have provided level A evidence in sup-
port of the potential for training in multitasking, specif-
ically, doing 2 things at once. Evans et al54 evaluated,
in a randomized trial involving 19 people with brain
injury, more than half of whom had TBI, the efficacy of
twice-daily practice in exercises combining walking with
cognitive activities with gradually increasing demands,
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
325
as compared with a treatment as usual control condi-
tion. Outcomes were assessed on a range of dual tasks.
Performance in the walking and talking tasks improved
significantly in the treated group. These most closely re-
sembled the training tasks, which also involved listening
and generating verbal responses while walking. No sig-
nificant gains were evident on the other dual task activ-
ities, involving 2 motor or 2 cognitive tasks. This study
was limited by a lack of blinding in outcome measure-
ment. A randomized crossover trial by Couillet et al55
evaluated the efficacy of training in dividing attention
between 2 cognitive tasks in 12 patients with severe TBI.
Training involved learning to perform each task sepa-
rately and then simultaneously with another task, fol-
lowing a hierarchy of difficulty. Controls received train-
ing on other cognitive tasks. A significant training effect
was evident on several dual-task measures, each of which
bore some resemblance to the trained tasks, as well as
the divided attention item of the Rating Scale of Atten-
tional Behavior. Little effect was evidence on executive
or working memory measures or on nontarget measures.
Unfortunately, the outcome assessors were not blinded
to training group in this study either and in fact had also
administered the training. Nevertheless, these 2 studies
suggest that it may be possible to increase dual-tasking
skills on specific tasks, which may generalize to similar
tasks in the same modalities. A likely mechanism under-
pinning the improved performance of dual tasks with
practice over time is that of automatization, whereby
the conscious attentional demands of a task reduce with
repetition of the task.56 If this is the mechanism un-
derpinning improvement in task performance, then the
underlying impairment in dual-tasking capacity is likely
to remain and become evident on novel tasks. There-
fore, to maximize functional impact from such training,
it would seem most pragmatic to provide such training
on tasks that need to be performed in everyday life.
Attention #3. Cognitive behaviour therapy techniques should
be considered to develop strategies to maximise attention in
individuals with mild to moderate TBI in whom anxiety and
depression are impacting on attentional function.
Several studies have highlighted the difficulties in dif-
ferentiating symptoms directly associated with the brain
injury from those due to pain, medication effects, post-
traumatic stress, anxiety, depression, or other stressors,
particularly in the case of mild TBI.28,57–60 Since all of
these conditions may contribute to attentional difficul-
ties, it is clearly important to assess the potential con-
tribution of these factors and intervene accordingly.61
Psychotherapeutic input to manage psychiatric symp-
toms may also have beneficial effects on attention.62,63
In discussing the management of mild TBI, Mateer
et al58 and Ruff 59 recommended a cognitive behavioral
therapy (CBT) approach. The CBT aims to show the
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326 JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2014
individuals that their symptoms are common following
such injuries, that their inner dialogue may be increasing
stress levels and associated attentional and other symp-
toms, and equips them with strategies to manage these
symptoms and take control of their lifestyle. Training in
stress management, relaxation, or meditation techniques
is also commonly used in these conditions. These con-
siderations and strategies may also be appropriate in
some individuals with moderate and severe TBI, who
also show high rates of emotional distress following
TBI.64,65 An RCT by Tiersky et al66 conducted in indi-
viduals with mild and moderate TBI demonstrated sig-
nificantly improved emotional functioning, including
lessened anxiety and depression, as well as improved per-
formance on a measure of divided attention (PASAT),
following a combined program of individual CBT of-
fered 3 times per week for 11 weeks and designed to
increase coping skills and decrease stress, as well as cog-
nitive remediation. It was not possible to differentiate
the effects of the psychological therapy from that of the
cognitive remediation exercises, however. There have
been no other studies evaluating the impact of CBT on
attentional functions in individuals with brain injury.
Attention #4. Screening for and treatment of co-morbid sleep-
wake disorders may help to optimize attentional processes.
Sleep-wake disorders occur in up to 50% of indi-
viduals with TBI across all levels of severity. Sleep
and adequate day-time alertness are crucial for opti-
mal attention, particularly in the areas of vigilance (sus-
tained attention) and speed of processing.67 Some stud-
ies have suggested that sleep-wake disorders exacerbate
impairments in attention post-TBI, and those with poor
sleep quality (by self-report) demonstrated significantly
poorer sustained attention than those with TBI who re-
ported good quality of sleep.32 There is recent level C
evidence from a preliminary (small sample size) prospec-
tive single-blind cohort study that treatment of sleep-
wake disorders in a sample of adults with chronic mod-
erate to severe TBI resulted in statistically significant
and self-reported improvements in speed of processing,
divided auditory attention, and selective attention. Par-
ticipants in the study also reported improvements in so-
cial, vocational, and academic participation.68 Further
well-designed and controlled studies are needed to fully
determine the impact of treatment of sleep-wake disor-
ders on attention impairments in those with TBI.
Attention #5. Alterations to the environment and tasks may
be used to reduce the impact of attentional problems on daily
activities.
A number of authors have noted that some in-
dividuals with TBI have difficulty spontaneously us-
ing compensatory strategies to alleviate attentional
problems.69–71 An alternative intervention strategy is to
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
make alterations to the environment or tasks to reduce
the impact of attentional problems. For example, the
work environment might be altered to reduce distrac-
tions (eg, work in a quiet room, reduce interruptions),
tasks may be altered to reduce the speed or amount of
information to be processed, prompts may be used to
assist the person to refocus or shift attention to another
aspect of a task, or material may be repeated or made
available in written form to ensure its comprehension.71
However, no studies have evaluated the use of such
strategies to alleviate attentional problems.
Attention #6. Reliance on repeated exposure and practice on
de-contextualized computer based attentional tasks is NOT
recommended due to lack of demonstrated impact on ev-
eryday attentional functions. (Adapted from ABIKUS 2007,
G42
72(22)
; Cicerone et al
46(p521)
)
Much of the early work in the fields of cognitive re-
habilitation focused on the use of training exercises to
ameliorate impairments of attention. In a small series of
single case studies, Wood73 reported improvements in
attention to task in response to training and token rein-
forcement. Many of these programs involved computer-
mediated exercises purporting to exercise attentional
functions.62,74–89 A significant number of these predom-
inantly level C studies, involving samples with TBI, re-
ported gains on the training tasks, and some also showed
improvements in performance on other cognitive mea-
sures of attentional function that bore some resem-
blance to the trained task, such as the PASAT.62,86,90,91
The study with strongest methodology, rated class I by
Cicerone et al,44 was that of Gray et al.77 This RCT in-
volving 31 participants, 17 of whom had TBI, found sig-
nificant gains on the PASAT but not on other cognitive
measures of attention on completion of training, but it
did find significant relative gains on the PASAT as well
as a number of other attentional measures at 6-month
follow-up in the trained versus untrained groups. There
was no assessment of everyday attentional behavior.77
Sturm et al88 argued for the importance of specificity,
demonstrating differential gains from programs focused
on alertness and vigilance, versus those training selective
and divided attention, but this study focused on indi-
viduals with unilateral vascular lesions rather than TBI.
Novack et al80 found no specific effects from focused
versus general training in individuals with TBI, and Mid-
