J Head Trauma Rehabil

Vol. 38, No. 1, pp. 1–6

Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc.

INCOG 2.0 Guidelines for Cognitive

Rehabilitation Following Traumatic
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Brain Injury: What’s Changed From

2014 to Now?
Mark Theodore Bayley, MD, FRCPC; Shannon Janzen, MSc; Amber Harnett, MSc, BScN;
Peter Bragge, PhD; Leanne Togher, PhD, BAppSc (Speech Path); Ailene Kua, MSc, PMP;
Eleni Patsakos, MSc; Lyn S. Turkstra, PhD, Reg-CASLPO; Robert Teasell, MD, FRCPC;
Mary Kennedy, PhD, CCC-SLP; Shawn Marshall, MD, MSc, FRCPC;
Jennie Ponsford, PhD, AO, MA (Clinical Neuropsychology)

Author Affiliations: Neuro Rehabilitation Program, KITE Research

Institute, Toronto Rehabilitation Institute–University Health Network,
Temerty Faculty of Medicine, University of Toronto, Ontario, Canada (Dr
Bayley and Mss Kua and Patsakos); Lawson Health Research Institute,
I T IS CRITICAL TO KEEP clinical practice guide-
lines (CPGs) up to date through integration of the
latest evidence. Therefore, it is with great excitement that
Parkwood Institute, London, Ontario, Canada (Mss Janzen and Harnett the INCOG team presents the INCOG 2.0 Guidelines for
and Dr Teasell); Monash Sustainable Development Institute Evidence
Review Service, BehaviourWorks Australia (Dr Bragge), and Monash Cognitive Rehabilitation Following Traumatic Brain Injury
Epworth Rehabilitation Research Centre, Turner Institute for Brain and (TBI). In this brief introduction, we provide an overview
Mental Health, School of Psychological Sciences (Dr Ponsford), Monash of changes in the evidence from 2014; share insights into
University, Melbourne, Australia; Faculty of Health Sciences, The
University of Sydney, Camperdown, New South Wales, Australia (Dr the current state and challenges implementing cognitive
Togher); NHMRC Centre of Research Excellence in Aphasia rehabilitation; and provide an overview of INCOG
Rehabilitation, La Trobe University, Bundoora, Victoria, Australia (Dr 2022.
Togher); Speech-Language Pathology Program, School of Rehabilitation
Science, McMaster University, Hamilton, Ontario, Canada (Dr Turkstra);
Department of Physical Medicine and Rehabilitation, Schulich School of WHY ARE RECOMMENDATIONS FOR
Medicine & Dentistry, University of Western Ontario, London, Ontario,
Canada (Dr Teasell); Communication Sciences and Disorders, Chapman COGNITIVE REHABILITATION FOLLOWING
University, Irvine, California (Dr Kennedy); The Ottawa TBI STILL A PRIORITY?
Hospital-Rehabilitation Center, University of Ottawa, Bruyere Research
Institute, Ottawa, Ontario, Canada (Dr Marshall); and Epworth Prior to the publication of the first version of INCOG,
Healthcare, Melbourne, Australia (Dr Ponsford) (on behalf of the INCOG the team prioritized cognitive rehabilitation among
Expert Panel).
all other areas within the field of TBI rehabilitation
The authors gratefully acknowledge the support of the Ministry of Health of the for knowledge translation.1 The decision to prioritize
province of Ontario, Canada.
cognitive rehabilitation was based on a number of con-
The project described in this article was funded through the Ministry of Health siderations. First, by its very nature, TBI causes diffuse
of the province of Ontario, Canada (Lead: Dr Mark Bayley).
damage to the brain networks that are essential for
The authors declare that no competing financial interests exist. The authors attention, memory, executive functions, and cognitive
further declare that the funders did not participate in the organization of the
project, nor the expert panel process, evidence synthesis, or formulation of the aspects of communication. Second, ongoing systematic
recommendations. reviews highlight that cognitive rehabilitation is one of
The opinions, results and conclusions reported are those of the authors. No
endorsement by the Ontario Ministry of Health is intended or should be The authors declare no conflicts of interest.
inferred.
Corresponding Author: Mark Theodore Bayley, MD, FRCPC, KITE Re-
This is an open-access article distributed under the terms of the Creative search Institute, Toronto Rehabilitation Institute–University Health Network,
Commons Attribution-Non Commercial-No Derivatives License 4.0 3rd Floor East Wing, Ste 3-102-11, 550 University Ave, Toronto, ON M5G
(CCBY-NC-ND), where it is permissible to download and share the work 2A2, Canada ([email protected]).
provided it is properly cited. The work cannot be changed in any way or used
commercially without permission from the journal. DOI: 10.1097/HTR.0000000000000826

