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20. Cognitive-Communication Post Acquired Brain Injury

Marshall S, Harnett A, Welch-West P, Ferri C, Janzen S, Togher L, Teasell R. (2021). Cognitive Communication Post Acquired Brain Injury. In Teasell R, Cullen N, Marshall S, Bayley M, Harnett A editors. Evidence-Based Review of Moderate to Severe Acquired Brain Injury. Version 14.0: p1-60.

Summary


Intervention Key Point

Level of Evidence

Verbal and Written Communication  
Interventions for Verbal or Written Communication Targeted hypnosis may improve memory, attention, and cognitive function in post TBI patients or stroke; however, only as long as the intervention is being administered.

–          There is level 1b evidence that targeted hypnosis may transiently improve cognitive function in post TBI patients or stroke.

Attention training programs likely do not improve executive functioning.

–          There is level 1b evidence that an attention remediation intervention may not be superior to TBI education alone and improving executive function in patients post TBI.

–          There is level 2 evidence that dual-task training may improve not general cognitive functioning compared to a non-specific cognitive program in patients post TBI.

General cognitive training programs which include problem-solving appear to be effective for improving executive functioning following an ABI.

–          There is level 1b evidence that a comprehensive cognitive treatment strategy program (which include problem solving), compared to controls, are effective for improving metacognition and goal achievement post TBI.

Virtual reality does not likely improve executive functioning following an ABI.

–          There is level 1b evidence that virtual-reality training is not superior to conventional cognitive training at improving cognitive and executive function outcomes post TBI.

Computer or smartphone software programs (BrainHQ, Parrot Software, ProSolv app) may not be superior to common interventions at improving memory, attention, and problem-solving skills in patients post TBI.

–          There is level 1b evidence that the specific cognitive training program ProSolv, compared to standard therapy, does not improve measures of executive functioning following an ABI.

–          There is level 2 evidence that computer or smartphone software programs, such as BrainHQ, Parrot Software, ProSolv app, may not be superior to no intervention at improving problem-solving skills and general functioning in patients post TBI.

Goal management training may be superior to motor skills training at improving everyday skills (meal preparation), but not intelligence or neuropsychological outcomes in patients post TBI.

–          There is level 2 evidence that goal management training may be superior (compared to motor skills training or no treatment controls) for improving goal attainment or measures of intelligence following an ABI.

Heart rate variability biofeedback may improve executive functions; however, more controlled studies are required to make further conclusions.

–          There is level 4 evidence that heart rate biofeedback may improve executive functioning following an ABI, although higher level studies are required to fully determine this.

Group-Based Interventions Communicating “yes/no” responses with consistent training and environmental enrichments does not improve communication responses in individuals post ABI.

–          There is level 1b evidence that yes/no training and an enriched environment does not significantly improve communication responses in individuals with an ABI.

Retrieval practice is effective for improving verbal communication in individuals with an ABI.

–          There is level 4 evidence that retrieval practice is more effective for memory recall in individuals with an ABI than massed restudy (i.e., cramming) and spaced restudy (i.e., distributed learning).

Targeted figurative language therapy improves communication and comprehension in individuals with TBI; although the severity of the injury may moderate these effects.

–          There is level 4 evidence that cognitive-communication therapy targeting the interpretation of figurative language is effective for improving language and metaphor comprehension following an ABI.

Text-to-speech technology improves reading rates in individuals with TBI, but not comprehension.

–          There is level 4 evidence that text-to-speech technology improves reading rates post ABI but not reading comprehension.

Social Communication Skills Training for Individuals and Communication Partners
Social Communication Skills Training Training in social skills, social communication or pragmatics is effective in improving communication following brain injury.

–          There is level 1b evidence that a variety of communication skills training programs improve social communication skills in individuals with an ABI, as well as self-concept and self-confidence in social communications.

Goal-driven interventions may be effective in improving social communication skills and goals following TBI.

–          There is level 4 evidence suggesting that a goal-driven, metacognitive approach to intervention may be beneficial in assisting individuals with TBI to achieve social communication goals.

Group Interactive Structured Treatment (GIST) is effective for improving social communication skills following an ABI.

–          There is level 2 evidence that the Group Interactive Structured Treatment program (GIST) is effective for improving social communication skills in those with a TBI as well as other neuropsychological comorbidities.

Computer-based game programs which deliver cognitive-communication skills training may be effective for improving social skills.

–          There is level 4 evidence that interactive touch screen games focused on areas of reasoning, knowledge and action may be effective for improving social skills following an ABI.

Training Communication Partners Providing communication training to individuals who interact with people with TBI is effective and encourages two-way dialogue.

–          There is level 2 evidence to support the effectiveness of interventions that focus on training communication partners in the community, compared to no training, for improving interactions between responders and those with an ABI. 

Providing training to the communication partner and the individual with TBI together is more effective than training the individual with TBI alone.

–          There is level 2 evidence that providing training to both the communication partner and the individual with a TBI together is more effective than only training the individual with TBI alone or no training at all.

Non-Verbal Communication Facial affect recognition and emotional interference training improves emotional perception post ABI.

–          There is level 1b evidence that facial affect recognition training and emotional inference training is beneficial at improving the emotional perception of individuals with ABI.

Short intervention designed to improve emotional prosody is not effective post ABI.

–          There is level 1b evidence that short intervention designed to improve the ability to recognize emotional prosody was minimally effective in individuals with ABI. 

Cognitive Pragmatic Treatment (CPT) program is effective at improving comprehension and production of a communication act.

–          There is level 4 evidence that a Cognitive Pragmatic Treatment (CPT) program is effective in improving communicative-pragmatic abilities in individuals with ABI.