dleton et al92 found gains in all cognitive domains re-
gardless of the focus of training. However, many of
these evaluative studies did not employ a control group
to control for the effects of practice on repeated mea-
sures or spontaneous recovery, and the majority did not
evaluate the extent to which the therapy gains general-
ized to impact on the everyday attentional functioning
of participants. Those studies that employed a control
group and evaluated gains in terms of their impact on
 INCOG Recommendations for Management of Cognition Following TBI
attentional function in daily activities did not show
greater gains relative to controls.75,83,89,93
One well-known computer-mediated program that fo-
cuses training on various aspects of attention, includ-
ing focused, sustained, selective, alternating, and di-
vided attention, employing auditory and visual exer-
cises, is Attention Process Training (APT), developed
by Sohlberg and Mateer.86 This has been evaluated in
studies with variable methodological rigor, often involv-
ing small numbers of cases.82,86,90,93,94 The largest of
these, a crossover trial involving 14 participants, 12 of
whom had TBI, found increased gains on the PASAT fol-
lowing treatment with APT compared with brain injury
education.90 This study was rated as class I by Cicerone
et al45 but would rate as level B evidence according to
our classification system because of the small sample size
and unblended outcome assessments. Another study by
Park et al82 involving 46 participants found that both
the treated group (using APT) and the nontreated con-
trol group showed similar gains in performance on the
PASAT. Following a meta-analysis of attention training
studies, Park and Ingles81 found that gains were more
evident in uncontrolled pre-post studies but less so in
studies including control groups. They concluded that
training in specific skills might result in improvements
in that skill, which may also be evident on tasks similar
to those trained but that it could not be assumed that
underlying attentional mechanisms were being restored.
Findings from another recent series of single case studies
by Zickefoose et al95 were consistent with this conclu-
sion. In a meta-analysis, Rohling et al96 corrected for
gains due to practice effects or spontaneous recovery
and found a small though significant effect of atten-
tion training, but studies included in the review had
predominantly employed neuropsychological outcome
measures.
A factor that may underpin some of the gains ob-
served following repeated performance of these exercises
is the development of compensatory strategies, such as
chunking, which may enhance the performance on tasks
used to assess outcome, especially those involving work-
ing memory, such as those used by Serino et al.91 They
reported success in training of working memory in 9
people with severe TBI by providing repeated practice
in tasks such as the PASAT and a series of word games
(level B study). Indeed, the most recent version of APT
(APT-III) includes increased emphasis on the develop-
ment of compensatory strategies as part of the training.
It is arguable that gains are made as a result of use of
these compensatory strategies, rather than as a result of
restoration of attentional functions. In support of this
contention are the results of a controlled trial by Dirette
and Hinojosa,98 using an intervention delivered weekly
for 6 weeks. Computerized instruction in verbalization,
chunking, and pacing with a speech pathologist pro-
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
327
viding initial guidance was compared with a computer
training–only condition in terms of impact on perfor-
mance on data entry tasks. Both groups showed a simi-
lar degree of improvement, and degree of improvement
was related to use of compensatory strategies. The lack
of differences between groups suggested that controls
had spontaneously adopted many of the same strategies
as the strategy training group.
In summary, there is mixed evidence of efficacy of
repeated practice on de-contextualized tasks, and most
positive findings are on neuropsychological measures,
with limited evidence of impact on everyday attentional
activities. This recommendation is consistent with the
practice option suggested by Cicerone et al.46 There is
some evidence to suggest that repeated practice on tasks
may facilitate the development of strategies that improve
task performance. As recommended in the Attention 1
guideline, training in compensatory strategies applied
to everyday activities should be considered, especially
in cases with mild to moderate TBI.
Attention #7. Training with periodic random auditory alert-
ing tones for patients with attentional deficits should not be
conducted in therapy outside of a research protocol, as cur-
rent evidence is conflicting. (Adapted from ABIKUS 2007,
72(p22)
G36)
There has been mixed evidence regarding whether
self-alerting or external alerting tones can be used to fa-
cilitate arousal and self-monitoring in patients with ex-
ecutive dysfunction, who have difficulty planning and
following through with a course of action. Manly et al98
demonstrated that provision of a brief auditory alert-
ing stimulus, acting as a cue to consider the overall
goal of the activity, assisted 10 brain injured individ-
uals to monitor their performance and make fewer er-
rors on the multistep “Hotel task,” bringing their perfor-
mance to a level that did not differ from that of healthy
controls. On the contrary, in a larger study, Sweeney
et al99 found no significant improvement in patients’
performance of a virtual reality prospective memory task
that simulated working in a furniture storage unit in re-
sponse to periodic auditory alerts, in comparison with
healthy controls. Thus, there is yet insufficient evidence
to suggest that the use of periodic alerting enhances the
allocation of or switching of attention across different as-
pects of complex tasks. Other metacognitive approaches
to support planning, self-monitoring, and execution of
complex tasks, such as goal management training, are
discussed in the article on rehabilitation of executive
functioning by Tate et al100 in this series.
Attention #8. Training in Mindfulness-based meditation tech-
niques is not recommended for remediation of attention
deficits outside of a research protocol due to lack of demon-
strated efficacy.
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328 JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2014
Some research has also focused on rehabilitation
of sustained attention. This has generally used self-
instructional techniques. In a level A RCT, McMillan
et al101 evaluated the impact of a brief mindfulness med-
itation technique, which involved training TBI partic-
ipants, using an audiotape, to control their attention
by concentrating on breathing over extended periods.
After 4 weeks of training, there was no significant reduc-
tion in cognitive failures or improvement on measures
of attention, memory, or psychological adjustment in
comparison with 2 control groups, which received ei-
ther physical fitness training or no treatment. While the
authors acknowledged that more intensive training by
skilled therapists may have been more effective, this was
not considered feasible within the existing healthcare
system.
There has been some evidence of treatment effects in
less rigorous studies. Two single case studies have pro-
vided level C evidence that training in self-monitoring of
slips of attention and identifying their causes, together
with relaxation and use of self-talk strategies for dealing
with internal and external distraction, resulted in re-
duced attentional slips when reading or listening.102,103
In a more recent group-based intervention, evaluated in
a crossover trial, Novakovic-Agopian et al104 trained 16
individuals with brain injury of multiple etiologies to
use a range of attentional self-regulation strategies, in-
cluding mindfulness, to overcome everyday attentional
and problem-solving challenges, while receiving brain
injury education during a control condition. They found
improvements in performance on a range of cognitive
measures and reported subjective improvements in per-
sonal functioning, which were not evident following
an education control condition. However, the method-
ology of this level B study was not as strong as that
in the study by McMillan et al,101 and, in particular,
the impact on everyday functioning over time was not
evaluated objectively. Using the same sample as that
of Novakovic-Agopian and colleagues,104 Chen et al105
used pattern classification to decode individual func-
tional magnetic resonance imaging data acquired during
a visual selective attention task and found significantly
enhanced modulation of neural processing in extras-
triate cortex following attention regulation training as
compared with the control condition of education pro-
vision. Neural changes in prefrontal cortex, which they