1
 2 Journal of Head Trauma Rehabilitation/January–February 2023

the rapidly growing evidence bases within the field of tem leaders.8–11 The limited awareness and use of
TBI rehabilitation. Indeed, since the last publication CPGs by potential adopters (ie, clinicians, funders,
of INCOG, more than 160 interventional studies on and healthcare leaders) also represent a significant
cognitive rehabilitation in moderate to severe TBI have barrier. A survey of potential users found that
been published, more than 40 of which are randomized only 47% of the respondents knew of at least
controlled trials. In addition, observational studies, one practice guideline to support the rehabilitation
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systematic reviews, and meta-analyses continue to be of people with TBI and only 34% of documents
published at a rapid pace.2 Third, there is a bias toward named by respondents as guiding their practice ac-
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rehabilitation focused on inpatients and activities of tually met the definition of a CPG.12 Respondents
daily living (ADL) function whereas cognition plays also felt ill-equipped to implement CPGs and iden-
an extremely important role in instrumental activities tified cognitive and behavioral impairments as the
of daily living (IADL) and return to activities for a most important areas for guidance.12 As part of a
generally younger rehabilitation population. Finally, the multicenter implementation study, Poulin et al13
team recognized clinicians have challenges applying the found that only 25% of cognitive rehabilitation
evidence in this field to everyday practice, resulting in a best practices were implemented in Quebec. In
significant knowledge-to-practice gap. These challenges Australia, Downing et al14 surveyed more than
are 2-fold; in addition to the long-established evidence- 200 clinicians regarding their practices and found
practice gap across all areas of medicine,3 cognitive that while practice broadly followed the recom-
rehabilitation is an especially complex and highly in- mendations, clinicians found implementation of
dividualized set of therapy interventions. Since 2014, the guidelines for executive function particularly
none of these challenges have materially changed. The challenging. This may be a function of both
COVID-19 pandemic has necessitated a rapid pivot to the inherent complexity of this intervention and
telehealth-assisted rehabilitation and therefore we felt the aforementioned lack of CPG implementation
that updated evidence-based recommendations for in- processes.
person and virtual cognitive rehabilitation were both 3. Barriers related to the practice environment. Downing
timely and necessary.4 et al14 and Nowell et al15 highlighted clinicians’
views of the importance of client self-awareness,
family involvement, team collaboration, and goal
WHAT IS THE CURRENT STATE OF, AND
setting as important ingredients for success of cog-
ONGOING CHALLENGE FOR,
nitive rehabilitation. Having a multidisciplinary
IMPLEMENTATION OF INCOG GUIDELINES?
team that understands TBI, working together with
Broadly speaking, barriers to implementation of CPGs family on common goals in real-world contexts
can be due to the nature of the intervention, the is an ideal practice environment that may not
beliefs and awareness of potential adopters, and the always be present. Even in well-developed health-
practice environment; cognitive rehabilitation is no care systems, human and technical resources are
exception5,6 : significantly limited. Most inpatient TBI rehabil-
1. Barriers related to the nature of the intervention. Cog- itation programs aim for independence in basic
nitive rehabilitation is intrinsically challenging, self-care, mobility, and safety in the community,
given the need for comprehensive assessment of but outpatient and community-based rehabilita-
the cognitive strengths and weaknesses of persons tion programs, where most cognitive rehabilitation
with TBI, their priorities, the demands of their research is done, receive limited funding, may be
lifestyle and environment, and the availability of too brief to fully execute cognitive rehabilitation
supports, as a basis for treatment planning and protocols, and have faced closure and redeploy-
implementation. Clinicians in health professions ment, retirement, or resignation of staff during
often receive limited training in cognitive rehabili- the worst of the COVID-19 pandemic. It is also
tation methods. Moreover, studies on which CPGs likely that in low- and middle-income countries,
are based typically have incomplete descriptions resources are further constrained and despite the
of treatment methods; therefore, it is not always prevalence of TBI, cognitive rehabilitation is not
possible to identify active ingredients or critical consistently implemented.16,17
aspects of treatment such as optimal dose and 4. Barriers related to the comorbidities and impairments of
timing.7 the persons with TBI within the practice environment.
2. Barriers related to the potential adopters. Many CPGs Comorbidities and impairments of the person
do not provide tools to guide implementation, with TBI within the practice environment can
such as decision rules or algorithms. Furthermore, present another significant barrier to cognitive
CPG developers often provide lists of recom- rehabilitation. In their international survey of
mendations without considering which of them cognitive rehabilitation providers, Nowell et al15
could be the focus of funders and health sys- also found the presence of mental health and
 INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury 3

