EUR MED PHYS 2006;42:59-67

Attention rehabilitation following stroke

A
and traumatic brain injury
A review

C
T ® DI
J. A. MICHEL, C. A. MATEER

H E
Attentional capacities, which are frequently impaired Department of Psychology
IG M
following brain injury, have also been found to be University of Victoria, Victoria, Canada
amenable to rehabilitation. This review discusses vari-
ous approaches to attention rehabilitation in adult clients
following stroke and traumatic brain injury. Attention
process training has been accepted by many as a prac-
R A

tice standard in postacute clients, however, its ability

to generalize to new situations and to functional capac-
ities is unclear. There is evidence for the use of psy- an effective utilization of higher functions may take
Y V

chostimulant medication, which may be most helpful place. Without attending to information and being
when prescribed in combination with attention training. able to hold information in mind, one is unlikely to be
Biofeedback is a new avenue for intervention and is able to remember or to use that information to help
P R

beginning to show some promising results. Rather than solve problems and guide appropriate behavior.
train underlying processes, another approach which
shows promising results in a few small studies is train-
Following brain injury, basic attentional processes
O E

ing clients on specific functional skills, such as driving (e.g. focused attention) recover in the great majority
or vocational duties. Finally, modifications to the envi- of patients, while problems with higher-order atten-
ronment, implementation of strategies, provision of tional processes may persist.3 These continuing prob-
C IN

emotional support, and introduction of external sup-
ports/aids are important parts of a rehabilitation pro-
gram, especially as the client returns to their home envi-
ronment.
M
lems may include: orienting to novel stimuli, vigi-
lance, speed of processing, shifting set, divided atten-
tion and working memory (which can be considered
to be an impairment of attentional control).

Key words: Attention - Rehabilitation - Stroke - Truma -
Brain injureis.
T he most common sequelae following brain injury
in both children and adults are deficits in attention,
concentration, memory and executive function.1 The
idea that deficits in attention impeded the recovery of
other cognitive and functional abilities was first pro-
posed and investigated by Ben-Yishay et al.2 This the-
ory proposes that intact attention is required so that
Address reprint requests to: C. Mateer, University of Victoria
Department of Psychology PO Box 3050 Victoria, BC V8W 3P5
Canada. E-mail: cmateer@uvic.ca
The goal of this paper is to summarize the
approaches to and review the evidence for remedia-
tion of attention deficits in individuals with stroke
and traumatic brain injury (TBI). Ipsilateral neglect
will not be included due to the specific assessment and
treatment considerations for the disorder. Three broad
categories for remediation will be included: 1) direct
remediation of attention processes (including training
attentional processes, medication and biofeedback);
2) specific skills training (intensive training on a spe-
cific functional task); 3) modification of the environ-
ment, self-management, and supports. While for the
purposes of this review the evidence for each of these
areas will be examined separately, in practice, most

Vol. 42 - No. 1 EUROPA MEDICOPHYSICA 59

MICHEL ATTENTION REHABILITATION FOLLOWING STROKE AND TRAUMATIC BRAIN INJURY
clinicians combine interventions, for example com-
bining direct attention training with external aids,
modifications to the environment, and training in cog-
nitive and emotional self-regulation.
A
Direct remediation of attention deficits
Training attentional processes
C
Beginning in the late 1980’s, there was an increasing
interest in providing direct training to rehabilitate atten-
T ® DI
tion functions following acquired brain injury.1, 4
Training attentional process usually involves a series
of repetitive drills or exercises which increase hierar-
chically in attentional demand as the client progress-
es. The theoretical basis of this approach is that repeat-
H E
ed activation and stimulation of attentional systems
facilitates changes in cognitive capacity, and results in
IG M
improved attentional processes. The treatment activ-
ities are, at least at the start, typically not functional
activities (e.g. meal planning, vocational tasks), as
functional activities involve multiple cognitive process-
R A
es. The activities resemble laboratory tasks, such as
detecting targets with the presence of a distracter
noise, engaging in more and more demanding work-
Y V
ing memory tasks, working on tasks that involve shift-
ing of set, and engaging in more than one task at
once (to practice divided attention). As improvements
P R
are made in these tasks, the focus of treatment shifts
to practicing the skills in real life activities, and in
O E
more naturalistic settings.
With training attentional processes, it is important
to use a treatment model that is grounded in attention
C IN
theory.1 The model which drives the attention program
dictates the aspects of attention that are to be
addressed. For example, the Attention Process Training
(APT) program 5 is based on the clinical model,1 which
M
divides attention into 5 components: focused attention,
sustained attention, selective attention, alternating
attention, and divided attention. These 5 components
provide a framework for organizing attention treatment
activities. Other training approaches may be based
on a different model, therefore clinicians should
attempt to ascertain what type of attention a particu-
lar task addresses within the broader framework of
attention theory.