suggest is a likely mediator for attention regulation, ap-
peared to depend on individual baseline state. How-
ever, given their relatively weaker methodology, these
studies are subject to risk of bias and would need confir-
mation with well-designed controlled studies evaluating
everyday outcomes. As with the application of any com-
pensatory strategy, the extent to which self-instructional
techniques can be used to enhance arousal and improve
sustained attention may depend on the injured indi-
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
vidual’s self-awareness, motivation, and ability to carry
out instructions in a goal-directed manner, which may
in turn depend on severity of executive impairment.
These interventions involved individuals with only mild
to moderate executive difficulties. The extent to which
these factors influence response to these interventions
requires systematic investigation.
PHARMACOLOGICAL STRATEGIES FOR
IMPROVING ATTENTION
Attention #9. Methylphenidate is recommended to enhance
speed of information processing. (adapted from Warden
106(p1482)
et al).
Given the impact of TBI on neurotransmitter systems
underpinning attention, numerous studies have evalu-
ated pharmacological interventions. Methylphenidate,
a central nervous system stimulant, increases re-
lease and blocks reuptake of dopamine and nora-
drenaline, resulting in increased synaptic and extracellu-
lar concentrations.107 Actions at D1 and α-2-adrenergic
receptors have been linked to the facilitative effects of
methylphenidate on prefrontal cortical modulation of
attention and working memory.108 Seven RCTs109–115
and 2 case series116,117 have evaluated the effective-
ness of methylphenidate in improving attention after
TBI. Four of the RCTs, which are also the 4 largest
studies, namely, those by Whyte et al,110,112 Willmott
and Ponsford,109 and Plenger et al113 all showed in-
creased cognitive processing speed and attention on
neuropsychological tests, when methylphenidate was
administered at a dose of 0.3 mg/kg twice daily, al-
though no significant improvements were noted in di-
vided attention, sustained attention, or susceptibility
to distraction. Whyte et al110 showed an impact on
caregiver ratings of everyday attention and Willmott
and Ponsford109 showed a positive but nonsignificant
trend in such ratings. Thus, there is level A evidence
supporting use of methylphenidate to increase infor-
mation processing speed as measured neuropsycholog-
ically, with 1 study showing an impact on everyday at-
tention. However, there has been no investigation of the
impact of long-term use of methylphenidate by individ-
uals with TBI. Thus, its impact on activity and partici-
pation is yet to be demonstrated. Dextroamphetamine
has been studied in a single case series with reported
benefit.118
Attention #10. Whilst Amantadine may enhance arousal in
patients in a minimally conscious state, there is little evidence
that it enhances more complex attentional functions following
emergence from coma.
Amantadine is a dopaminergic agent that acts presy-
naptically to enhance dopamine release and decrease
dopamine reuptake. Although there is level A evidence
 INCOG Recommendations for Management of Cognition Following TBI
that amantadine may enhance arousal in people in a
vegetative or minimally conscious state,119 there is lim-
ited evidence that amantadine enhances more complex
attentional functions. Uncontrolled case studies have
suggested that amantadine may improve attention but
more commonly executive functions.120–122 However,
these level C studies have been marred by small sam-
ples, lack of blinding, and failure to control for practice
effects. A small placebo controlled study did not find
that amantadine increased the rate of improvement in at-
tention and other cognitive functions in the acute stages
of recovery from TBI123 (level B). More well-controlled
studies are required to examine the impact of amanta-
dine on attention.
Table 2 sets out the guidelines and supporting evi-
dence. Figure 1 presents the algorithm illustrating rec-
ommended decision-making pathways for managing
attentional problems, based on the guidelines.
RECOMMENDED PRACTICE
On the basis of the guidelines, the following practices
are recommended. Given the high frequency of atten-
tional problems in individuals with TBI, it is recom-
mended that all individuals with moderate to severe TBI
have a neuropsychological assessment to determine the
specific nature and extent of their attentional difficul-
ties. It is also important to investigate the ways in which
these attentional problems are manifested and impact-
ing on performance of daily activities. It is acknowledged
that this recommendation is based on clinical consen-
sus. As it is typical of rehabilitation teams to assess a
condition prior to implementing an intervention, the
panel opted to similarly recommend this process for the
assessment of attention. The use of everyday measures
such as the Rating Scale of Attentional Behavior29 or
the Moss Attention Rating Scale,124 which may be com-
pleted by a clinician or a relative, may assist with this.
It is also important to identify the attentional demands
of the injured individual’s lifestyle and the availability
of environmental supports, as well as factors that may
be exacerbating attentional problems, including fatigue,
sleep-wake disturbances, pain, medication, anxiety, and
depression.
In implementing therapy to alleviate attentional prob-
lems, there is evidence in support of training in metacog-
nitive strategies applied directly to everyday attentional
difficulties. Such strategies might include TPM strate-
gies, chunking, or pacing.
There is also support for provision of training in dual
tasking, whereby each task is trained separately and then
together. This may facilitate automatization of task per-
formance, reducing the burden on a limited conscious
processing capacity of the injured individual. Thus, gains
may be expected only on trained tasks or similar.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
329
Methylphenidate, administered at 0.3 mg/kg in di-
vided doses, has been shown to increase speed of infor-
mation processing both in inpatients in postacute reha-
bilitation and when delivered for up to 6 weeks at longer
periods after injury and to enhance everyday attentional
behavior. Although the long-term effects on outcome
are not yet known, methylphenidate is indicated for
short-term use to maximize attention in individuals aged
16 to 60 years who have no history of attention deficit
hyperactivity disorder previous stimulant use, drug or
alcohol dependence, or other psychiatric disorder.
Despite their apparent applicability, especially for
individuals without the capacity to implement self-
regulatory strategies, there has been no formal evalua-
tion of efficacy of the use of adaptive changes to the envi-
ronment or tasks to minimize the impact of attentional
problems, such as removing noise or other sources of
distraction from the home or work environment, or al-
tering tasks to reduce their demands in terms of speed or
multitasking, providing prompting to reorient to tasks,
or using checklists. Addressing other contributing fac-
tors to attentional problems, such as fatigue, sleep-wake
disturbances, pain, medication effects, and/or anxiety
and depression, also represents important aspects of the
intervention process. The outcome of all interventions
should be assessed not only in terms of their impact of
measures of attentional impairment but also on the indi-
viduals’ ability to participate in daily activities to which
they wish to return.
Table 3 sets out the audit tool items recommended
by the INCOG panel for examining management of
attentional problems in clinical settings.
DISCUSSION
Given the high frequency of attentional impairments
following TBI, the identification and treatment of these
problems is of paramount importance. Despite the de-
bilitating nature of attentional difficulties in individuals
with TBI, there is a lack of established rehabilitation
practices to address attention. The evidence in support
of most interventions is not strong. It is recommended
that both assessment and intervention not only be fo-
cused on attentional impairments but also be conducted
in the context of the individual’s daily life. Evidence
supports training in metacognitive strategies applied to
everyday attentional difficulties. Making adjustments to
the environment and tasks undertaken by the injured in-
dividual may also be important, as is addressing fatigue,
sleep-wake disturbances, pain, medication effects, and
anxiety and depression. Of the pharmacological inter-
ventions available, the strongest evidence is for the use
of methylphenidate to enhance speed of information
processing in individuals without any history of atten-
tion deficit hyperactivity disorder, stimulant use, drug
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 330

