J Head Trauma Rehabil

Vol. 38, No. 1, pp. 38–51

Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc.

INCOG 2.0 Guidelines for Cognitive

Rehabilitation Following Traumatic
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Brain Injury, Part II: Attention and

Information Processing Speed
Jennie Ponsford, AO, PhD, MA; Diana Velikonja, PhD, MScCP; Shannon Janzen, MSc;
Amber Harnett, MSc, BSc; Amanda McIntyre, RN;
Catherine Wiseman-Hakes, PhD, Reg CASLPO; Leanne Togher, PhD, BAppSc;
Robert Teasell, MD, FRCPC; Ailene Kua, MSc, PMP; Eleni Patsakos, MSc;
Penny Welch-West, MCLSc, SLP Reg CASLPO; Mark Theodore Bayley, MD, FRCPC

Introduction: Moderate to severe traumatic brain injury (MS-TBI) commonly causes disruption in aspects of
attention due to its diffuse nature and injury to frontotemporal and midbrain reticular activating systems. Attentional
impairments are a common focus of cognitive rehabilitation, and increased awareness of evidence is needed to
facilitate informed clinical practice. Methods: An expert panel of clinicians/researchers (known as INCOG) reviewed
evidence published from 2014 and developed updated guidelines for the management of attention in adults, as well
as a decision-making algorithm, and an audit tool for review of clinical practice. Results: This update incorporated
27 studies and made 11 recommendations. Two new recommendations regarding transcranial stimulation and an
herbal supplement were made. Five were updated from INCOG 2014 and 4 were unchanged. The team recommends
screening for and addressing factors contributing to attentional problems, including hearing, vision, fatigue, sleep-
wake disturbance, anxiety, depression, pain, substance use, and medication. Metacognitive strategy training focused
on everyday activities is recommended for individuals with mild-moderate attentional impairments. Practice on de-
contextualized computer-based attentional tasks is not recommended because of lack of evidence of generalization,
but direct training on everyday tasks, including dual tasks or dealing with background noise, may lead to gains
for performance of those tasks. Potential usefulness of environmental modifications is also discussed. There is
insufficient evidence to support mindfulness-based meditation, periodic alerting, or noninvasive brain stimulation

Author Affiliations: Monash-Epworth Rehabilitation Research Centre, The authors gratefully acknowledge the support of the Ministry of Health of the
Turner Institute for Brain and Mental Health, School of Psychological province of Ontario, Canada.
Sciences, Monash University, Melbourne, Australia, and Epworth
The project described in this manuscript was funded through the Ministry
Healthcare, Melbourne Australia (Dr Ponsford); Acquired Brain Injury
of Health of the province of Ontario, Canada (Lead: Dr Mark Bayley).
Program, Hamilton Health Sciences, Hamilton, Ontario, Canada, and
The authors declare that no competing financial interests exist. The authors
Department of Psychiatry and Behavioural Neurosciences, DeGroote
further declare that the funders did not participate in the organization of the
School of Medicine, McMaster University, Hamilton, Ontario, Canada
project, nor the expert panel process, evidence synthesis, or formulation of the
(Dr Velikonja); Lawson Health Research Institute, Parkwood Institute,
recommendations.The opinions, results and conclusions reported are those of
London, Ontario, Canada (Mss Janzen, Harnett, and McIntyre and Dr
the authors. No endorsement by the Ontario Ministry of Health is intended or
Teasell); Speech Language Pathology Program, School of Rehabilitation
should be inferred.
Science, McMaster University, Hamilton, Ontario, Canada, and KITE
Research Institute, Toronto Rehabilitation Institute—University Health This is an open-access article distributed under the terms of the Creative
Network, Toronto, Ontario, Canada (Drs Wiseman-Hakes and Bayley Commons Attribution-Non Commercial-No Derivatives License 4.0
and Mss Patsakos and Kua); Faculty of Health Sciences, The University of (CCBY-NC-ND), where it is permissible to download and share the work
Sydney, New South Wales, Australia, and NHMRC Centre of Research provided it is properly cited. The work cannot be changed in any way or used
Excellence in Aphasia Rehabilitation, Australia (Dr Togher); Department commercially without permission from the journal.
of Physical Medicine and Rehabilitation, Schulich School of Medicine &
Dentistry, University of Western Ontario, London, Ontario, Canada (Dr The authors declare no conflicts of interest.
Teasell); Parkwood Institute, St Joseph’s Health Care, and School of
Corresponding Author: Jennie Ponsford, AO, PhD, MA, Monash-Epworth
Communication Sciences and Disorders, University of Western Ontario,
Rehabilitation Research Centre, Epworth Healthcare, 89 Bridge Rd, Rich-
London, Ontario, Canada (Ms Welch-West); and Temerty Faculty of
mond, Victoria 3121, Australia (jennie.ponsford@monash.edu).
Medicine, University of Toronto, Ontario, Canada (Dr Bayley); on behalf
of the INCOG Expert Panel. DOI: 10.1097/HTR.0000000000000839
38
 INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part II 39

for alleviating attentional impairments. Of pharmacological interventions, methylphenidate is recommended to

improve information processing speed. Amantadine may facilitate arousal in comatose or vegetative patients but
does not enhance performance on attentional measures over the longer term. The antioxidant Chinese herbal
supplement MLC901 (NeuroAiD IITM) may enhance selective attention in individuals with mild-moderate TBI.
Conclusion: Evidence for interventions to improve attention after TBI is slowly growing. However, more controlled
trials are needed, especially evaluating behavioral or nonpharmacological interventions for attention. Key words:
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attention, cognitive rehabilitation, information processing, traumatic brain injury