Sturm et al.6 suggest that specific deficits (e.g. sus-
tained attention) require specific training, and that
training in more basic functions can improve both
basic and more complex functions. To examine this
60 EUROPA MEDICOPHYSICA
question, their study involved 38 patients with focal
lesions of vascular origin who were trained in one of
the aspects of attention found to be deficient in that
particular participant. Before and after fourten 1-h
training periods, the change in performance on the
specifically trained attention function was compared
to the change in performance for all other (untrained)
attention functions. They concluded that specific train-
ing effects followed training in specific aspects of
attention. Interestingly, training at higher levels in
those with significant deficits did not improve atten-
tion, and, in some cases, resulted in a decline in atten-
tional functioning.
These findings highlight the importance of tailoring
the remediation approach to the individual’s particu-
lar pattern of deficits. Similarly, decisions regarding
when to increase or decrease the difficulty level, or
when to start or stop a therapy program, should be
dictated by client performance. Therefore, a standard
set of intervention activities is likely less useful than
one tailored to the specific areas of weakness demon-
strated by a particular client. Activities should be hier-
archically organized, such that as the client progress-
es, the same components of attention are stimulated
at higher levels.1 For example, a sustained attention
task may begin by requiring detection of particular tar-
get numbers presented auditorily, and progress to
detection of ascending or descending sequences of
numbers, then to pairs of numbers that add to a par-
ticular sum, and finally to holding in mind and
sequencing sets of auditorily presented numbers.
More complex forms of attention (such as divided
attention) should not be trained until more basic
processes are trained. For those who have milder
deficits, the APT-II program 1 provides a more chal-
lenging experience, with higher level tasks that require
more executive aspects of attentional control (work-
ing memory, divided attention, set shifting).
Another important aspect of training attentional
process is that each task should provide sufficient
repetition to stimulate improved attentional process-
ing. An investigation of the factors associated with a
positive response to cognitive remediation in 48 adult
psychiatric outpatients revealed that there was a
threshold of treatment intensity below which there
was no treatment effect.7 Repetition may be carried on
in therapy sessions, or with the cooperation of care-
givers outside of clinical hours. For example, a recent
study by Boman et al.8 evaluated the effectiveness of
cognitive rehabilitation in adults with mild to moder-
March 2006
ATTENTION REHABILITATION FOLLOWING STROKE AND TRAUMATIC BRAIN INJURY
ate acquired brain injury in their own home or voca-
tional environment. Treatment involved APT, imple-
mentation of a generalization plan, and teaching com-
pensatory strategies for self-selected cognitive prob-
lems. It was a 9 h program conducted over 3 weeks.
The study suggested some improvement at the level
A
of specific attentional impairments, but not for activ-
ities of daily living or general everyday functioning.
C
However, this study suggests that, even when con-
ducted in the patient’s natural environment, with a
strong focus on generalization, improvement may not
T ® DI
be seen in functional activities. This study was quite
brief, and, therefore, does not rule out the possibili-
ty of success of a more intensive program. It does,
however, highlight the importance of attention to gen-
H E
eralization. Clinicians must plan for and measure gen-
eralization from attention process tasks to real-world
activities. Throughout treatment, clients should be
IG M
encouraged to apply the trained skills to everyday
activities which involve multiple cognitive process-
es. For example, the APT program includes General-
ization Sheets where clients can track their perfor-
R A
mance on everyday tasks which are specific to the
type of attention they are training.
In examining the literature on the effectiveness of
Y V
attention training, factors relating both to the indi-
vidual and to the nature of the training must be tak-
P R
en into account. Individual factors include: 1) injury
severity; 2) time postinjury (e.g. acute vs subacute); 3)
location and nature of injury (e.g. left vs right, focal vs
O E
diffuse), and other patient characteristics, including
education, motivation, age, and comorbidity.
Important characteristics of the training include: 1)
C IN
type of skills trained; 2) duration/intensity; 3) fre-
quency; 4) setting. Given the myriad of individual
and injury characteristics and variety of training
approaches, “When does it work best and for whom?”
M
may be a better question than “Does it work?”.9, 10
There have been a number of recent reviews of the
effectiveness of training attentional processes.4, 9-13 The
effectiveness of attention training may be evaluated at
multiple levels including changes on: 1) the training
task itself; 2) other psychometric measures of attention;
3) psychometric measures of other abilities (e.g. mem-
ory); 4) functional or everyday tasks; 5) neurophysi-
ological measures (e.g. electroencephalography, EEG,
or magnetic resonance imaging, MRI).