TABLE 2 Recommendation table, attention

Guideline recommendation Grade Reviews RCTs Other
Nonpharmacological interventions for attention/information processing speed
Attention #1
Metacognitive strategy training using functional everyday A Fasotti et al49 Cicerone52
activities should be considered, especially in patients with Vallat-Azouvi et al53
mild-moderate attention deficits.
INCOG (2014)42 /Sohlberg et al48(p37) /Cicerone et al46(p521) (Level
Propose B)
Attention #2
Training in dual tasking should be used to improve dual-task A Couillet et al55
performance on tasks similar to those trained. Evans et al54

Attention #3
Cognitive behavior therapy techniques should be considered to B Tiersky et al66 Mateer et al58
develop strategies to maximize attention in individuals with Ruff59
mild to moderate traumatic brain injury in whom anxiety
depression is impacting on attentional function.
Attention #4
Screening for and treatment of comorbid sleep-wake disorders C Wiseman-Hakes et al68
may help optimize attentional processes.
Attention #5
Alterations to the environment and tasks may be used to C Sloan and Ponsford71
reduce the impact of attentional problems on daily activities
Attention #6
Reliance on repeated exposure and practice on B Park and Ingles81 Dirette and Hinojosa97 Gansler and McCaffrey75
de-contextualized computer-based attentional tasks are NOT Rohling et al96 Gray et al77 Gray and Robertson76
recommended because of lack of demonstrated impact on Malec et al78 Middleton et al92
JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2014

everyday attentional functions. Niemann et al79 Palmese and Raskin62

ABIKUS G42 p. 22 (2007)78 /Cicerone (2011)51(p521) Novack et al80 Park et al82
Sohlberg et al90 Ponsford and Kinsella83
Robertson et al84
Serino et al91
Sohlberg and Mateer86
Wood73
Zickefoose et al95
(continues)

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 TABLE 2 Recommendation table, attention (Continued)
Guideline recommendation Grade Reviews RCTs Other
Attention #7
Training with periodic random auditory alerting tones for B Manly et al98
patients with attentional deficits should not be conducted in Sweeney et al99
therapy outside of a research protocol, as current evidence is
conflicting.
ABIKUS G36 p. 22 (2007)72
Attention #8
Training in mindfulness-based meditation techniques is not A McMillan et al101 Chen et al105
recommended for remediation of attention deficits outside of Novakovic-Agopian et al104
a research protocol because of lack of demonstrated. Wilson and Robertson102
Webster and Scott103
Pharmacological management for attention/information processing speed
Attention #9
Methylphenidate is recommended to enhance speed of A Gualtieri and Evans114 Bleiberg et al118
information processing. Kim et al111 Kaelin et al116
Warden et al106(p1482) Plenger et al112 Pavlovskaya et al117
Speech et al115
Whyte et al110
Whyte et al112
Willmott and Ponsford109
Attention #10
While amantadine may enhance arousal in patients in a C Kraus and Maki120
minimally conscious state, there is little evidence that it
enhances more complex attentional functions following
emergence from coma.
Kraus et al121
Nickels et al122
Schneider et al123
INCOG Recommendations for Management of Cognition Following TBI

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www.headtraumarehab.com
331
 332

TABLE 3 Audit guidelines for priority recommendations: attentiona

Intervention Assessment of
(guideline Specific activities, need and Patient
recommendation) devices, or tools effectiveness characteristics Discipline
Attention Training
“Metacognitive strategy  Combined with  Assessment for  Mild to moderate  OT
training using functional metacognitive executive need conducted attention deficit  PT
everyday activities should strategy training  Training provided  SLP
be considered, especially in  Functional everyday  MD
patients with activities  Neuro
mild-moderate attention  Environmental  Other
deficits.” (Attention #1) manipulation
 Use of checklists
 Other
Pharmaceutical interventions: Attention
Patient
Drug Used Indication characteristics Found in
Methylphenidate
“Methylphenidate is Yes No  Attentional  Drug charts
recommended to enhance function
speed of information  Speed of cognitive  MD notes
processing.” (Attention #9) processing  Other
 Sustained
JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2014

attention/vigilance
 Other (please
specify):

a Theaudit tool items that the panel voted as the most important for implementation are listed. It is important to note that many different strategies may be applicable and that the language
used to describe these interventions is likely to vary across settings and cultures.

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 INCOG Recommendations for Management of Cognition Following TBI 333

Impaired attention?
Mild-moderate Training with
impairment metacognitive
strategies applied to
Consider potential medication side-effects (+self-aware) real-world activities
and modify as appropriate.

Dual-task training
Screen for sleep-wake
disturbance Avoid sole use of
computer-mediated
drills

Environmental
Address sleep-wake disturbance Severe
modification
impairment

Time Pressure
Screen for
Management
anxiety and/or
Consider cognitive depression
behavioral therapy for
anxiety and mood Consider
Slow methylphenidate
information
0.3 mg/kg in divided
processing
Assess/consider motivation, doses for up to 6
close other support, (No substance wk
substance use history, and abuse, high
cognitive functions, i.e., self- blood pressure)
awareness, executive and
memory function