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A TTENTION IS A COMPLEX and multidimen-

sional construct. Component processes identified
in theoretical models include arousal, selective atten-
METHODS

Updated INCOG guideline

tion, speed of information processing, and strategic con-
The reader is referred to the Methods article of
trol of attention, including sustained attention, shifting,
this series (INCOG 2.0: Methods, Overview, and
and dividing of attention and working memory.1 Trau-
Principles)29 for a complete review of the strategies
matic brain injury (TBI) may disrupt any or all of these
used for the updated literature review (after 2014)
processes, given its diffuse nature and high frequency of
and development of the recommendations and other
injury to neural networks and neurotransmitter systems
tools. The Updated INCOG (with INCOG being an
in the frontotemporal and midbrain reticular activating
acronym standing for “International Cognitive”) Guide-
systems.2 Among individuals with TBI, experimental
line follows a thorough search, review, and critical
studies have confirmed the presence of slowed infor-
evaluation of currently published studies in adults
mation processing,3–5 working memory difficulties,6,7
for each domain including principles of assessment,
impaired vigilance or sustained attention,8,9 diffi-
posttraumatic amnesia, attention, memory, executive
culty dividing attention with high working memory
functions, and cognitive communication. An inter-
load,5,10,11 behavioral distraction,12 and problems with
national expert panel comprising TBI cognitive re-
goal-directed allocation of attention.13,14 Attention rep-
habilitation researchers and clinicians from the first
resents an important component of executive function,
version of INCOG formed the authors. In prepara-
memory, and communication,15 and the reader is
tion, a detailed internet and MEDLINE search was
therefore also referred to the INCOG reviews of in-
conducted to identify new published TBI and cognitive
terventions for executive functions,16 memory,17 and
rehabilitation evidence-based guidelines (after 2014).
cognitive-communication difficulties.18 Attentional dif-
A systematic search (2014 to July 2021) of multiple
ficulties are reported by more than 60% of individuals
databases (MEDLINE, EMBASE, Cochrane, CINAHL,
with moderate to severe traumatic brain injury (MS-
PsycINFO) was also conducted to identify TBI arti-
TBI) over 10 or more years postinjury19–21 and are
cles and reviews. Research articles meeting inclusion
also common following mild TBI.22 Attentional im-
but published after July 2021 were added on the ba-
pairments contribute to difficulty with work, study,
sis of the discretion of the expert panel. Two authors
and social interaction.19 They may also be associated
independently aligned the research articles within the
with impairments of hearing, including central audi-
existing INCOG guidelines and flagged areas where new
tory processing23 or vision, or with anxiety,24 fatigue,25
guidelines may be warranted on the basis of the re-
and sleep-wake disturbances.26 Therefore, improving
search evidence. This synopsis of evidence for attention
or maximizing attention represents an important re-
was distributed to the INCOG 2022 attention working
habilitation goal. A recent survey of 115 allied health
group. During the series of videoconference meetings,
professionals worldwide identified that addressing at-
the working group examined the recommendations ma-
tentional impairments was the second most commonly
trix and updated some recommendations based on new
reported focus of cognitive rehabilitation.27 However,
evidence, articulated novel recommendations based on
increased awareness of up-to-date evidence is needed
the evidence available, and considered the clinical ap-
to facilitate informed clinical practice. As such, the
plicability of recommendations to enhance outcomes
purpose of this article was to evaluate the effective-
for individuals with TBI. For each recommendation,
ness of specific approaches to ameliorating attentional
the cumulative evidence (studies used in the original
difficulties, including pharmacologic interventions, to
guidelines and new articles) was evaluated by the panel
provide an update to the INCOG 2014 guidelines
in terms of study design and study quality to deter-
for the management of attention in individuals with
mine the level of evidence grading (see Table 1). All
TBI.28
relevant references from 2014 were consolidated into