At the first level (changes in performance on the
training task), improvements have consistently been
shown across studies even in studies of patients with
Vol. 42 - No. 1 EUROPA MEDICOPHYSICA
MICHEL
severe brain injury.1 However, Park and Ingles 4 suggest
that if the only evidence is that individuals improve
on a similar task to the training task, what has occurred
is the learning of a specific skill (e.g. mentally manip-
ulating numbers) rather than improving an aspect of
attention. A more rigorous approach is to look for gen-
eralization of skills to untrained tasks (including mea-
sures of attention or other cognitive abilities). In addi-
tion, the goal of any rehabilitation program is to pro-
duce changes in the person’s ability to function in their
everyday life. Functional changes have been the most
difficult to demonstrate experimentally.
A Cochrane review 11 examined the evidence for the
effectiveness of attention training following stroke.
Only 2 studies, with a total of 56 participants, met
the stringent criteria required of a Cochrane review.14, 15
These studies both showed a benefit of training on
measures of alertness and sustained attention com-
pared to control treatments 14 or in a crossover
design.15 Only one study 14 examined measures of
functional independence, and these showed no sig-
nificant improvement with attention training. This
review concluded that there appears to be some sup-
port for treating attentional deficits in stroke patients
to improve alertness and sustained attention. However,
as neither study was conducted with the assessor
blind to the intervention category, the authors sug-
gested that the routine use of attentional training can-
not be supported or refuted.
A review by Park and Ingles 4 highlighted the impor-
tance of including control groups, and suggested that
the findings from attention training studies in acquired
brain injury may be primarily due to practice effects
rather than true gains acquired from training. They
found that while all measures of cognitive function sig-
nificantly improved from pre to post-test, none sig-
nificantly improved when control estimates were
accounted for. Of those 12 studies which included a
control condition, 6 reported no statistically significant
improvement after training. In those 6 studies which
did report improvement, Park and Ingles suggest that
the improvement seems to be more attributable to
the acquisition of specific skills rather than improve-
ment in attention per se. Criticisms of this review
include the fact that its inclusion criteria were overly
broad, for example including studies which included
participants with severe brain injury who would not
be expected to significantly benefit from training. In
addition, the types of programs and what was mea-
sured varied extensively between studies included in
61
MICHEL ATTENTION REHABILITATION FOLLOWING STROKE AND TRAUMATIC BRAIN INJURY
the review.
In another review, Cicerone et al. reported the find-
ings of a subcommittee of the American Congress of
Rehabilitation Medicine. They reviewed the evidence
for effectiveness of cognitive rehabilitation in people
with TBI and stroke. One article reviewed the evi-
A
dence up to 1997,16 followed by an updated review of
the literature from 1998 through 2002.13 The original
C
review selected 13 studies which examined the effec-
tiveness of remediation of attention deficits. Three
met criteria for a Class 1 study (well designed, prospec-
T ® DI
tive, randomized clinical trials). The others met crite-
ria for less stringent Class 2 and Class 3 studies. This
review supported the effectiveness of attention train-
ing during the postacute stage. The most recent review
H E
found 2 additional Class 1 studies, 1 on attention train-
ing 17 and 1 on strategy training,18 1 small Class 2
study, and 2 Class 3 studies. The authors concluded
IG M
that these recent studies support the earlier conclusions
regarding the effectiveness of attention training.
Attention training was recommended as a practice
standard for individuals in the postacute stage of TBI
R A
or stroke.
Sohlberg et al. provided a review of the evidence
and practice guidelines for the implementation of
Y V
direct attention training in individuals with TBI.9 As an
alternative to answering the binary question, does it
P R
work or does it not work, a template of 5 key ques-
tions are proposed which can be used to evaluate
the literature. These questions are as follows: 1) who
O E
are the participants who received the intervention?
2) What comprises the attention training? 3) What are
the outcomes of the intervention? 4) Are there method-
C IN
ological concerns? Are there other explanations for
given outcomes, and may results be either exaggerated
or hidden? 5) Are there clinically applicable trends
across different attention remediation studies? The
M
authors use these questions to evaluate the studies
identified by Cicerone et al.16 and Park and Ingles,4 as
well as 3 well designed studies published after those
reviews.17, 19, 20 In turn, they developed a set of clini-
cal recommendations/practice guidelines which follow
the above questions: 1) mildly injured, postacute
clients with intact vigilance are best suited for atten-
tion training; 2) attention training should include com-
plex attention tasks, be conducted in conjunction with
metacognitive training, and should be individualized;
3) the outcomes which can be expected are task spe-
cific, at the impairment level. It is unknown whether
generalization to untrained or functional level tasks
62 EUROPA MEDICOPHYSICA
occurs.
A task force of the European Federation of
Neurological Societies also evaluated the effective-
ness of cognitive rehabilitation.12 This report specifi-
cally reviewed the evidence for acute (1 Class 1 and
2 Class 2 studies) versus the evidence for postacute (2
Class 1 and 2 Class 2 studies) attention training. They
concluded that while evidence is not able to distin-
guish the effects of attention training from sponta-
neous recovery in the acute phase of recovery, there
is sufficient Class 1 evidence to support attention
training in the postacute phase.