neuropsychiatric issues, such as depression or anx- as well as general principles for cognitive rehabilitation
iety, and premorbid personality issues (narcissistic, (INCOG 2.0: Methods, Overview, and Principles).21
borderline, paranoid personality). These issues are This article has been enhanced and updated with a
compounded by existing disparities and inequity new section on telerehabilitation. The next article, con-
of access to rehabilitation for underserved, vulner- cerning management of posttraumatic amnesia (PTA),
able, and racialized populations.16–19 has been revised to reflect new and emerging evidence
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For all of the aforementioned reasons, we believe that regarding assessment and therapy during this phase, with
it is safe to conclude that there are significant variations a recent randomized controlled trial showing the value
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in implementation of best practice cognitive rehabilita- of a structured error-controlled and procedural learning
tion. approach to training ADL during PTA (INCOG 2.0, Part
I: Posttraumatic Amnesia).22 The fourth article concerns
WHAT’S NEW IN THE INCOG 2.0 rehabilitation of attention and processing speed. This
GUIDELINES?
article probably contains the least changes, given the
Concerted efforts are necessary to overcome the bar- ongoing limitations in the evidence for behavioral in-
riers mentioned earlier, and CPG developers should terventions in this domain, but does provide stronger
provide implementation tools that are easy to under- evidence underpinning pharmacological interventions
stand and use. Furthermore, they should highlight the for attention (INCOG 2.0, Part II: Attention and In-
3 to 5 priorities that are necessary for administrators to formation Processing Speed).23 Executive functions are
implement. Service improvement efforts need to ensure the subject of the fifth article, which documents the
that therapy teams have multidisciplinary representa- evolving and strengthening evidence for metacognitive
tion, have regular opportunities for communication and strategy instruction and the use of telerehabilitation
community access, receive training in goal setting and to promote recovery in this domain (INCOG 2.0,
evidence-based cognitive rehabilitation methods, and Part III: Executive Functions).24 Recommendations for
evaluate their outcomes in terms of what is meaningful treatment of cognitive-communication disorders are the
to the person with TBI and their family. Recent evalua- topic of the next article (INCOG 2.0, Part IV: Cognitive-
tions of audit and feedback in brain injury rehabilitation Communication and Social Cognition Disorders).25
programs have shown positive changes in adherence These recommendations have been revised and updated
to CPGs and appear to be a promising approach to as a result of ongoing strengthening of the evidence,
implementation.20 and there has been an inclusion of recommendations on
In response to the issues mentioned earlier, the telerehabilitation. A further enhancement is inclusion
INCOG team has enhanced the guidance for clinicians of rehabilitation for impairments of social cognition,
and healthcare administrators for cognitive rehabilita- defined as the cognitive processes underlying Theory
tion throughout this special issue. The basic structure of Mind (ie, understanding another’s thoughts, also
of each article is similar with an overview of the rec- known as perspective taking and cognitive empathy),
ommendations, tabulated references, rationales for the and emotion perception and emotional empathy. In-
recommendations, algorithms to assist treatment deci- clusion of social cognition in INCOG 2.0 recognizes
sions, and audit tools. As outlined in the methodology the developments in this area and recognizes the role
article, all previous recommendations were reviewed, of social cognition in forming and maintaining rela-
modified, and/or updated with new evidence (INCOG tionships after TBI. Memory rehabilitation (INCOG
2.0: Methods, Overview, and Principles).21 To assist clin- 2.0, Part V: Memory)26 is influenced strongly by sever-
icians, we revised the clinical algorithms that support ity of impairment of memory. There is a continuing
decision making and individualizing intervention. Sim- focus on teaching of strategies, which are the most
ilarly, we revised the audit tools to determine adherence widely utilized cognitive rehabilitation interventions by
to best practices, to reflect the changes in the accom- clinicians.15 The final article in the series reflects the
panying recommendations. In response to the need for future of INCOG and how changing evidence and tech-
guidance on use of groups and/or telerehabilitation, the nology may affect the future of guidelines (The Future
general recommendations have been updated to address of INCOG (Is Now)).27
telerehabilitation and each topic area contains specific The project team has been gratified with the response
recommendations for providing individual or group- to the first version of the INCOG recommendations.
based intervention telerehabilitation to enhance that We recognize that much work remains and hope that
function. INCOG 2.0 is a positive step toward promoting bet-
The special issue mirrors the topics covered in the ter outcomes for those living with the effects of TBI
first version of INCOG. In article 2, the recommen- and their families. The INCOG Team is outlined in
dations commence with an overview of the methods, Table 1.