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 40 Journal of Head Trauma Rehabilitation/January–February 2023
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
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size with relevant control group.
B: Recommendation supported by cohort
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studies that at minimum have a
comparison group (includes small
randomized controlled trials) and
well-designed single case experimental
designs.
C: Recommendation supported primarily by
expert opinion based on their experience
though uncontrolled case studies or series
may also be included here.
a reference library that was made available to the au-
thor teams as they drafted the article and finalized the
recommendations accordingly. Consensus of the work-
ing group was reached when members unanimously
agreed to the wording and evidence grading assign-
ment of all the recommendations. By the end, the
team added 27 new references related to attention from
2014 and after for inclusion in the recommendations
in this article. The clinical algorithm and audit tool
was updated accordingly in the management area of
attention.
LIMITATIONS OF USE AND DISCLAIMER
These guidelines are informed by evidence for TBI
cognitive rehabilitation interventions published up to
time of review. Relevant evidence published after the
INCOG guideline could influence the recommenda-
tions contained herein. Clinicians must also consider
their own clinical judgment, patient preferences, and
contextual factors such as resource availability in their
decision-making processes about implementation of
these recommendations.
The INCOG developers, contributors, and supporting
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.
RESULTS
Recommendations and literature review
The expert panel made 11 recommendations, with 2
new recommendations, 5 updated from INCOG 2014,
and 4 remaining unchanged from INCOG 2014. Six
recommendations are based on level A evidence, 3 on
level B, and 2 on level C evidence. Since 2014, there
have been 27 studies published in this area. Table 2 sets
out the recommendations and supporting evidence for
each.
Nonpharmacological strategies to enhance attention
Attention no. 1: Clinicians should screen for and address
factors that impact attention including hearing, vision, fatigue,
sleep-wake disturbance, anxiety, depression, pain, substance
use, and medication (updated from INCOG 2014,28 (p326)
Attention 4). Level C evidence.
Other factors, some of which may be related to
the brain injury, may exacerbate attentional difficul-
ties, including hearing and central auditory processing
disorder, vision, fatigue, sleep-wake disturbances, anx-
iety, depression, pain, substance use, and medication.
Therefore, this recommendation has been expanded to
cover this broader range of symptoms that may affect
attention. It is important to screen for the potential
impact of these factors while assessing attention us-
ing neuropsychological measures and rating scales and
address them wherever possible. It is imperative that
accommodations are made for sensory loss or distur-
bance, including availability of eyeglasses and hearing
aids to ensure accurate assessment and interventions
(in attention). Methylphenidate may be used to treat
fatigue, resulting in increased speed of information
processing.30 One small cohort study has shown that
individualized treatment of sleep-wake disorders may
result in self-reported improvements in attention,31 but
there have been no controlled trials evaluating the
impact of nonpharmacological interventions for sleep-
wake disturbance on attention after TBI. We failed to
identify any study that formally evaluated the impact
of interventions for anxiety, depression, pain, substance
use, and medication changes on attention in individuals
with TBI. Nevertheless, it is our expert opinion that
such factors should be considered and addressed before
implementing other forms of intervention.
Attention no. 2: Metacognitive strategy training using func-
tional everyday activities should be considered for individuals
with TBI, especially those with mild-moderate attention deficits
(updated from INCOG 2014,28 (pp324–325) Attention 1). Level
A evidence.
This recommendation has been updated from
INCOG 2014. In the INCOG 2014 guideline, we
reported level A evidence that strategies may be
developed, practiced, and applied to compensate for
attentional problems, specifically speed of information
processing. This evidence came from the work of Fasotti
et al32 in trialing time pressure management (TPM) to
enhance coping with slowed information processing.
The 3-step training program facilitates awareness of
manifestations of mental slowness in daily activities
and encourages the development of managing steps
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TABLE 2 INCOG 2.0 guideline recommendations for attention and information-processing speed and new supporting
a
evidence
Guideline recommendation Grade Reviews RCTs Other
Nonpharmacological interventions for attention/information processing speed
Attention Clinicians should screen for and address factors that impact C Johansson et al30
no. 1 attention including hearing, vision, fatigue, sleep-wake
disturbance, anxiety, depression, pain, substance use, and
medication (updated from INCOG 2014,28(p326) Attention 4).
Attention Metacognitive strategy training using functional everyday A Cicerone et al50 Dymowski et al35
no. 2 activities should be considered for individuals with TBI, Roitsch et al40
especially those with mild-moderate attention deficits Virk et al36
(updated from INCOG 2014,28(pp324–325) Attention 1).
Attention Computer-based de-contextualized attentional tasks for B Bogdanova et al41 Dundon et al51
no. 3 individuals with TBI are NOT recommended because of lack Cicerone et al50 Straudi et al42
of demonstrated impact on everyday attentional functions.
Everyday task-specific training should be considered but
cannot be expected to generalize beyond trained or similar
tasks (updated from INCOG 2014,28(pp326–327) Attention 6).
Attention Training in dual tasking for individuals with TBI can be used to A
no. 4 improve dual-task performance, only on tasks similar to
those trained (INCOG 2014,28(p325) Attention 2).
Attention Training with periodic random auditory alerting tones is not B Dymowski et al35
no. 5 recommended for addressing attentional deficits following
TBI (INCOG 2014,28(p327) Attention 7).
Attention Training in mindfulness-based meditation techniques is not A
no. 6 recommended for remediation of attention deficits (INCOG
2014,28(pp327–328) Attention 8).
Attention Alterations to the environment and tasks may be used to C Dymowski et al35
no. 7 reduce the impact of attentional deficits on daily activities
for individuals with TBI (INCOG 2014,28(p326) Attention 5).
Attention The use of repetitive transcranial magnetic stimulation (rTMS) B Ahorsu et al65 Lee and Kim64 Boissonault et al67
no. 8 and transcranial direct current stimulation (tDCS) to Nousia et al66 Neville et al63
ameliorate attention following TBI is not recommended Rushby et al61
outside of the context of a research trial protocol (INCOG Sacco et al62
INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part II

