Ontario Neurotrauma Foundation

Clinical Practice Guideline

For the rehabilitation of Adults with Moderate to Severe TBI

Ontario Neurotrauma Foundation INESSS
SECTION 2: Assessment and Rehabilitation of Brain Injury Sequelae > J. Cognitive Functions

J. Cognitive Functions

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Persons with traumatic brain injury (TBI) frequently encounter impairments in physical, communication, cognition and behaviour domains. Cognitive rehabilitation is a critical element in returning survivors of TBI to independent functioning. Thorough assessment accounting for pre-injury attributes and lifestyle as well as injury related factors will all influence both the management plan for patients and families. The most commonly affected cognitive functions include arousal and attention, learning and memory, attention/ information processing speed and executive functioning/problem solving. Strategies targeted at the identified deficits can be effective when provided in a planned fashion that incorporates metacognitive strategies and patient focused goals. Medications may also play a role in assisting cognition recovery post TBI; however, efforts must be put in place to formally monitor the effects of the medication while adhering to principles of medication use.

Health professionals with experience and adequate training in TBI and cognitive rehabilitation are required to evaluate the various components of cognition and provide the appropriate rehabilitation interventions.  The environment should be conducive to cognitive rehabilitation including a structured, quiet and non-distracting environment.

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Several studies have been conducted on cognitive rehabilitation post ABI. Five large, robust systematic reviews were conducted by the INCOG group on the following domains of cognition: post-traumatic amnesia (PTA), attention, executive functioning, communication, and learning and memory (Jennie Ponsford et al., 2014; J. Ponsford & Sinclair, 2014; R. Tate et al., 2014; L. Togher et al., 2014; Velikonja et al., 2014). When assessing cognitive impairment, initially, it is important to consider other factors besides the injury such as a patient’s cultural background, premorbid intelligence, substance abuse, or mental illness, as these have been found to impact one’s cognitive abilities (MacMillan, Hart, Martelli, & Zasler, 2002; Prigatano & Leathern, 1993; L. A. Taylor, Kreutzer, Demm, & Meade, 2003).

Deficits in attention are a common complaint amongst patients. Attentional disorders can impede patients’ activities of daily living, ability to drive and their vocational status. Rehabilitation strategies for attention include tasks that emulate everyday activities. In an RCT, Fasotti, Kovacs, Eling, and Brouwer (2000) employed a training program that emulated many real life tasks versus a verbal instruction program for improving attention. The authors noted greater concentration and speed of processing in participants exposed to the real life task program in their everyday tasks.

Dual task training is another effective way to train attention; this rehabilitation strategy encourages participants to actively engage in two attentional processes that are sometimes not even related to one another. In a recent RCT-crossover, patients were divided into an experimental program with dual task training for two specific cognitive tasks or a control group for six weeks before crossing over. At the six-week assessment, the experimental group showed significant improvement in reaction times and omissions compared to the control group (Couillet et al., 2010). Another RCT found similar improvements in dual-task training for cognitive-motor tasks (Evans, Greenfield, Wilson, & Bateman, 2009). Stablum, UmiltÓ, Mogentale, Carlan, and Guerrini (2000) demonstrated that patients who had a closed head injury, or had experienced an aneurysm after dual task training, could have reaction times similar to matched controls for attentional tasks.

After an acquired brain injury (ABI) some individuals have altered emotional and affective states. One RCT demonstrated that cognitive behavioural therapy (CBT) was effective in improving anxiety, depression, and divided attention (Tiersky et al., 2005)  after a TBI; additionally, a prospective controlled trial demonstrated the efficacy of CBT for sleep/wake disorders (Wiseman-Hakes et al., 2013). Two review articles advocate for CBT in improving emotional and affective disorders after a TBI (Mateer, Sira, & O'Connell, 2005; R. Ruff, 2005).

