Ontario Neurotrauma Foundation

Clinical Practice Guideline

For the rehabilitation of Adults with Moderate to Severe TBI

Ontario Neurotrauma Foundation INESSS
SECTION 2: Assessment and Rehabilitation of Brain Injury Sequelae > K. Cognitive Communication

K. Cognitive Communication

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Brain injury frequently affects the pragmatic aspects of communication such as staying on topic, understanding intonation, remembering the topic of discussion, appropriate turn taking and paying attention to the speaker. The goal of cognitive communication intervention should be to facilitate return to full life participation. The specific goals must be set collaboratively with the patient and possibly their family. The assessment should include a broad variety of situations, complexities and environments using standardized tests in domains of cognition, language, insight/awareness, pragmatics and physical issues. Premorbid health, psychosocial status, cognitive abilities and communication style should also be factored into the treatment plan. Patients should be trained by skilled staff members. Recognition of factors that cause variability of cognitive-communication abilities is important.

In very severely injured patients, a reliable yes/no communication strategy (response) should be established as soon as possible. Training should include use of appropriate alternative and augmentative communication aids, as well as social skills training with relevant practice opportunities.


Indicators exemples

  • Proportion of individuals with TBI for whom a reliable yes/no response was tested within the first two days after admission in rehabilitation.


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:

The establishment of a consistent yes/no response is desirable when working with patients following severe brain injury, to facilitate communication between patient and care providers. It has been argued that the establishment of a yes/no response is important in differentiating between patients in a vegetative state versus those in a minimally responsive condition (Andrews, 1996; Childs, Mercer, & Childs, 1993; Giacino & Zasler, 1995; Grossman & Hagel, 1996). An RCT by Barreca et al. (2003) found that patients with severe head injuries improved their ability to communicate “yes/no” responses when undergoing consistent training and environmental enrichments. Increased interactions between patients and nursing were informally observed. As well, families reported on a satisfaction questionnaire that they were better able to communicate with their loved one.

When communication needs cannot be met through speech alone, augmentative or alternative communication strategies (AAC) may need to be adopted. AAC can be basic aids (e.g. alphabet boards, memory books, day planners, etc) to more advanced options, such as voice output communication aid devices. Powell et al. (2012) found that the use of a PDA combined with systematic instruction greatly improved patients’ abilities to communicate with therapists and their peers.

Social skills training programs are encouraged to develop patients’ interpersonal and conversational abilities. Two RCTs found that the use of specialized weekly discussion groups facilitated patients’ confidence in their communication skills and to meet participation goals within conversations (Dahlberg et al., 2007; McDonald et al., 2008). The setting for cognitive communication training is important; ideally it should be appropriate to where patients will have most of their conversations. The above RCTs have training occur within patient’s living rooms (Dahlberg et al., 2007), at home to practice exercises with a regular conversational partner (Togher, Davy, & Siriwardena, 2013), at residential care facilities (Behn et al., 2012), and in the community or outpatient centers (McDonald et al., 2008).

Role playing was important in increasing conversational abilities for patients. Interventions that role-played when a patient should speak and listen are particularly useful.  Knowing when to assume the speaker or the listener role greatly facilitated the length, participation and satisfaction of conversations (Dahlberg et al. 2007). Group therapy for cognitive communication training supports and benefits patients from the experiences of their peers within a non-judgmental environment to experiment with compensatory strategies and acquisition of appropriate interaction skills (College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO), 2015). A pre-post study found that after social communication training in a group, patients reported improved social skills, satisfaction with life and goal attainment within conversations (Braden et al., 2010).

Providing training to communication partners allowed for their communication styles to be modified (i.e., asking less test questions) which in turn allowed for the individual with TBI to also improve their communication (Sim, Power, & Togher, 2013). This study highlights the benefits of monitoring the two-way interaction using discourse analysis to ensure that information is given, received and negotiated in an effective and appropriate way (Sim et al., 2013). When looking at training communication partners, the most efficacious way to improve interactions is to have both the individual with TBI and their communication partner participate in training together. A study by Togher et al. (2013) found that those who completed social communication training jointly (person with TBI and partner) made significantly greater gains compared to those who received no training and individuals with TBI who attended alone.