Given the evidence that specific aspects of attention
can be improved through training, the next question
is: what are the neurophysiological correlates of these
changes? This question is beginning to be addressed
by researchers who examine changes in brain func-
tioning before and after attention training. For exam-
ple, Sturm 21 conducted functional magnetic reso-
nance imaging (fMRI) before and after alertness train-
ing in 8 postacute subjects with right hemisphere vas-
cular lesions, in order to test the hypothesis that
improvement on an attention task is related to reor-
ganization of attentional processes in the brain. Four
subjects were given computerized attention training
using a car-driving paradigm. Four control subjects
were trained in verbal and topographical memory.
Fourteen 45-min sessions were conducted with pre
and post fMRI and PET scans. Three of the 4 in the
treatment group improved and showed the expected
change of activation pattern in the right fronto-parietal
area. The one who did not improve showed an
increase of activation only in the left hemisphere. In
contrast, only 1 of the 4 in the memory group
improved, while another participant in the memory
group showed a change in the activation pattern sim-
ilar to the treatment group. This suggests that an
increase in attention can only occur if at least part of
the right hemisphere network (and especially the
frontal region), is reactivated.
Medication
Methylphenidate (MP) and other psychostimulant
medication have been successfully used to treat atten-
tion deficit hyperactivity disorder (ADHD). A recent
meta-analysis of the last 40 years of research con-
cluded that MP consistently improves the core clini-
cal features of ADHD.22
Whyte et al.23 conducted a detailed review and cri-
March 2006
ATTENTION REHABILITATION FOLLOWING STROKE AND TRAUMATIC BRAIN INJURY
tique of research into the use of psychostimulant med-
ication in TBI. They found 10 controlled studies of the
effects of MP in brain injury (2 of these were in the
pediatric population). Of these 10, 6 reported some
measure of attentional function. However, large dif-
ferences in sample characteristics, experimental rigor,
A
statistical power, dependent measures and other fac-
tors made the studies difficult to compare. Overall,
C
they concluded that the evidence indicates that psy-
chostimulant medication does not have a very strong
effect on aspects of attention such as sustained atten-
T ® DI
tion or resistance to distraction. In contrast, medica-
tion does seem to have a positive effect on process-
ing speed. A recent double-blind, placebo-controlled
study of 34 adults in the postacute stage of moderate
H E
to severe TBI supported this conclusion.24 Three vari-
ables showed statistically significant improvement in
both the pilot and the replication samples: speed of
IG M
information processing, attentiveness during individ-
ual work tasks and caregiver ratings of attention. Effect
sizes were small to medium. Whyte et al.24 have sug-
gested that medication may provide incremental ben-
R A
efit when combined with training attentional process-
es, as medication affects speed of processing, an area
typically unaffected by attentional training.
Y V
Biofeedback
P R
EEG biofeedback is an operant conditioning pro-
cedure where, through feedback, an individual is
O E
trained to modify the amplitude, frequency or coher-
ence of his or her brain waves. A number of studies
have supported the notion that people with atten-
C IN
tional problems (e.g. ADHD) have increased power in
delta, theta and alpha frequency bands (the bands
involved in drowsy conditions), and decreased pow-
er in the beta frequency band (involved in more active
M
cognitive processes) relative to arousal. Biofeedback
treatment in ADHD typically involves theta-beta train-
ing, where individuals are trained to increase beta
and decrease theta waves (see a review of EEG use in
the assessment and treatment of ADHD 25). A similar
beta-increasing biofeedback procedure has been
found to be effective in enhancing attention in normal
subjects.26
A number of investigators have found EEG differ-
ences in patients with acquired brain injuries,27 and
EEG biofeedback has been used as a treatment in
such individuals. For example, in one study, a group
of 27 individuals with brain injury (stroke, TBI or
Vol. 42 - No. 1 EUROPA MEDICOPHYSICA
MICHEL
hemispherectomy) received 3 to 5 thirty-min biofeed-
back sessions per week. Successful alterations of EEG
parameters were found in patients with mild to severe
brain damage. Symptom improvement (based on
agreement between client, caregiver and physician
report) was also found, but did not correlate with
EEG changes.28
Stathopoulou and Lubar 29 suggested that atten-
tional processes training may work in the same way
as biofeedback, by training individuals to modify their
brain waves. They examined 5 subjects with TBI
before and after 22 sessions of computerized APT.
While results showed an improvement in attention
on psychometric measures in all participants, the
expected EEG changes were not consistently found.
Only a reduction in alpha frequency was consistent
with the hypothesis in most of the participants. Follow-
up with a larger sample size and a nontreated control
group is necessary.