The Treatment for Impairments in Social Cognition and Emotion Regulation and Cogniplus protocols are effective for improving emotional processing and emotional intelligence in individuals with an ABI.

–          There is level 1a evidence that the Treatment for Impairments in Social Cognition and Emotion Regulation and Cogniplus protocols are effective for improving emotional processing and emotional intelligence in individuals with an ABI.

Alternative and Augmentative Communication Augmentative and alternative communication interventions designed to assist with organization, access, and efficiency of communication may be beneficial for individuals with severe ABI.

Introduction

Communication remediation focuses on one’s ability to improve expressive language, speech production, reading, writing, and cognition. Due to impairments in cognitive abilities following an ABI, difficulties in producing proficient discourse is commonplace. Previous treatments have focused on improving narrative and structured conversations post injury (Kilov et al., 2009). Established treatments often focus on the individual’s ability to communicate with a clinician or researcher but not in the presence of a friend or family member (Jorgensen & Togher, 2009). Whether an individual communicates with a friend, a family member or community member, rather than a trained clinician post brain injury, has had an effect on the language choices made by both partners (Jorgensen & Togher, 2009).

Group treatment may be an effective intervention for post ABI individuals with cognitive-communication deficits and may be used to target more complex and higher-level skills within the communication domain and with a wide array of communication partners. Within a group treatment setting, patients with ABI gain support and benefit from the experience 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, 2002).

Some specific goals of group treatment post ABI include having individuals focus on having their basic needs met, improving word fluency, word usage and word finding, and, to have tools to help better organize ideas in conversation. Strategies to ensure meeting these goals is possible would be to implement the use of a yes/no response system, alphabet boards to serve as phonemic cueing for word retrieval, and word retrieval strategies. To improve clarity of speech and phonation, patients are encouraged to speak clearly and with vocal effort, all while receiving proper breath support. For clinical use, the Lee Silverman Voice treatment (LSVT®) would be the primary tool when addressing these issues.

Remediation of Verbal and Written Communication

Key Points

Targeted hypnosis may improve memory, attention, and cognitive function in post TBI patientsor stroke; however, only as long as the intervention is being administered.

Attention training programs likely do not improve executive functioning.

General cognitive training programs which include problem-solving appear to be effective for improving executive functioning following an ABI.

Virtual reality does not likely improve executive functioning following an ABI.

Computer or smartphone software programs (BrainHQ, Parrot Software, ProSolv app) may not be superior to common interventions at improving memory, attention, and problem-solving skills in patients post TBI.

Goal management training may be superior to motor skills training at improving everyday skills (meal preparation), but not intelligence or neuropsychological outcomes in patients post TBI.

Heart rate variability biofeedback may improve executive functions; however, more controlled studies are required to make further conclusions.

Several authors have reviewed a variety of studies focusing on cognitive-communication therapies used to assist those post ABI (Coelho et al., 1996; Kennedy et al., 2008; MacDonald & Wiseman-Hakes, 2010). In a review conducted by Coelho et al. (1996), the concluding findings suggest that those who sustain an ABI benefit from the work of an SLP. Study authors found evidence to suggest that individuals undergoing therapy showed gains in receptive and expressive language, speech production, reading, writing, and cognition. Further they noted that patients with more severe cognitive-communication deficits are more effectively remediated when treatment is directed toward the development of compensatory rehabilitation strategies such as the use of memory aids (Coelho et al., 1996). Additionally, Coelho and colleagues (1996) reported that although interventions directed at particular cognitive deficits are important, clinicians must attend to broader issues of social skills retraining, timing of treatment during recovery, treatment location and its effectiveness (e.g. hospital, home, school, work). Study results from Mackay et al. (1992) suggest that intervention programs offered earlier post injury result in shorter rehabilitation stays. Further, for individuals with comparable disabilities, those who receive rehabilitation have better than average cost outcomes compared to those not receiving these services (Aronow, 1987).

Discussion

The effects of hypnosis, as delivered in a targeted or non targeted manner, on memory, attention, and cognitive function in a mixed TBI and stroke population has been investigated (Lindelov et al. 2017). The researchers showed that working memory, attention, and cognitive function could be transiently increased during targeted hypnosis; however, the benefits of the treatment were not sustained when the treatment was discontinued. With respect to attention process training, it was shown that this intervention may have indirectly improved executive function as individuals with higher vigilance achieved higher executive function scores, but it was not explicitly demonstrated that training resulted in increased vigilance (Sohlberg et al., 2000).

Siponkoski et al. (2020) investigated the effects of 20 sessions of music therapy (rhythmical training, structured cognitive-motor training and assisted music playing) on measures of executive function. Compared to the control group, significant improvements on measures of executive function were observed for those receiving music therapy.

Dual-task training which is also used as a form of attention training was also evaluated in another RCT and although individuals were improved on measures of attention to a significantly greater extent than controls, no such relationship was found for measures of executive function (Couillet et al., 2010).

With the development of technology, the use of virtual-reality training and computer programs have gained traction as an intriguing tool used for improving executive function in patients post TBI. In terms of cognitive functioning, two RCTs found varying results for executive functioning outcomes after training in a virtual environment (Jacoby et al., 2013; Man et al., 2013). One RCT focusing on vocational problem-solving skills (Man et al., 2013) identified significant improvements in both VR intervention and conventional psychoeducation control groups; however, there were no significant between-group differences for cognitive or vocational outcomes except on WCST % errors and % conceptual level response (Man et al., 2013). Conversely, Jacoby et al (2013) found that patients receiving virtual reality training improved more on multi-tasking measures and executive function when compared to the control group who received general cognitive re-training treatment. In a pre-post study, Dadah et al. (2017) investigated virtual reality interventions in a mixed ABI population. The researchers found that repetition of the Stroop test in different virtual reality environments showed limited improvement in performance on those specific tests (Dahdah et al., 2017). As a result of the mixed results reported on the efficacy of virtual reality training post ABI, it is difficult to make a conclusive decision on what aspects of executive functioning virtual reality benefits, and to what degree.