Pharmacological agents have been suggested for use in cognitive rehabilitation post ABI. Methylphenidate has been found to increase reaction time, speed of processing and sustain attention (Kim, Ko, Na, Park, & Kim, 2006; Pavlovskaya, Hochstein, Keren, Mordvinov, & Groswasser, 2007; Plenger et al., 1996; Whyte et al., 2004; Willmott & Ponsford, 2009).  An older study however found methylphenidate did not significantly improve attention, information processing speed, or learning compared to placebo. Additionally, one study found that attention and awareness from disorders of consciousness can be improved using amantadine (Mura et al., 2014). Finally, two RCTs demonstrated that amantadine produced significantly greater improvements than placebo medications in restoring consciousness (Giacino et al., 2012; Meythaler, Guin-Renfroe, Johnson, & Brunner, 2001). Three chart reviews also found to produce greater improvements in promoting consciousness over non-medication use (Hughes, Colantonio, Santaguida, & Paton, 2005; Saniova, Drobny, Kneslova, & Minarik, 2004) and compared to other medications (Whyte et al., 2004).

The use of computer-based attentional tasks can provide patients with repeated exposure to training tasks without the use of a therapist; however, these tasks are often hard to apply outside of this context because they cannot be generalized to other everyday tasks. Two meta-analyses found that cognitive rehabilitation interventions focusing on repetitive computer-based attentional tasks were only as effective control interventions (Park & Ingles, 2001; Rohling, Faust, Beverly, & Demakis, 2009). Similarly, numerous RCTs demonstrate that computer-based attentional tasks are less effective when compared to tasks that mimic everyday attentional abilities (Dirette & Hinojosa, 1999; Gray, Robertson, Pentland, & Anderson, 1992; J. Malec, Jones, Rao, & Stubbs, 1984; Niemann, Ruff, & Baser, 1990; Novack, Caldwell, Duke, Bergquist, & Gage, 1996; Sohlberg & Mateer, 1987).

The use of auditory stimulation has also been studied among individuals post ABI. Two RCTs have evaluated the use of auditory alerting tones to increase attention, although the findings are conflicting.  Manly, Hawkins, Evans, Woldt, and Robertson (2002)  report that tones significantly improved attentional abilities compared to no presence of tones, while Sweeney, Kersel, Morris, Manly, and Evans (2010) reported that tones had no effect on performance.

Memory impairments encompass a large portion of cognitive problems following a TBI. Internal compensatory strategies including mnemonics and self-cueing are an effective way to improve memory. Several RCTs have examined the use of imagery based mnemonics in patients with moderate and severe TBI and found them to be effective. Similarly, several studies have evaluated prospective memory interventions using self-awareness, imagery and active control and these have been found to be effective (Fleming, Shum, Strong, & Lightbody, 2005; Grilli & McFarland, 2011; Potvin, Rouleau, Senechal, & Giguere, 2011; Raskin & Sohlberg, 1996; Raskin & Sohlberg, 2009; Shum, Fleming, Gill, Gullo, & Strong, 2011). Two studies found that cueing strategies were effective (Manasse, Hux, & Snell, 2005; Schefft et al., 2008) and one study found that categorizing items based on their everyday function prompted successful memory retrieval (O'Neil-Pirozzi et al., 2010).

The development of cognitive rehabilitation strategies, and the presence of therapists who can facilitate these strategies, is crucial to cognitive skills training. Computer-based training can be an effective way to develop strategies; however, their restorative capacity is limited. While pre-post studies have shown that computerized cognitive skills training is effective (Fernandez et al., 2012; Johansson & Tornmalm, 2012), an RCT comparing computer-based training to traditional therapy reported no significant difference between the two methods of delivery (Dou, Man, Ou, Zheng, & Tam, 2006).