Mindfulness techniques and training with periodic random

tones not recommended

Figure 1. Algorithm: Attention. Participant characteristics, measures, and treatments. Studies demonstrating efficacy of interventions
for attentional difficulties in a controlled fashion have been sparse. Those that have demonstrated success in remediating
attentional difficulties by integrating training in performance of attentional tasks with metacognitive or compensatory skills
training have included people with mild to severe injuries, generally aged between 16 and 60 years, and having adequate visual
acuity, hand function, and cognitive function to perform the assessment and training tasks. Participants were generally excluded if
they had other neurological or developmental issues or preexisting psychiatric or substance use problems. They received training
between 3 months and many years after injury. Therefore, it cannot be assumed that other individuals would benefit from these
interventions. Screening measures included a broad range of neuropsychological tests of attention, including the PASAT, Trail
Making Test, cancellation, Digit Span and Digit Symbol substitution tasks, and many others. These tasks have also been used
to evaluate the outcome of interventions. Outcomes have also been measured in terms of subjectively reported changes and
performance on real-world data entry tasks and activity and participation scales. The published studies evaluating the efficacy of
methylphenidate have included individuals with moderate to severe brain injury usually aged 16 to 60 years and having adequate
physical and cognitive abilities to undertake the tasks. While Willmott and Ponsford109 and Kaelin et al116 included patients
in inpatient rehabilitation, others have included individuals more than 6 months postinjury. There was no common attention
measure used to screen for inclusion. Most investigators excluded those with preexisting treatment with methylphenidate, or
substance dependence, concurrent treatment with psychoactive medications, or current drug or alcohol dependence. The most
common outcome was improvement in impairments in processing speed assessed on measures of reaction time and the Symbol
Digit Modalities Tests, but 2 randomized controlled trials included a Rating Scale of Attentional Behavior and 2 case series
reported improvements in function on the Disability Rating Scale.

dependence, or other psychiatric problems. There is both large RCTs, but also well-designed single case stud-
clearly a need for not only much larger studies eval- ies, which allow for a focus on the individuals in the
uating interventions focusing on attentional problems, context of their daily life.

