Incog - Cognitive Comunication

J Head Trauma Rehabil
Vol. 29, No. 4, pp. 353–368

c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Copyright
INCOG Recommendations for

Management of Cognition Following
Traumatic Brain Injury, Part IV:
Cognitive Communication
Leanne Togher, BAppSc, PhD; Catherine Wiseman-Hakes, PhD;
Jacinta Douglas, BAppSc, MSc; Mary Stergiou-Kita, PhD; Jennie Ponsford, MA, PhD;
Robert Teasell, MD, FRCPC; Mark Bayley, MD;
Lyn S. Turkstra, PhD, CCC-SLP; on behalf of the INCOG Expert Panel
Introduction: Cognitive-communication disorders are common in individuals with traumatic brain injury (TBI) and
can have a major impact on long-term outcome. Guidelines for evidence-informed rehabilitation are needed, thus
an international group of researchers and clinicians (known as INCOG) convened to develop recommendations for
assessment and intervention. Methods: An expert panel met to select appropriate recommendations for assessment
and treatment of cognitive-communication disorders based on available literature. To promote implementation,
the team developed decision algorithms incorporating the recommendations, based on inclusion and exclusion
criteria of published trials, and then prioritized recommendations for implementation and developed audit criteria
to evaluate adherence to best practice recommendations. Results: Rehabilitation of individuals with cognitive-
communication disorders should consider premorbid communication status; be individualized to the person’s needs,
goals, and skills; provide training in use of assistive technology where appropriate; include training of communication
partners; and occur in context to minimize the need for generalization. Evidence supports treatment of social
communication problems in a group format. Conclusion: There is strong evidence for person-centered treatment
of cognitive-communication disorders and use of instructional strategies such as errorless learning, metacognitive
strategy training, and group treatment. Future studies should include tests of alternative service delivery models and
development of participation-level outcome measures. Key words: cognitive communication, cognitive rehabilitation,
guidelines, rehabilitation, traumatic brain injury
T
Author Affiliations: Speech Pathology, Faculty of Health Sciences, The
University of Sydney, Australia (Dr Togher); NHMRC Centre of
HE TERM COGNITIVE-COMMUNICATION
Research Excellence in Traumatic Brain Injury Psychosocial DISORDER was adopted by the American Speech-
Rehabilitation, Australia (Drs Togher and Ponsford and Ms Douglas); Language-Hearing Association and the College of
Bloorview Research Institute, Holland Bloorview Kids Rehabilitation
Hospital, Toronto, Ontario, Canada (Dr Wiseman-Hakes); Department
Audiologists and Speech-Language Pathologists of On-
of Human Communication Sciences, La Trobe University, Victoria, tario (CASLPO) to differentiate communication disor-
Australia (Ms Douglas); Department of Occupational Science and ders resulting from primary cognitive impairments, as
Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
(Dr Stergiou-Kita); School of Psychology and Psychiatry, Monash
in acquired brain injury, from those resulting from pri-
University and Epworth Hospital, Melbourne, Australia (Dr Ponsford); mary language impairments, as in aphasia after stroke.
National Trauma Research Institute, Monash University and The Alfred As defined by CASLPO,1 cognitive-communication
Hospital (Dr Ponsford); Aging, Rehabilitation and Geriatric Care
Program, Lawson Health Research Institute, Parkwood Hospital, London,
Ontario, Canada (Dr Teasell); Department of Physical Medicine and
Rehabilitation, Schulich School of Medicine, University of Western tive (VNI), Monash University, and the Ontario Neurotrauma Foundation
Ontario, London, Ontario, Canada (Dr Teasell); UHN–Toronto (ONF) for their support of this project.
Rehabilitation Institute and Division of Physical Medicine and The authors declare no conflicts of interest.
Rehabilitation University of Toronto, Toronto, Ontario, Canada (Dr
Bayley); and Department of Communication Sciences and Disorders, Corresponding Author: Leanne Togher, BAppSc, PhD, Speech Pathology,
University of Wisconsin-Madison (Dr Turkstra). Faculty of Health Sciences, The University of Sydney, Rm. No 155, 75 East
St, Lidcombe NSW, Australia ([email protected]).
The authors gratefully acknowledge the support of the Victorian Transport
Accident Commission (TAC) through its Victorian Neurotrauma Initia- DOI: 10.1097/HTR.0000000000000071
353
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
354 JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2014
disorders are “communication impairments resulting tive to cognitive-communication impairments.2 Re-

