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Rehabilitation Guidelines for TBI- Social Cognition and Communication Disorders

Iliana Perez

Front Range Community College

Intro to Neuropsychology PSY 2000

Dr. Lucinda Baker

May 2, 2024
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Traumatic brain injury (TBI), occurs when external forces disrupt normal brain function,

and causes damage to the brain. This can happen from a motor vehicle collision, a hit to the head

from falling or playing contact sports without proper safety equipment and pretty much any

scenario with sudden blunt force trauma (Kolb and Whishaw, 2020). Sudden trauma, when the

head suddenly and violently hits or collides with objects or when some object stabs the skill and

enters the brain tissue, can result in a TBI with varying severities and symptoms. A TBI can me

mild, moderate, or severe, depending on how much the brain was damaged during the incident

(Kolb and Whishaw, 2020). After experiencing a TBI, the presentation afterwards will be unique

to the patients’ demographics and damage done, symptoms will range from complete

consciousness to the loss of consciousness of a couple minutes, and the result can be a mild

concussion to severe cognitive impairments (Lindsey et al., 2023). According to the NIH other

symptoms may include headache, confusion, lightheadedness, dizziness, blurred vision or tired

eyes, ringing in the ears, bad taste in the mouth, fatigue or lethargy, a change in sleep patterns,

behavioral or mood changes, and trouble with memory, concentration, attention, or thinking. In

cases of moderate to severe TBI’s patient can experience some or all of the previously mentioned

symptoms, but could also have headaches that are continuously worsening or not going away,

repeated vomiting or nausea, seizures, inability to wake from sleep, dilation of one or both pupils

of the eyes, slurred speech, weakness or numbness in the extremities, loss of coordination, and

increased confusion, restlessness, or agitation (National Academies of Sciences, Engineering,

and Medicine, 2019). It is always recommended to seek medical attention immediately after the

incident, but what does rehabilitation look like and how would we be able to have guidelines

when all the emergency problems have been addressed? How would we be able to help different

presentations and levels of severity once everything on the scan ‘looks’ normal? This paper aims
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to review the current guidelines for cognitive rehabilitation following TBI, specifically looking

at cognition- communication and social cognition disorders.

The after effects of a TBI will not only include physical pain and rehabilitation of any

adjacent procedures related to the incident, but also can potentially consist of cognitive

impairments that affect various communication processes (Kolb and Whishaw, 2020). TBI’s.,

and in particular close – head injuries, will commonly alter frontal subcortical areas, which affect

the regions of linguistic function and performance as a secondary consequence (Lindsey et al.,

2023). These altered frontal subcortical circuits lead to observable changes in attention, memory,

executive functioning, and social behaviors, leading to possible communication disorders

(Lindsey et al., 2023). Cognitive- Communication disorders or deficits are potential consequence

after strokes, tumors, TBI’s, degenerative brain disorders, including other neurological disorders.

The deficits make it hard for individuals to properly think and use language, those that are

diagnosed with CCS’s post TBI will have a myriad of impaired communication profiles which

include disorganized conversations that lack critical content or has an abundance of redundancy

(Togher et al., 2023). During conversations, the individual’s communication can have flat

affects, or difficulty finding words, and not have the capacity to stay on topic or start a new one,

they can display poor problem-solving skills, lack inhibition when speaking, and fail to

acknowledge social cues (Togher et al., 2023). They can also have difficulty with understanding

emotions within themselves as well as interpret emotions in others, and altered processing of

cadence and tones used in everyday speech and conversation that would be had with social

support groups, family, and/or caretakers (Togher et al., 2023). People with traumatic brain

injury (TBI) often appear egocentric in their communication, unresponsive to social cues, and

violate norms for interpersonal space.

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These symptoms of cognitive-communication disorders (CCD) underscore the multifocal

aspects of TBI, where damage is sudden and can affect various brain areas (Lindsey et al., 2023).