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334 JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2014
REFERENCES
1. James W. The Principles of Psychology. Dover Publications Inc; 1890.
2. Whyte J, Ponsford J, Watanabe T, Hart T. Traumatic brain injury.
In: Frontera WR, Delisa JD, Gans BM, Walsh NA, Robinson
L, eds. Delisa’s Physical Medicine and Rehabilitation: Principles and
Practice. 5th ed. Philadelphia, PA: Wolters Kluwer, Lippincott
Williams & Wilkins; 2010:575–623.
3. Amsten AF, Robbings TW. Neurochemical modulation of pre-
frontal cortical function in humans and animals. In: Stuss DT,
Knight RT, eds. Principles of Frontal Lobe Function. New York, NY:
Oxford University Press; 2002:51–84.
4. McAllister TW, Flashman LA, Sparling MB, Saykin AJ. Work-
ing memory deficits after traumatic brain injury: catecholaminer-
gic mechanisms and prospects for treatment—a review. Brain Inj.
2004;18(4):331–350.
5. Posner MI, Rothbart MK. Attentional mechanisms and conscious
experience. In: Milner AD, Rugg MD, eds. The Neuropsychology of
Consciousness. London: Academic Press; 1992:91–112.
6. Stuss DT, Benson DF. The Frontal Lobes. New York, NY: Raven
Press; 1986.
7. Cohen RA. The Neuropsychology of Attention. New York, NY:
Plenum Press; 1993.
8. Van Zomeren AH, Brouwer WH. Clinical Neuropsychology of At-
tention. New York, NY: Oxford University Press; 1994.
9. Shiffrin RM, Schneider WM. Controlled and automatic human
information processing: II. Perceptual learning, automatic attend-
ing, and a general theory. Psychol Rev. 1977;84(2):127–190.
10. Baddeley AD. Working Memory. Oxford: Claredon Press;
1986.
11. Shallice T. Specific impairments in planning. In: Broadbent
DE, Weiskrantz L, eds. The Neuropsychology of Cognitive Function.
London: The Royal Society; 1982:199–209.
12. Povlishock J, Katz D. Update of neuropathology and neurologi-
cal recovery after traumatic brain injury. J Head Trauma Rehabil.
2005;20(1):76–94.
13. Spikman JM, van Zomeren AH, Deelman BG. Deficits of at-
tention after closed-head injury: slowness only? J Clin Exp
Neuropsychol. 1996;18(5):755–767.
14. Willmott C, Ponsford J, Hocking C, Schönberger M. Factors con-
tributing to attentional impairments following traumatic brain
injury. Neuropsychology. 2009;23(4):424–432.
15. Ponsford JL, Kinsella G. Attentional deficits following closed-
head injury. J Clin Exp Neuropsychol. 1992;14(5):822–838.
16. Vallat-Azouvi C, Weber T, Legrand L, Azouvi P. Working mem-
ory after severe traumatic brain injury. J Int Neuropsychol Soc.
2007;13(5):770–780.
17. Ziino C, Ponsford J. Vigilance and fatigue following traumatic
brain injury. J Int Neuropsychol Soc. 2006;12:100–110.
18. Robertson IH, Manly T, Andrade H, Baddeley BI, Yiend J.
‘Oops!’ Performance correlates of everyday attentional failures
in traumatic brain injured and normal subjects. Neuropsychology.
1997;35:747–758.
19. Asloun S, Soury S, Couillet J, et al. Interactions between divided
attention and working-memory load in patients with severe trau-
matic brain injury. J Clin Exp Neuropsychol. 2008;30(4):481–490.
20. Azouvi P, Vallat-Azouvi C, Belmont A. Cognitive deficits after
traumatic coma. Prog Brain Res. 2009;177:89–110.
21. Whyte J, Fleming M, Polansky M, Cavallucci C, Coslett HB. The
effects of visual distraction following traumatic brain injury. J Int
Neuropsychol Soc. 1998;4:127–136.
22. Shallice T, Burgess PW. Deficits in strategy application following
frontal lobe damage in man. Brain. 1991;114(2):727–741.
23. Renison B, Ponsford J, Testa R, Richardson B, Brownfield K. The
ecological and construct validity of a newly developed measure
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
of executive function: the Virtual Library Task. J Int Neuropsychol
Soc. 2012;18(3):440–450.
24. Ponsford JL, Downing M, Olver J, et al. Longitudinal follow-up
of patients with traumatic brain injury: outcome at 2, 5, and
10-years postinjury. J Neurotrauma. 2014;31(1):64–77.
25. Himanen L, Portin R, Isoniemi H, Helenius H, Kurkj T, Tenovuo
O. Longitudinal cognitive changes in traumatic brain injury: a
30-year follow-up study. Neurology. 2006;66:187–192.
26. Hoofien D, Gilboa A, Vakil E, Donovick PJ. Traumatic brain
injury 10–20 years later: a comprehensive outcome study of psy-
chiatric symptomatology, cognitive abilities, and psychosocial
functioning. Brain Inj. 2001;15:189–209.
27. Ponsford J, Willmott C, Rothwell A, et al. Factors influencing
outcome following mild traumatic brain injury in adults. J Int
Neuropsychol Soc. 2000;6(5):568–579.
28. Carroll LJ, Cassidy JD, Peloso PM, et al. Prognosis for mild
traumatic brain injury: results of the WHO Collaborating Cen-
tre Task Force on Mild Traumatic Brain Injury. J Rehabil Med.
2004(43 suppl):84–105.
29. Ponsford JL, Kinsella G. The use of a Rating Scale of Attentional
Behaviour. Neuropsychol Rehabil. 1991;1:241–257.
30. Gould KR, Ponsford JL, Spitz G. Contributions of cognitive
impairments to anxiety disorder following traumatic brain injury.
J Clin Exp Neuropsychol. In press.
31. Ziino C, Ponsford J. Selective attention deficits and subjec-
tive fatigue following traumatic brain injury. Neuropsychology.
2006;20(3):383–390.
32. Bloomfield ILM, Espie CA, Evans JJ. Do sleep difficulties exac-
erbate deficits in sustained attention following traumatic brain
injury? J Int Neuropsychol Soc. 2010;16:17–25.
33. ADAPTE Collaboration. The ADAPTE Process: Resource Toolkit for
Guideline Adaptation. Version 2.0 ed. 2009. http://www.g-i-n.net.
Accessed January 29, 2014.
34. Graham ID, Harrison MB. Evaluation and adaptation of clinical
practice guidelines. Evidence Based Nurs. 2005;8(3):68–72.
35. Bragge P PL, Marshall S, et al. Quality of guidelines for cognitive
rehabilitation following traumatic brain injury. J Head Trauma
Rehabil. 2014;29(4):277–289.
36. Appraisal of Guidelines Research & Evaluation. AGREE: advanc-
ing the science of practice guidelines. http://www.agreetrust.org/.
Published 2014. Accessed January 2012.
37. Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advanc-
ing guideline development, reporting and evaluation in health
care. CMAJ. 2010;182(18):E839–E842.
38. Teasell R, Bayona N, Marshall S, et al. A systematic review of
the rehabilitation of moderate to severe acquired brain injuries.
Brain Inj. 2007;21(2):107–112.
39. Bragge P, Clavisi O, Turner T, Tavender E, Collie A, Gruen
RL. The Global Evidence Mapping Initiative: scoping research
in broad topic areas. BMC Med Res Methodol. 2011;11:92.
40. Tate R, Perdices M, McDonald S, et al. Development of a
database of rehabilitation therapies for the psychological con-
sequences of acquired brain impairment. Neuropsychol Rehabil.
2004;14(5):517–534.
41. Lindsay P, Bayley M, Hellings C, Hill M, Woodbury E, Phillips S.
Canadian best practice recommendations for stroke care (updated
2008). CMAJ. 2008;179(12):S1–25.
42. Bayley M, Tate R, Douglas J, et al. INCOG guidelines for cogni-
tive rehabilitation following traumatic brain injury: methods and
overview. J Head Trauma Rehabil. 2014;29(4):290–306.
43. Rees L, Marshall S, Hartridge C, Mackie D, Weiser M.
Cognitive interventions post acquired brain injury. Brain Inj.
2007;21(2):161–200.
 INCOG Recommendations for Management of Cognition Following TBI
44. Cicerone KD, Dahlberg C, Kalmar K, et al. Evidence-based cog-
nitive rehabilitation: recommendations for clinical practice. Arch
Phys Med Rehabil. 2000;81(12):1596–1615.
45. Cicerone KD, Dahlberg C, Malec JF, et al. Evidence-based cog-
nitive rehabilitation: updated review of the literature from 1998
