Brain Impairment

State of the Art Reviews

Integrating Interventions after Traumatic Brain Injury: A Synergistic Approach to Neurorehabilitation

Kristen Dams-O'Connora1 c1 and Wayne A. Gordona1

a1 Department of Rehabilitation Medicine, Ichan School of Medicine at Mount Sinai, New York, NY, USA


Deficits in attention, processing speed and executive functioning are among the most commonly reported and functionally limiting cognitive impairments among individuals with TBI. Changes in mood can exacerbate cognitive deficits and reduce life quality. Contemporary hierarchical models of cognitive functioning suggest that attention/arousal processes underlie and support higher-order functions. Building on decades of clinical research, a synergistic, integrative approach to neurorehabilitation is described, which combines bottom-up and top-town cognitive interventions in addition to psychotherapeutic interventions for mood. This approach is intended to address directly impairments in both foundational (i.e., attention) and higher-order (i.e., executive functions) processes. Executive dysfunction is addressed in a top-down fashion through the application of a series of problem-solving and emotional regulation modules that teach and integrate strategies that can be generalised across situations with practice. Attention, arousal and information processing are necessary prerequisites of successful higher-order thinking, attention skills, and are addressed in a bottom-up fashion through intensive individualised attention and processing training tasks. Combining top-down and bottom-up approaches within a comprehensive day-treatment programme can effect a synergistic improvement of overall functioning.


  • traumatic brain injury;
  • neurorehabilitation;
  • executive functioning


c1 Address for correspondence: Kristen Dams-O'Connor, PhD, Assistant Professor, Department of Rehabilitation Medicine, Ichan School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1240, New York, NY 10029, USA. E-mail: Kristen.dams-o'