2022). Ulam et al60

(continues)

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42

TABLE 2 INCOG 2.0 guideline recommendations for attention and information-processing speed and new supporting
a
evidence (Continued)
Guideline recommendation Grade Reviews RCTs Other
Pharmacological management for attention/information-processing speed
Attention Methylphenidate (initiated at a dose of approximately A Barnett and Reid74 Dorer e al72
no. 9 0.10 mg/kg and increased gradually to a target of 0.25- Chien et al76 Dymowski et al73
0.30 mg/kg bid) is recommended in adults with TBI to Huang et al75 Jenkins et al78
enhance speed of information processing (updated from Johansson et al30
INCOG 2014,28(p328) Attention 9). Manktelow et al71
Moreno-Lopez70
Zhang and
Wang69
Attention While amantadine may enhance arousal in patients in a A Hammond et al84
no. 10 minimally conscious state, it should not be used to enhance
attentional functions following emergence from coma
(updated from INCOG 2014,28(p328) Attention 10).
Attention The traditional Chinese medicine MLC901 (NeuroAiD IITM) A Theadom et al86
no. 11 may enhance complex attention in individuals with
mild-moderate TBI (INCOG 2022).
Journal of Head Trauma Rehabilitation/January–February 2023

Abbreviations: RCTs, randomized controlled trials; TBI, traumatic brain injury.