from underlying cognitive deficits due to neurologi- search investigating the assessment and treatment of
cal impairment. These are difficulties in communica- cognitive-communication disorders is, therefore, rela-
tive competence (listening, speaking, reading, writing, tively more recent than investigation of TBI sequelae
conversation, and social interaction) that result from such as basic neuropsychological deficits. Research on
underlying cognitive impairments (attention, memory, cognitive-communication disorders has been informed
organization, information processing, problem solving not only by historical studies of pragmatic commu-
and executive functions).”1(p3) This definition is based nication in children but also by recent development
on the premise that basic language functions such as of theories of social communication after TBI, result-
syntax and semantics are intact, by contrast to dis- ing in new methods of standardized and nonstandard-
orders such as aphasia and developmental language ized assessment.17,18 These new theories in turn have
impairments, in which impairments in basic language spawned new treatment approaches, which specifically
functions are the defining characteristic.2 Cognitive- target the unique communication difficulties that arise
communication disorders have unique features, comor- following TBI. As a result, the body of literature on
bidities, trajectories of change over time, and long-term assessment and treatment of cognitive-communication
outcomes, necessitating different approaches to assess- disorders is still evolving, and guidelines presented here
ment and treatment. While aphasia can result from will be refined and expanded in the future.
TBI, particularly in the presence of focal lesions to
left hemisphere and subcortical structures important for
METHODS
language form and content,3 primary language impair-
ments are relatively rare. Thus, our recommendations The Guidelines Adaptation and Development
focus on cognitive-communication disorders as defined (ADAPTE) process was used to develop the INCOG
by CASLPO. guidelines.19,20 An international expert panel was
While TBI is a complex and multifocal disorder, formed through invitations of authors of previously
there are some common patterns in brain pathology published cognitive rehabilitation guidelines and con-
and related cognitive and communication impairments. tacts of the team. In preparation, a detailed Internet
Traumatic brain injury typically affects the ventrolateral and Medline search was conducted to identify pub-
and anterior surfaces of the frontal and temporal lobes lished TBI and cognitive rehabilitation evidence-based
and also causes diffuse white matter injury.4,5 These guidelines.21 The quality of the development process for
injury patterns generally result in slowed information each eligible clinical practice guideline (CPG) was evalu-
processing; impaired working memory and attention; ated using the Appraisal of Guidelines for Research and
executive function problems including inertia, rigidity, Evaluation (II) instrument.22,23 The ADAPTE process
poor conceptualization and planning; and poor self- involves extracting recommendations from these CPGs
control of cognition and behavior.6 Communication to allow easy comparison, for example, all recommenda-
disturbances reflect these various underlying cognitive tions about executive function were tabulated together.
problems. Thus, adults with TBI have been described The Evidence Based review of Acquired Brain Injury
as overtalkative,7,8 inefficient,9 tangential10 or drifting (ERABI: http://www.abiebr.com/) synopses of evidence
from topic to topic,11 or lacking in language output.9,12 for each topic area were also distributed to the panel.24
Communication of adults with TBI has been described The initial expert panel meeting was scheduled for con-
as slow, with incomplete responses, numerous pauses, venience just prior to the World Congress of Neurore-
and a reliance on set expressions.13 People with TBI habilitation in Melbourne, Australia, in May of 2012.
may also demonstrate confused, inaccurate, and confab- Some members attended via Web conferencing from
ulatory verbal behavior, with frequent interruptions, in- the United States and Canada. This panel examined the
appropriate disinhibited responses, swearing, tangential recommendations matrix and selected suitable recom-
topic changes or perseveration on topics, or some com- mendations from existing guidelines or articulated novel
bination of these features.14 Likewise, in adolescents and recommendations on the basis of the evidence available.
adults with TBI, there may be reduced conversational This yielded an initial draft set of recommendations;
fluency, difficulties with interpretation of abstract lan- however, to ensure that the recommendations were up-
guage, and an inability to juggle the multiple demands dated according to the most current evidence, the re-
of conversation.15 Indeed, changes in pragmatic com- search team prepared synopses of large systematic re-
munication, with resulting impairments in overall social views of the Global Evidence Mapping Initiative25 based
competency, are a hallmark of TBI. in Australia (www.evidencemap.org), the Acquired Brain
It became clear to researchers in the late 1980s Injury Evidence-Based Review24 and PsycBITE (http:
and early 1990s that traditional language tests, such //www.psycbite.com).26 Furthermore, the reference sec-
as the Western Aphasia Battery,16 were not sensi- tions of all eligible cognitive rehabilitation CPGs were
INCOG Recommendations for Management of Cognition Following TBI 355
also extracted. All relevant references were consolidated published after the INCOG guideline could influence
into a reference library that was made available to the the recommendations contained herein. Clinicians must
author teams as they drafted the manuscripts and final- also consider their own clinical judgment, patient pref-
ized the recommendations accordingly. By the end, the erences, and contextual factors such as resource avail-
team completed the evidence review of more than 600 ability in their decision-making processes about imple-
references found in this search process. This task has mentation of these recommendations.
resulted in a comprehensive mapping of evidence to all (Note: The INCOG developers, contributors, and sup-
previously and newly developed recommendations. The porting partners shall not be liable for any damages,
tables will be made available on online content on the claims, liabilities, costs, or obligations arising from the
Web site of the Journal of Head Trauma Rehabilitation. use or misuse of this material, including loss or damage
With the updated literature search in mind, the experts arising from any claims made by a third party.)
graded the evidence. As various systems for determin-
ing the level of evidence were used across the CPGs, the
Recommendations and literature review
INCOG team standardized this by using the grading sys-
tem outlined later (see Table 1), which was based upon The INCOG guidelines include 7 recommendations
that used in previous guideline development projects.27 regarding best practice for the assessment and manage-
These final recommendations were then presented to ment of cognitive-communication disorders following
the entire team for approval and then the expert panel TBI (see Table 2). Two recommendations (Cognitive
used Modified Delphi Voting Technique to prioritize Communication #2 and #3) encompass principles of
the recommendations from the INCOG guideline for practice embodied in current international practice stan-
audit. Each of the experts was asked in this exercise to dards for the speech-language pathology profession, and
vote for his or her top 15 recommendations considering consensus expert opinion, and, therefore, represent level
both the importance to practice and the feasibility of C evidence; 2 recommendations (Cognitive Communi-
auditing the recommendations. For each cognitive reha- cation #1 and #6) are based on level B evidence and
bilitation domain of posttraumatic amnesia, attention, 3 recommendations (Cognitive Communication #4,
memory, executive function, and cognitive communi- #5, and #7) are based on level A evidence. Each of
cation, a clinical algorithm was developed to help clin- the cognitive-communication recommendations is dis-
icians decide to whom the recommendations applied. cussed with reference to the supporting evidence.
To finalize the algorithm, evidence tables were reviewed
Cognitive Communication #1. Rehabilitation staff should
to find the inclusion and exclusion criteria for the study
recognize that levels of communication competence and
populations that were used. By understanding the sub- communication characteristics may vary as a function of
populations of patients with TBI to whom the evidence communication partner, environment, communication de-
applies, it is possible to understand what treatments are mands, communication priorities, fatigue and other personal
29(p24)
appropriate for each patient. In contrast to other guide- factors. (Adapted from ABIKUS, G51 ; Royal College of
30(p33)
lines, the INCOG team has identified recommendations Physicians, G70 )
that could be audited from clinical charts to determine
adherence to the best practice guidelines in each section. Communicative competence during everyday activi-
This is known as the INCOG audit tool. More detailed ties requires an awareness of sociolinguistic factors such
version of the “Methods” section is available in the third as the person’s culture, sex and gender, and languages
article of the series.28 spoken, as well as an understanding of the person’s pre-
morbid and current interpersonal skills, which may vary
according to the communication partner.31 Rehabilita-
Limitations of use and disclaimer
tion staff should also recognize the strong influence
These recommendations are informed by evidence of the environment on communication performance,
for TBI cognitive rehabilitation interventions that was whether it be a hospital in- 32 or outpatient therapy
current at the time of publication. Relevant evidence room, a busy reception area, the client’s workplace, his
TABLE 1 INCOG level of evidence grading system