In a RCT conducted by Togher et al. (2004), a small group of police officers were trained in communication strategies for talking to individuals with a TBI about regaining their licenses. Officers who received training needed significantly fewer inquiries to get information from their callers, and spent more time answering caller questions. An RCT found that communication-training programs for paid caregivers were effective; the program used modeling, roleplaying, feedback and rehearsal to improve caregivers’ communication skills (Behn et al., 2012). An observational study suggests that inpatient rehabilitation staff need communication training to better guide treatment schedules and to assist in activities of daily living (Valitchka & Turkstra, 2013). A recent systematic review found that many studies employed context-sensitive cognitive communication interventions which were functionally relevant to the patient improved communication deficits (Finch et al., 2015).
The effectiveness of communication-training programs was also evaluated for caregivers. Behn and colleagues (2012) found that training allowed for caregivers to interact more easily with the individual with an ABI and encouraged a two-way dialogue. The training in this study was a number of didactic and performance -based approaches such as modeling, role-playing, feedback and rehearsal. Strategies used were both elaborative and collaborative. 

Andrews, K. (1996). International Working Party on the Management of the Vegetative State: summary report. Brain Injury, 10(11), 797-806.

Barreca, S., Velikonja, D., Brown, L., Williams, L., Davis, L., & Sigouin, C. S. (2003). Evaluation of the effectiveness of two clinical training procedures to elicit yes/no responses from patients with a severe acquired brain injury: a randomized single-subject design. Brain Inj, 17(12), 1065-1075.

Behn, N., Togher, L., Power, E., & Heard, R. (2012). Evaluating communication training for paid carers of people with traumatic brain injury. Brain Inj, 26(13-14), 1702-1715.

Braden, C., Hawley, L., Newman, J., Morey, C., Gerber, D., & Harrison-Felix, C. (2010). Social communication skills group treatment: a feasibility study for persons with traumatic brain injury and comorbid conditions. Brain Inj, 24(11), 1298-1310.

Childs, N. L., Mercer, W. N., & Childs, H. W. (1993). Accuracy of diagnosis of persistent vegetative state. Neurology, 43(8), 1465-1465.

College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO). (2015). Practice Standards and Guidelines for Acquired Cognitive Communication Disoders.

Dahlberg, C. A., Cusick, C. P., Hawley, L. A., Newman, J. K., Morey, C. E., Harrison-Felix, C. L., & Whiteneck, G. G. (2007). Treatment Efficacy of Social Communication Skills Training After Traumatic Brain Injury: A Randomized Treatment and Deferred Treatment Controlled Trial. Arch Phys Med Rehabil, 88(12), 1561-1573.

Evidence-Based Review of Moderate To Severe Acquired Brain Injury (ERABI). (2016). http://www.abiebr.com/.  

Finch, E., Copley, A., Cornwell, P., & Kelly, C. (2015). Systematic Review of Behavioral Interventions Targeting Social Communication Difficulties After Traumatic Brain Injury. Arch Phys Med Rehabil.

Giacino, J. T., & Zasler, N. D. (1995). Outcome after severe traumatic brain injury: Coma, the vegetative state, and the minimally responsive state. J Head Trauma Rehabil, 10(1), 41-56.

Grossman, P., & Hagel, K. (1996). Post-traumatic apallic syndrome following head injury. Part 1: clinical characteristics. Disability and rehabilitation, 18(1), 1-20.

McDonald, S., Tate, R., Togher, L., Bornhofen, C., Long, E., Gertler, P., & Bowen, R. (2008). Social skills treatment for people with severe, chronic acquired brain injuries: a multicenter trial. Arch Phys Med Rehabil, 89(9), 1648-1659.

Powell, L. E., Glang, A., Ettel, D., Todis, B., Sohlberg, M. M., & Albin, R. (2012). Systematic instruction for individuals with acquired brain injury: results of a randomised controlled trial. Neuropsychological Rehabilitation, 22(1), 85-112.
Sim, P., Power, E., & Togher, L. (2013). Describing conversations between individuals with traumatic brain injury (TBI) and communication partners following communication partner training: Using exchange structure analysis. Brain Inj, 27(6), 717-742.

Togher, F., Davy, Z., & Siriwardena, A. N. (2013). Patients' and ambulance service clinicians' experiences of prehospital care for acute myocardial infarction and stroke: a qualitative study. Emerg Med J, 30(11), 942-948.

Togher, L., McDonald, S., Code, C., & Grant, S. (2004). Training communication partners of people with traumatic brain injury: A randomised controlled trial. Aphasiology, 18(4), 313-335.

Valitchka, L., & Turkstra, L. S. (2013). Communicating with inpatients with memory impairments. Paper presented at the Semin Speech Lang.



