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.
Indicators examples
The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially
Clinical tools:
Patient and Family Resource:
INCOG 2.0 Guidelines Series Open Access:
INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury: What's Changed From 2014 to Now?
Bayley, Mark Theodore; Janzen, Shannon; Harnett, Amber; More
Journal of Head Trauma Rehabilitation. 38(1):1-6, January/February 2023.
INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury: Methods, Overview, and Principles
Bayley, Mark Theodore; Janzen, Shannon; Harnett, Amber; More
Journal of Head Trauma Rehabilitation. 38(1):7-23, January/February 2023.
INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part I: Posttraumatic Amnesia
Ponsford, Jennie; Trevena-Peters, Jessica; Janzen, Shannon; More
Journal of Head Trauma Rehabilitation. 38(1):24-37, January/February 2023.
INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part II: Attention and Information Processing Speed
Ponsford, Jennie; Velikonja, Diana; Janzen, Shannon; More
Journal of Head Trauma Rehabilitation. 38(1):38-51, January/February 2023.
INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part III: Executive Functions
Jeffay, Eliyas; Ponsford, Jennie; Harnett, Amber; More
Journal of Head Trauma Rehabilitation. 38(1):52-64, January/February 2023.
INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part IV: Cognitive-Communication and Social Cognition Disorders
Togher, Leanne; Douglas, Jacinta; Turkstra, Lyn S.; More
Journal of Head Trauma Rehabilitation. 38(1):65-82, January/February 2023.
INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part V: Memory
Velikonja, Diana; Ponsford, Jennie; Janzen, Shannon; More
Journal of Head Trauma Rehabilitation. 38(1):83-102, January/February 2023.
The Future of INCOG (Is Now)
Bragge, Peter; Bayley, Mark Theodore; Velikonja, Diana; More
Journal of Head Trauma Rehabilitation. 38(1):103-107, January/February 2023.
Refer to Tools and Resources for INCOG 2.0 Guidelines Series Open Access
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, Umiltà, 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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During assessment of a person with TBI, 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 conditions, and post-injury factors.
(Adapted from INCOG 2014,8 Assess 6)
Last Updated January 2023
Individuals with persistent cognitive deficits due to TBI should receive 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, life contexts and goals.
(INCOG 2014,8 Assess 12 and Principle 1)
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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)
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Cognitive rehabilitation should:
(INCOG 2014,8 Principle 5)
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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 TBI to enhance speed of information processing
(Updated from INCOG 2014,28 Attention 9, p.328).
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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
Last Updated January 2023
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
Last Updated January 2023
Amantadine can be considered to enhance arousal and consciousness and accelerate functional recovery in the short term in individuals in vegetative or minimally responsive state or in coma following TBI
(Updated from INCOG 2014,9 Attention 10 p.328-329).
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 Attention 10, p.328).
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The traditional Chinese medicine MLC901 (NeuroAiD IITM) may enhance complex attention in individuals with mild-moderate TBI (INCOG 2022).
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Metacognitive strategy training using functional everyday activities should be considered for individuals with TBI, especially those with mild-moderate attention deficits
(Updated from INCOG 2014,28 Attention 1, p.324-325).
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Training in dual-tasking for individuals with TBI can be used to improve dual-task performance, only on tasks similar to those trained
(INCOG 2014,28 Attention 2, p.325).
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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 Attention 4, p.326).
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Alterations to the environment and tasks may be used to reduce the impact of attentional deficits on daily activities for individuals with TBI
(INCOG 2014,28 Attention 5, p.326).
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Computer-based de-contextualized attentional 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 Attention 6, p.326-327).
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Training with periodic random auditory alerting tones is not recommended for addressing attentional deficits following TBI
(INCOG 2014,28 Attention 7, p.327).
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The use of repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) to ameliorate attention following TBI is not recommended outside of the context of a research trial protocol (INCOG 2022).
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Teaching internal compensatory strategies may be used for individuals with TBI who have memory impairments. Their use tends to be most effective with individuals who have mild-to-moderate impairments and/or some preserved executive cognitive skills. These strategies include instructional (e.g., visualization/visual imagery, repeated practice, retrieval practice, Preview, Question, Read, State, Test (PQRST)) and metacognitive strategies (e.g., self-awareness, self-regulation, etc.). Using multiple strategies is considered effective, selected separately or in a structured program, and strategies can be taught individually or in a group format. With severe memory impairment internal compensatory strategies that are found to be effective may be used in conjunction with external memory compensatory strategies
(Updated from INCOG 2014,16 Memory 1, p.374).