A: Recommendation supported by at least 1 meta-analysis, systematic review, or randomized controlled trial of
appropriate size with relevant control group.
B: Recommendation supported by cohort studies that at minimum have a comparison group, well-designed single
subject experimental designs, or small sample size randomized controlled trials.
C: Recommendation supported primarily by expert opinion on the basis of their experience although uncontrolled
case series without comparison groups that support the recommendations are also classified here.
www.headtraumarehab.com
TABLE 2
356
INCOG guideline recommendations: cognitive communication
Guideline recommendation
Interventions to improve cognitive
communication Grade Reviews RCTs Other
35
Cognitive Communication #1 Rehabilitation staff should recognize that B Togher et al Togher et al34
levels of communication competence Douglas15
and communication characteristics may Wiseman-
vary as a function of: Hakes et al38
• Communication partner: patients may Valitchka and
communicate at a higher level with Turkstra32
family and friends who know them well Larkins et al36
than with professional staff
Environment
• Communication demands (e.g., time
pressure, need to follow multiple
speakers)
• Communication priorities Fatigue
• Other personal factors.
Adapted from ABIKUS G51 p. 24
(2007)29 /RCP G70 p. 33 (2003)30
Cognitive Communication #2 A person with traumatic brain injury who C American
has a cognitive communication disorder Speech-
should be offered an appropriate Language-
treatment program by a speech Hearing
language pathologist. Association41
Adapted from ABIKUS G47 p. 23 (2007)29 College of
Audiologists
and Speech-
Language
Pathologists of
Ontario1
JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2014
Cognitive Communication #3 A cognitive communication rehabilitation C MacDonald and Larkins et al36

program should take into account the Wiseman-Hakes48
person’s premorbid:
• Native language
• Literacy and language proficiency
• Cognitive abilities, and
• Communication style, including
communication standards and
expectations in that individual’s culture.
Adapted from NZGG, 6.1.5, p. 97
(2006)/DeRuyter (1988)46
(continues)
TABLE 2 INCOG guideline recommendations: cognitive communication (Continued)
Guideline recommendation
Interventions to improve cognitive
communication Grade Reviews RCTs Other
Cognitive Communication #4 A cognitive communication rehabilitation A MacDonald and Dahlberg et al59
program should provide the opportunity Wiseman-Hakes48 McDonald et al60
to rehearse communication skills in Togher et al57
situations appropriate to the context in Behn et al58
which the individual will live, work,
study, and socialize.
Adapted from ABIKUS G49 p. 24 (2007)29
Cognitive Communication #5 A cognitive communication rehabilitation A MacDonald and Togher et al35
program should provide education and Wiseman-Hakes48 Togher et al57
training of communication partners. Behn et al58
ABIKUS G48 p. 23 (2007)29
Cognitive Communication #6 Individuals with severe communication B Wilson66 Powell et al70 Campbell et al63
disability should be assessed for, Doyle et al65
provided with and trained in the use of
appropriate alternative and
augmentative communication aids by
suitably accredited clinicians: speech
language pathologists (for
communication) and occupational
therapists (for access to devices,
writing aids, seating etc.)
From ABIKUS G46 p. 23 and G50 p.24
(2007)29 /RCP CPG (2003)30 / Deruyter
(1991)62
Cognitive Communication #7 Interventions to address patient-identified A MacDonald and Helffenstein and Coelho et al17
goals for social communication deficits Wiseman-Hakes48 Wechsler76 Behn Parente and
are recommended after TBI, with et al58 Togher et Stapleton75
outcomes measured at the level of al35 Togher et al57 Ylvisaker et al54
participation in everyday social life. McDonald et al60
These interventions can be provided in McDonald et al80
either group or individual settings; Struchen et al81
however, published evidence is
INCOG Recommendations for Management of Cognition Following TBI
strongest for group-based