Another study 30 administered 6 months of stan-
dardized, computerized cognitive remediation to 21
adults with severe closed head injury. Subjects were
compared to 22 matched head-injured controls who did
not receive training. While the groups showed some sig-
nificant differences on neurophysiological measures
following treatment, the authors concluded that the
pattern of differences was consistent with increased
motivation, attentional effort and improved stimulus
processing, rather that improved attentional selectivity.
Finally, Penkman and Mateer 31 examined both
behavioral and event-related potential (ERP) corre-
lates of brain activity using the P300 oddball para-
digm. Multiple baseline measures of attentional behav-
ior and brain activity were taken before 3 weeks of
attention training, administered in a group format,
and again after training. Although pretreatment base-
line measures were stable, post-treatment, there were
both improvements on attention measures and
changes in the pattern of N100 and P200 waveforms
associated with the P300 tasks. The changes differed
across participants, however, suggesting that under-
lying brain based correlates of attentional problems dif-
fered across subjects or that training effects had dif-
ferent neural substrates.
Specific skills training
Training attentional processes has been criticized for
its lack of focus on functional changes,4 and specific
skills training has been proposed as an alternative.
63
MICHEL ATTENTION REHABILITATION FOLLOWING STROKE AND TRAUMATIC BRAIN INJURY
Specific skills training attempts to train (or retrain) skills
of functional significance, such as driving, or specific
vocational tasks. The theoretical rationale behind spe-
cific skills training is that it is possible for brain-damaged
individuals to develop skills that rely on preserved
brain areas. When a specific skill is learned in this way,
A
the cognitive processes used in the tasks may be dif-
ferent from the processes a non brain-damaged indi-
C
vidual would use.32 This contrasts with the theory
behind training attentional processes, in which basic
attentional skills are retrained such that the individual
T ® DI
uses the same processes as a non brain-damaged indi-
vidual performing the same task. In specific skills train-
ing, there is little or no expectation of generalization to
untrained abilities, whereas in attentional processes
H E
training, the theory is that it is possible to train under-
lying attentional processes, which will in turn improve
higher, more complex cognitive functions.
IG M
In their meta-analysis of attention rehabilitation,
Park and Ingles 4 found 4 studies which focused on
performing a specific functional skill, or a closely
related skill, that required attention.33-36 The review
R A
concluded that all specific areas assessed (activities of
daily living, driving and attention behavior) increased
from pre to post-test. Unlike APT, which yielded non
Y V
significant results when the control conditions were
accounted for, driving and attention behavior remained
P R
significant even when the control condition was
accounted for. It should be noted that the sample
sizes for specific skills studies were extremely small.
O E
For example, only one subject was included in each
of the 2 categories with pre/post control. However, the
small studies are encouraging, and worthy of increased
C IN
attention.
A major challenge for rehabilitation professionals is
how to actually work with individuals in functional set-
tings. Working in people’s homes, communities,
M
schools, and places of employment might be very
valuable, but is often expensive and/or difficult to
implement within the limitations of medical rehabil-
itation programs. One promising approach in other
areas of psychological treatment has been the use of
virtual environments. These three-dimensional, immer-
sive environments are achieved through the use of
specialized helmets or goggles. The technology, once
rather exotic and very expensive, has reduced in price
and is much more flexible and available. It has been
used in the treatment of a variety of psychological
disorders (e.g., phobias) and has more recently begun
to be used in rehabilitative contexts. Rizzo et al.37
64 EUROPA MEDICOPHYSICA
have begun to develop virtual environments that mim-
ic household, community, and office settings in which
attentional, memory and planning tasks can be pre-
sented. Practice in these virtual contexts has been
shown to generalize in a number of studies to real
world environments as well.
Strategies and supports
Self management strategies, environmental sup-
ports, and environmental modifications may be imple-
mented in conjunction with, or as an alternative to,
training of attentional processes or functional skills.
They may be most useful later in the recovery phase,
when an individual is reintegrating into home and
work environments. At these times, specific strate-
gies or supports may be the most practical form of mit-
igating problems in specific situations. Strategies and
supports can be divided into 2 broad categories: 1)
external support and modifications (which involve
modification of the environment in some way); 2)
self-management strategies. Careful attention to assess-
ment of a client’s strengths and weaknesses will help
the clinician to choose the most effective strategies. To
increase the chances of success, clients should be
involved as much as possible in the selection and
development of strategies and supports.1
Supports and modifications
Implementation of external modifications, supports
and strategies to minimize the effects of attention
deficits should be considered as part of any rehabili-
tation program. For example, if distracting environ-
ments are a problem, the client may be encouraged to
avoid those environments whenever possible.
