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Posttraumatic amnesia (PTA) is a common occurrence following moderate to severe traumatic brain injury (TBI) and emergence from coma. It is characterized by confusion, disorientation, retrograde and anterograde amnesia, poor attention and frequently, agitation. Clinicians and family need guidelines to support management practices during this phase.An international team of researchers and clinicians (known as INCOG) met to update the INCOG guidelines for assessment and management of PTA. Previous recommendations and audit criteria were updated on the basis of review of the literature from 2014.Six management recommendations were made: 1 based on level A evidence, 2 on level B, and 3 on level C evidence. Since the first version of INCOG (2014), 3 recommendations were added: the remainder were modified. INCOG 2022 recommends that individuals should be assessed daily for PTA, using a validated tool (Westmead PTA Scale), until PTA resolution. To date, no cognitive or pharmacological treatments are known to reduce PTA duration. Agitation and confusion may be minimized by a variety of environmental adaptations including maintaining a quiet, safe, and consistent environment. The use of neuroleptic medications and benzodiazepines for agitation should be minimized and their impact on agitation and cognition monitored using standardized tools. Physical therapy and standardized activities of daily living training using procedural and errorless learning principles can be effective, but delivery should be tailored to concurrent levels of cognition, agitation, and fatigue.Stronger recommendations regarding assessment of PTA duration and effectiveness of activities of daily living training have been made. Evidence regarding optimal pharmacological and nonpharmacological management of confusion and agitation during PTA remains limited, with further research needed. These guidelines aim to enhance evidence-based care and maximize consistency of PTA management.

Moderate to severe traumatic brain injury (TBI) results in complex cognitive sequelae. Despite hundreds of clinical trials in cognitive rehabilitation, the translation of these findings into clinical practice remains a challenge. Clinical practice guidelines are one solution. The objective of this initiative was to reconvene the international group of cognitive researchers and clinicians (known as INCOG) to develop INCOG 2.0: Guidelines for Cognitive Rehabilitation Following TBI.The guidelines adaptation and development cycle was used to update the recommendations and derive new ones. The team met virtually and reviewed the literature published since the original INCOG (2014) to update the recommendations and decision algorithms. The team then prioritized the recommendations for implementation and modified the audit tool accordingly to allow for the evaluation of adherence to best practices.In total, the INCOG update contains 80 recommendations (25 level A, 15 level B, and 40 level C) of which 27 are new. Recommendations developed for posttraumatic amnesia, attention, memory, executive function and cognitive-communication are outlined in other articles, whereas this article focuses on the overarching principles of care for which there are 38 recommendations pertaining to: assessment (10 recommendations), principles of cognitive rehabilitation (6 recommendations), medications to enhance cognition (10 recommendations), teleassessment (5 recommendations), and telerehabilitation intervention (7 recommendations). One recommendation was supported by level A evidence, 7 by level B evidence, and all remaining recommendations were level C evidence. New to INCOG are recommendations for telehealth-delivered cognitive assessment and rehabilitation. Evidence-based clinical algorithms and audit tools for evaluating the state of current practice are also provided.Evidence-based cognitive rehabilitation guided by these recommendations should be offered to individuals with TBI. Despite the advancements in TBI rehabilitation research, further high-quality studies are needed to better understand the role of cognitive rehabilitation in improving patient outcomes after TBI.

Moderate to severe traumatic brain injury (MS-TBI) commonly causes disruption in aspects of attention due to its diffuse nature and injury to frontotemporal and midbrain reticular activating systems. Attentional impairments are a common focus of cognitive rehabilitation, and increased awareness of evidence is needed to facilitate informed clinical practice.An expert panel of clinicians/researchers (known as INCOG) reviewed evidence published from 2014 and developed updated guidelines for the management of attention in adults, as well as a decision-making algorithm, and an audit tool for review of clinical practice.This update incorporated 27 studies and made 11 recommendations. Two new recommendations regarding transcranial stimulation and an herbal supplement were made. Five were updated from INCOG 2014 and 4 were unchanged. The team recommends screening for and addressing factors contributing to attentional problems, including hearing, vision, fatigue, sleep-wake disturbance, anxiety, depression, pain, substance use, and medication. Metacognitive strategy training focused on everyday activities is recommended for individuals with mild-moderate attentional impairments. Practice on de-contextualized computer-based attentional tasks is not recommended because of lack of evidence of generalization, but direct training on everyday tasks, including dual tasks or dealing with background noise, may lead to gains for performance of those tasks. Potential usefulness of environmental modifications is also discussed. There is insufficient evidence to support mindfulness-based meditation, periodic alerting, or noninvasive brain stimulation for alleviating attentional impairments. Of pharmacological interventions, methylphenidate is recommended to improve information processing speed. Amantadine may facilitate arousal in comatose or vegetative patients but does not enhance performance on attentional measures over the longer term. The antioxidant Chinese herbal supplement MLC901 (NeuroAiD IITM) may enhance selective attention in individuals with mild-moderate TBI.Evidence for interventions to improve attention after TBI is slowly growing. However, more controlled trials are needed, especially evaluating behavioral or nonpharmacological interventions for attention.

