INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part II: Attention and Information Processing Speed

Abstract

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, sleepwake 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 decontextualized 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

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury: Methods, Overview, and Principles

“…While there are numerous level A ( n = 25) and level B ( n = 15) recommendations, half of the recommendations are based on level C evidence (ie, consensus of the experts; 40 recommendations). The recommendations for PTA ( n = 6),22 attention ( n = 11),23 memory ( n = 8),24 executive functions ( n = 8),25 and cognitive-communication ( n = 9)26 are provided within other articles in this series. Foundational to all the articles are recommendations for the assessment of persons with TBI requiring cognitive rehabilitation (see Table 2; 10 recommendations), as well as general principles for cognitive rehabilitation (see Table 3; 6 recommendations) and pharmacological management (see Table 4; 10 recommendations).…”

“…The INCOG guideline algorithm suggests that once a detailed cognitive assessment has been completed, 4 main domains of cognition may be amenable to intervention: attention and processing, executive dysfunction, cognitive communication, or memory that is covered in the relevant sections of this supplement. The reader is referred to the relevant articles for specific algorithms for these topics 23–26…”

“…The reader is referred to the relevant articles for specific algorithms for these topics. [23][24][25][26] Health records chart audit items to assess adherence to general recommendations for cognitive assessment and rehabilitation…”

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part III: Executive Functions

“…More evidence from high-quality studies is needed. Subacute transcranial direct current stimulation . As detailed under Attention #8 in the INCOG 2.0, Part II: Attention and Information Processing Speed40 article, subacute transcranial direct current stimulation should not be used outside the context of clinical research due to insufficient evidence of its efficacy. Recombinant human growth hormone (rHGH). Reimunde and colleagues41 examined the use of rHGH in a cohort study finding that both placebo and rHGH improved functioning on cognitive subtests of digit, and manipulative IQ but only the rHGH group improved significantly on cognitive subtests such as understanding, numbers and incomplete figures ( P < .05), verbal IQ, and total IQ ( P < .01).…”

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury: What's Changed From 2014 to Now?

“…This article probably contains the least changes, given the ongoing limitations in the evidence for behavioral interventions in this domain, but does provide stronger evidence underpinning pharmacological interventions for attention (INCOG 2.0, Part II: Attention and Information Processing Speed). 23 Executive functions are the subject of the fifth article, which documents the evolving and strengthening evidence for metacognitive strategy instruction and the use of telerehabilitation to promote recovery in this domain (INCOG 2.0, Part III: Executive Functions). 24 Recommendations for treatment of cognitive-communication disorders are the topic of the next article (INCOG 2.0, Part IV: Cognitive-Communication and Social Cognition Disorders).…”