Modifications could also include strategies to reduce
or eliminate distractions during tasks which require
attention (e.g. facing away from visual distractions,
using earplugs, shopping in less crowded environ-
ments). In addition, specific modifications may be
made to the client’s environment to reduce attentional
demands. Organizational systems (e.g. filing systems,
bill paying systems, labeling of cupboards) are one
such approach. Another approach is reducing visual
distractions and clutter.1
Some have found the use of external devices help-
ful. A recent review describes the state of the art in
assistive technology for cognition (ATC) for those with
March 2006
ATTENTION REHABILITATION FOLLOWING STROKE AND TRAUMATIC BRAIN INJURY
deficits in a diverse range of cognitive skills.38 ATCs
range from alarms to remind a client to take their med-
ication to robotic technology utilizing artificial neural
networks to assist with everyday activities. This review
discusses ATCs for problems with initiation, attention,
memory, executive function, and sensory processing
A
impairments as well as for social and behavioral prob-
lems. Of note is the high level of customization (and
C
recustomization as the client’s needs change) required
in order for an ATC device to be of practical use.
Indeed, today there are a number of assistive devices
T ® DI
designed specifically for individuals with cognitive
deficits. Some programs provide a high level of guid-
ance and structure, such as walking a client through the
steps required to make dinner. In addition, a new gen-
H E
eration of devices provides context-sensitive cues
based on sensors placed in the client’s environment
(e.g. a cue to wash hands when in the bathroom if
IG M
the water has not yet been turned on). The clinician
should note that anyone, especially someone with
cognitive deficits, needs time to effectively utilize sup-
ports and modifications. Therefore, sufficient time
R A
should be set aside for teaching their use.
Y V
Self-management strategies
Sohlberg and Mateer 1 describe 3 types of self-man-
agement strategies aimed at helping clients deliber-
P R
ately focus their attention. The first is orienting proce-
dures, which encourage clients to consciously monitor
O E
their activities in order to avoid lapses in attention.
This may be a general orienting procedure (e.g. to
focus them on the task at hand), or may be designed
C IN
for a specific task (e.g. to avoid forgetting their desti-
nation while they are driving). Second, pacing strate-
gies may be helpful for clients who experience fatigue
or difficulty maintaining concentration over an extend-
M
ed period. These may involve setting realistic expec-
tations, building in breaks, or self-monitoring of
fatigue/attention levels. Finally, the “key ideas log”
involves teaching people to quickly write or tape record
questions or ideas which they want to address later, so
that they may continue with the task at hand. As with
supports and modifications, it is important to allocate
sufficient time to effectively establish a strategy.
Typically, the research literature in this area is
restricted to case reports which describe the proce-
dures and outcomes for an individual client. However,
one approach which has been studied in a small
group format is time pressure management (TPM).18
Vol. 42 - No. 1 EUROPA MEDICOPHYSICA
MICHEL
This program was designed to provide cognitive strate-
gies to compensate for deficits in speed of processing
during daily tasks such as holding a conversation or
preparing a meal. Strategies involved included enhanc-
ing awareness, planning and organization, rehears-
ing of task requirements or modifying the environ-
ment, all with the goal of preventing or managing
time pressure. The study included 22 individuals in the
chronic or subacute stage following a severe to very
severe closed head injury. Subjects were randomized
into 2 conditions: 12 subjects participated in TPM
training while 10 participated in concentration train-
ing (a control condition). While both groups showed
some improvement, TPM produced larger gains and
also appeared to generalize to other measures of
speed and memory function.
Another approach to research into the effective-
ness of strategy use is combining it with direct atten-
tion training. Cicerone 19 took this approach, com-
bining working memory training with encouraging
participants to consciously use strategies to allocate
attention and manage the rate of information.
Strategies included verbal mediation, self-pacing strate-
gies, sharing attentional resources during multiple
tasks, self-monitoring of mental effort, and manage-
ment of secondary emotional reactions during task
performance. Compared to untreated controls, those
who participated in treatment were more likely to
exhibit clinically significant improvement on mea-
sures of attention and reduction of self-reported atten-
tional difficulties in their daily functioning. However,
in this study, strategy use was confounded with atten-
tion training. Further research is required which would
examine the incremental benefit of adding strategy
training to attention training.
It is well acknowledged that awareness of and
insight into the nature of one’s own difficulties may be
compromised after brain injury. In a recent study by
Sawchyn et al.39 individuals with moderate to severe
brain injury tended to underappreciate cognitive
impairments, whereas individuals with mild brain
injury often appeared to report much great difficulties
in cognition than were observed by others. Working
on attentional skills can often assist the injured indi-
vidual in gaining some insight into the nature of their
cognitive difficulties and in managing their emotion-
al response to cognitive challenges (often frustration
or hopelessness). Mateer 1, 40 emphasizes the impor-
tance of integrating cognitive interventions with inter-
ventions designed to manage such emotional respons-
65
MICHEL ATTENTION REHABILITATION FOLLOWING STROKE AND TRAUMATIC BRAIN INJURY
es and to correct negative beliefs about cognitive abil-
ity that lead to catastrophic reactions and avoidance
of cognitive challenges. In particular, blending prin-
ciples of cognitive-behavioral therapy (CBT) with cog-
nitive interventions has been found to be beneficial.