Moderate to severe traumatic brain injury causes significant cognitive impairments, including impairments in social cognition, the ability to recognize others' emotions, and infer others' thoughts. These cognitive impairments can have profound negative effects on communication functions, resulting in a cognitive-communication disorder. Cognitive-communication disorders can significantly limit a person's ability to socialize, work, and study, and thus are critical targets for intervention. This article presents the updated INCOG 2.0 recommendations for management of cognitive-communication disorders. As social cognition is central to cognitive-communication disorders, this update includes interventions for social cognition.An expert panel of clinicians/researchers reviewed evidence published since 2014 and developed updated recommendations for interventions for cognitive-communication and social cognition disorders, a decision-making algorithm tool, and an audit tool for review of clinical practice.Since INCOG 2014, there has been significant growth in cognitive-communication interventions and emergence of social cognition rehabilitation research. INCOG 2.0 has 9 recommendations, including 5 updated INCOG 2014 recommendations, and 4 new recommendations addressing cultural competence training, group interventions, telerehabilitation, and management of social cognition disorders. Cognitive-communication disorders should be individualized, goal- and outcome-oriented, and appropriate to the context in which the person lives and incorporate social communication and communication partner training. Group therapy and telerehabilitation are recommended to improve social communication. Augmentative and alternative communication (AAC) should be offered to the person with severe communication disability and their communication partners should also be trained to interact using AAC. Social cognition should be assessed and treated, with a focus on personally relevant contexts and outcomes.The INCOG 2.0 recommendations reflect new evidence for treatment of cognitive-communication disorders, particularly social interactions, communication partner training, group treatments to improve social communication, and telehealth delivery. Evidence is emerging for the rehabilitation of social cognition; however, the impact on participation outcomes needs further research.

Moderate-to-severe traumatic brain injury (MS-TBI) causes debilitating and enduring impairments of executive functioning and self-awareness, which clinicians often find challenging to address. Here, we provide an update to the INCOG 2014 guidelines for the clinical management of these impairments.An expert panel of clinicians/researchers (known as INCOG) reviewed evidence published from 2014 and developed updated recommendations for the management of executive functioning and self-awareness post-MS-TBI, as well as a decision-making algorithm, and an audit tool for review of clinical practice.A total of 8 recommendations are provided regarding executive functioning and self-awareness. Since INCOG 2014, 4 new recommendations were made and 4 were modified and updated from previous recommendations. Six recommendations are based on level A evidence, and 2 are based on level C. Recommendations retained from the previous guidelines and updated, where new evidence was available, focus on enhancement of self-awareness (eg, feedback to increase self-monitoring; training with video-feedback), meta-cognitive strategy instruction (eg, goal management training), enhancement of reasoning skills, and group-based treatments. New recommendations addressing music therapy, virtual therapy, telerehabilitation-delivered metacognitive strategies, and caution regarding other group-based telerehabilitation (due to a lack of evidence) have been made.Effective management of impairments in executive functioning can increase the success and well-being of individuals with MS-TBI in their day-to-day lives. These guidelines provide management recommendations based on the latest evidence, with support for their implementation, and encourage researchers to explore and validate additional factors such as predictors of treatment response.