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TABLE 1 INCOG 2.0 guidelines expert panel (2022)
Australia Canada United States
Dr Peter Bragge, PhD, Associate Dr Mark Bayley, MD, FRCPC, Physiatrist-in-Chief and Program Professor Mary Kennedy, PhD,
Professor and Director, Monash Medical Director, Neuro Rehabilitation Program, KITE Research CCC-SLP, Professor,
Sustainable Development Institute Institute, Toronto Rehabilitation Institute–University Health Communication Sciences and
Evidence Review Service, Network, Temerty Faculty of Medicine, University of Toronto, Disorders, Chapman University,
BehaviourWorks Australia, Monash Toronto, Ontario, Canada Irvine, California
University, Melbourne, Australi Specialty: Neurorehabilitation, knowledge translation, guideline Specialty: Cognition,
Specialty: Knowledge translation, development communication
quality improvement research, Dr Robin Green, CPsych, Toronto Rehabilitation Institute, Canada
evidence mapping and synthesis, Research Chair (II) Traumatic Brain Injury, Toronto, Ontario, Canada
guideline development Specialty: Traumatic brain injury, neuropsychology, neurorehabilitation,
Professor Jacinta Douglas, PhD, MSc MRI
(Psych), Emerita Professor, Living Shannon Janzen, MSc, Lawson Health Research Institute, Parkwood
with Disability Research Centre, La Institute, London, Ontario, Canada
Trobe University, Bundoora, Victoria, Specialty: Evidence-based review, neurorehabilitation
Australia; Summer Foundation, Amber Harnett, MSc, BScN, RN (c), Lawson Health Research
Melbourne, Australia Institute, Parkwood Institute, London, Ontario, Canada
Specialty: Brain Injury, cognition, Specialty: Evidence-based review, neurorehabilitation
communication Dr Eliyas Jeffay, PhD, CPsych, KITE Research Institute, Toronto
Dr Adam McKay, PhD, MPsych Rehabilitation Institute–University Health Network, Toronto, Ontario,
(Clinical Neuropsychology), Canada
Monash Epworth Rehabilitation Specialty: Traumatic brain injury, neuropsychology, neurorehabilitation
Research Centre, Turner Institute for Ailene Kua, MSc, PMP, Research Associate, KITE Research Institute,
Brain and Mental Health, School of Toronto Rehabilitation Institute–University Health Network, Toronto,
Psychological Sciences, Monash Ontario, Canada
University, Melbourne, Australia; Specialty: Knowledge translation, guideline development
Epworth Healthcare, Melbourne, Lyn Turkstra, PhD, Reg-CASLPO, Assistant Dean and Professor,
Australia Speech-Language Pathology Program, School of Rehabilitation
Specialty: Neuropsychology, brain injury Science, McMaster University, Hamilton, Ontario, Canada
rehabilitation Specialty: Cognition, communication, guideline development,
Journal of Head Trauma Rehabilitation/January–February 2023