a Refer to Ponsford et al28 for evidence contributing to the recommendations prior to 2014.
 INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part II
before or during task performance to reduce time
pressure.32 There have been no additional controlled
studies of TPM among TBI published since that by
Fasotti et al.32
Evidence regarding the use of strategy training (eg,
chunking, pacing) to alleviate problems with working
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memory and divided attention in everyday life after TBI
remains confined to 2 case series studies: by Cicerone33
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in mild TBI and by Vallat-Azouvi et al34 in 2 highly
motivated individuals with severe TBI.
A case series (n = 3) by Dymowski et al35 examined
effects of 3 to 4 weeks of individualized strategy training
on attention, relative to that of computerized atten-
tion training using Attention Process Training (APT-III)
after severe TBI. Variability in attentional deficits and
everyday attentional requirements necessitated individ-
ualized goals and approaches and highlighted the need
to address the interplay of fatigue, mood, memory,
and executive dysfunction with attentional behavior.
All participants achieved individual goals after strategy
training (eg, stay on task, complete a full day of work,
manage anxiety, pay attention during introductions).
Improvements in speed of processing occurred in both
conditions but were greatest following strategy train-
ing. Although limited generalization was evident on
participant self-ratings of attention, close-other ratings
of attentional behavior improved more after strategy
training than APT. Individualized strategy training was
also generally preferred by participants over computer-
ized training. The work by Dymowski et al35 highlights
the need for metacognitive strategy training to be in-
dividualized and to accommodate the impact of other
impairments on attention such as mood and fatigue.
A systematic review and meta-analysis by Virk et al36
found no evidence of significant overall improvement in
attention in response to intervention, but this was based
on 4 disparate studies with a TBI population.32,37–39 A
quality appraisal of systematic reviews for behavioral
treatments of attention disorders after TBI by Roitsch
et al40 concluded that effects of direct attention training
are minimal and limited to training tasks, with more
evidence supporting training in strategy use to reduce
the impact of attentional impairments.
Attention no. 3: Computer-based de-contextualized atten-
tional tasks for individuals with TBI are not recommended
because of lack of demonstrated impact on everyday attentional
functions. Everyday task-specific training should be considered
but cannot be expected to generalize beyond trained or similar
tasks (updated from INCOG 2014,28 (pp326–327) Attention 6).
Level B evidence.
This recommendation has been updated to reflect
a continuing lack of evidence of generalization be-
yond the specifically trained attentional tasks. There
continues to be a significant focus on the use of train-
ing exercises to ameliorate impairments of attention.27
43
These exercises are predominantly computer-mediated
and decontextualized, delivered on the premise that
training underlying components of attention will result
in improved attentional performance in other contexts.
Bogdanova et al41 reviewed 28 studies using comput-
erized, cognitive interventions targeting attention and
executive functions in adults with acquired brain in-
jury. The review reported significantly greater gains in
computerized retraining groups in 8 of 11 TBI-only
studies. The gains reported were on neuropsychological
measures only, with a few studies additionally including
self-report measures. There was no objective evidence
of generalization to everyday attentional behaviors.
The authors noted many methodological limitations of
these studies, including the absence of control groups,
ecologically valid outcome assessments, and long-term
follow-up. One further study by Straudi et al42 similarly
found positive impacts of video game performance on
selective attention measures only.
Attention Process Training is a widely used computer-
ized attention training program that has been evaluated
in studies with variable methodological rigor and small
samples.43–47 Repeated practice on any task may facil-
itate the development of strategies that improve task
performance.48 Although the most recent version of
APT (APT-III) includes increased emphasis on devel-
opment of compensatory strategies within training, we
argue that strategy development may be more effec-
tive if applied and practiced directly in the context of
real-world activities, rather than on decontextualized
tasks. Consistent with this premise, Park and Ingles49
concluded from an earlier meta-analysis that training
in specific skills can result in improvements in that
skill, which may also be evident on tasks similar to
those trained, but it cannot be assumed that under-
lying attentional mechanisms are being restored. The
INCOG recommendation deviates from that of the
updated review of studies conducted from 2009 to 2014
by Cicerone et al,50 who supported working memory
training based on a single case study in stroke and
did not clearly differentiate repeated drill practice from
strategy development.
One well designed study by Dundon et al51 studied
training in capacity to focus attention on speech in
noisy or distracting environments. After recruiting in-
dividuals with post–acute TBI who self-reported being
easily distracted, they demonstrated a linear decline in
dichotic listening performance with the presence of a
second stream of irrelevant speech. The cognitive train-
ing procedure based on APT included graded exposure
to irrelevant noise in adaptive and nonadaptive training
schedules as compared with no treatment. Both types of
training resulted in improvements in dichotic listening
and naturalistic tasks of performance in noise, and mea-
sures of selective attention and event-related potentials
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 44 Journal of Head Trauma Rehabilitation/January–February 2023
linked to target processing. There were, however, no
self-reported gains in everyday distractibility. Although
Dundon et al.51 demonstrated that specific training can
result in changes that generalize to performance of sim-
ilar measures, it does not generalize more broadly to
impact everyday activities.
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Attention no. 4: Training in dual-tasking for individuals
with TBI can be used to improve dual-task performance,
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only on tasks similar to those trained (updated from INCOG
2014,28 (p325) Attention 2). Level A evidence.
This recommendation remains unchanged, with no
new evidence. The evidence supporting this recommen-
dation comes from 2 small lower-quality unblinded
randomized controlled trials (RCTs). The first RCT by
Evans et al52 provided training in combining walking
with cognitive activities as compared with treatment as
usual. The second RCT by Couillet et al37 trained par-
ticipants to divide their attention between 2 cognitive
tasks of increasing difficulty, each learned individu-
ally beforehand. Both studies demonstrated significant
training effects on trained and similar tasks. These
findings reinforce the conclusion that individuals with
TBI can benefit from training on specific tasks or
activities. 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 no. 5: Training with periodic random auditory
alerting tones is not recommended for addressing attentional
deficits following TBI (updated from INCOG 2014,28 (p327)
Attention 7). Level B evidence.
This recommendation is unchanged as no further ev-
idence has emerged regarding the use of self-alerting or
external alerting tones to facilitate arousal and atten-
tional performances after TBI. These strategies were used
by Dymowski et al35 in their single case studies to facili-
tate self-monitoring. Manly and colleagues53 found that
providing a brief auditory alerting stimulus as a cue to
consider the goal of an activity improved performance
on the “Hotel task.” A larger study by Sweeney et al54
found that periodic auditory alerts did not improve
performance of a virtual reality prospective memory task
that simulated working in a furniture warehouse. There
remains insufficient evidence to suggest that periodic
alerting enhances the allocation, or switching, of atten-
tion across complex tasks.
Attention no. 6: Training in mindfulness-based meditation
techniques is not recommended for remediation of attention
deficits (updated from INCOG 2014,28(pp327–328) Attention
8). Level A evidence.
No new evidence has been published on this topic and
the recommendation remains unchanged from INCOG
2014. Consensus was that this intervention should not
be used outside of research protocols due to lack of
demonstrated evidence. Although less rigorous studies
have reported benefits from self-instructional and mind-
fulness techniques,55–57 an RCT by McMillan et al38
found that a brief mindfulness meditation technique,
involving audiotape training to control attention by
concentrating on breathing over extended periods, did
not reduce cognitive failures or improve attention,
memory, or psychological adjustment more than physi-
cal fitness training or no treatment.
Attention no. 7: Alterations to the environment and tasks
may be used to reduce the impact of attentional deficits on daily
activities for individuals with TBI (updated from INCOG
2014,28(p326) Attention5). Level C evidence.
This recommendation is also unchanged. Individuals
with TBI who have significant cognitive impairments
and those who lack awareness of their difficulties are
rarely able to initiate the use of compensatory strate-
gies to alleviate attentional problems.58 An intervention
approach that does not rely on active participation by
the person with TBI could include making changes
to the environment or tasks to reduce the impact of
attentional problems. In the context of work or study,
this might involve removing distractions (eg, work in
a quiet room, reduce interruptions), altering tasks to
reduce the speed, amount or complexity of information
to be processed, providing information in written form
to ensure that it is understood, or providing prompts
to refocus or shift attention to another aspect of a
task. The case studies performed by Dymowski et al35
used some of these strategies including minimizing dis-
traction and environmental cueing, which focused on
specific attention-related goals, alongside compensatory
strategies such as TPM. We could find no clinical tri-
als evaluating the use of such strategies, despite their
reported use in clinical settings.59
Attention no. 8: The use of repetitive transcranial magnetic
stimulation (rTMS) and transcranial direct current stimu-
lation (tDCS) to ameliorate attention following TBI is not
recommended outside of the context of a research trial protocol
(INCOG 2022). Level B evidence.
This is a new recommendation to account for the
progressive but still limited research in the field of
tDCS and rTMS. Numerous studies have investigated
the impact of noninvasive brain stimulation, tDCS, and
rTMS on attention and working memory after TBI and
the findings have been mixed. Given the mixed out-
comes and lack of evidence of generalization to everyday
attention, the expert panel recommends that, at this
time, rTMS and tDCS should not be used outside of
a research context.
Ulam et al60 did not find greater gains in performance
on tests of attention and working memory following