The patient's age also influences recovery and the risk of permanent damage (Kolb and

Whishaw, 2020). TBI's present an intersection of cognitive, physical, linguistic, and

biopsychosocial deficits, which all combine and may contribute to the individual’s case,

interfering with their ability to establish and maintain new relationships through rehabilitation

and could also increasing their vulnerability to exploitation, abuse, and crime (Lindsey et al.,

2023). The way that severity of injury is usually measured is through brain imaging and through

memory, some patients enter a comatose state and could experience post traumatic amnesia upon

waking up leading to delirium and aggression if not treated properly, but even with milder

versions there is always risk of developing (Togher et al., 2023). When looking at the

communication capacity, an important part of understanding lies within social cognition.

Involving both understanding another’s thoughts and believes (Theory of Mind), and the

emotional perception and emotional empathy (Togher et al., 2023). Unfortunately, the damage

effects of a TBI can lead to a limited capacity of these skills and at a time where support from

loved ones is vital, and has been reported by people with TBI and their communication partners.

Caring for someone with moderate to severe TBI can be profoundly challenging for caregiver.

Such injuries not only demand physical rehabilitation, but also bring about significant

psychological stress on both parties involved. The burden is compounded when the individual

loses the ability to communicate effectively or empathize, due to their cognitive impairments.

The patient may no longer reflect their former self, emotionally or behaviorally, which can be

incredibly taxing taking for both the caregiver adapting to these changes, and for the patient

facing their own struggles with these new limitations.

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The study was designed to update the INCOG (with INCOG being an acronym standing

for “International Cognitive”) guideline by completing a complete critical analysis, including

searching and reviewing with an international panel of clinicians and researchers within TBI

cognitive rehabilitation. The paper aims to critically analyze publishing guidelines within

domains such as PTA, assessment principles, attention, memory, executive function, and

cognitive-communication. Its goal was to assess the number of new advancements in treatments

and interventions to expand our current guidelines, a part of this was looking at cognitive

underpinnings of social communications within a multitude of disorders and nonclinical

populations, making sure that guidelines for clinicians are updated with the best information and

staying relevant (Togher et al., 2023). The articles and research were sourced through internet

and Medline searches of multiple databases systematically from 2014 through July 2021,

focusing on TBI guidelines and evidence based cognitive rehabilitation (Togher et al., 2023).

Cognitive rehabilitation plays an important role in aiding recovery for individuals with

TBI’s. Emerging evidence, despite often stemming from studies with small sample sizes,

highlights significant theoretical advances in the understanding of cognitive-communication

disorders and their rehabilitation, including the integration of social cognition studies in TBI to

rehab practices (Togher et al., 2023). Informed by the Rehabilitation Treatment Specification

System, rehabilitation strategies in the literature review they conducted, emphasize identifying

effective treatment components. These components would play a big role in improving

cognitive- communication outcomes, include behavioral shaping, high-dose practice

opportunities, and feedback mechanisms (Togher et al., 2023). Treatments often incorporate

social communication interventions aimed at enhancing or developing new communication

strategies. Modeling, feedback, role-play, self-monitoring, and self-regulation are integral

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ingredients in supporting the acquisition and generalization of social communication skills

(Togher et al., 2023). Additionally, cognitive behavioral treatments and awakened training play a

role in about 20% of studies, focusing on problem- solving strategies, behavior and emotional

regulation. Overall, most treatment programs blended behavioral and cognitive techniques,

providing comprehensive “packages” that facilitate skill acquisition and encourage the

application of new communication methods in varied contexts (Togher et al., 2023).

Following their literature review, the clinicians and researchers got together to create a

critical analysis and found eight rehabilitation strategies for managing cognitive and

communications impairments in TBI patients include innovative treatments and refinement of

established techniques culminated through recent research (Togher et al., 2023).