Professor Jennie Ponsford, PhD, AO, traumatic brain injury rehabilitation

MA (Clinical Neuropsychology), Dr Shawn Marshall, MD, MSc, FRCPC, Professor, The Ottawa
Professor of Neuropsychology, Turner Hospital-Rehabilitation Center, University of Ottawa, Ottawa,
Institute for Brain and Mental Health, Ontario, Canada; Bruyere Research Institute, Ottawa, Ontario,
School of Psychology and Psychiatry, Canada
Monash University, Melbourne, Specialty: Brain injury rehabilitation, epidemiology, driving, medicine,
Australia; Director, Monash-Epworth pharmacology
Rehabilitation Research Centre, Amanda McIntyre, PhD (candidate), RN, Lawson Health Research
Turner Institute for Brain and Mental Institute, Parkwood Institute, London, Ontario, Canada
Health, School of Psychology and Specialty: Evidence-based review, neurorehabilitation
Psychiatry, Monash University, Eleni Patsakos, PhD (candidate), MSc, KITE Research Institute,
Melbourne, Australia; Epworth Toronto Rehabilitation Institute–University Health Network, Toronto,
Healthcare, Melbourne, Australia Ontario, Canada
(continues)
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TABLE 1 INCOG 2.0 guidelines expert panel (2022) (Continued)

Australia Canada United States
Specialty: Neuropsychology, traumatic Specialty: Knowledge translation
brain injury rehabilitation Dr Robert Teasell, MD, FRCPC, Schulich School of Medicine &
Professor Leanne Togher, PhD, Dentistry, University of Western Ontario, London, Ontario, Canada;
BAppSc (Speech Path), Professor of St Joseph’s Health Care London, London, Ontario, Canada; Lawson
Communication Disorders Following Health Research Institute, Parkwood Institute, London, Ontario,
Traumatic Brain Injury, Senior NHMRC Canada
Research Fellow, Speech Pathology, Specialty: Evidence-based review, neurorehabilitation
Faculty of Health Sciences, The Dr Diana Velikonja, PhD, MScCP, Associate Professor, Department of
University of Sydney, Camperdown, Psychiatry and Behavioural Neurosciences, DeGroote School of
New South Wales, Australia Medicine, McMaster University, Hamilton, Ontario, Canada;
Specialty: Communication disorders Acquired Brain Injury Program, Hamilton Health Sciences, Hamilton,
following acquired brain injury; Ontario, Canada
evidence-based review, Specialty: Neuropsychology, traumatic brain injury rehabilitation,
communication partner training guideline development
Dr Jessica Trevena-Peters, DPsych, Penny Welch-West, MClSc, SLP Reg CASLPO, Parkwood Institute,
Monash-Epworth Rehabilitation London, Ontario, Canada; St Joseph’s Health Care London, London,
Research Centre, Turner Institute for Ontario, Canada; Lecturer, School of Communication Sciences and
Brain and Mental Health, School of Disorders, University of Western Ontario, London, Ontario, Canada
Psychological Sciences, Monash Specialty: Cognitive-communication disorders
University, Melbourne, Australia; Dr Catherine Wiseman-Hakes, PhD, Reg CASLPO, Speech
Epworth Healthcare, Melbourne, Language Pathology Program, School of Rehabilitation Science,
Australia McMaster University, Hamilton, Ontario, Canada; KITE Research
Specialty: Neuropsychology, traumatic Institute, Toronto Rehabilitation Institute–University Health
brain injury rehabilitation Network, Toronto, Ontario, Canada
Specialty: Cognitive-communication disorders, community
reintegration, pediatric rehabilitation, sleep, traumatic brain injury
INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury

www.headtraumarehab.com
5
 6 Journal of Head Trauma Rehabilitation/January–February 2023

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