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:

• Algorithm for impaired Communication and Cognitive-Communication Rehabilitation, p. 362 (INCOG publications)
• Cognitive-Communication Abilities Following Brain Injury: A Functional Approach by Leila Hartley. Singular Publishing Group, 1995 – 289 pages
• Social and Communication Disorders following traumatic Brain Injury, 2nd Edition, Edited by Skye McDonald, Leanne Togher and Chris Code. Psychology Press, 2014 – 420 pages
• Practice Standards Section - College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO’s)
• Speech Pathology Database of Best Interventions and Treatment Efficacy – (speechBITE)
• Cognitive-communication CHECKLIST for Acquired Brain Injury (CCCABI)
• Group interactive structured treatment (GIST): a social competence intervention for individuals with brain injury
• Improving First Impressions: A Step-by-Step Social Skills Program – Australian Society for the Study of Brain Impairments
• TBI Express – Australian Society for the Study of Brain Impairments

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. 

REFERENCES
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.