One useful application of technology-based interventions includes personal device assistants which prompt individuals to remember an action. Several RCTs have examined the use of pagers or mobile devices for setting reminders or to prompt an action, and have found them to be more effective than traditional techniques such as the use of a notebook or a calendar (Dowds et al., 2011; Fish, Manly, Emslie, Evans, & Wilson, 2008; Powell et al., 2012; Wilson, Emslie, Quirk, & Evans, 2001). Traditional notebooks and diaries are still effective as memory aids (Cicerone et al., 2000; Ownsworth, Fleming, Shum, Kuipers, & Strong, 2008; Schmitter-Edgecombe, Fahy, Whelan, & Long, 1995; Zencius, Wesolowski, & Burke, 1990; Zencius, Wesolowski, Krankowski, & Burke, 1991). The use of apps such as Google calendar (McDonald et al., 2011) or instant messaging services (Bergquist, Gehl, Lepore, Holzworth, & Beaulieu, 2008) are also useful environmental aids for memory.

In general, objectives and targets of rehabilitation should be identified and align with both the patients’ and therapists’ goals (Powell et al., 2012). An RCT found that teaching strategies that minimize errors through either a therapist or a computer were more effective than conventional training (Dou et al., 2006). Systematic instruction which broke tasks down into smaller target components was better than trial and error learning (Ehlhardt, Sohlberg, Glang, & Albin, 2005; Powell et al., 2012).

Other strategies to improve memory include specialized memory groups (Jennett & Lincoln, 1991; Thickpenny-Davis & Barker-Collo, 2007). Groups provide an effective way to discuss and brainstorm memory strategies. Several pre-post studies have found that groups are useful memory-aids and social support avenues (Evans et al., 2009; O'Neil-Pirozzi et al., 2010).

Pharmacological agents have also been used post ABI for treatment of memory and attention. It is important to note that individuals are often receiving seizure prophylactic medications such as phenytoin. Several studies have found that administration of anticonvulsants s such as phenytoin may actually inhibit functional recovery (Bhatnagar, Iaccarino, & Zafonte, 2016; Bhullar et al., 2014; Bogner et al., 2015; Szaflarski, Nazzal, & Dreer, 2014). There are two pharmaceutical options to treat memory impairments after a brain injury: rivastigmine and donepezil. In two RCTs rivastigmine was administered to patients who had sustained a moderate to severe TBI (Silver et al., 2006; Silver et al., 2009). Study results, from both studies, indicate that rivastigmine did improve cognitive function and memory impairment, although results were not significantly different from control treatments. For pharmacological treatment of attention disorders donepezil may be effective. One RCT found that donepezil significantly increased scores on tasks of sustained attention and short-term memory when compared to placebo and that these improved results were sustained after the wash-out period (Zhang, Plotkin, Wang, Sandel, & Lee, 2004).

Executive function disorders are another common problem after a TBI. One way to remediate these problems is through the use of metacognitive strategies. Several RCTs have evaluated and found the following metacognitive strategies to be effective: time pressure management to slow information processing (Fasotti et al., 2000), problem solving strategies using metacomponents or focus groups (Fong & Howie, 2009; Rath, Simon, Langenbahn, Sherr, & Diller, 2003), goal management training (Levine et al., 2011) and goal setting (McPherson, Kayes, & Weatherall, 2009; P. M. Webb & Glueckauf, 1994). Finally, a multi-center RCT evaluated a combination of the former strategies using a multifaceted approach which was effective (Spikman et al., 2010).

Strategies that can increase reasoning skills include self-cueing to reinforce autobiographical memories (Delazer Thomas Bodner Thomas Benke, 1998; Hewitt, Evans, & Dritschel, 2006), categorization techniques (Constantinidou, Thomas, & Robinson, 2008), tele-rehabilitation to communicate problem solving techniques (Man, Soong, Tam, & Hui-Chan, 2006; Soong, Tam, Man, & Hui-Chan, 2005) and the use of interactive pictorials (Man et al., 2006).