As previously mentioned, computer software programs have also been investigated for their efficacy in improving executive dysfunctions post TBI. Recently, BrainHQ, a commercially available online computerized cognitive exercise program, showed mixed results for improving executive function post ABI (O’Neil-Pirozzi & Hsu, 2016). Although individuals self-reported improvements in daily functioning, no significant results were seen on objective measures (O’Neil 2016). Parrot Software is another computer-based cognitive retraining program, and was investigated by a pre-post study assessing the efficacy of using eight modules focussed on attention and memory (Li et al., 2015; Li et al., 2013).  While significant post-treatment improvements in attention and memory on the Cognistat assessment were found in a pilot study (Li et al., 2013), a subsequent study did not find significant improvements on the Montreal Cognitive Assessment (MoCA) or a medication-box sorting task despite significantly improved overall MoCA scores (Li et al., 2015). This lack of improvement compared to a control group was also reported by Powell et al. (2017) when the ProSolv smartphone application was used to improved pressure management and problem-solving skills. Finally, Chen et al. (1997) studied the effect of computer assisted cognitive rehabilitation versus traditional therapy methods. While measures of attention significantly improved in both groups after treatment, no significant differences were observed between groups on any measures related to executive function (Chen et al., 1997). Cumulatively, by observing studies from across a period of nearly 20 years, the literature reveals little support for the use of computer software programs for the improvement of executive function post TBI.

In an RCT, Spikman et al. (2010) randomly divided a group of individuals who had sustained a TBI to either a multifaceted strategy training group or a control group. Those in the treatment group were taught a comprehensive cognitive strategy which allowed them to tackle the issues and problems of daily living, compared to the control group which received a computerized training package that was aimed at improving general cognitive functioning. Overall, results indicate both groups improved on many aspects of executive functioning; however, those in the treatment group showed greater improvement in their ability to set and accomplish realistic goals and to plan and initiate real life tasks (Spikman et al., 2010). The findings of the previous experiment agree with the findings of the study by Laatsch et al. (1999) and Freeman et al. (1992), where cognitive rehabilitation therapy was found to increase productivity and everyday functioning. This older study (Laatsch et al., 1999) also had the benefit of reporting SPECT imaging results, which revealed increases in cerebral blood flow during the intervention. It should be noted that one study has found mixed results on measures of executive functioning after administering a cognitive training program, with individuals improving on some measures of executive functioning, such as metacognition, but not others (Fong & Howie, 2009). It should be noted that none of the above studies were completed by the same groups or had overlapping methodology and although the results suggest cognitive training programs are effective for improving executive functioning following an ABI, programs themselves should be considered unique.

A specific cognitive program (Categorization Program) was evaluated in an RCT by Constantinidou et al. (2008). The authors found that after 13 weeks of therapy (mean 4.5 hr/day), individuals significantly improved on measures of executive functioning such as object recognition. Although the Categorization Program treatment group and standard therapy therapy group showed improvement on the community reintegration questionnaire and adaptability measures, there were greater executive function gains in the treatment group (Constantinidou et al., 2008). The Intensive NeuroRehabilitation Programme investigated by Holleman et al. (2018) resulted in significantly reduced depression and anxiety compared to the control group but did not improve measures of executive functioning. Similarly, a novel program – Cognitive Applications for Life Management, did not find significant improvements in measure of executive functioning (Elbogen et al., 2019). Although the program did improve measures of emotion and behavioural regulation (Elbogen et al., 2019).

Another unique study used heart rate variability biofeedback in an attempt to increase awareness and cognitive control (Kim et al., 2018). In this study it was noted that individuals who underwent heart rate biofeedback significantly improved scores of executive functioning on the Category Test. However, this study consisted of a pre-post design and lacked a control group for comparison, and as such results should be interpreted with caution. Only one study evaluated the effects of repetitive transcranial magnetic stimulation on executive function; however, no significant improvements were observed between groups (Neville et al., 2019).

Levine et al. (2000) completed an RCT comparing a group of patients using goal management training strategies to a control group who were received only motor skills training. The treatment group improved on paper and pencil everyday tasks as well as meal preparation-which the authors used as an example of a task heavily reliant on self-regulation in comparison to the motor treatment group. It is important to note, however, that the motor group performed superiorly on timed neuropsychological tests, and no differences were found between treatments in terms of intelligence. Two other studies evaluated goal management training and did not find any significant results suggesting that goal management training improves executive functioning following an ABI (Cizman Staba et al., 2020; Levack et al., 2009). A single older study reported positive affects of a goal setting program in its ability to help an individual achieve goals (Webb & Glueckauf, 1994). The execution of goals themselves requires executive functioning; however, no objective measures of executive function were directly evaluated in this study.

Conclusions

There is level 1b evidence that targeted hypnosis may transiently improve cognitive function in post TBI patients or stroke.

There is level 1b evidence that an attention remediation intervention may not be superior to TBI education alone and improving executive function in patients post TBI.

There is level 2 evidence that dual-task training may improve not general cognitive functioning compared to a non-specific cognitive program in patients post TBI.

There is level 1b evidence that a comprehensive cognitive treatment strategy program (which include problem solving), compared to controls, are effective for improving metacognition and goal achievement post TBI.

There is level 4 evidence that cognitive rehabilitation may increase productivity in everyday functioning, and cerebral blood flow during treatment in patients post TBI.