interventions.
Adapted from Cicerone p. 522 (2011)55
Abbreviations: RCT, randomized controlled trial; TBI, traumatic brain injury.
357
or her conversation with a family member or friend,33 (e.g., preinjury variables such as prior history of sub-
or a shopping encounter.34 The communication part- stance abuse, level of education, employment history,
ner’s level of experience in interacting with people and postinjury variables such as concomitant psychiatric
with TBI can affect the nature of the interaction, and conditions, vision or hearing deficits, and other medi-
conversational skills training for the partner can im- cal conditions such as seizures). Therefore, clinicians
prove the interaction of the person with TBI.35 Togher should thoroughly investigate these variables and take
and colleagues35 compared trained versus untrained po- results into account when determining the person’s com-
lice officers in a randomized controlled trial (RCT) of munication competence and needs for intervention.
partner training, in which the training group received
Cognitive Communication #2. A person with TBI who has
6 weeks of communication instruction aimed at im-
a cognitive-communication disorder should be offered an ap-
proving their interactions with people with TBI. After
propriate treatment program by a speech-language pathologist
police officers received training, their communication (SLP). (Adapted from ABIKUS, G47
29(p23)
)
partners with TBI made fewer inappropriate and unre-
lated comments, although the individuals with TBI had Managing cognitive-communication disorders aris-
not received training. Results indicated that everyday ing from TBI is integral to a speech-language pathol-
communication partners—including service providers— ogist’s (SLP’s) scope of practice, as SLPs are uniquely
can have a significant positive influence on communi- trained to manage communication disorders and have
cation of people with TBI. The study also highlighted essential clinical knowledge regarding the interaction
the value of measuring communication during everyday between cognition and communication.39 Basic assump-
interactions. tions underlying the management of cognitive com-
People with TBI, their families, healthcare providers, munication disorders were described within an initial
and payers likely differ in what they consider to be im- committee report to the Academy of Neurological
portant communication interactions, and views of these Communication Disorders and Sciences in 2002.40
stakeholders should be considered individually. Larkins These included the assumption that managing cognitive-
et al36 asked different stakeholders about the relative communication disorders requires interdisciplinary
importance of functional communication assessments support from all relevant professions, particularly neu-
for people with TBI. Stakeholders included people with ropsychology; cognitive-communication intervention
TBI, health professionals, case managers, family mem- methods are specific to these disorders (i.e., differ from
bers, and employers. Stakeholders differed in their pri- treatments for aphasia); approaches to management
orities for communication assessment. For example, the of cognitive-communication disorders include compen-
top priority for health professionals was that individuals satory and restorative methods (e.g., metacognitive strat-
with TBI could use communication to “get basic help,” egy training vs. attention training); and multimodal ap-
whereas persons with TBI and their families listed assess- proaches. It is also agreed by consensus that numerous
ment of “listening and concentrating” as the highest pri- service delivery models exist that improvements in im-
ority. People with TBI also listed skills required for inter- pairments may not facilitate a change in a person’s ac-
viewing and communicating in the workplace, making tivity or participation or vice versa, and finally, that the
appointments, having social conversations in groups, ultimate goal of cognitive-communication intervention
writing their thoughts, speaking slowly and clearly, ask- is to help the individual achieve the highest level of
ing questions, and using the telephone. Evaluation of participation in everyday communication life.
communication competence needs to consider stake- International SLP professional associations also
holder opinions when determining communication pri- acknowledge the central role of the SLP in the
orities. management of cognitive-communication disorders.
Communication performance also varies in response American Speech-Language-Hearing Association added
to changing communication demands. For example, a management of cognitive-communication disorders to
person with TBI may show significantly poorer com- the scope of SLP practice in 1988 and formally ac-
munication skills in situations in which time pressure knowledged the role of SLPs in the identification,
is applied or in which he or she is required to attend diagnosis, and treatment of individuals with cognitive-
to multiple speakers or deal with noisy environments.37 communication disorders in 2004.41 College of Audi-
An important and frequently forgotten factor, which ologists and Speech-Language Pathologists of Ontario
can significantly affect communication performance, is acknowledged the importance of SLP management of
the effect of sleepiness and fatigue associated with sleep individuals with cognitive-communication disorders in
disorders following TBI,38 as well as fatigue occurring 2002.1 The Acquired Brain Injury Knowledge to Up-
independently of sleep disorders. Performance can also take Strategy (ABIKUS)29 recommendations for the re-
be influenced by personal factors such as those out- habilitation of moderate to severe TBI were the first in-
lined in recommendation 6 of the INCOG guideline ternational practice guidelines to explicitly recommend
that an SLP should offer treatment to people with TBI evaluation of individuals with cognitive communication
with a communication disorder. Recognition of the cen- disorders and with proven reliability and validity.43,48
tral role of SLPs is, therefore, relatively recent, which A growing number of studies have recognized the im-
has contributed to the paucity of research in the area. portance of client- and patient-centered goal setting in
Nonetheless, there have been significant and important healthcare.49 Individuals with TBI often lack awareness
advances in the assessment and management of indi- of deficits, however, particularly in the acute stage af-
viduals with cognitive communication disorders, with ter TBI,50 and patients’ unrealistic thinking could pose
practice guidelines published over the past decade pro- a challenge for identifying goals. A qualitative study51
viding guidance to SLPs in best practice.42–44 showed no difference over time in overall types of goals,
as the frequency of goals such as returning to work
Cognitive Communication #3. A cognitive-communication and relationships with family and friends did not dif-
rehabilitation program should take into account the person’s fer between patients in postacute rehabilitation and in-
premorbid native language, literacy, and language proficiency;
dividuals who were several years postinjury. Thus, re-
cognitive abilities; and communication style, including com-
munication standards and expectations in that individual’s cul- duced awareness may change the methods by which
ture. (Adapted from New Zealand Guideline Group, 6.1.5
45(p97)
; goals are achieved but does not obviate the need for
DeRuyter and Becker ) 46 client-centered goal setting.
People with TBI are a diverse group in regard to Cognitive Communication #4. A cognitive-communication
age, socioeconomic status, cultural background, native rehabilitation program should provide the opportunity to re-
language, educational background, literacy, premorbid hearse communication skills in situations appropriate to the
intelligence, vocational background, and sociocultural context in which the individual will live, work, study, and
29(p24)
networks. Therefore, it is imperative that personal so- socialize. (Adapted from ABIKUS, G49 )
ciodemographic factors be taken into account when
assessing and treating an individual with a cognitive- Communication is a complex activity that occurs nat-
communication disorder. The New Zealand Guidelines urally in our everyday lives and can be disrupted after a
Group Guidelines for Traumatic Brain Injury explicitly TBI. Therefore, to assess and treat cognitive communi-
recommend that a communication rehabilitation pro- cation disorders, it is necessary to focus on situations in
gram should take into account the person’s premorbid which communication may break down and in which
communication style and current cognitive deficits.45 intervention can have the greatest impact, which is typ-
Cultural and religious background can influence the ically during everyday conversations with families,52
communication activities in which a person engages, work colleagues,53 and friends.33 Clinicians should be
and when these are disrupted after TBI, the clinician cautious when using standardized tests to assess com-
needs to determine which of these activities could form munication in individuals with TBI, as these tests do not
functional goals.36 For example, cultural background take into account the individual’s context-dependent
may contribute to whether the person with TBI wishes pragmatic communication behaviors, the range of skills
to focus on being able to communicate in large com- among the typical population, and the many variables
munity gatherings or engage in religious ceremonies. that contribute to judgments of “appropriateness” in a
Perspectives of the person with TBI are critical for iden- given social, ethnic, or cultural group.44 Furthermore,
tifying which communication activities are a priority,47 persons with TBI often have difficulties with transfer
as reliance on other stakeholders, such as funding agen- and generalization of skills from one environment to
cies or employers, may lead to goals that are perceived to another. Thus, an important principle of rehabilitation
be less important by the person with TBI. For example, for persons with TBI is the need for activities that pro-
a group of New Zealand Maori TBI participants rated mote generalization and maintenance of skills in the
communication activities such as “participating in a spe- target communication context. Training of communi-
cific cultural protocol,” “self-expression through art and cation skills within natural contexts will also ensure that