To increase a patient’s awareness of their cognitive deficits, feedback can be provided verbally to a person with a brain injury by a therapist describing the positive and negative aspects of the person’s task performance, visually by watching video-recordings of the one’s task performance, and in a group setting through peer feedback. Goverover, Johnston, Toglia, and Deluca (2007) found that self-awareness training through therapist feedback greatly increased activities of daily living performance. Group therapy serves as an effective way to provide feedback and social support between participants; it has been found to increase behavioural competency and psychological well-being (Ownsworth et al., 2008). Schmidt, Fleming, Ownsworth, and Lannin (2012) evaluated different ways of providing feedback training and found that feedback provided in a video with verbal instruction was most effective for increasing self-awareness. Finally, Rath et al. (2003) demonstrated that group therapy was an effective way for individuals with TBI to improve their problem solving skills. Group therapy allowed patients to identify their problems, observe their own and others’ reactions, and come up with plans and alternatives to deal with their problems. Group therapy is an appealing option because it helps patients improve goal attainment (Ownsworth et al., 2008).

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Wilson, B., Emslie, H., Quirk, K., & Evans, J. (2001). Reducing everyday memory and planning problems by means of a paging system: a randomised control crossover study. Journal of Neurology, Neurosurgery & Psychiatry, 70(4), 477-482.

Wiseman-Hakes, C., Murray, B., Moineddin, R., Rochon, E., Cullen, N., Gargaro, J., & Colantonio, A. (2013). Evaluating the impact of treatment for sleep/wake disorders on recovery of cognition and communication in adults with chronic TBI. Brain Injury, 27(12), 1364-1376.

Zencius, A., Wesolowski, M. D., & Burke, W. H. (1990). A comparison of four memory strategies with traumatically brain-injured clients. Brain Injury, 4(1), 33-38.

Zencius, A., Wesolowski, M. D., Krankowski, T., & Burke, W. H. (1991). Memory notebook training with traumatically brain-injured clients. Brain Injury, 5(3), 321-325.

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J1. Cognitive Functions Assessment

P Priority F Fundamental New Level of evidence A B C
J 1.1 P C

During assessment of a person with traumatic brain injury, clinicians should consider the possibility of other factors that may be contributing to cognitive performance impairments and functional limitations including:

  • Personal factors

  • Pre-injury medical conditions

  • Injury-related factors and conditions

(Adapted from INCOG 2014, Assess 6, p. 297)

Personal factors include:

  • Cultural background

  • Fluency and literacy in language of assessment

  • Level of education/academic history/premorbid learning difficulties

  • Premorbid intellectual level of functioning

  • Occupational/vocational history

  • Recreational, hobby history

Pre-injury medical conditions include:

  • Substance use/abuse

  • Mental health issues

  • Psychosocial trauma or abuse

  • Neurological disorders (e.g., dementia, seizures)

  • Hearing or vision impairment

  • Nutritional status

Injury-related factors and conditions include:

  • Medical conditions

  • Psychiatric conditions, especially mood disorders

  • Fatigue

  • Sleep-wake disorders

  • Medications (pre- and post-injury) including over-the-counter remedies, herbs or supplements

  • Seizures

  • Sensorimotor changes

  • Endocrine dysfunction (e.g., growth hormone deficiency) (High 2010)

  • Pain

  • Acquired language changes (e.g., aphasia, dysgraphia)

  • Injury-related vision or hearing deficits

  • Manual limb or oral-motor dysfunction (e.g., weakness, incoordination)

  • Consider the possibility of other comorbid factors

J2. Cognitive Rehabilitation Principles

P Priority F Fundamental New Level of evidence A B C
J 2.1 P C

Individuals with persistent cognitive deficits following traumatic brain injury should be offered functionally-oriented cognitive rehabilitation. Treatment must be considered within a framework that considers the person’s pre-injury characteristics, stage of development and recovery, and personally meaningful everyday activities and life contexts.

(Adapted from NZGG 2006, 6.1.6, p. 98 and INCOG 2014, Assess 12, p. 299)

J 2.2 P B

Cognitive rehabilitation in the acute phase for individuals with traumatic brain injury should be managed in a structured and distraction-free environment.