This approach builds self-confidence in cognitive abil-
A
ities, and assists the individual in feeling that their
own actions (metacognitive strategies, external aids,
C
etc.) can influence how successful they are in man-
aging everyday cognitive demands.
T ® DI
Conclusions
Twenty-five years of research has demonstrated
H E
that while attentional capacities are sensitive to brain
injury, they are also amenable to intervention. One
method of rehabilitation is direct training of basic
IG M
attentional processes. Numerous studies have sup-
ported the ability of attentional process training to
improve attentional functioning in individuals in the
postacute stage. However, its ability to generalize to
R A
untrained abilities or functional capacity has yet to
be conclusively demonstrated. Psychostimulant med-
ication appears to be another avenue for rehabilitation,
Y V
primarily impacting processing speed, and, therefore,
may be particularly useful when used in combina-
P R
tion with training attentional processes. While a num-
ber of studies have demonstrated neurophysiologi-
cal changes (e.g. fMRI, EEG, ERP) changes with atten-
O E
tion training, evidence is just beginning to accumulate
for the effectiveness of biofeedback as a treatment.
There are a few studies which suggest that training
C IN
of specific skills, such as driving, can be a successful
method for retraining those with attention deficits.
The availability of specialized virtual reality programs
provides an exciting new avenue for such training.
M
Finally, modifications to the environment, the imple-
mentation of strategies, emotional support, and exter-
nal supports are important parts of a rehabilitation
program, especially as the client returns to their home
environment. Whatever approach is taken, it is vital
that it be guided by the individual’s strengths and
weaknesses and be implemented in full cooperation
with the client.
References
1. Sohlberg MM, Mateer CA. Cognitive Rehabilitation, an Integrative
Neuropsychological Approach. New York: Guildford Press; 2001.
66 EUROPA MEDICOPHYSICA
2. Ben-Yishay Y, Piasetsky EB, Rattock J. A systematic method for
ameliorating disorders in basic attention. In: Meier MJ, Benton
AL, Diller L editors. Neuropsychological Rehabilitation. New York:
Churchill Livingstone; 1987.p.165-81.
3. Mateer CA, Sohlberg MM, Crinean JJ. Focus on clinical research:
perceptions of memory function in individuals with closed-head
injury. Head Trauma Rehabil 1987;2:74-84.
4. Park NW, Ingles JL. Effectiveness of attention rehabilitation after
an acquired brain injury: a meta-analysis. Neuropsychology
2001;15:199-210.
5. Sohlberg MM, Mateer CA. Attention Process Training I and II.
Wake Forest, NC: Lash and Associates Publishing; 2001.
6. Sturm W, Wilmes K, Orgass B. Do specific attention deficits need
specific training? Neuropsychol Rehabil 1997;7:81-103.
7. Choi J, Medalia A. Factors associated with a positive response to
cognitive remediation in a community psychiatric sample. Psychiatr
Serv 2005;56:602-4.
8. Boman IL, Lindstedt M, Hemmingsson H. Cognitive training in
home environment. Brain Inj 2004;18:985-95.
9. Sohlberg MM, Avery J, Kennedy M, Ylvisaker M, Coelho C, Turkstra
L et al. Practice guidelines for direct attention training. J Med
Speech Lang Pathol 2003;11:19-39.
10. Sohlberg MM. Can disabilities resulting from attentional impair-
ments be treated effectively? In: Halligan PW, Wade DT editors.
Effectiveness of rehabilitation for cognitive deficits.Oxford: Oxford
University Press; 2005. p.91-102.
11. Lincoln NB, Majid MJ, Weyman N. Cognitive rehabilitation for
attention deficits following stroke. Cochrane Database Syst Rev
2000;(4):CD002842.
12. 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;10:11-23.
13. Cicerone KD, Dahlberg C, Malec JF, Langenbahn DM, Felicetti T,
Kneipp S et al. Evidence-based cognitive rehabilitation: updated
review of the literature from 1998 through 2002. Arch Phys Med
Rehabil 2005;86:1681-91.
14. Schottke H. [Rehabilitation of attention deficits after stroke -
Effectivity of a neuropsychological training program for attention
deficits]. Verhaltenstherapie 1997;7:21-3. German.
15. Sturm W, Willmes K. Efficacy of a reaction training on various
attentional and cognitive functions in stroke patients. Neuropsychol
Rehabil 1991;1:259-80.
16. Cicerone KD, Dahlberg C, Kalmar K, Langenbahn DM, Malec JF,
Bergquist TF et al. Evidence-based cognitive rehabilitation: rec-
ommendations for clinical practice. Arch Phys Med Rehabil
2000;81:1596-615.