20-minute sessions of tDCS daily for 10 days relative
to a sham control. Rushby et al61 found no significant
impact of a single dose of tDCS on working memory
(n-back Task Measure) performance. Sacco et al62 found
 INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part II
that 10 sessions of tDCS for more than 5 days, followed
by computer-assisted training for 40 minutes, resulted
in greater improvement in reaction times on a divided
attention task than in a sham-treated control group.
However, it is unclear whether the gains were due to the
tDCS or computer training, or a combined effect. Of
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RCTs trialing rTMS, Neville et al63 found no significant
impact of 10 sessions of rTMS on performance of
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attentional and processing speed measures (ie, Trail
Making Test, Digit Span, Symbol Digit Modalities
test) or other cognitive measures. In contrast, a smaller
RCT by Lee and Kim64 reported a positive impact of
rTMS (30 minutes, 5 days a week) following muscle
strengthening and movement therapy (2 weeks) on
performance of the Trail Making Test and Stroop Color
Word tasks and on the Montgomery-Astberg Depression
Rating Scale in comparison with the control group.
A recent meta-analysis combining rTMS and tDCS
studies65 concluded that noninvasive brain stimulation
has a significant positive effect on attentional measures,
but no functional outcomes were included. It is
important to note that tDCS and rTMS have differing
mechanisms of action on the brain, and the INCOG
team felt that they should not be combined in a meta-
analysis, and the findings should be interpreted with
caution. Another review by Nousia et al,66 which also
combined these approaches, concluded that there was
insufficient evidence to support use of noninvasive
brain stimulation for attention or any cognitive
function. Most importantly, there is no evidence
of generalization of gains from these interventions
to everyday activities. Boissonnault et al67 attempted
to implement a tDCS protocol in the context of a
rehabilitation center but had extremely low recruitment
and retention, thus highlighting the limitations of
application in a general rehabilitation setting.
Pharmacological strategies for improving attention
Attention no. 9: Methylphenidate (initiated at a dose of
approximately 0.10 mg/kg and increased gradually to a tar-
get of 0.25-0.30 mg/kg bid) is recommended in adults with
TBI to enhance speed of information processing (updated from
INCOG 2014,28 (p328) Attention 9). Level A evidence.
This recommendation has been updated. Traumatic
brain injury is associated with changes in neurotransmit-
ter systems associated with attention. Methylphenidate,
a central nervous system stimulant, increases the re-
lease and blocks reuptake of dopamine and nora-
drenaline, resulting in increased synaptic and extra-
cellular concentrations.68 Since INCOG 2014, sev-
eral new RCTs,30,69–73 1 systematic review,74 and 2
meta-analyses75,76 have been published. As such, the
recommendation was modified to reflect the new evi-
dence. The most recent meta-analysis by Chien et al76
45
found that methylphenidate significantly improved pro-
cessing speed as measured by Choice Reaction Time
and Digit Symbol Coding. Reaction time was inversely
associated with duration of treatment; however, there
were no statistically significant effects on other mea-
sures of attention or working memory. With respect to
adverse events, methylphenidate significantly increased
heart rate but did not impact blood pressure. Although
several studies have evaluated only a single dose of
methylphenidate, 1 RCT by Zhang and Wang69 showed
efficacy with administration for more than 30 weeks.
An inverted U dose-response relationship has been
demonstrated between prefrontal dopamine activity and
working memory. Stimulants at low dose increased
dopamine levels and enhanced arousal and attention,
while high doses could impair them.77 In a randomized
double crossover study (n = 40), Jenkins et al78 found
that patients with low caudate dopamine transporter
binding, measured using single photon emission com-
puted tomography, showed significant improvement
in response speed with methylphenidate compared
with placebo, with concomitant self and caregiver-
reported improvements in apathy. Participants with
normal dopamine transporter binding did not improve.
These findings suggest that identifying the presence of a
hypodopaminergic state after TBI may be important for
selecting recipients of methylphenidate therapy.
Although everyday attentional measures were not
included in the Chien et al76 meta-analysis, sev-
eral RCTs have shown generalization of gains from
methylphenidate to everyday attentional ratings, in-
cluding the aforementioned study by Jenkins et al.78
Whyte et al79 found generalization to everyday rating
of attentional behavior by caregivers, while Willmott
and Ponsford80 found a strong trend in that direction,
and Johansson et al30 and Zhang and Wang69 found
reductions in fatigue ratings.
Attention no. 10: While amantadine may enhance arousal
in patients in a minimally conscious state, it should not be
used to enhance attentional functions following emergence from
coma (updated from INCOG 2014,28 (p328) Attention 10).
Level A evidence.
This updated recommendation on the use of amanta-
dine is based on the scientific literature since INCOG
2014. Amantadine is a dopaminergic agent that acts
presynaptically to enhance dopamine release and de-
crease dopamine reuptake. It has demonstrated efficacy
in facilitating arousal and general function in patients
in a comatose or vegetative state when administered
over the short term (<4 weeks).81–83 However, it appears
not to enhance attentional function when administered
to conscious patients at longer periods after injury.
Hammond et al84 compared the effects of 100 mg of
amantadine twice daily or placebo in 119 individu-
als with chronic TBI (all >6 months postinjury) and
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 46 Journal of Head Trauma Rehabilitation/January–February 2023
irritability. They evaluated behavioral and cognitive dis-
turbance over 60 days of treatment or placebo and found
no significant impact on attentional measures at any
time point up to 60 days.
Attention no. 11: The traditional Chinese medicine
MLC901 (NeuroAiD IITM) may enhance complex attention
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in individuals with mild-moderate TBI (INCOG 2022).
Level A evidence.
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Based on research conducted since the INCOG 2014
review, a recommendation has been added to reflect
use of traditional Chinese medicine MLC901. MLC901
(NeuroAiD IITM) is a traditional Chinese herbal
supplement with antioxidant properties shown to im-
prove survival, recovery, and cognitive functioning
in rodents after ischemic injury.85 Among humans,
Theadom et al86 conducted a 9-month pilot randomized
placebo controlled trial involving 78 individuals aged
18 to 65 years, 1 to 12 months after mild-moderate
TBI (97% mild). They found that participants receiv-
ing MLC901 (0.8-g capsules, 3 times daily) showed
greater gains on the CNS Vital Signs complex attention
measure (P = .04, d = 0.6) at 6 months relative to con-
trols. There were no group differences for self-reported
neurobehavioral sequelae, mood, fatigue, physical dis-
ability, or overall quality of life at 6 months. No serious
adverse events were reported. Replication of this finding
is needed.
Algorithm
Clinicians are encouraged to follow the decision
algorithm in Figure 1 that highlights how to navi-
gate through this series of guidelines for managing
attentional problems, further elaborated in the section
“Discussion.”
Audit tool
Table 3 sets out the audit tool items recommended
by the INCOG panel for examining management of
attentional problems in clinical settings. Clinicians and
organizational leaders are encouraged to use these tools
in review or audit of individual patient charts to de-
termine degree of adherence to the recommendations.
This is most successful in changing practice when these
audit results are fed back to the team for discussion of
opportunities for improvement.
DISCUSSION
Given the high frequency of attentional problems in
individuals with TBI, it is recommended that all individ-
uals with MS-TBI have a neuropsychological assessment
to determine the nature of their attentional difficulties
and also assess their everyday manifestations. It is also
important to identify and address the attentional de-
mands of the injured individual’s lifestyle, availability
of environmental supports, and factors that may be ex-
acerbating attentional problems, including hearing and
vision disruptions, anxiety, depression, fatigue, sleep
disturbance, pain, medication, and substance use.
To alleviate attentional problems, there is evidence
in support of training in metacognitive strategies ap-
plied directly to everyday attentional difficulties, such
as TPM. Given evidence of learning on trained tasks,
training may be provided on specific tasks such as dual
tasking or dealing with background noise, but given a
lack of evidence of generalization, training should be
focused on everyday tasks rather than decontextualized
computer tasks. Modifications to the task (reducing
attentional demands) or environment (removing dis-
traction) may be helpful, although evaluation of such
strategies is needed.
Methylphenidate, administered at 0.3 mg/kg in
divided doses, may increase speed of information
processing, enhance everyday attentional behavior, or
reduce fatigue in individuals aged 16 to 60 years who
have no history of attention deficit hyperactivity disor-
der, previous stimulant use, drug or alcohol dependence,
or other psychiatric disorder. Amantadine may facilitate
arousal over the short term in individuals in vegetative
state or emerging from coma, but there is no evidence of
positive impact of amantadine on attention in chronic
TBI. The traditional Chinese medicine MLC901
(NeuroAiD IITM) in 0.8-g capsules 3 times daily may
enhance complex attention in individuals with mild
TBI, although replication of this finding is needed.
Research investigating behavioral interventions for
attention, in the context of the everyday life of the
individual with TBI, including both metacognitive
strategies and environmental modifications remains
very limited in quantity, quality, and scope. There
is a growing body of research supporting the use of
contextualized approaches to rehabilitation,87 and the
findings from our reviews support this. Unfortunately,
clinicians continue to use computerized attention
training27 despite there being no clear evidence of
generalization to everyday activities. The current
guideline was limited to studies conducted in adults.
Similar reviews are needed for pediatric TBI. There is
an enormous need for further RCTs and well-designed
single case studies in both adults and children that
evaluate the impact of real-world interventions not only
on attentional impairments but also more importantly
on the individual’s daily life and to identify what works
and for whom. Many methodological challenges must
be overcome to achieve this, including the development
and more universal use of attentional outcome measures
that reflect lived experience of everyday attentional
function and are psychometrically sound and sensitive
to change. Qualitative feedback from individuals
receiving the interventions is also needed.
 INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part II 47
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Figure 1. Algorithm: Attention.