Background Although the COVID-19 pandemic resulted in a rapid implementation and scale-up of telehealth for patients in need of rehabilitation, an overall slower scaling up to telerehabilitation has been documented. Objective The purpose of this study was to understand experiences of implementing telerehabilitation during the COVID-19 pandemic as well as using the Toronto Rehab Telerehab Toolkit from the perspective of rehabilitation professionals across Canada and internationally. Methods The study adopted a qualitative descriptive approach that consisted of telephone- or videoconference-supported interviews and focus groups. Participants included rehabilitation providers as well as health care leaders who had used the Toronto Rehab Telerehab Toolkit. Each participant took part in a semi-structured interview or focus group, lasting approximately 30-40 minutes. Thematic analysis was used to understand the barriers and enablers of providing telerehabilitation and implementing the Toronto Rehab Telerehab Toolkit. Three members of the research team independently analyzed a set of the same transcripts and met after each set to discuss their analysis. Results A total of 22 participants participated, and 7 interviews and 4 focus groups were included. The data of participants were collected from both Canadian (Alberta, New Brunswick, and Ontario) and international sites (Australia, Greece, and South Korea). A total of 11 sites were represented, 5 of which focused on neurological rehabilitation. Participants included health care providers (ie, physicians, occupational therapists, physical therapists, speech language pathologists, and social workers), managers and system leaders, as well as research and education professionals. Overall, 4 themes were identified including (1) implementation considerations for telerehabilitation, encompassing 2 subthemes of “infrastructure, equipment, and space” and “leadership and organizational support”; (2) innovations developed as a result of telerehabilitation; (3) the toolkit as a catalyst for implementing telerehabilitation; and (4) recommendations for improving the toolkit. Conclusions Findings from this qualitative study confirm some of the previously identified experiences with implementing telerehabilitation, but from the perspective of Canadian and international rehabilitation providers and leaders. These findings include the importance of adequate infrastructure, equipment, and space; the key role of organizational or leadership support in adopting telerehabilitation; and availing resources to implement it. Importantly, participants in our study described the toolkit as an important resource to broker networking opportunities and highlighted the need to pivot to telerehabilitation, especially early in the pandemic. Findings from this study will be used to improve the next iteration of the toolkit (Toolkit 2.0) to promote safe, accessible, and effective telerehabilitation to those patients in need in the future.

Objective Stakeholder engagement in clinical practice guideline (CPG) creation is thought to increase relevance of CPGs and facilitate their implementation. The objectives were to survey stakeholders involved in the care of adults with traumatic brain injury (TBI) regarding general perceptions of CPGs, key elements to be included, and needs and expectations about format and implementation strategy. Settings Hospitals and inpatient and outpatient rehabilitation facilities providing services to persons with TBI. Participants Stakeholders identified as primary end users of the CPG: clinicians, hospital leaders, health system managers, and funders in Quebec and Ontario (Canada). Design Cross-sectional online survey conducted between May and September 2014. Results In total, 332 individuals expressed their needs and expectations. Despite positive perceptions of CPGs, only a small proportion of respondents used them. Intensity and frequency of interventions, behaviors disorders and cognitive function impairment, and social participation and community life were important subjects to cover in the CPG. Finally, respondents asked for specific recommendations including a ranking of recommendations based on level of underlying evidence. Conclusion Respondents have important expectations toward a CPG. We anticipate that early and meaningful engagement of end users could facilitate CPG implementation.

Objective Traumatic brain injury (TBI) clinical practice guidelines are a potential solution to rapidly expanding literature. The project objective was to convene experts to develop a unique set of TBI rehabilitation recommendations incorporating users' priorities for format and implementation tools including indicators of adherence. Methods The Guidelines Adaptation & Development Cycle informed recommendation development. Published TBI recommendations were identified and tabulated. Experts convened to adapt or, where appropriate, develop new evidence-based recommendations. These draft recommendations were validated by systematically reviewing relevant literature. Surveys of experts and target users were triangulated with strength of evidence to identify priority topics. Results The final recommendation set included a rationale, implementation tools (algorithms/adherence indicators), key process indicators, and evidence summaries, and were divided in 2 sections: Section I: Components of the Optimal TBI Rehabilitation System (71 recommendations) and Section II: Assessment and Rehabilitation of Brain Injury Sequelae (195 recommendations). The recommendations address top priorities for the TBI rehabilitation system: (1) intensity/frequency of interventions; (2) rehabilitation models; (3) duration of interventions; and (4) continuity-of-care mechanisms. Key sequelae addressed (1) behavioral disorders; (2) cognitive dysfunction; (3) fatigue and sleep disturbances; and (4) mental health. Conclusion This TBI rehabilitation guideline used a robust development process to address users' priorities.