craft,” and “communicating in a sports team” as impor- these skills will have social validity (i.e., will contribute
tant, whereas employers were more concerned with the to the individual’s social, vocational, educational, and
ability to “answer questions.” It is also critical for clini- independent living success) and thus are more likely
cians to take the cultural appropriateness of standardized to generalize into real-life situations.54 The ABIKUS29
tests into consideration when interpreting results. Cul- evidence-based recommendations for moderate to se-
tural differences may influence test performance, such vere TBI, therefore, suggest that a communication re-
that errors may not be indicative of a deficit in function- habilitation program should provide opportunities for
ing. In addition, there is a need for normative data from the person to rehearse his or her communication skills
minority populations and the development of new stan- in situations appropriate to the context in which that
dardized norm referenced instruments designed for the person will live, work, study, and socialize.
Developing a rehabilitation program that addresses law and justice personnel. It is recommended that every-
personally relevant contexts requires a focus on everyday day communication partners of people with TBI receive
communication skills, including pragmatic conversa- skills training to facilitate everyday communication with
tional skills. A recently published practice standard rec- persons with TBI. This recommendation is based on 2
ommended intervention for pragmatic conversational RCTs35,58 and 1 waitlist-control, single-blind, multicen-
skills in adults with TBI.55 Communication practice ter clinical trial.57 The first RCT was by Togher and
should occur in contexts in which the person with colleagues,35 who developed and evaluated a program to
TBI typically interacts, such as the individual’s place train police officers how to manage service encounters
of employment, school, leisure activities, and interac- with people with TBI. Individuals with TBI telephoned
tions with families, friends, and other social networks.56 police officers to ask advice about regaining a driving
These interactions may be in person or via telehealth.56 license, before and after police officers had been trained
Rehabilitation efficacy has been shown to be bet- in communication strategies. Training resulted in more
ter when individuals with TBI have practiced conver- efficient, focused communication interactions and con-
sations daily with their family members, at home and firmed that training communication partners improved
during social events, than when participants did not the communication performance of people with TBI.
practice at home.57 In an RCT,58 people paid carers Building on findings of police-officer training, the re-
who received training in conversational interaction had searchers conducted a 3-arm waitlist-control single-blind
more interesting, rewarding, and appropriate conversa- clinical trial to ask whether conversational skills training
tions with residents with TBI than carer group that did for family members could lead to improved commu-
not receive training. Improvements were maintained at nication by the person with TBI.61 Casual conversa-
6 months postintervention. Social communication skills tions were significantly better when training included
have been the focus of 2 RCTs in which home practice communication partners than either training the per-
was an essential element of the training programs.59,60 son with TBI alone or no treatment.57 Positive findings
Participants in 1 study59 were given copies of a so- were maintained at a 6-month follow-up assessment. The
cial skills workbook and asked to share them with a training program, TBI Express,53 comprised 10 weeks in
family member. In both the RCTs evaluating the ef- which each person with TBI and his or her communi-
fectiveness of a social skills program,59,60 participants cation partner attended a 2.5-hour group session, with 3
were given weekly homework tasks that required the to 4 other pairs and a weekly 1-hour individual session.
participant to practice particular social skills, such as Communication partners were taught to ask questions
topic maintenance, with a family member. In both stud- in a positive, nondemanding manner; encourage discus-
ies, partner-directed behavior improved in the training sion of opinions in conversations; and work through
group and home practice helped participants generalize difficult communication situations collaboratively.
newly learned skills to novel communication partners. TBI Express was adapted for a second RCT that
These findings support a recommendation to embed examined the effectiveness of communication training
rehabilitation processes in activities of everyday life, in- with paid attendant carers who were employed in
cluding the opportunity to practice conversational skills a long-term care facility for people with acquired
during everyday life activities. brain injury.58 Training comprised a 17-hour program
delivered across 8 weeks, with structured, casual con-
Cognitive Communication #5. A cognitive-communication
versational interactions between paid carers and people
rehabilitation program should provide education and train-
with TBI. Conversations were videotaped pretraining,
ing of communication partners. (Adapted from ABIKUS,
G48
29(p23)
) posttraining, and 6 months after training. Results
showed that training led to improved, purposeful
Cognitive-communication disorders following TBI conversations between carers and people with severe
can lead to profound impairments in communication TBI, compared with a matched control group. Trained
interactions, which can be challenging and embarrass- paid carers were better able to acknowledge and reveal
ing for communication partners during everyday con- the communication competence of people with TBI.
versations. Because of changes in social behavior after Conversations were perceived as more appropriate,
TBI, some individuals interact primarily with their fam- interesting, and rewarding than that in the control
ily members, a few close friends, and healthcare pro- group. Improvements were confined to the structured
fessionals, including paid carers and nursing staff. Af- conversation and were maintained for 6 months.
ter discharge from the inpatient setting, a person with
TBI may also have contact with people in the com- Cognitive Communication #6. Individuals with severe com-
munity, including shop assistants, community service munication disability should be assessed for, provided with
providers, people who work with government agencies and trained in the use of appropriate alternative and augmen-
that serve individuals with disabilities, and in some cases, tative communication aids by suitably accredited clinicians:
speech language pathologists (for communication) and occu- that targeted selected use of a Palm personal digital
pational therapists (for access to devices, writing aids, seating assistant. While there were no significant differences
29(pp23–24)
etc.). (Adapted from ABIKUS, G46,50 ; Royal College between the groups at immediate posttest with regard
of Physicians30 ; De Ruyter and Kennedy62 ) to accuracy and fluency, participants who received sys-
This recommendation was originally reported in the tematic instruction retained and generalized gains more
ABIKUS29 guidelines on the basis of level C evidence. than those in the trial-and-error learning group. There
The individual’s stage of recovery and specific com- are published practice guidelines for instructional meth-
munication needs are important determinants of the ods for individuals with TBI,71 and these apply to AAC
most appropriate alternative and augmentative com- as well as ACT.
munication (AAC) systems63 and methods of training Integrated systems of technological supports for a
AAC system use.44,64 During the early stages of re- range of communication and cognitive disorders (e.g.,
covery, individuals with TBI may use simple yes/no memory, planning, and organization) are well suited to
or 2-choice response methods, while those who have the needs of people with TBI. Such systems are likely
emerged from posttraumatic amnesia may use a range to become increasingly available. However, there is a
of simple communication systems, including gesture, pressing need for research not only to evaluate the ef-
word and symbol boards, alphabet boards, and simple fectiveness of such systems in promoting participation
output devices. At the later stages of recovery, when the but also to evaluate interventions designed to develop
rate of cognitive recovery has slowed, long-term systems the skills underpinning the use these systems.72
may be considered.65 In these situations, the goal of Cognitive Communication #7. Interventions to address
rehabilitation is to compensate for impaired cognitive- patient-identified goals for social communication deficits are
communication functioning and reduce the extent to recommended after TBI, with outcomes measured at the level
which impaired communication prevents successful of participation in everyday social life. These interventions can
return to everyday activities.66 Wilson66 offers a com- be provided in either group or individual settings, however
pensatory framework wherein consequences of the com- published evidence is strongest for group-based interventions.
pensatory behavior should result in functional and adap- (Adapted from Cicerone et al55 )
tive performance, thus reducing the mismatch between Loss of friends and social life is a common prob-
environmental demands and skills of the person with lem for adults with severe TBI, up to 30% of whom
TBI. Detailed assessment is needed regarding the pa- report no social contacts outside their families.73 Social
tient’s cognitive-linguistic abilities, his or her potential communication impairments play a key role in negative
for speech production, clinical observation of commu- social outcomes for adults with TBI,74 and SLPs play a
nication skills, physical impairments, seating and posi- central role in supporting effective social communica-
tioning requirements, the best method of device access, tion for their patients and clients. Improvements in dis-
and visuoperceptual and visual acuity skills.62 Assess- crete social communication skills are not enough: social
ment and prescription of AAC devices require an in- communication outcomes should be measured in real-
terdisciplinary approach by trained SLPs, occupational world environments during meaningful activities.17,48,75