(Adapted from NZGG 2006, 6.1.6, p. 98)

J 2.3 P B

To facilitate/achieve generalization of skills/strategies to daily activities for the person with traumatic brain injury, rehabilitation should:

  • Focus on activities that are perceived as meaningful by the person

  • Include therapy interventions provided in the person’s own environment and/or adapted to the person’s own life.

(Adapted from ABIKUS 2007, G34, p. 21)

J3. Medication for Arousal and Attention

Medications should only be prescribed by qualified physicians, and guideline users should consult the section on "Principles of medication management" before prescribing.
P Priority F Fundamental New Level of evidence A B C
J 3.1 P B

Methylphenidate (initiated at a dose of approximately 0.10mg/kg and increased gradually to a target of 0.25–0.30 mg/kg bid) is recommended in adults with traumatic brain injury to enhance attentional function and speed of information processing.

(Adapted from ABIKUS 2007, G44, p. 23 and INCOG 2014, Attention 9, p. 331)

Suggested tool: Health Canada Indications of Use

J 3.2 C

Dextroamphetamine should be considered to enhance attentional function after traumatic brain injury when methylphenidate is not tolerated.

(Adapted from NGWG 2006, p. 1483)

Suggested tool: Health Canada Indications of Use

J 3.3 B

Consider amantadine to improve attention in individuals with traumatic brain injury who are out of post-traumatic amnesia and who have not responded to other medication alternatives.

(Adapted from NGWG 2006, p. 1483)

Suggested tool: Health Canada Indications of Use

J 3.4 P A

Amantadine may be considered to enhance arousal and consciousness and accelerate the pace of functional recovery in individuals in vegetative or minimally responsive state following traumatic brain injury.

(Adapted from SIGN 2013, 9.2, p. 36)

Suggested tool: Health Canada Indications of Use


- Giacino et al. (2012)

J4. Attention / Information Processing

P Priority F Fundamental New Level of evidence A B C
J 4.1 P A

Metacognitive strategy training using functional everyday activities should be considered for individuals with traumatic brain injury, especially those with mild-moderate attention deficits.

(Adapted from INCOG 2014, Attention 1, p. 330)

J 4.2 P A

Training in dual-tasking for individuals with traumatic brain injury can be used to improve dual-task performance, only on tasks similar to those trained.

(Adapted from INCOG 2014, Attention 2, p. 330)

J 4.3 P C

Cognitive behaviour therapy should be considered for improving attentional functioning in individuals with traumatic brain injury with attentional deficits thought to be secondary to sleep-wake disorders, pain, fatigue, polypharmacy or anxiety and/or depression.

(Adapted from INCOG 2014, Attention 3 and 4, p. 330)

J 4.4 C

Alterations to the environment and tasks may be used to reduce the impact of attentional problems on daily activities for individuals with traumatic brain injury.

(INCOG 2014, Attention 5, p. 330)

J 4.5 B

Reliance on repeated exposure and practice on de-contextualized computer-based attentional tasks for individuals with traumatic brain injury are NOT recommended because of lack of demonstrated impact on everyday attentional functions.

(INCOG 2014, Attention 6, p. 330)

J 4.6 B

Training with periodic random auditory alerting tones for individuals with attentional deficits following traumatic brain injury should NOT be conducted in therapy outside of a research protocol, as current evidence is conflicting.

(Adapted from INCOG 2014, Attention 7, p. 331)

J5. Learning and Memory

P Priority F Fundamental New Level of evidence A B C
J 5.1 P A

Teaching internal compensatory strategies may be used for individuals with traumatic brain injury who have memory impairments. Their use tends to be most effective with individuals who have mild-to-moderate range impairments and/or some preserved executive cognitive skills. These strategies include instructional and/or metacognitive strategies (e.g., visualization / visual imagery, repeated practice, retrieval practice, Preview, Question, Read, State, Test [PQRST], self-cueing, self-generation, self-talk). Using multiple strategies is considered effective, and strategies can be taught individually or in a group format.