Following the identification of attentional impairments using neuropsychological assessment and consideration of their everyday
manifestations, it is important to consider factors that may be exacerbating attentional problems, including hearing and vision
disruptions, fatigue, sleep-wake disturbance, anxiety, depression, pain, medication effects, and substance use, and address these
wherever possible. It is also important to consider the individual’s level of motivation, self-awareness, memory, and executive
functions to determine capacity for adopting strategies, as well as the degree of support from close others and other factors in
the environment. To alleviate attentional problems with individuals with mild-moderate impairment and some degree of self-
awareness, there is evidence in support of training in metacognitive strategies applied directly to everyday attentional difficulties.
Time pressure management may be used to address impaired speed of information processing. Given evidence of learning on
trained tasks, training may be provided on specific tasks such as dual tasking or dealing with background noise, but given a lack
of evidence of generalization, training should be focused on everyday tasks rather than decontextualized computer tasks. An
additional approach that may be used in these individuals as well as those with severe attentional impairment and poor awareness
and executive function is modifications to the task (reducing attentional demands) or environment (removing distraction) may
be helpful, although studies evaluating these approaches are much needed. Studies evaluating these approaches 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. 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. Methylphenidate, administered at
0.3 mg/kg in divided doses, may increase speed of information processing as measured on measures of reaction time and the
Symbol Digit Modalities Test and on a Rating Scale of Attentional Behaviour in individuals aged 16 to 60 years who are in acute
stages of recovery from mild to severe TBI or longer than 6 months postinjury, have no history of attention deficit hyperactivity
disorder previous stimulant use, drug or alcohol dependence, or other psychiatric disorder. Amantadine may facilitate arousal
and function on the Disability Rating Scale over the short term in inpatients in vegetative state or emerging from coma, but there
is no evidence of positive impact of amantadine on attention following emergence from coma.
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48