therapists, and physical therapists. For example, seat- Helffenstein and Wechsler76 published the first RCT
ing and positioning requirements are often evaluated to evaluate the effectiveness of communication train-
by occupational and physical therapists, while the best ing for people with TBI. The primary outcome measure
method of device access may be established by the phys- was the participant’s score on a communication rating
ical therapists. Clinicians may require additional edu- scale, completed by staff during evening recreation activ-
cation and training in AAC and TBI.67,68 Long-term ities in a rehabilitation facility. Two independent raters
follow-up of adults with TBI who have been assessed also evaluated a 15-minute videotaped interaction be-
and prescribed AAC devices shows high levels of initial tween each person with TBI and an unfamiliar com-
acceptance (>90%) and relatively high levels of contin- munication partner. This was the first published RCT
ued use where necessary (>80%).69 to incorporate outcomes beyond the therapy session
While few studies have addressed AAC use by in- in adults with TBI who received social communication
dividuals with TBI, clinical practice in AAC may be training. A number of studies followed the original work
informed by research on assistive technology for cogni- by Hellfenstein and Wechsler,76 including direct social
tion (ACT). For example, one RCT compared 2 instruc- skills training studies such as the RCT by Dahlberg and
tional approaches for ACT training.70 Twenty-nine par- colleagues59 ; direct social skills training combined with
ticipants with moderate to severe acquired brain injury partner training57,60 ; and training of partners only.35
(with 80% TBI in both groups) were randomly allocated Communication goals were also among goals selected by
to either trial-and-error learning (conventional instruc- participants in an RCT on telehealth intervention for ev-
tion) or systematic instruction conditions. Both groups eryday memory problems in adults with TBI77 and were
received twelve 45-minute individual training sessions successfully trained using systematic instruction. An
evidence review by Cicerone and colleagues55 con- we have created an algorithm diagram (see Figure 1)
cluded that social communication intervention for in- to summarize these characteristics and assist with
dividuals with TBI should be considered a practice stan- translation of the current research evidence into clinical
dard. Studies with positive results have common ele- practice. We describe the features of the algorithm here.
ments: individualized goals that are important to partic- Social communication training for people with TBI
ipants, instructional methods that match participants’ has been shown to be effective for individuals with
learning ability, activities for planned generalization, in- chronic injuries, which has been quantified variously
clusion of important communication partners, and mea- as more than 6 months postinjury,78 at least 9 months
surement of outcomes beyond the therapy room. Partic- postinjury,57 more than 12 months postinjury,60,79 or
ipants in all studies to date also had enough awareness within 2 years of injury.76 Participants in all studies
to want to participate in therapy. had severe TBI, indicated by posttraumatic amnesia
for more than 24 hours and/or loss of consciousness
Summary of participant characteristics and for more than 6 hours. Most participants lived in the
treatments studied community35,57,60,78,80 or in long-term care facilities.58
This article seeks to describe the current evidence base Participants were included if others considered them
for the assessment and management of cognitive com- to have pragmatic communication problems, which
munication disorders following traumatic brain injury. included inappropriate behaviors,57,60,80 below-average
To interpret whether this evidence applies to a particular facial affect recognition,79 chronic social difficulty or
person with TBI or a clinician’s current caseload, it is social isolation, apparent disregard or lack of awareness
necessary to examine the characteristics of the partici- of social cues or inappropriate social responding, or
pants who were involved in these studies and the nature to have scored at least 2 standard deviations (SDs)
of the treatments studied. This information is critically below the norms on any emotion perception measures
important for clinicians to enable them to make a con- used at pre- and postassessment.78 Participants were
sidered judgment as to whether the findings of existing excluded from treatment if they had severe visual
studies are relevant to their current caseload. Therefore, or hearing impairments,76,79 visual neglect,79 severe
Figure 1. Algorithm diagram describing the characteristics of the participants and the treatment approaches underlying the
INCOG cognitive communication guidelines. TBI indicates traumatic brain injury.
aphasia,57,60,76,79 severe dysarthria,57 severe cognitive developing clinical guidelines is not sufficient to modify
impairments that would preclude participation in clinical practice. The use of audit and feedback is a com-
training activities,60 drug and alcohol addiction,57,58,79 monly employed strategy to enhance health profession-
active psychosis,60 non–English-speaking background, als’ uptake of guideline recommendations and measure
insufficient English to be able to follow instructions their adherence to suggested practice standards.85 As in-
and converse with group members,60 severe amnesia,57 dicated by the Appraisal of Guidelines for Research and
previous brain injury,57 or previous or recent psychiatric Evaluation II instrument, audit criteria can include pro-
history.78–80 These exclusion criteria characterize many cess or behavioral elements and/or clinical and health
of our clients and patients and which should be kept outcomes. The INCOG team has agreed upon the fol-
in mind when using any of the recommended social lowing 4 items from the guideline deemed most signif-
communication training methods. icant to clinical practice and auditable (see Table 3):
Treatment approaches for social communication (i) evidence that speech and language pathology treat-
deficits following TBI have predominantly used group ment programs have been provided to individuals with
formats,59 although some reported increased benefit by TBI with indicators of the use of objective individual
combining individual and group treatment sessions.57,60 measures of outcomes, including measurement of activ-
Treatment dose varied across studies: 2 to 3 weeks,79 ity and participation; (ii) evidence that in addition to the
three 2-hour sessions,80 1 hour per day for 4 weeks,76 individual with TBI, relevant communication partners
and 3 months of active peer mentoring.81 Social com- have received education and training; (iii) evidence that
munication group treatments have been delivered in individuals with severe communication impairments re-
sessions of 8,78 10,57 and 12 weeks.60 ceive assessment for and training in the use of alternative
Group-based treatments have employed 2 ap- and/or augmentative communication, and (iv) evidence
proaches: standardized social skills training and conver- that assessment and prescription of augmentative and
sational skills training. Standardized social skills training alternative communication devices is provided by suit-
has been least effective, as there is evidence that trained able accredited clinicians, that is, SLPs and occupational
skills do not automatically generalize to untreated skills therapists.
and contexts,44,64 at least for individuals with impaired These items reflect the central importance of special-
declarative memory and executive functions. Training ist speech language pathology services for people with
that incorporates everyday communication partners has severe TBI. It is critical that SLPs provide assessment and
been more successful, both immediately and after sev- treatment throughout the rehabilitation journey of the
eral months without treatment, perhaps because part- person with TBI. In addition to managing the cognitive
ners were able to recall the training and continue to communication sequelae of TBI, the SLP is also respon-
practice their skills beyond the period of the training. sible for ensuring that the person has access and training
Research on autism spectrum disorders has intro- to appropriate augmentative and alternative communi-
duced the concept of social cognition to the study of prag- cation if this is needed, that everyday communication
matic communication. Social cognition includes pro- partners receive specialist conversational skills training,
cesses such as emotion recognition from facial affect and that the outcome measures that are reported are de-
and voice and Theory of Mind, the belief that others signed to reflect improvements in the person’s everyday
have thoughts separate from one’s own and that these social life.
thoughts influence others’ behaviors.82 There is a large It is expected that evidence of all 4 auditable items
body of research on social cognition in individuals with would be found in the person with TBI’s medical record.
TBI,83,84 and treatment research is beginning to emerge. Referral to an SLP should occur at admission to the
At the time of publication of these guidelines, there were acute hospital, and ongoing SLP involvement should
3 published RCTs focusing on emotion recognition and occur into the chronic stages of rehabilitation, which
recognition of social inference.78–80 Results showed ben- may be years after the injury.
efits of training, and in one case, affect recognition train-
ing generalized to improvements in social interactions
Current state of practice
beyond the study. Research in this area is likely to in-
crease in the future, as understanding of social cognition Speech-language pathologists working in the field of
in TBI advances. TBI rehabilitation are posed with a number of chal-
lenges in delivering evidence-based practice services to
their patients. Insurers may deny coverage for cognitive
Audit items arising from the cognitive
rehabilitation or limit the number of sessions, and in-
communication recommendations
stitutional constraints often limit the extent to which
Recent advances in the field of implementation sci- clinicians can implement treatment in everyday set-
ence suggest that simply making recommendations and tings. We are pleased to report that there is a rapidly
364
TABLE 3 Audit guidelines for priority recommendations: cognitive communication