(INCOG 2014, Memory 1, p. 372)

J 5.2 B

Cognitive skill training for individuals with traumatic brain injury should be strategy-focused and conducted with an experienced therapist who can further facilitate the functional integration of the strategy being practised into meaningful and practical tasks.

(Adapted from INCOG 2014, Memory 7, p. 374)

Note: There is limited evidence to suggest that using restorative techniques such as computer-based training strategies alone is effective.

J 5.3 P B

Environmental supports and reminders (e.g., mobile/smartphones, notebooks and whiteboards) are recommended for individuals with traumatic brain injury (TBI) who have memory impairment, and most especially for those who have severe memory impairment. Individuals with TBI and their caregivers must be trained in how to use these external supports.

(Adapted from INCOG 2014, Memory 3, p. 372)

Note: The selection of environmental supports and reminders should take into account the following factors regarding the person with TBI:

  • Age

  • Severity of impairment

  • Premorbid use of electronic and other memory devices

  • Cognitive strengths and weaknesses (e.g., executive cognitive skills)

  • Physical comorbidities

J 5.4 P A

The following practices are recommended to promote learning for individuals with memory impairments following traumatic brain injury (TBI):

  • Clearly define intervention goals.
    - Selection of and training of goals that are relevant to the person with TBI (i.e., ecologically valid)

  • Allow sufficient time and opportunity for practice.

  • Integrate methodologies that allow for breaking down tasks into smaller components such as task analysis when training multistep procedures.

  • Use principles of distributed practice.

  • Teach strategies using variations in the stimuli/information being presented (e.g., multiple exemplars, practical tasks).

  • Promote strategies that allow for more effortful processing of information/stimuli (e.g., verbal elaboration, visual imagery).

  • Use teaching strategies that constrain errors (e.g., errorless, spaced retrieval) when acquiring new or relearning information and procedures.

(Adapted from INCOG 2014, Memory 4, p. 373)

J 5.5 B

Group-based interventions may be considered for enhancing memory capacity with individuals with mild-to-moderate memory deficits following traumatic brain injury.

(Adapted from INCOG 2014, Memory 5, p. 373)

J6. Medication for Memory

Medications should only be prescribed by qualified physicians, and guideline users should consult the section on "Principles of medication management" before prescribing.
P Priority F Fundamental New Level of evidence A B C
J 6.1 B

Rivastigmine may be considered for individuals with moderate-to-severe memory impairment in the subacute to chronic phase of recovery after traumatic brain injury.

(INESSS-ONF, 2015)

Suggested tool: Health Canada Indications of Use


- Silver et al. (2009)

J 6.2 P B

Donepezil (5–10 mg/day) is recommended to enhance aspects of memory in individuals with traumatic brain injury.

(Adapted from NGWG 2006, p. 1482)

Suggested tool: Health Canada Indications of Use

J7. Executive Functions

P Priority F Fundamental New Level of evidence A B C
J 7.1 P A

Metacognitive strategy instructions (e.g., goal management training, plan-do-check-review, prediction performance) should be used with individuals with traumatic brain injury (TBI) for difficulty with problem-solving, planning and organization. Common elements of all metacognitive strategies are self-monitoring and incorporation of feedback into future performance. These strategies should be focused on everyday problems and functional outcomes of personal relevance to the person.

(Adapted from INCOG 2014, EXEC 1, p. 343)

Note: Metacognitive strategy instruction is optimized when the person with TBI has awareness of the need to use a strategy and can identify contexts in which the strategy should be used.

J 7.2 P A

Strategies to improve the capacity to analyze and synthesize information should be used with individuals with traumatic brain injury who have impaired reasoning skills.

(INCOG 2014, EXEC 2, p. 343)

J 7.3 P A

Strategies that encourage monitoring of performance and feedback should be used with individuals with traumatic brain injury who have impaired self-awareness.

(Adapted from INCOG 2014, EXEC 3, p. 343)

J 7.4 B

Group-based interventions should be considered for remediation of executive and problem-solving deficits after traumatic brain injury.

(Adapted from INCOG 2014, EXEC 4, p. 343)

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