There is level 1b evidence that virtual-reality training is not superior to conventional cognitive training at improving cognitive and executive function outcomes post TBI.

There is level 1b evidence that the specific cognitive training program ProSolv, compared to standard therapy, does not improve measures of executive functioning following an ABI.

There is level 2 evidence that the Intensive NeuroRehabilitation programme, compared to no treatment, does not improve executive functioning following an ABI. 

There is level 2 evidence that computer or smartphone software programs, such as BrainHQ, Parrot Software, ProSolv app, may not be superior to no intervention at improving problem-solving skills and general functioning in patients post TBI.

There is level 4 evidence that heart rate biofeedback may improve executive functioning following an ABI, although higher level studies are required to fully determine this.

There is level 2 evidence that goal management training may be superior (compared to motor skills training or no treatment controls) for improving goal attainment or measures of intelligence following an ABI.

Group-based Interventions

Key Points

Communicating “yes/no” responses with consistent training and environmental enrichments does not improve communication responses in individuals post ABI.

Retrieval practice is effective for improving verbal communication in individuals with an ABI.

Targeted figurative language therapy improves communication and comprehension in individuals with TBI; although the severity of the injury may moderate these effects.

Text-to-speech technology improves reading rates in individuals with TBI, but not comprehension.

Although executive function deficits are a common there is little overall research directly addressing the impact of rehabilitation on executive function. However, community integration and other similar group-based interventions are highly related to executive function and it is possible that programs and interventions presented in a group-based setting may in fact be focusing efforts on instrumental activities of daily living which may reflect (or are dependent on) executive functions. The efficacy of group-based interventions on cognitive and executive function are discussed below.

Discussion

Barreca et al. (2003) compared two rehabilitation approaches that attempted to establish correct responses to yes/no questions. In addition to providing an enriched environment to the first group, a communicative disorders assistant provided yes/no training to the individuals. In addition, the assistant trained healthcare team members and families to follow scripted procedures to increase arousal/attention and to elicit yes/no responses. This was compared against standard care. Despite no significant differences on the Western Aphasia Battery, families reported on a satisfaction questionnaire that they were better able to communicate with their loved one (Barreca et al., 2003).

Another study examined retrieval practice, administered in person, compared to massed restudy and spaced restudy (Sumowski et al., 2014). In the retrieval practice intervention, the participants were first exposed to a verbal paired associate; the subsequent trials for that verbal paired associate were structured as cued recall tests. For individuals with severe TBI and memory-impairments, this retrieval practice was significantly more effective for memory recall than the massed restudy and spaced restudy interventions both immediately following the intervention and at 1 week post (Sumowski et al., 2014).

Technology interventions have also been used to improve communication post TBI. In a study conducted by Harvey et al. (2013) participants completed six sessions of computerized text-to-speech training. Results showed a significant improvement in reading rates during the text-to-speech conditions compared to the no text-to-speech conditions (Harvey et al., 2013). These findings suggest that text-to-speech technology is a useful tool in improving reading rates among individuals with a TBI. However, the authors note that while reading rates improved, comprehension of the written material was not affected.

Brownell et al. (2013) utilized therapy targeting deficiencies in figurative language. All participants completed 10 sessions of word task training resulting in significant improvements in oral metaphor interpretation (Brownell et al., 2013). Participants in the study were approximately eight years post injury suggesting that post TBI individuals are capable of advanced improvements in non-literal language even after the period of rapid and pronounced spontaneous recovery.

In a study by O’Neil-Pirozzi et al. (2010), individuals with ABI participated in twelve 90-minute sessions which were held twice a week. The intervention included memory education, and to improve memory function the study emphasized internal strategy acquisition. Primary emphasis was placed on semantic association followed by semantic elaboration/chaining and imagery. Results from the Hopkins Verbal Learning Test (HVLT) indicated significant differences between the groups and those with a severe ABI performed more poorly than those with a moderate injury. Despite this finding, those with severe ABIs did perform better than those in the control group. In all, memory performance was seen to improve for all in the intervention group compared to the control group, however this relationship was slightly modified by injury severity.

Conclusions

There is level 1b evidence that yes/no training and an enriched environment does not significantly improve communication responses in individuals with an ABI.

There is level 4 evidence that retrieval practice is more effective for memory recall in individuals with an ABI than massed restudy (i.e., cramming) and spaced restudy (i.e., distributed learning).

There is level 4 evidence that targeted therapy towards figurative language improves communication in chronic TBI individuals.

There is level 4 evidence that text-to-speech technology improves reading rates post ABI but not reading comprehension.

There is level 4 evidence that cognitive-communication therapy targeting the interpretation of figurative language is effective for improving language and metaphor comprehension following an ABI.

Social Communication Skills Training for Individuals and Communication Partners

After an ABI, issues may present in either verbal or nonverbal communication skills; difficulties with conversation may include topic introduction, topic maintenance, topic choice, turn taking and perspective taking (College of Audiologists and Speech Language Pathologists of Ontario, 2002)

Pragmatics describe “a person’s ability to perceive, interpret and respond to the contextual and situational demands of conversation” (Wiseman-Hakes et al., 1998). In other words, pragmatics refers to the interaction between language behavior and the context in which language occurs (Strauss HM & RS, 1994).  Studies have shown that the conversations of individuals with ABI, compared to individuals without injury, have been rated as significantly less interesting, less appropriate, less rewarding, more effortful, and more reliant on conversation partners to maintain the flow of the conversation (Bond & Godfrey, 1997; Coelho et al., 1996). Since it is through conversation that we form and maintain relationships, impaired communication can have a significant negative impact on social competence, vocational competence and academic competence. Social communication deficits in ABI can result in social isolation, frustration, and a sense of helplessness (Kilov et al., 2009; Sarno et al., 1986).