Specific activities, Assessment of need Patient
Intervention (guideline recommendation) devices, or tools and effectiveness characteristics Discipline
Cognitive communication treatment • Speech pathology • Cognitive • OT
A person with traumatic brain injury who has cognitive treatment program communication • PT
communication difficulties should be offered an appropriate documented impairment • SLP
treatment program by a speech-language pathologist. • MD
• Neuro
• Other
Education and training of communication partners • Assessment for need • Cognitive • OT
A cognitive communication rehabilitation program should conducted communication • PT
provide education and training of communication partners. • Training provided impairment • SLP
• MD
• Neuro
• Other
Prescription of augmentative and alternative communication • Assessment for need • Severe • OT
devices conducted communication • PT
Patients with severe communication disability should be • Training provided impairment (i.e., • SLP
assessed for, provided with and trained in the use of unintelligible speech • MD
appropriate alternative and augmentative communication aids or lack of production • Neuro
by suitably accredited clinicians: speech language of speech) • Other
pathologists (for communication) and occupational therapists
(for access to devices, writing aids, seating etc).
Participation in everyday social life should be measured • Results of • Cognitive • OT
Interventions to address patient-identified goals for social assessment of communication • PT
communication deficits are recommended after TBI, with participation in social impairment • SLP
JOURNAL OF HEAD TRAUMA REHABILITATION/JULY–AUGUST 2014
outcomes measured at the level of participation in everyday life reported • MD

