Major update of the INCOG guidelines for cognitive rehabilitation following traumatic brain injury

Reviewed by Emily Henderson, B.Sc.Jan 3 2023

A rapidly growing body of evidence shows the importance and effectiveness of cognitive rehabilitation for individuals with traumatic brain injury (TBI). A major update of the groundbreaking INCOG guidelines for cognitive rehabilitation following TBI is presented in the January/February special issue of the Journal of Head Trauma Rehabilitation (JHTR). The official journal of the Brain Injury Association of America, JHTR is published in the Lippincott portfolio by Wolters Kluwer.

The INCOG 2.0 guidelines for cognitive rehabilitation reflect the "rapid pivot to telehealth-assisted rehabilitation" in the wake of the COVID-19 pandemic and new tools to aid in translating the updated recommendations into clinical practice, according to an introduction by Mark Bayley, MD, of University of Toronto, Jennie Ponsford of Monash University in Australia and colleagues of the INCOG international Expert Panel.

Cognitive rehabilitation after TBI: High priority, persistent challenges

Improving the practice of cognitive rehabilitation is an ongoing priority for patients with TBI, reflecting the "diffuse damage to the brain networks that are essential for attention, memory, executive functions, and cognitive aspects of communication," Dr. Bayley and coauthors write. They highlight the continuously expanding evidence base on cognitive rehabilitation after moderate to severe TBI, with more than 160 interventional studies published since the original INCOG guidelines in 2014.

In addition to the "especially complex and highly individualized" nature of cognitive rehabilitation, barriers remain to translating research evidence into clinical practice – contributing to "significant variations in implementation of best practice cognitive rehabilitation," the Expert Panel writes. INCOG 2.0 seeks to address these barriers by adding tools to promote clinical implementation, as part of ongoing efforts to close the "evidence-practice gap."

What's new in INCOG 2.0? Latest evidence, new tools to promote implementation

The 2022 update addresses critical issues in cognitive rehabilitation after TBI, mirroring the topics addressed in the original INCOG guidelines:

• Overview introducing the general principles of cognitive rehabilitation, including an enhanced section on telerehabilitation.
• New and emerging evidence on management of posttraumatic amnesia, including new findings on structured error-controlled and procedural learning approaches.
• Rehabilitation of attention and processing speed – reflecting ongoing limitations in the evidence for behavioral interventions.
• New approaches to executive function, including the "evolving and strengthening" evidence on metacognitive strategy instruction and the use of telerehabilitation to promote recovery.
• Revised and updated recommendations for cognitive-communication disorders. A key focus is the growing appreciation of the importance of the role of social cognition in forming and maintaining relationships after TBI.
• Strategies for rehabilitation of memory impairment, which continue to be the most widely used cognitive rehabilitation interventions.

"The Future of INCOG (Is Now)," according to a concluding article by Peter Bragge, PhD, of Monash University, Melbourne, Australia, and colleagues. They discuss recent advances in the review and guideline sciences, such as "living" guidelines that are kept up to date on a more continuous basis, and their relevance to INCOG 2.0 and future updates. The new document incorporates enhanced guidance for clinicians and healthcare administrators and revised clinical algorithms to support decision making and individualized interventions.

The members of the Expert Panel reaffirm their commitment to prioritizing and continually improving advances in research and clinical practice in cognitive rehabilitation. Dr. Bayley and colleagues write: "We recognize that much work remains and hope that INCOG 2.0 is a positive step toward promoting better outcomes for those living with the effects of TBI."