TABLE 3 Audit guidelines for priority recommendations: Attentiona

Intervention (guideline Specific activities, Assessment of need
recommendation) devices, or tools and effectiveness Patient characteristics Discipline
Attention training  Combined with metacognitive  Assessment for need  Mild to moderate at-  OT
“Metacognitive strategy training using executive strategy training conducted tention deficit  PT
functional everyday activities should  Functional everyday activities  Training provided  SLP
be considered, especially in patients  Use of checklists  MD
with mild-moderate attention  Other  Neuro
deficits” (Attention no. 2).  Other
Training may be conducted on tasks in  Functional everyday activities  Assessment for need  Mild, moderate, or se-  OT
real-world contexts (eg, dual tasks, conducted vere attention deficit  PT
background noise) without  Training provided  SLP
expectation of generalization  MD
(Attention nos. 3 and 4).  Neuro
 Other
“Alterations to the environment and  Functional everyday activities  Assessment for need  Mild, moderate, or se-  OT
tasks may be used to reduce the  Environmental manipulation conducted vere deficit  PT
impact of attentional problems on  Use of checklists  Environmental  SLP
daily activities” (Attention no. 7).  Other alterations made  MD
 Neuro
 Other
Pharmaceutical interventions: Attention
Drug Used Indication Patient characteristics Found in
Methylphenidate Yes No  Attentional function  Mild, moderate, or se-  Drug charts
Journal of Head Trauma Rehabilitation/January–February 2023

“Methylphenidate is recommended to  Speed of cognitive pro- vere attention deficit  MD notes

enhance speed of information cessing  Other
processing” (Attention no. 9)  Sustained 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.
 INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part II
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