Non-Verbal Communication

Key Points

Facial affect recognition and emotional interference training improves emotional perception post ABI.

Short intervention designed to improve emotional prosody is not effective post ABI.

Cognitive Pragmatic Treatment (CPT) program is effective at improving comprehension and production of a communication act.

The Treatment for Impairments in Social Cognition and Emotion Regulation and Cogniplus protocols are effective for improving emotional processing and emotional intelligence in individuals with an ABI.

Goals of treatment regarding non-verbal communication post ABI include initiating conversation with others, learning to understand the emotion presented in verbal language, the ability to respond appropriately, and to maintain conversation. In order to achieve these goals, the necessary strategies to be employed consist of environmental and behavioural modification, counselling and support, pragmatic skills trailing, and targeted speech and language therapy. Patients will require positive reinforcement of the appropriate responses, as well as auditory/visual feedback by others.

Studies have shown that the conversations of individuals with ABI, compared to individuals without injury, have been rated as significantly less interesting, less appropriate, less rewarding, more effortful, and more reliant on conversation partners to maintain the flow of the conversation (Bond & Godfrey, 1997; Coelho et al., 1996). Since it is through conversation that we form and maintain relationships, impaired communication can have a significant negative impact on social competence, vocational competence and academic competence. Social communication deficits in ABI can result in social isolation, frustration, and a sense of helplessness (Kilov et al., 2009; Sarno et al., 1986).

Discussion

Westerhof-Evers et al. (2017) conducted an RCT describing social communication training. Not only did this study evaluate social understanding and social behaviour, it also examined emotional regulation and perception. On the emotional intelligence components of the study, the experimental group improved significantly on the facial affect recognition (Westerhof-Evers et al. 2017). Participants in the experimental group also reported higher quality of life and their life partners rated relationship quality to be higher than those in the control group (Westerhof-Evers et al. 2017).

A short treatment aimed at improving the ability to recognize emotional prosody was overall found to be ineffective (McDonald et al., 2013). Activities consisted of mostly games designed to focus on prosodic cues but found no change related to communication competence. Significance was approached for the treatment group in terms of improvements in the accuracy on the prosody task and ratings of intensity of emotions. However, participants in the treatment group self-reported that their ability to comprehend daily conversations had improved (McDonald et al., 2013).

Radice-Neumann et al. (2009) and Neumann et al. (2015) demonstrated that training focused on emotional processing (either by face affect recognition or by emotional inference training) can be effective when introduced to a group of individuals who had sustained an ABI. They assert that individuals with ABI can re-learn affective recognition skills. Two interventions to enhance emotion processing were utilized in both studies. The first intervention (Facial Affect Recognition), focused on attention to important visual information and attention to the participant’s own emotional experience. The second intervention (Stories of Emotional Inference) taught patients to read emotions from contextual cues presented in stories and then relate these stories to personal events. Participants who received Facial Affect Recognition training had more positive outcomes (Neumann et al., 2015). Participants were better at reading faces (emotions) and were more descriptive in relating how they or others would feel in a similar situation. Decreased level of aggression was an additional finding.

The Stories of Emotional Inference group produced fewer improvements; however, they were able to make more emotional inferences about how they would feel in a given context. Individuals were still unable to make improvements in their ability to infer how others would feel in a given situation. The authors hypothesized that this might be related to self-centeredness, a trait often attributed to post ABI individuals(Radice-Neumann et al., 2009). However, Neumann et al. (2015) noted that the ability to identify one’s own emotions is an important precursor to recognizing the emotions of others and therefore, should not be dismissed prematurely. The previous Radice-Neumann et al. (2009) RCT found slightly depressed effects compared to its 2015 follow-up. In 2009, groups were not significantly different from each other on the Diagnostic Assessment of Nonverbal Affect. However, both groups still significantly improved in their ability to infer emotions from contextual situations on the Levels of Emotional Awareness Scale (Radice-Neumann et al., 2009).

Gabbatore et al. (2015) evaluated a cognitive pragmatic rehabilitation program aimed at improving communicative-pragmatic abilities, in particular self-awareness and executive functioning. Study authors aimed at improving comprehension and production of a communication act. No improvements in comprehension were found from baseline to pre-training (p=0.41); however, significant improvements were demonstrated at post-training and follow-up (Gabbatore et al., 2015).

Conclusions

There is level 1b evidence that facial affect recognition training and emotional inference training is beneficial at improving the emotional perception of individuals with ABI.

There is level 1a evidence that the Treatment for Impairments in Social Cognition and Emotion Regulation and Cogniplus protocols are effective for improving emotional processing and emotional intelligence in individuals with an ABI.

There is level 1b evidence that short intervention designed to improve the ability to recognize emotional prosody was minimally effective in individuals with ABI. 

There is level 4 evidence that a Cognitive Pragmatic Treatment (CPT) program is effective in improving communicative-pragmatic abilities in individuals with ABI.

Social Communication Skills Training

Key Points

Training in social skills, social communication or pragmatics is effective in improving communication following brain injury.

Goal-driven interventions may be effective in improving social communication skills and goals following TBI.

Group Interactive Structured Treatment (GIST) is effective for improving social communication skills following an ABI.

Computer-based game programs which deliver cognitive-communication skills training may be effective for improving social skills.

ABI can influence every aspect of life including physicality, cognitive function, emotional responses, and social functioning. Social communication training more specifically addresses social competence and removing barriers to returning to a meaningful and productive life, which includes having the ability to sustain interpersonal relationships (Braden et al., 2010). Communication remediation focuses on one’s ability to improve expressive language, speech production, reading, writing, and cognition.