social life. These interventions can be provided in either • Patient identified • Neuro
group or individual settings; however, published evidence is goals measured and • Other
strongest for group-based interventions. reported group
training
• Individual training
Abbreviation: TBI, traumatic brain injury.
expanding evidence base to support best practices in Future research should be considered to investigate
assessing and managing cognitive communication dis- alternative service delivery models, such as those of-
orders for people with TBI. This evidence includes sup- fered by telehealth or e-health models, particularly to
port for ecologically valid assessments such as the Func- facilitate access to specialist SLP services for those in ru-
tional Assessment of Verbal Reasoning and Executive ral and remote health regions, or for those who cannot
Skills,86 and intervention approaches such as commu- travel to rehabilitation centers.87 In addition, further re-
nication partner training, which includes families and search is required to evaluate communication partner
friends in training; context-sensitive interventions that training across a range of contexts and to determine the
are embedded in the communication environments of optimal dose of treatment required. With advances in
the person’s everyday life; metacognitive strategy train- technology, it is anticipated that use of devices such
ing; and employment of instructional techniques such smart phones and tablets will be increasingly incorpo-
as errorless learning. New evidence also reinforces the rated into treatment for people with cognitive commu-
importance of measuring outcomes that are meaningful nication disorders. However, treatment should remain
for the person at a social participation level. These ad- focused on everyday social participation activities, rather
vances are situated within a broader rehabilitation focus than decontextualized games that have little relevance or
on life participation for the person with TBI and a mul- generalization to the person’s everyday communication
tidisciplinary approach to treatment. We recognize that experiences.
a person’s cognitive-communication ability should not Outcome measurement of cognitive communica-
be evaluated and treated as an isolated skill but should tion disorders also requires further development and
be viewed within the broader context of the person’s ev- research.17 Developing an international set of common
ery day communication needs. Treatment should be in- outcome measures is an approach being undertaken by
dividualized, with person-centered goals and treatment the NHMRC Centre of Research Excellence in Brain Re-
techniques that take into account the person’s neuropsy- covery in Australia to remedy the gap in this area. In the
chological and psychosocial status. field of social cognition, there are emerging treatment
approaches that appear promising; however, outcomes
are measured using standardized measures, which do
DISCUSSION
not reflect real-world performance. Clearly, this is an
The study of cognitive communication disorders fol- area for further development. Research is also needed
lowing TBI is an emerging field; however, over the in the areas of comprehension and information process-
past three decades, considerable progress has been made ing, written expression, and academic and vocational
which provides us with sufficient evidence to produce communication.48
the INCOG recommendations for clinical practice. It The cognitive communication algorithm highlights
should be noted however that some of the recommen- the relevant populations from which the evidence un-
dations are at the consensus level. The emphasis in this derpinning these guidelines has been drawn. This can
guideline statement rests on the involvement of a spe- assist clinicians in operationalizing the guideline rec-
cialist SLP who can provide assessment and intervention ommendations at the point of care of the person with
focusing on the person’s social communication skills in severe TBI who has a communication disability. The
the context of their everyday life activities. Communi- audit items provide a mechanism to establish how doc-
cation partners should be involved in this training pro- umented practice aligns with high-priority recommen-
cess and be provided with specific conversational skills dations and are designed to be used as part of an overall
training. People with TBI who have a severe communi- audit tool covering all high-priority recommendations
cation disability should be provided augmentative and within the INCOG guideline. Our goal is to ensure that
alternative communication, by the speech pathologist all people with severe TBI receive best practice that has
in consultation with other specialist clinicians such as been informed by the highest available level of current
occupational therapists. Finally, outcome measurement evidence. Utilizing this guideline and particularly us-
should incorporate an evaluation of the person during ing the audit items within clinical practice will assist in
every day social activities. meeting this goal.
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Incog - Cognitive Comunication

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J Head Trauma Rehabil

Vol. 29, No. 4, pp. 353–368

INCOG Recommendations for

disorders are “communication impairments resulting tive to cognitive-communication impairments.2 Re-

TABLE 1 INCOG level of evidence grading system

Cognitive Communication #3 A cognitive communication rehabilitation C MacDonald and Larkins et al36

strongest for group-based

TABLE 3 Audit guidelines for priority recommendations: cognitive communication

outcomes measured at the level of participation in everyday life reported • MD

Abbreviation: TBI, traumatic brain injury.

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