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Rehabilitation of alternating attention

Rehabilitation of alternating attention

What is alternating attention?

Alternating attention is the ability to shift the focus of attention and move between two or more activities with different cognitive requirements. Mental flexibility is thereby required to enable the switch and to perform the different tasks efficiently, without the cognitive load of one task limiting the performance of the others, or task switching itself altering concentration1.

The engagement of lower levels of attention is clear. On the one hand, focused attention, the most basic type, is required to respond to different stimuli. On the other hand, sustained attention is needed to properly perform a task, while selective attention is essential to carrying out an activity at a given time without interference from other stimuli or items of information. An example of a task included in the Attention Process Training (APT) program to target deficits in alternating attention is a cancellation task in which participants are asked to first cross out a target stimulus and then, when directed, switch to crossing out the other2. As you can see, this is a cancellation task in which attention must be sustained on the target stimulus while at the same time, ignoring the other stimuli until switching takes place, that is, the moment in which mental flexibility comes into play.

We use this type of attention in many daily life situations since we are constantly performing several tasks at the same time. By way of illustration, here is an example: meal preparation. Imagine heating soup on the stove that must be stirred from time to time; when you are not stirring the soup, you are chopping other ingredients that will later be added to the soup. Here you have two tasks, stirring and chopping, and each one requires carrying out a pattern of movements and a different cognitive load since chopping an onion requires more attention and caution to avoid cutting ourselves than stirring the soup. This may seem like two relatively simple tasks, however, for people who have difficulties in alternating attention, this would be very complicated because they need more time to shift their focus of attention, pick up and initiate new task requirements.

Assessment of alternating attention

Commonly used tests to assess alternating attention usually involve other cognitive processes such as working memory. Some of these tests—briefly described below—are the Trail Making Test Part B (TMT-B), the Letter-Number Sequencing subtest from the WAIS-IV, and the Symbol Digit Modalities Test (SDMT).

The Trail Making Test (TMT) is one of the most widely used neuropsychological tests to assess attention and executive functions, and consists of two parts. In part A (TMT-A), 25 circles are distributed over a sheet of paper and numbered 1-25; participants should draw lines to connect the numbers in ascending order (i.e., 1-2-3-4-etc.) as quickly as possible. In part B (TMT-B), the circles include 13 numbers (1-13) and 12 letters (A-L); participants should draw lines to connect the circles in an ascending pattern and alternate between the numbers and letters (i.e., 1-A-2-B-3-C, etc.). This second part of the test is widely used as a measure of executive function and alternating attention since mental flexibility is required to shift between sets3.

Letter-Number Sequencing is a subtest from the WAIS-IV. A sequence of mixed-up numbers and letters are presented orally to the participant. The examinee must repeat the numbers first in ascending order and then the letters in alphabetical order. This subtest measures alternating attention, concentration, and working memory4.

The Symbol Digit Modalities Test (SDMT) is used to assess attention and processing speed. Using a reference key, the subject’s task is to place the correct number that is associated with each symbol in designated boxes. The test includes a total of 110 items and the final score is the correct number of substitutions in 90 seconds5.

Rehabilitation of alternating attention

As in any rehabilitation program, patients should start training with simple tasks, that is, short-duration exercises with low stimulus load and kibg oeruidis in-between changes. As rehabilitation progresses, these variables should be adjusted so that the time spent on the task, the stimuli—in quantity and complexity—, and the frequency of change increase, and the duration of stimulus, in the case of virtual programs, decreases.

Towards this purpose, there are several rehabilitation programs that we have addressed, such as the APT or the platform NeuronUP, which use pencil-and-paper tasks or computer games. This task modality is however not the only one used, as it has been found that by using music as a rehabilitation tool, considerable progress can be achieved.

Music as a therapeutic tool in rehabilitation

Over the last few decades, numerous research studies have been done on the benefits of music in all its variants, either passively, i. e. music listening can enhance the recovery of cognitive functions and mood6, or actively through the practice of a musical instrument7,8 or through dance9,10. Since the studies reported positive results, musical therapy is now widely used in rehabilitation programs. This is the case of the Musical Attention Training Program (MATP), an adaptation of Sohlberg and Mateer’sAPT, in which four out of the five levels of attention of the APT program are trained, but through the use of musical components11.

In alternating attention training, the task is as follows: a melodic line is presented to participants, who are instructed to press a key on the keyboard when they hear a pre-determined melodic motive. At a certain point, a drum track begins and participants must press another key to produce a percussion sound along with the drum track at the downbeat of every measure. When the drum track ends, they shift attention back to the melodic task component, thus alternating attention between both task components; the trials included in this training are made up of target motives of progressively increasing length. One advantageous aspect of this therapy intervention was the variety of musical styles available (rock, pop, reggae etc.), so that training could be customized to suit individual tastes, thus increasing participant motivation11.

Once again, we must highlight the importance of adapting and tailoring rehabilitation programs to the individual needs of patients by using ecologically valid tasks that are motivating for them, as this will increase collaboration and participation in rehabilitation, while also enabling the extrapolation of rehabilitation outcomes in their daily life.


  1. Sohlberg MM, Mateer CA. Effectiveness of an attention-training program. Journal of Clinical and Experimental Neuropsychology. 1987;9(2):117–30.
  2. Sohlberg MM, Mateer CA. Improving Attention and Managing Attentional Problems. Annals of the New York Academy of Sciences. 2006;931(1):359–75.
  3. Reitan, R. M. (1958). The validity of the Trail Making Test as an indicator of organic brain damage. Perceptual and Motor Skills, 8, 271-276.
  4. Amador, J. A. (2013). Escala de inteligencia de Wechsler para adultos-IV (WAIS-IV).
  5. Arribas, D. (2002). Symbol DigitModalities Test (Test de Símbolos y Dígitos). Madrid: TEA Ediciones S.A.
  6. Särkämö, T., Tervaniemi, M., Laitinen, S., Forsblom, A., Soinila, S., Mikkonen, M., … &Peretz, I. (2008). Music listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain, 131(3), 866-876.
  7. Forgeard, M., Winner, E., Norton, A., &Schlaug, G. (2008). Practicing a musical instrument in childhood is associated with enhanced verbal ability and non verbal reasoning. PloSone, 3(10), e3566.
  8. Schneider, S., Schönle, P. W., Altenmüller, E., &Münte, T. F. (2007). Using musical instruments improve motor skill recovery following a stroke. Journal of Neurology, 254(10), 1339-1346.
  9. Hackney, M. E., & Earhart, G. M. (2009). Effects of dance on movement control in Parkinson’s disease: a comparison of Argentine tango and American ballroom. Journal of rehabilitation medicine, 41(6), 475-481.
  10. Earhart, G. M. (2009). Dance as therapy for individuals with Parkinson disease. European journal of physical and rehabilitation medicine, 45(2), 231.
  11. Knox R, Yokota-Adachi H, Kershner J, Jutai J. Musical attention training program and alternating attention in brain injury: An initial report. Music Therapy 2003;21(2):99-104.
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