Discussion

An RCT by Westerhof-Evers et al. (2017) compared the use of a Social cognition and Emotion regulation treatment (T-ScEmo) to a treatment for general cognitive gains (Cogniplus) (control group), to evaluate how participants performed on emotion perception, social understanding, and social behavior. The T-ScEmo group had statistically significant improvements on emotion perception (facial affect recognition), theory of mind, proxy-rated empathic behavior, societal participation, and treatment goal attainment, when compared with the Cogniplus group (Westerhof-Evers et al., 2017). Participants in the T-ScEmo group also reported higher quality of life and their life partners rated relationship quality to be higher than those in the Cogniplus group. Similarly, in a pre-post study, Douglas et al. (2019) examined the effects of a communication-specific coping program and found a significant improvement in functional communication, stress, and communication-specific coping strategies.

In an RCT conducted by Dahlberg et al. (2007) it was found that subjects in the experimental group, when exposed to twelve, 1.5 hour communication sessions, significantly improved their scores on the general participation in conversation subscale on the Profile of Functional Impairment in Communication and the Social Communication Skills questionnaire-adapted (Dahlberg et al., 2007). These improvements were also noted at 6- and 9-month follow-up periods. It’s worth noting that both Dahlberg et al. (2007) and Westerhof-Evers et al. (2017) interventions included components of emotional regulation.

Finch et al. (2017) conducted pre-post study in adults with brain injury aimed at improving and maintaining social communication skills, in particular, the study authors focused on improved perceived communication skills, and achievement of goals. The results from this study indicated that goal-driven and metacognitive strategy-based interventions may help individuals with TBI achieve social communication goals. Similarly, three studies examined the effects of a group social communication intervention, focused on achieving social communication goals, on improving social communication skills (Behn et al., 2019a, 2019b). The results from these studies support that of Finch et al. (2017), in that conservational interaction significantly improved with the achievement of social communication goals. In contrast, one study found that a goal orientated communication program did not significantly improve social communication skill; however, it is important to note that the population size of this study was only seven (Cizman Staba et al., 2020).

Braden et al. (2010) examined the efficacy of the Group Interactive Structured Treatment (GIST) for social competence in a cohort study examining 30 individuals greater than one year post ABI. The 13 week training reviewed the following topics: skills of the great communicator, self-assessment and goal setting, starting conversations, keeping conversations going and using feedback, assertiveness in solving problems, practice in the community, social confidence through positive self-talk, social boundaries, videotaping, video review, conflict resolution, closure and celebration (Braden et al., 2010). Overall, data gathered demonstrated significant positive effects of GIST on social communication. Further, the program seemed to be effective for individuals with TBI who also comorbidities had, as stratification revealed there were no significant differences between these groups in terms of outcome. Two other studies have examined the effects of group cognitive pragmatic therapy (Bosco et al., 2018; Parola et al., 2019). In both studies, individuals were seen to improve on measures of communication, communication in daily activities, and verbal span. Although these studies demonstrated significant improvements in social and functional communication, there was no control group to determine the effects of this therapy compared to no or alternative therapies.

One study used interactive touch screens to apply a game-based question activity, which included topics around knowledge, reasoning, action, and cohesion of thoughts (Llorens et al., 2012). Although formal statistical analysis was not performed, 6/10 participants initially showed altered levels of communication on the Social Skills Scale, compared to only 2/10 post-treatment.

Lastly, two cohort studies investigated the effects of in-person versus telehealth delivery of a social communication skills program (R. Rietdijk et al., 2020; Rachael Rietdijk et al., 2020). Both studies found no significant differences on communication skills outcomes, suggesting that telehealth delivery of social communication programs is equally effective as in-person programs.

Conclusions

There is level 1b evidence that the Social Cognition and Emotion Regulation protocol when administered by a neuropsychologist is more effective for the remediation of social communication skills than the Cogniplus protocol in individuals with an ABI.

There is level 1b evidence that a variety of communication skills training programs improve social communication skills in individuals with an ABI, as well as self-concept and self-confidence in social communications.

There is level 4 evidence suggesting that a goal-driven, metacognitive approach to intervention may be beneficial in assisting individuals with TBI to achieve social communication goals.

There is level 4 evidence that interactive touch screen games focused on areas of reasoning, knowledge and action may be effective for improving social skills following an ABI.

There is level 2 evidence that the Group Interactive Structured Treatment program (GIST) is effective for improving social communication skills in those with a TBI as well as other neuropsychological comorbidities.

There is level 2 evidence that telehealth social communication skills programs are equally effective as in-person programs for improving social communication skills in individuals with TBI.

Training Communication Partners

Key Points

Providing communication training to individuals who interact with people with TBI is effective and encourages two-way dialogue.

Providing training to the communication partner and the individual with TBI together is more effective than training the individual with TBI alone.

The success of communication interventions often relies on the understanding, compliance and competence of communication partners. Training of communication partners has become a central component of communication interventions with many populations. This development is consistent with the World Health Organization (2001) emphasis on context (environmental and attitudinal) as a determinant in health and disability outcomes. Training of communication partners has been shown to have a positive effect on communication effectiveness and reacquisition of communication skills in children with language disorders and developmental disabilities (Girolametto et al., 1994), adults with aphasia (Kagan et al., 2001), adults with dementia (Ripich et al., 1999), and adults with ABI (Togher et al., 2004).