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K1. Cognitive Communication Assessment

P Priority F Fundamental New Level of evidence A B C
K 1.1 P C

Assessment of cognitive communication abilities of individuals with traumatic brain injury should include:

  • A survey or broad variety of communication situations, complexities and environments

  • A case history

  • The consideration of standardized and non-standardized assessments/surveys

  • Specific assessments in the following areas:
    - Attention and concentration
    - Orientation
    - Verbal memory and new learning
    - Linguistic organization
    - Auditory comprehension and information processing
    - Hearing and vision
    - Oral expression and discourse
    - Reading comprehension and reading rate
    - Written expression
    - Social communication and pragmatics
    - Reasoning and problem-solving
    - Executive functions and metacognitive processes
    - Insight, awareness and adjustment to disability
    - Speech
    - Nonverbal communication
    - Consideration of visual, perceptual, pain, fatigue, and other physical difficulties
    - Performance in different communication contexts
    - Communication partners’ needs and abilities to provide communication support and strategies

(INESSS-ONF, 2015)


- College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO) (2015) p.15

K 1.2 C

A cognitive communication evaluation and rehabilitation program for individuals with traumatic brain injury should take into account the person’s premorbid:

  • Physical and psychosocial variables

  • Native language

  • Literacy and language proficiency

  • Cognitive abilities

  • Communication style, including communication standards and expectations in the person’s culture

(Adapted from INCOG 2014, Cognitive Communication 3, p. 356)

K 1.3 B

Rehabilitation staff should recognize that levels of communication characteristics may vary as a function of:

  • Communication partner: individuals with traumatic brain injury may communicate at a higher level with family and friends who know them well than with healthcare professionals

  • Environment

  • Communication demands (e.g., time pressure, need to follow multiple speakers)

  • Communication priorities

  • Fatigue

  • Physical variables

  • Psychosocial variables

  • Other personal factors

(Adapted from INCOG 2014, Cognitive Communication 1, p. 356)

K2. Cognitive Communication Rehabilitation

P Priority F Fundamental New Level of evidence A B C
K 2.1 C

A person with traumatic brain injury who has a cognitive communication disorder should be offered an appropriate treatment program.

(Adapted from INCOG 2014, Cognitive Communication 2, p. 356)

Note: The primary goal of management is to facilitate the maximum return to full life participation. Evidence to date favours management approaches that are individualized, functional, goal- and outcome-oriented, patient-centred, and grounded in the contexts of real life communications and cognitive demands. Intervention should take place in a variety of environments and should provide opportunities for rehearsal of communication skills (Togher et al., 2014). Treatment can be both direct and indirect, and can include:

  • Improving and restoring cognitive communication functions

  • Assisting with a gradual reintegration to daily functions and productive activities that require cognitive communication skills

  • Modification of the communication environment

  • Training communication partners and improving communication environments and settings

  • Assisting with adjustment to impairments, coping strategies, confidence and self-esteem

  • Compensatory strategy training

  • Provision of education and information regarding the nature of acquired cognitive communication disorders


- College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO) (2015) p.25

K 2.2 C

Cognitive communication therapy goals should be set collaboratively with the person with traumatic brain injury and their family and include activities that are functional and personally relevant.

(INESSS-ONF, 2015)


- Finch et al. (2015)

K 2.3 P B

A reliable Yes/No response in verbal and non-verbal individuals with traumatic brain injury should be established as soon as possible. This may be facilitated by consistent training and environmental enrichments.

(INESSS-ONF, 2015)


- Barreca et al. (2003)
- ERABI Module 7- Cognitive-Communication Treatments, p.33

K 2.4 B

Individuals with severe communication disability following traumatic brain injury should be provided with and trained in the use of appropriate alternative and augmentative communication aids by suitably trained clinicians.

(Adapted from INCOG 2014, Cognitive Communication 6, p. 357)

K 2.5 B

Social skills training should be offered to address interpersonal and pragmatic conversational skills problems in individuals with traumatic brain injury.

(INESSS-ONF, 2015)


- Dahlberg et al. (2007)
- McDonald et al. (2008)

K 2.6 P A

A cognitive communication rehabilitation program for individuals with traumatic brain injury should provide the opportunity to rehearse communication skills in situations appropriate to the context in which the person will live, work, study and socialize.

(INCOG 2014, Cognitive Communication 4, p. 357)

K 2.7 B

Intervention for social communication for individuals with traumatic brain injury should include role playing to improve a variety of social communication skills as well as self-concept and self-confidence in social communications.

(INESSS-ONF, 2015)


- Dahlberg et al. (2007)

K 2.8 B

Clinicians should consider group therapy as an appropriate context for social skills training when social communication impairments exist post traumatic brain injury.

(INESSS-ONF, 2015)


- Braden et al. (2010)

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