Cognitiive Rehabilitation of Attention-Control in TBI: A Randomized Cross-Over Pilot Trial

Catherine Tocci, University of Florida, Gainesville, United States
Christopher Sozda, Malcolm Randall Veterans Administration Medical Center, Gainesville, United States
Sarah Long, University of Florida, Gainesville, United States
William Perlstein, University of Florida, Gainesville, United States


Attention impairment is ubiquitous in traumatic brain injury (TBI) survivors. This is a devastating impairment because attention is the backbone of cognitive systems, and requisite for other cognitive processes that are vital to everyday functioning. There is currently limited literature on the effectiveness of direct-attention training in traumatic brain injury samples to remediate attention deficits.  Consequently, our study aimed to test the preliminary efficacy of computerized direct-attention training via BrainHQ in a sample of TBI patients.

Participants and Methods:

11 chronic TBI survivors (> 3 months post-injury) with non-penetrating head injuries aged 21-49 years who were 10-35 months post-injury with self-reported (and neuropsychologically confirmed) impairments in attention compared to normed data from demographically-matched healthy controls. Using an AB/BA cross-over design, patients completed four weeks of at-home computerized attention training and 4 weeks of at-home sham/control training (exercises that mimic the active intervention but provide no known cognitive benefit) in a counter-balanced fashion. Both active and control training exercises were delivered via BrainHQTM software (Posit Science Corp). Cognitive and mood outcome measures were assessed at baseline, following the first 4-week study period, and upon completion of the second 4-week study period. Cognitive outcomes included neuropsychological tests examining attention, executive functioning, and processing speed, and a computerized test of 3 sub-networks of attention (Alerting, Orienting, Executive-Control; Attention Network Test, ANT). Mood measures included mood questionnaires assessing symptoms of depression (BDI-II) and anxiety (GAD-7), and subjective perception of attentional lapses (MAAS-LO).  Additionally, 64-channel electroencephalography were acquired while participants performed the ANT at each time point. Statistical analyses included mixed-model repeated-measures ANOVA with Visit as a within-subject factor and treatment order (i.e., “Group”) as the between-subject factor.


No significant changes were seen on neuropsychological measures of attentional functioning. There was a significant main effect of time/visit on processing-speed measures (Trails A and Stroop-Word) and measures of executive functioning (Trails B and Stroop-Interference score) reflecting linear trends toward improvement over visits. Reaction time (RT) on the ANT showed a significant Group X Visit interaction on the orienting-network difference scores; which were disproportionally reduced following active than control training. The executive-control network also showed a significant linear effect over visit. There were no significant main effects for perceived attentional lapses or anxiety symptoms, but there was a significant linear improvement in reported depressive symptoms over visits.


Many of the observed significant linear effects on attentional neuropsychological measures likely reflect practice-related improvements, as we did not use alternate forms. Our findings do not indicate significant objective improvements in neuropsychological-test performance following engagement in direct-attention training; while recognizing limited statistical power due to small sample size. There was, however, a notable improvement in symptoms of depression, possibly attenuated by subjective feelings of improvement related to participating in training program and a disproportionate improvement in attentional orienting speed following treatment. Findings are consistent with prior research indicating that direct-attention training may be more effective when paired with meta-cognitive-strategy training programs (e.g., Goal-Management Training; GMT; Waid-Ebbs, et al., 2023).

Category: Acquired Brain Injury (TBI/Cerebrovascular Injury and Disease - Adult)

Keyword 1: cognitive rehabilitation