Following an ABI individuals may have difficulty engaging in meaningful conversation with others. Training communication partners is particularly helpful in successfully facilitating communication with those with moderate to severe ABI. The strategies that are most useful in ensuring success of treatment include speaking in short, simple sentences, making and maintaining eye contact, and asking the patient to repeat the messages being conveyed (Behn et al., 2013). Also, asking patients to clarify that they understand the information and repeating the information, when necessary, while allowing adequate time to receive an answer. Presenting the information in written form can also elicit a positive outcome from patients (Behn et al., 2013). Eliminating environmental distractions will be a tremendous aid to allow proper focus and attention for optimal results. Communication partners should present choices to patients and clarify the intent of the message being delivered. Using a variety of modes of communication (such as nonverbal) can also be a useful strategy (Behn et al., 2012, Togher et al., 2004, Togher et al., 2016, Sim et al., 2013, Togher et al. 2013).

Discussion

Studies examining communication partner training either focused on training individuals and their communication partners jointly (n=5), or independently (n=1). For the single study examining communication training interventions only for communication partners positive effects were still found (Togher et al., 2004). In a RCT conducted by Togher et al. (2004), the benefits of training individuals regarding how to effectively communicate with post ABI individuals was evident. Police officers were trained to respond to individuals with ABI, while the remaining officers who volunteered did not participate in the training. Overall, it was noted that trained officers significantly reduced the number of inquiries required to gain the necessary information from their callers, as well as spent less time establishing the nature of the service request and more time answering the questions being presented.

For studies using grouped training Behn et al. (2012) found that training allowed for caregivers to interact more easily with the individual with a TBI when strategies were used to encourage dialogue, this was compared to an untrained control group. The training in this study consisted of a number of didactic and performance-based approaches such as modeling, role-playing, feedback and rehearsal. As well, the strategies used were both elaborative and collaborative.

When examining training communication partners, the most efficacious way to improve interactions is to have both the individual with an ABI and their communication partner participate in training together. Two studies by Togher et al. (2013; 2016) found that those who completed social communication training together, made significantly greater gains in participation and overall communication compared to individuals with TBI who attended alone or those who received no training. In a similar study, providing training to communication partners allowed for their communication styles to be modified, which in turn allowed for the individual with TBI to improve their communication (Sim et al., 2013). This study highlighted 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).

Conclusions

There is level 2 evidence to support the effectiveness of interventions that focus on training communication partners in the community, compared to no training, for improving interactions between responders and those with an ABI. 

There is level 2 evidence that providing training to both the communication partner and the individual with a TBI together is more effective than only training the individual with TBI alone or no training at all.

Alternative and Augmentative Communication

Key Points

Augmentative and alternative communication interventions designed to assist with organization, access, and efficiency of communication may be beneficial for individuals with severe ABI.

Following severe ABI, patients present with significant communication challenges that interfere with daily communication needs. Whereas those who sustain a mild or moderate ABI may be more readily able to communicate using natural speech with minor difficulties, those with severe ABI may not be able to meet communication needs through speech alone and may benefit from an augmentative or alternative communication (AAC) strategy (M. S. Bourgeois et al., 2001; Burke et al., 2004; de Joode et al., 2012; Fager et al., 2006; Johannsen-Horbach et al., 1985). Many individuals eventually recover their speech abilities post ABI, but there are still many who remain unable to speak for extended periods of time (Fager et al., 2006). For this specific group, assessments and AAC interventions may be a continual process, ensuring that the individual’s level of function is matched appropriately with new systems as needed (Fager et al., 2006).

In the AAC domain, there are divisions of complexity that include simple, low-tech options (e.g., alphabet boards, picture-based communication boards, memory books, conversation books, day planners) and high-tech options that include Voice Output Communication Aids (i.e., Dynavox, McCaw, Message Mate, Big Mack, Voice Pal and Boardmaker) (Fager et al., 2006). Notably, both low-tech and high-tech solutions to communication difficulties may have access that is either direct (i.e., touching/ pointing) or indirect (i.e., switch access or partner-assisted scanning).

Clinicians working in the area of AAC or Assistive/Enabling Technology are well acquainted with the recent explosion of technology options available. Presently, clinicians and patients have access to an extensive set of devices and peripherals including but not limited to iPad, Android, and Windows based tablets as well as a wide variety of associated applications and software (e.g., Proloquo2go, Talking Tiles). Changes in cost, improved ease of access/availability in mainstream retail, and rapid changes in the technology itself and associated applications have resulted in AAC clinical practice that is both invigorating and exhausting. Given that we are in the midst of unprecedented technology growth, the research in this area is lagging and limited.

In this particular area, difficulties sustained post ABI include verbal expression and severe dysarthria, with the primary goal of treatment being to allow individuals with severe ABI to efficiently access and communicate effectively via AAC. Particular treatment strategies for ACC may be to complete an initial assessment of the individuals needs from access and communication perspectives. From there, clinicians are able to determine the best device and method of access for individuals on a one-to-one basis (taking into account age and gender), and to allow time for training and teaching of both patient and communication partners (i.e., facilitator).

While there is a great deal of discussion around the importance of AAC, there is limited literature supporting the effectiveness of the strategies currently available for ABI populations. Further research is required in order to understand how these communication approaches or alternatives work to benefit individuals with an ABI and their care giving team.

Alphabet Boards

Individuals with dysarthria or who are non-verbal may benefit from an alphabet board. These boards are helpful for spelling single word or short phrase messages. Board sizes may vary depending on the person’s abilities, necessity, or access (Bhatnagar SC & F, 1999). A lexical communication board is another type of AAC that uses common words such as nouns, pronouns, verbs and adjectives to improve sentence formation in patients, however this is not supported by academic sources and therefore requires further research.