Objective Clinical practice guidelines (CPGs) aim to improve quality and consistency of healthcare services. A Canadian group of researchers, clinicians, and policy makers developed/adapted a CPG for rehabilitation post-moderate to severe traumatic brain injury (MSTBI) to respond to end users' needs in acute care and rehabilitation settings. Methods The rigorous CPG development process began assessing needs and expectations of end users, then appraised existing CPGs, and, during a consensus conference, produced fundamental and priority recommendations. We also surveyed end users' perceptions of implementation gaps to determine future implementation strategies to optimize adherence to the CPG. Results The unique bilingual (French and English) CPG consists of 266 recommendations (of which 126 are new recommendations), addressing top priorities for MSTBI, rationale, process indicators, and implementations tools (eg, algorithms and benchmarks). Conclusion The novel approach of consulting and working with end users to develop a CPG for MSTBI should influence knowledge uptake for clinicians wanting to provide evidence-based care.

Introduction: Cognitive rehabilitation following traumatic brain injury can aid in optimizing function, independence, and quality of life by addressing impairments in attention, executive function, cognitive communication, and memory. This study aimed to identify and evaluate the methodological quality of clinical practice guidelines for cognitive rehabilitation following traumatic brain injury. Methods: Systematic searching of databases and Web sites was undertaken between January and March 2012 to identify freely available, English language clinical practice guidelines from 2002 onward. Eligible guidelines were evaluated using the validated Appraisal of Guidelines for Research and Evaluation II instrument. Results: The 11 guidelines that met inclusion criteria were independently rated by 4 raters. Results of quality appraisal indicated that guidelines generally employed systematic search and appraisal methods and produced unambiguous, clearly identifiable recommendations. Conversely, only 1 guideline incorporated implementation and audit information, and there was poor reporting of processes for formulating, reviewing, and ensuring currency of recommendations and incorporating patient preferences. Intraclass correlation coefficients for agreement between raters showed high agreement (intraclass correlation coefficient > 0.80) for all guidelines except for 1 (moderate agreement; intraclass correlation coefficient = 0.76). Conclusion: Future guidelines should address identified limitations by providing implementation information and audit criteria, along with better reporting of guideline development processes and stakeholder engagement. Key words: clinical practice guidelines, cognitive rehabilitation, traumatic brain injury

Introduction Traumatic brain injury results in complex cognitive sequelae. However, clinicians have difficulty implementing the available evidence. An international group of researchers and clinicians (known as INCOG) convened to develop clinical practice guidelines for cognitive rehabilitation posttraumatic brain injury. Methods The Guidelines Adaptation and Development cycle was used to derive the recommendations. Previously published cognitive rehabilitation recommendations were identified and tabulated. An expert panel met to select appropriate recommendations. Afterward, the team enhanced the recommendations by reviewing available literature. To address shortfalls of previous guidelines, the team developed decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials and expert opinion. The team then prioritized the recommendations for implementation and developed audit criteria to evaluate adherence to best practice. Results The team recommends that individuals have detailed assessments of cognition after resolution of posttraumatic amnesia. Cognitive assessment and rehabilitation should be tailored to the patient's neuropsychological profile, premorbid cognitive characteristics, and goals for life activities and participation. Clinical algorithms and audit tools to evaluate current practice are provided. Conclusion Cognitive rehabilitation should be offered to select individuals with traumatic brain injury. These guidelines provide assistance to clinicians who want to provide evidence-based care.

INTRODUCTION Treatment of patients with traumatic brain injury (TBI) should be based upon the strongest evidence to achieve optimal patient outcomes. Given the challenges, efforts involved, and delays in uptake of evidence into practice, priorities for knowledge translation (KT) should be chosen carefully. An international workshop was convened to identify KT priorities for acute and rehabilitation care of TBI and develop KT projects addressing these priorities. METHODS An expert panel of 25 neurotrauma clinicians, researchers, and KT scientists representing 4 countries examined 66 neurotrauma research topics synthesized from 2 neurotrauma evidence resources: Evidence Based Review of Acquired Brain Injury and Global Evidence Mapping projects. The 2-day workshop combined KT theory presentations with small group activities to prioritize topics using a modified Delphi method. RESULTS Four acute care topics and 3 topics in the field of rehabilitation were identified. These were focused into 3 KT project proposals: optimization of intracranial pressure and nutrition in the first week following TBI; cognitive rehabilitation following TBI; and vocational rehabilitation following TBI. CONCLUSION Three high-priority KT projects were developed: the first combined 2 important topics in acute TBI management of intracranial pressure management and nutrition, and the other projects focused on cognitive rehabilitation and vocational rehabilitation.