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Cognitive skills training for MS-TBI should be strategy-focused and conducted by an experienced therapist who can further facilitate the functional integration of the strategy being practiced into meaningful and practical tasks. There is little evidence for using restorative techniques such as computerized cognitive training (CCT) alone
(Updated from INCOG 2014,16 Memory 7, p.382).
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(Updated from INCOG 2014,16 Memory 2 and 3, p.378).
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There are several key instructional practices that can promote learning for individuals with TBI memory impairments, which include:
(Updated from INCOG 2014,16 Memory 4, p.379).
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Group-based interventions may be considered as part of cognitive rehabilitation to address:
(INCOG 2014,8 Principle 6).
Group-based interventions may be considered for teaching memory strategies with individuals with MS-TBI, but there is no evidence that it is more effective than individually oriented rehabilitation. Consider reducing heterogeneity in group membership, encourage participation for an adequate number of sessions and teach generalization of learned skills
(Updated from INCOG 2014,16 Memory 5, p.381).
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Consider the use of non-pharmacological interventions prior to the initiation of pharmacological interventions. (INCOG 2022)
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Rivastigmine may be considered for individuals with moderate-to-severe memory impairment in the subacute to chronic phase of recovery after traumatic brain injury.
Suggested tool: Health Canada Indications of Use
REFERENCE:
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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
Last Updated January 2023
Metacognitive Strategies
Metacognitive strategy instructions (e.g., goal management training, plan-do-check-review, prediction performance) should be used with individuals with TBI for difficulties with a range of executive functioning impairments that may include problem-solving, planning and organization, and other elements of executive function. Common elements of all metacognitive strategies are self-monitoring, incorporating feedback into future performance, and emotional self-regulation training. These strategies should be focused on everyday problems and functional outcomes of personal relevance to the person.
Note: Metacognitive strategy instruction is optimized when the person with traumatic brain injury has awareness of the need to use a strategy and can identify contexts in which the strategy should be used. Further metacognitive strategy instruction should be conducted at least six months post-TBI and in the community in context.
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Strategies to improve Reasoning skills
Strategies to improve the capacity to analyze and synthesize information should be used with individuals with traumatic brain injury who have impaired reasoning skills.
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Monitoring and Feedback
Strategies that encourage self-monitoring of performance and involve feedback should be used with individuals with TBI who have impaired self-awareness.
Self-Awareness Training
Consider self-awareness training such as video feedback to improve the ability to recognize and correct errors during task performance.
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Group Based Interventions
Group-based interventions should be considered for remediation of executive and problem-solving deficits after traumatic brain injury.
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Rhythmical/Music Therapy
In individuals with executive function impairments (with or without previous musical experience), consider a structured music therapy program that includes (1) rhythmical training, (2) structured cognitive-motor training, and (3) assisted music playing that is individualized to the person's interests and progression through the program.
Definitions from Siponkoski et al. (2020):
Rhythmical training: playing sequences of musical rhythms and coordinated bimanual movements on a djembe drum and own body.
Structured cognitive-motor training: playing musical exercises on a drum set with varying levels of movement elements and composition of drum pads, accompanied by the therapist with piano.
Assisted music playing: learning to play the participant's own favourite songs on the piano with the help of the therapist and using Figure Notes.
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Virtual Reality
Where available, we recommend clinicians consider the use of virtual reality programs, in addition to in-person visits to provide timely and equitable access to care for individuals with a TBI with executive dysfunction.
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Telerehabilitation Delivered Metacognitive Strategy Training
Telerehabilitation delivered metacognitive strategy training
One-to-one remotely delivered interventions (e.g. for goal management training), set up according to established telerehabilitation guidelines, is recommended if remote delivery is the most convenient or the only mode of reaching the person.
Last Updated January 2023
Telerehabilitation-Delivered Group Based Treatment
Telerehabilitation-delivered group-based treatments of executive function may not achieve the same outcomes as in person and requires further evaluation. Therefore are not recommended at this time.
Last Updated January 2023