17. Sohlberg MM, McLaughlin KA, Pavese A, Heidrich A, Posner MI.
Evaluation of attention process training and brain injury education
in persons with acquired brain injury. J Clin Exp Neuropsychol
2000;22:656-76.
18. Fasotti L, Kovacs F, Eling PA, Brouwer WH. Time pressure man-
agement as a compensatory strategy training after closed head
injury. Neuropsychol Rehabil 2000;10:47-65.
19. Cicerone KD. Remediation of ‘working attention’ in mild trau-
matic brain injury. Brain Inj 2002;16:185-95.
20. Park NW, Proulx G, Towers W. Evaluation of the Attention Process
Training Programme. Neuropsychol Rehabil 1999;9:135-54.
21. Sturm W, Longoni F, Weis S. Functional reorganisation in patients
with right hemisphere stroke after training of alertness: a longitu-
dinal PET and fMRI study in eight cases. Neuropsychologia
2004;42:434-50.
22. Conners CK. Forty years of methylphenidate treatment in attention-
deficit/hyperactivity disorder. J Atten Disord 2002;6 Suppl 1:S17-
30.
23. Whyte J, Vaccaro M, Grieb-Neff P. Psychostimulant use in the
rehabilitation of individuals with traumatic brain injury. J Head
Trauma Rehabil 2002;17:284-99.
24. Whyte J, Hart T, Vaccaro M, Grieb-Neff P, Risser A, Polansky M et
al. Effects of methylphenidate on attention deficits after traumat-
March 2006
ATTENTION REHABILITATION FOLLOWING STROKE AND TRAUMATIC BRAIN INJURY
ic brain injury: a multidimensional, randomized, controlled trial.
Am J Phys Med Rehabil 2004;83:401-20.
25. Loo SK, Barkley RA. Clinical utility of EEG in attention deficit
hyperactivity disorder. Appl Neuropsychol 2005;12:64-76.
26. Egner T, Gruzelier JH. The temporal dynamics of electroen-
cephalographic responses to alpha/theta neurofeedback training
in healthy subjects. J Neurotherapy 2004;8:43-57.
27. Thatcher RW, Walker RA, Gerson I, Geisler FH. EEG discriminant
A
analyses of mild head trauma. Electroencephalogr Clin Neuro-
physiol 1989;73:94-106.
28. Laibow RE, Stubblebine AN, Sandground H. EEG-NeuroBio-
C
Feedback treatment of patients with brain injury: Part 2: Changes
in EEG parameters versus rehabilitation. J Neurother 2001;5:45-68.
29. Stathopoulou S, Lubar JF. EEG changes in traumatic brain injured
patients after cognitive rehabilitation. J Neurotherapy 2004;8:21-51.
T ® DI
30. Baribeau J, Ethier M, Braun C. A neurophysiological assessment of
selective attention before and after cognitive remediation in patients
with severe closed head injury. J Neurolog Rehabil 1989;3:71-92.
31. Penkman L, Mateer CA. The specificity of attention retraining in
traumatic brain injury. J Cognitive Rehabil 2004;22:13-26.
32. Backman L, Dixon RA. Psychological compensation: a theoretical
33.
H E
framework. Psychol Bull 1992;112:259-83.
Carter LT, Oliveira DO, Duponte J, Lynch SV. The relationship of
IG M
R A
Y V
P R
O E
C IN
M
Vol. 42 - No. 1 EUROPA MEDICOPHYSICA
MICHEL
cognitive skills performance to activities of daily living in stroke
patients. Am J Occup Ther 1988;42:449-55.
34. Kewman DG, Seigerman C, Kinter H, Chu S, Henson D, Reeder C.
Simulation training of psychomotor skills: teaching the brain-
injured to drive. Rehabil Psychol 1985;30:11-27.
35. Sivak M, Hill CS, Henson DL, Butler BP, Silber SM, Olson PL.
Improved driving performance following perceptual training in per-
sons with brain damage. Arch Phys Med Rehabil 1984;65:163-7.
36. Wilson C, Robertson IH. A home-based intervention for atten-
tional slips following head injury: a single case study. Neuropsychol
Rehabil 1992;2:193-205.
37. Rizzo AA, Schultheis M, Kerns KA, Mateer CA. Analysis of assets
for virtual reality applications in neuropsychology. Neuropsychol
Rehabil 2004;14:207-39.
38. LoPresti EF, Mihailidis A, Kirsch N. Assistive technology for cog-
nitive rehabilitation: State of the art. Neuropsychol Rehabil
2004;14:5-39.
39. Sawchyn JM, Mateer CA, Suffield JB. Awareness, emotional adjust-
ment, and injury severity in postacute brain injury. J Head Trauma
Rehabil 2005;20:301-14.
40. Mateer CA, Sira CS, O’Connell ME. Putting Humpty Dumpty togeth-
er again, the importance of integrating cognitive and emotional
interventions. J Head Trauma Rehabil 2005;20:58-70.
67