Recommendations emphasize the need for rehabilitation staff to recognize that communication

competence is highly variable due to numerous factors like communication partners,

environment, and the patients physical and psychosocial condition (Togher et al., 2023). It is

crucial that evaluations and rehabilitation programs also consider the patients’ cultural

responsiveness and account for pre-injury lifestyle and cultural linguistic background.

Personalized interventions that focus on cognitive-communication rehabilitation principles are

necessary to create effective strategies that bare relevance to the individual’s social context,

interpersonal relationships, and daily functions (Togher et al., 2023). These may involve direct or

indirect methods, ranging from communication partner training to group therapy, and even the

use of telerehabilitation, which has proven as effective as in-person interventions (Togher et al.,

2023). Having such a holistic approach helps to establish such a great support system that is

flexible to meet the clients where they are, while remove excess cognitive load off the individual.

This allows them to recover and removes sometimes overbearing expectations through
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rehabilitation, the use of augmentative and alternative communication (AAC) systems is

recommended for severe cases, with ongoing training as needs evolve (Togher et al., 2023).

Additionally, the growth in telehealth and digital treatment options necessitates updating clinical

competencies to include digital communication skills, ensuring safe and effective online

engagement for TBI patients. This evolving landscape requires clinicians to adapt to new

technologies and integrate them into cognitive and social communication treatment to better

serve the TBI community at large (Togher et al., 2023).

Another challenge that is faced, including medical professionals and providers, is

understanding the diverse and almost indiscriminate impact of TBI on cognitive- communication

underscores the need for policies that address the comprehensive needs of diverse populations.

Research indicates that minorities and Indigenous peoples are disproportionately affected by

TBI, and experience worse outcomes with lower rates of rehabilitation services (Lindsey et al.,

2023). Making sure that providers and medical staff have the training and skills to distinguish

between cognitive- language impairments and cultural linguistic differences, would allow for

better care of those in under severed communities have access to appropriate medical care and

rehabilitation (Togher et al., 2023). This disparity in care, despite having similar needs highlights

just how essential policies ensuring equitable access to quality care across all demographic lines.

The neuropathology of TBI is extensive, and the impact on linguistic processes often co-

occurred with significant executive function impairments. This dual presence of linguistic and

non- linguistics deficits underlines the need for comprehensive diagnosis and targeted

interventions, potentially involving multiple healthcare providers (Lindsey et al., 2023). The

findings of this paper emphasizes consistently that treatments strategies need to be tailored

leading to policy recommendations such as that communication interventions should prioritize

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client engagement, focus on improving the accuracy, efficiency, and stability of cognitive-

communication, and ensure treatment generalizes to daily contexts through strategies like home

practice, group therapy, and family involvement (Togher et al., 2023). With the right approach

and guidelines, they aim to foster significant improvements in the life quality of individuals by

enhancing their communication abilities.

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References Page

Lindsey, A., Guernon, A., Stika, M., & Bender Pape, T. (2023). The diagnostic intersection
of cognitive–communication disorders and aphasia secondary to TBI. International
Journal of Language & Communication Disorders, 58(1), 82–93.
https://doi.org/10.1111/1460-6984.12770
Togher, L., Douglas, J., Turkstra, L. S., Welch-West, P., Janzen, S., Harnett, A., Kennedy,
M., Kua, A., Patsakos, E., Ponsford, J., Teasell, R., Bayley, M. T., & Wiseman-Hakes, C.
(2023). INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain
Injury, Part IV: Cognitive-Communication and Social Cognition Disorders. Journal of
Head Trauma Rehabilitation, 38(1), 65–82.
Kolb, B., & Whishaw, I. Q. (2020). Fundamentals of Human Neuropsychology (7th ed.).
Worth Publishers. ISBN 9781319247164.
National Academies of Sciences, Engineering, and Medicine. (2019). Evaluation of the
Disability Determination Process for Traumatic Brain Injury in Veterans. Washington,
DC: National Academies Press. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK542588/