through 2002. Arch Phys Med Rehabil. 2005;86(8):1681–1692.
46. Cicerone KD, Langenbahn DM, Braden C, et al. Evidence-
based cognitive rehabilitation: updated review of the literature
from 2003 through 2008. Archf Phys Med Rehabil. 2011;92(4):
519–530.
47. Cappa SF, Benke T, Clarke S, Rossi B, Stemmer B, van Heugten
CM. EFNS guidelines on cognitive rehabilitation: report of an
EFNS task force. Eur J Neurol. 2003;10(1):11–23.
48. Sohlberg MM, Avery J, Kennedy MRT, et al. Practice guide-
lines for direct attention training. J Med Speech-Lang Pathol.
2002;11(3):xix–xxxix.
49. Fasotti L, Kovacs F, Eling PATM, Brouwer WH. Time pressure
management as a compensatory strategy training after closed-
head injury. Neuropsychol Rehabil. 2000;10:47–65.
50. Winkens I, Van Heugten CM, Wade DT, Fasotti L. Training
patients in Time Pressure Management, a cognitive strategy for
mental slowness. Clin Rehabil. 2009;23(1):79–90.
51. Winkens I, Van Heugten CM, Wade DT, Habets E, Fasotti L.
Efficacy of time pressure management in stroke patients with
slowed information processing: a randomized controlled trial.
Arch Phys Med Rehabil. 2009;90(10):1672–1679.
52. Cicerone KD. Remediation of ‘working attention’ in mild trau-
matic brain injury. Brain Inj. 2002;16(3):185–195.
53. Vallat-Azouvi C, Weber T, Leqrand L, Azouvi P. Rehabilitation
of the central executive of working memory after severe traumatic
brain injury: two single case studies. Brain Inj. 2009;23(6):585–
594.
54. Evans JJ, Greenfield E, Wilson BA, Bateman A. Walking and
talking therapy: improving cognitive-motor dual-tasking in neu-
rological illness. J Int Neuropsychol Soc. 2009;15:112–120.
55. Couillet J, Soury S, Leborne C, et al. Rehabilitation of divided
attention after severe traumatic brain injury: a randomised trial.
Neuropsychol Rehabil. 2010;20(3):321–339.
56. Schmitter-Edgecombe M, Beglinger L. Acquisition of skilled vi-
sual search performance following severe closed-head injury. J Int
Neuropsychol Soc. 2001;7(5):615–630.
57. Meares S, Shores E, Taylor A, et al. Mild traumatic brain in-
jury does not predict acute postconcussion syndrome. J Neurol
Neurosurg Psychiatry. 2008;79(3):300–306.
58. Mateer CA, Sira CS, O’Connell ME. Putting Humpty Dumpty
together again. The importance of integrating cognitive and emo-
tional interventions. J Head Trauma Rehabil. 2005;20(1):62–75.
59. Ruff R. Two decades of advances in understanding of mild trau-
matic brain injury. J Head Trauma Rehabil. 2005;20(1):5–18.
60. Wood RL. Understanding the ‘miserable minority’: a diasthesis-
stress paradigm for postconcussional syndrome. Brain Inj.
2004;18(11):1135–1153.
61. Ponsford J. Rehabilitation interventions after mild head injury.
Current Opin Neurol. 2005;18(6):692–697.
62. Palmese CA, Raskin SA. The rehabilitation of attention in indi-
viduals with mild traumatic brain injury, using the APT-II pro-
gramme. Brain Inj. 2000;14(6):535–548.
63. Penkam I, Mateer CA. The specificity of attention retraining in
traumatic brain injury. J Cog Rehabil. 2004;2:13–26.
64. Gould KR, Ponsford JL, Johnston L, Schönberger M. The nature,
frequency and course of psychiatric disorders in the first year
after traumatic brain injury, a prospective study. Psychol Med.
2011;41(10):2099–2109.
65. Bombardier CH, Fann JR, Temkin NR, Esselman PC, Barber J,
Dikmen SS. Rates of major depressive disorder and clinical out-
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
335
comes following traumatic brain injury. JAMA. 2010;303:1938–
1945.
66. Tiersky LA, Anselmi V, Johnston MV, et al. A trial of neuropsy-
chologic rehabilitation in mild-spectrum traumatic brain injury.
Arch Phys Med Rehabil. 2005;86:1565–1574.
67. Banks S, Dinges DF. Behavioral and physiological consequences
of sleep restriction. J Clin Sleep Med. 2007;3:519–528.
68. Wiseman-Hakes C, Murray BJ, Moineddin R, et al. Evaluating the
impact of treatment for trauma related sleep/wake disorders on
recovery of cognition and communication in adults with chronic
TBI. Brain Inj. 2013;27(12):1364–1376.
69. Neistadt ME. The neurobiology of learning: implications for
treatment of adults with brain injury. Am J Occup Ther.
1994;48:421–430.
70. Sohlberg MM, Raskin SA. Principles of generalization applied
to attention and memory interventions. J Head Trauma Rehabil.
1996;11:65–78.
71. Sloan S, Ponsford J. Managing cognitive problems. In: Ponsford
JL, Sloan S, Snow P, eds. Traumatic Brain Injury: Rehabilitation
for Everyday Adaptive Living. 2nd ed. London: Psychology Press;
2012:99–132.
72. Bayley M, Teasell R, Marshall S, et al. ABIKUS Evidence Based
Recommendations for Rehabilitation of Moderate to Severe Acquired
Brain Injury. Toronto, Ontario, Canada: Ontario Neurotrauma
Foundation; 2007.
73. Wood RL. Rehabilitation of patients with disorders of attention.
J Head Trauma Rehabil. 1986;1:43–53.
74. Ben-Yishay Y, Piasetsky EB, Rattock J. A systematic method for
ameliorating disorders in basic attention. In: Meier MJ, Benton
AL, Diller L, eds. Neuropsychological Rehabilitation. New York, NY:
Churchill Livingston; 1987:165–181.
75. Gansler DA, McCaffrey RJ. Remediation of chronic atten-
tion deficits in traumatically brain injured patients. Arch Clin
Neuropsychol. 1991;6:335–353.
76. Gray JM, Robertson I. Remediation of attentional difficulties
following brain injury: three experimental case studies. Brain Inj.
1989;3:163–170.
77. Gray JM, Robertson IH, Pentland B, Anderson SJ.
Microcomputer-based cognitive rehabilitation for brain dam-
age. A randomized group controlled trial. Neuropsychol Rehabil.
1992;2:97–116.
78. Malec J, Jones R, Rao N, Stubbs K. Video-game practice effects
on sustained attention in patients with cranio-cerebral trauma.
Cog Rehabil. 1984;2(4):18–23.
79. Niemann H, Ruff RM, Baser CA. Computer-assisted attention
retraining in head-injured individuals: A controlled efficacy study
of an outpatient program. J Consult Clin Psychol. 1990;58:811–817.
80. Novack TA, Caldwell SG, Duke LW, Bergquist TF, Gage RJ. Fo-
cused versus unstructured intervention for attention deficits after
traumatic brain injury. J Head Trauma Rehabil. 1996;11(3):52–60.
81. Park NW, Ingles JL. Effectiveness of attention rehabilitation af-
ter an acquired brain injury: a meta-analysis. Neuropsychology.
2001;15(2):199–210.
82. Park NW, Proulx G, Towers W. Evaluation of the Attention
Process training programme. Neuropsychol Rehabil. 1999;9:135–
154.
83. Ponsford JL, Kinsella G. Evaluation of a remedial programme
for attentional deficits following closed-head injury. J Clin Exp
Neuropsychol. 1988;10:693–708.
84. Robertson I, Gray JM, McKenzie S. Microcomputer-based cog-
nitive rehabilitation of visual neglect: three multiple- baseline
single-case studies. Brain Inj. 1988;2:151–163.
85. Ruff R, Mahaffey R, Engel J, Farrow C, Cox D, Karzmark P.
Efficacy of THINKable in the attention and memory retraining
of traumatically head-injured patients. Brain Inj. 1994;8(1):3–14.
www.headtraumarehab.com
336 JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2014
86. Sohlberg MM, Mateer CA. Effectiveness of an attention-training
program. J Clin Exp Neuropsychol. 1987;9:117–130.
87. Stablum F, Umilta C, Mogentale C, Carlan M, Guerrini C. Re-
habilitation of executive deficits in closed-head injury and ante-
rior communicating artery aneurysm patients. Psychol Res. 2000;
63(3–4):265–278.
88. Sturm W, Willmes K, Orgass B, Hartje A. Do specific attention
deficits need specific training? Neuropsychol Rehabil. 1997;7:81–
193.
89. Wood RL, Fussey I. Computer-based cognitive retraining: a con-