Bliss Symbols

Bliss symbols or boards have been available and utilized for several years. The use of these symbols has been found to be very effective with those who have been diagnosed with aphasia or Broca’s aphasia (Rajaram et al., 2012). However, there is little in the literature specifically pertaining to individuals with an ABI.

Eye-Gaze Communication Board

Assistive technologies aim to improve outcomes in individuals with physical and cognitive impairments. Gaze-based communication boards use computers controlled by the individual’s eyes. This device replaces keyboard and mouse with eye gaze for those who have physical impairments that prevents the use of upper limb motor function (Borgestig et al., 2016). By using their eyes, individuals can control the computer and gain access to communication and activities, including playing games, music, and perform a range of activities that they would not otherwise be physically able to do (Borgestig et al., 2016). The limitation of this technology is that is not as cost effective as other AAC devices, and novice users may experience fatigue quickly, as there is a substantial learning curve with the type of specific eye movements needed to operate the communication board (it does not mimic natural/intuitive eye movements required for daily activities) (Borgestig et al., 2016).

Memory Aids

The use of memory aids as an AAC tool has been studied extensively in patients with dementia and Alzheimer’s, however their use in individuals with an ABI are not well documented. There are a number of different aids that can be used to compensate for memory loss and decline of cognitive and linguistic skills. Memory books are amongst the most popular and capitalize on procedural memory skills (page turning and reading aloud), they also promote transfer of information and increase social closeness (M. Bourgeois et al., 2001). Memory aids help compensate for memory loss by helping to access stored information and memories, therefore they can be an extremely effective tool that are easily accessible and straightforward to use from a patient’s perspective (M. Bourgeois et al., 2001).

Non-Electronic Communication Board

Assistive devices for AAC range in their properties and capabilities. Non-electronic communication boards, along with electronic counterparts, can aid post ABI individuals with messages and symbols depicted on the display. However, the number of messages they can display are limited, and they do not have the capacity for speech output (Iacono et al., 2011). This option would be ideal for people with complex communication needs, as they are easy to access, less expensive, and generally easier to use by patients, caregivers and clinicians.

Organizational Word Retrieval Strategies

Burke et al. (2004) studied the use of three organizational word retrieval strategies for adults with ABI who use AAC. These organizational strategies included semantic topic, geographic place, and first letter of alphabet. While the subjects retrieved words more accurately when using the alphabet organization strategy, they expressed the preference for use of the semantic topic strategy. Clinicians may consider providing these three strategies for clients using AAC and assisting with identification of the most beneficial and preferred strategy for the individual client.

Pictograms

Pictograms allow individuals to express their thoughts, emotions, wants and needs with pictures, as there is not a verbal explanation of all words. Pictogram-based ACC has been used for over 30 years and has been shown to help learn new linguistic skills (Pahisa-Solé & Herrera-Joancomartí, 2017).

Picture/Symbol Based Boards

Despite the surge in technology, picture and symbol-based boards remain in high use today (e.g. pictograms, Boardmaker). These symbols or pictures may represent a concept, object, activity, place or event. Symbols, pictures, and boards in general may be used with minimal training and software may be individualized (Bhatnagar SC & F, 1999). The selection of symbols should be appropriate to the individual’s communicative needs. Picture/symbol software is also available for computers, iPads, and iPhones.

Sign Language

All the above AAC treatments are considered to be “aided” forms of communication, meaning they require external support by way of auxiliary materials (communication board, printed words, etc.) (Sigafoos & Drasgow, 2001). In contrast, natural gestures and sign language are forms of “unaided” AAC (Sigafoos & Drasgow, 2001)American Sign Language is the most commonly used, however there are other systems including Pidgin Signed English (PSE), and Signed Exact English (SEE). The advantages of sign language as an AAC are that it is portable (it does not require materials or devices), and it can be easier to teach than speech; communication partners, and clinicians can help individuals with hand formations (Sigafoos & Drasgow, 2001). There is no literature to support use of sign language in brain injured populations specifically, therefore more research in this field is required to make conclusions about its efficacy as a potential therapy.

Synthetic Voice

Synthetic voice, or synthesized speech uses computer-generated text-to-speech synthesis to extract speech and sound components from words and then combine them to form a natural sounding voice (JL Flaubert, 2017)This differs from digitized speech, which uses human voices stored as segments of sounds waves. Synthesized speech is ideal because it allows greater message flexibility and accuracy of what the individual is trying to convey (JL Flaubert, 2017).

Conclusions

Cognitive interventions target a large variety of cognitive-communication functions and deficits. The rehabilitation of these functions is complicated by cross-study variability in treatment duration (e.g., from 30 minutes once a day for 5 days to 5 hours, every day for 6 weeks). Severity of injury and time since injury may also fluctuate from study to study.

Communication impairments among this group are generally described as non-aphasic in nature (Ylvisaker M & SF, 1994). This is a different type of communication impairment than that seen following stroke, and this distinction is an important one. Communication deficits in individuals with ABI may also include aphasic-like symptoms such as naming errors and word-finding problems, impaired self-monitoring, and auditory recognition impairments. These constraints may also be coupled with other cognitive-communication impairments, such as attention and perception difficulties, impaired memory, impulsivity, and severe impairment of the individual’s overall communicative proficiency within functional situations. These constraints can prevent individuals with ABI from exhibiting even simple communication skills (Lennox & Brune, 1993). (Amos, 2002)

Technology has increased the availability of external aids, although some seem more feasible to use than others (e.g., cell phones or hand-held recorders). Unfortunately, the studies reviewed did not specify the length of time subjects required to master compensatory strategies or the nature of the long-term effects. Generally, if these electronic appliances are used before the injury, they are more likely to be used post-injury as well. It was unclear from the studies if any of the participants had previous knowledge of these tools.

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