trolled study. Int Disabil Stud. 1987;9(4):149–153.
90. Sohlberg MM, McLaughliin KA, Pavese A, Heidrich A, Pos-
ner AI. Evaluation of attention process training and brain in-
jury education in persons with acquired brain injury. J Clin Exp
Neuropsychol. 2000;22:656–676.
91. Serino A, Ciaramelli E, DiSantantonio A, Malagu S, Servadei
F, Ladavas E. A pilot study for rehabilitation of central execu-
tive deficits after traumatic brain injury. Brain Inj. 2007;21(1):
11–19.
92. Middleton DK, Lambert MJ, Seggar LB. Neuropsychological re-
habilitation: microcomputer-assisted treatment of brain-injured
adults. Percept Mot Skills. 1991;72:527–530.
93. Murray LL, Keeton RJ, Karcher L. Treating attention in mild
aphasia: evaluation of attention process training-II. J Commun
Disord. 2006;39:37–61.
94. Pero S, Incoccia C, Caracciolo B, Zoccolotti P, Formisano
R. Rehabilitation of attention in two patients with traumatic
brain injury by means of ‘attention process training’. Brain Inj.
2006;20(11):1207–1219.
95. Zickefoose S, Hux K, Brown J, Wulf K. Let the games begin:
a preliminary study using Attention Process training -3 and
Lumosity brain games to remediate attention deficits following
traumatic brain injury. Brain Inj. 2013;27(6):707–716.
96. Rohling ML, Beverly B, Faust ME, Demakis G. Effectiveness of
cognitive rehabilitation following acquired brain injury: a meta-
analytic re-examination of Cicerone et al.’s (2000, 2005) system-
atic reviews. Neuropsychology. 2009;23(1):20–39.
97. Dirette DK, Hinojosa J. The effects of a compensatory interven-
tion on processing deficits of adults with acquired brain injuries.
Occup Ther J Res. 1999;19(4):223–240.
98. Manly T, Hawkins K, Evans J, Woldt K, Robertson IH. Re-
habilitation of executive function: facilitation of effective goal
management on complex tasks using periodic auditory alerts.
Neuropsychology. 2002;40:271–281.
99. Sweeney S, Kersel DA, Morris RG, Manly T, Evans JJ. The sensi-
tivity of a virtual reality task to planning and prospective memory
impairments: group differences and the efficacy of periodic alerts
on performance. Neuropsychol Rehabil. 2010;20(2):239–263.
100. Tate R KM, Ponsford J, Douglas J, Velikonka D, Bayley M,
Stergiou-Kita M, On Behalf of the InCog Expert Panel. INCOG
guidelines for cognitive rehabilitation following traumatic brain
injury: executive functioning and self-awareness. J Head Trauma
Rehabil. 2014;29(4):338–352.
101. McMillan T, Robertson IH, Brock D, Chorlton L. Brief
mindfulness training for attentional problems after traumatic
brain injury: A randomised control treatment trial. Neuropsychol
Rehabil. 2002;12(2):117–125.
102. Wilson C, Robertson IH. A home-based intervention for atten-
tional slips during reading following head injury: a single case
study. Neuropsychol Rehabil. 1992;2:193–205.
103. Webster JS, Scott RR. The effects of self-instructional training
on attentional deficits following head injury. Clin Neuropsychol.
1983;5(2):69–74.
104. Novakovic-Agopian T, Chen AJ, Rome S, et al. Rehabilita-
tion of executive functioning with training in attention regu-
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
lation applied to individually defined goals: a pilot study bridg-
ing theory, assessment, and treatment. J Head Trauma Rehabil.
2011;26(5):325–338.
105. Chen A, Novakovic-Agopian T, Nycum TJ, et al. Training
of goal-directed attention regulation enhances control over
neural processing for individuals with brain injury. Brain.
2011;134(5):1541–1554.
106. Warden DL, Gordon B, McAllister TW, et al. Guidelines for the
pharmacologic treatment of neurobehavioral sequelae of trau-
matic brain injury. J Neurotrauma. 2006;23(10):1468–1501.
107. Leonard BE, McCartan D, White J, King DJ. Methylphenidate:
a review of its neuropharmacological, neuropsychological and
adverse clinical effects. Hum Psychopharmacol. 2004;19(3):151–
180.
108. Arnsten AF, Dudley AG. Methylphenidate improves prefrontal
cortical cognitive function through alpha2 adrenoreceptor and
dopamine D1 receptor actions: relevance to therapeutic effects
in attention deficit hyperactivity disorder. Behav Brain Funct.
2005;1(1):2. doi:10.1186/1744-9081-1181-82.
109. Willmott C, Ponsford J. Efficacy of methylphenidate in the early
rehabilitation of attention following traumatic brain injury: a
randomized, crossover, double-blind, placebo controlled trial. J
Neurol Neurosurg Psychiatry. 2009;80(5):552–557.
110. Whyte H, Hart T, Vaccaro M, et al. Effects of methylphenidate
on attention deficits after traumatic brain injury: a multidi-
mensional randomized, controlled trial. Am J Phys Med Rehabil.
2004;83(6):401–420.
111. Kim Y, Ko M, Na S, Park S, Kim K. Effects of single-dose
methylphenidate on cognitive performance in patients with trau-
matic brain injury: a double-blind placebo-controlled trial. Clin
Rehabil. 2006;20:24–30.
112. Whyte J, Hart T, Schuster K, Fleming M, Polansky M, Coslett
HB. Effects of methylphenidate on attentional function after
traumatic brain injury: a randomized placebo-controlled trial.
Am J Phys Med Rehabil. 1997;76(6):440–450.
113. Plenger PM, Dixon CE, Castillo RM, Frankowski RF, Yablon
SA, Levin HS. Subacute methylphenidate for moderate to mod-
erately severe traumatic brain injury: a preliminary double-blind
placebo-controlled study. Arch Phys Med Rehabil. 1996;77:536–
540.
114. Gualtieri CT, Evans RW. Stimulant treatment for the neu-
robehavioral sequelae of traumatic brain injury. Brain Inj.
1988;2(4):273–290.
115. Speech TJ, Rao SM, Osmon DT, Sperry LT. A double-blind
controlled study of methylphenidate treatment in closed-head
injury. Brain Inj. 1993;7(4):333–338.
116. Kaelin DL, Cifu DX, Matthies B. Methylphenidate effect on
attention deficit in the acutely brain-injured adult. Arch Phys Med
Rehabil. 1996;77:6–9.
117. Pavlovskaya M, Hochstein H, Keren O, Mordvinov E,
Grosswasser Z. Methylphenidate effect on hemispheric atten-
tional imbalance in patients with traumatic brain injury: a psy-
chophysical study. Brain Inj. 2007;21(5):489–497.
118. Bleiberg J, Garmoe W, Cederquist J, Reeves D, Lux W. Effects of
Dexedrine on performance consistency following brain injury: a
double-blind placebo cross-over study. Neuropsychi, Neuropsychol
Behav Neurol. 1993;6(4):245–248.
119. Giacino J, Whyte J, Bagiella E, et al. Placebo-controlled trial of
amantadine for severe traumatic brain injury. New Eng J Med.
2012;366(9):819–826.
120. Kraus MF, Maki P. The combined use of l-dopa/carbidopa in
the treatment of chronic brain injury. Brain Inj. 1997;11(6):
455–460.
121. Kraus MF, Smith GS, Butters M, et al. Effects of the dopamin-
ergic agent and NMDA receptor antagonist amantadine on
 INCOG Recommendations for Management of Cognition Following TBI 337

cognitive function, cerebral glucose metabolism and D2 recep-
tor availability in chronic traumatic brain injury: a study us-
ing positive emission tomography (PET). Brain Inj. 2005;19(7):
471–479.
122. Nickels JL, Schneider WN, Dombovy ML, Wong TM. Clini-
cal use of amantadine in brain injury rehabilitation. Brain Inj.
1994;8(8):709–718.
123. Schneider WM, Drew-Cates J, Wong TM, Dombovy ML. Cog-
nitive and behavioral efficacy of amantadine in acute traumatic
brain injury: an initial double-blind placebo controlled study.
Brain Inj. 1999;13(11):863–872.
124. Hart T, Whyte J, Ellis C, Chervoneva I. Construct validity of an
attention rating scale for traumatic brain injury. Neuropsychology.
2009;23(6):729–735.

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