Knowledge translation in ABI rehabilitation: A model for ... · ASHA’s definition of CCD’s, developed though an expert consensus panel, is as follows: Cognitive-communication

Brain Injury, March 2010; 24(3): 486–508

Knowledge translation in ABI rehabilitation: A model forconsolidating and applying the evidence forcognitive-communication interventions

SHEILA MACDONALD1 & CATHERINE WISEMAN-HAKES2

1Sheila MacDonald & Associates, Guelph, Ontario, Canada and 2Graduate Department of Rehabilitation Sciences,

University of Toronto, Toronto, ON, Canada

(Received 2 January 2009; accepted 29 November 2009)

AbstractPrimary objectives: (1) To propose a model for consolidating and disseminating existing evidence relevant to cognitive-communication interventions after ABI. (2) To present the Cognitive-Communication Intervention Review Framework(CCIRF). (3) To outline future considerations for applying evidence to clinical practice.Research design: Employment of a model for knowledge translation.Methods and procedures: Application of evidence requires synthesis and dissemination of information in an accessible formatfor end users. A literature search identified 20 systematic reviews (1997–2007) with a complex array of 72 practicerecommendations relevant to cognitive-communication interventions. The CCIRF was used to synthesize the evidencewithin 11 intervention categories. Reviews were analysed according to: organization, population, intervention, comparisonand outcome, with a focus on communication outcomes.Main outcomes and results: Consolidated evidence revealed support for interventions relating to: social communication,behavioural regulation, verbal formulation, attention, external memory aids, executive functions and communicationpartner training. Research gaps were noted in the areas of comprehension (auditory/reading), written expression andvocational communication interventions. Similar recommendations emerge across reviews.Conclusions: Implementation of the growing body of evidence for cognitive-communication interventions is challenged byvariability in study populations, interventions, and research focus on communication. The CCIRF provides a means ofpromoting consistency in knowledge translation and application.

Keywords: Communication, cognitive-communication, speech-language pathology, speech-language therapy, speech therapy,communication therapy, intervention, treatment evidence, efficacy, evidence based practice, knowledge translation, knowledge transfer

Overview

As evidence builds in the field of acquired braininjury (ABI) rehabilitation, there exists the potentialfor this knowledge to translate to improved out-comes and quality of life for individuals living withABI. However, unless this knowledge is dissemi-nated and implemented, these benefits will not berealized. Constructing an evidence base for clinicalpractice involves a number of key steps including: Asearch for individual studies, evaluation of evidence,

generation of clinical recommendations and, finally,analysis and consolidation of findings into a formatthat is accessible to the end user [1–5]. Considerableattention has been paid to the first steps in thisprocess; however, gaps continue to exist with regardto the critical final steps in constructing a clinicalevidence base [6–10]. This paper focuses on the laststep in the process: analysis and consolidation of theevidence into a format for end users, i.e. knowledgetranslation and application.

Correspondence: Sheila MacDonald, MClSc SLP(C), Sheila MacDonald & Associates, Suite 26, 5420 Hwy 6 North, Guelph, Ontario, Canada N1H 6J2.E-mail: [email protected]

ISSN 0269–9052 print/ISSN 1362–301X online � 2010 Informa Healthcare Ltd.DOI: 10.3109/02699050903518118

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Large scale reviews of intervention studies for ABIrehabilitation have concluded that there is substan-tial evidence to support rehabilitation, includinginterventions for communication and communica-tion-related disorders [11–13]. Now it is time tomove beyond the general question of whethercommunication interventions work and to examinethe specific factors that optimize clinical outcomes[11, 13, 14]. To do so, clinicians must analyse thespecific population, intervention and outcome char-acteristics within evidence reviews in order to trans-late this evidence to clinical practice.

The challenges of translating evidence for

cognitive-communication interventions

Translation of evidence for communication inter-ventions after ABI proves to be particularly challen-ging due to the heterogeneity of the population,inconsistent use of terminology, wide variety ofcommunication conditions and outcomes and ageneral lack of a specific focus on communicationwithin current reviews [15, 16]. Communicationdeficits are among the most debilitating and complexconsequences of an ABI and communication inter-ventions warrant specific attention [15–28].

Communication deficits vary with respect to typeof injury, severity, neurological presentation, cogni-tive and communication profiles. Additionally,studies vary in terms of aetiology. Some studiesinclude only participants with traumatic braininjuries (TBI) caused by external force to the head(i.e. motor vehicle crashes, falls, assaults). Otherselect cubjects from the broader category of acquiredbrain injuries (ABI) or non-congenital, non-progressive brain injuries of both traumatic andnon-traumatic origins (i.e. meningitis, encephalitis,anoxia). Some include stroke and some do not. Anadded complexity is that reviews vary in theirdescription of communication status and communi-cation outcomes. Thus, consistency in terminologyand population descriptions is required.

Cognitive-communication disorders

Cognitive communication disorders (CCD’s) are themost prevalent group of communication disordersafter ABI, with a reported incidence as high as80–100% [21, 29, 30], although estimates vary as afunction of severity, acuity and assessment measures.The term CCD’s term was initially defined by theAmerican Speech and Hearing Association(ASHA) in 1987 [31] and there has been growingconsensus in the use of this term internationally[15, 16, 19, 20, 25, 26]. ASHA’s definition of

CCD’s, developed though an expert consensuspanel, is as follows:

Cognitive-communication disorders encompass diffi-culty with any aspect of communication that isaffected by disruption of cognition. Communicationincludes listening, speaking, gesturing, reading andwriting in all domains of language (phonologic,morphologic, syntactic, semantic and pragmatic).Cognition includes cognitive processes and systems(e.g. attention, memory, organization, executivefunctions). Areas of function affected by cognitiveimpairments include behavioural self-regulation,social interaction, activities of daily living, learningand academic performance and vocational perfor-mance ([32] p. 2).

CCD’s are unique from motor speech and specificlanguage impairments as they result from general-ized cognitive and self-regulatory disturbance[17, 33–38]. CCD’s have the greatest impact oncommunication at the level of discourse and socialexchange as opposed to speech sounds and words[24, 39–43]. CCD’s can have a negative impactacross the continuum of recovery. Impaired com-munication can affect the rehabilitation process,social re-integration, community independence,family interactions, successful employment and aca-demic success [15–18, 34–37, 43–46]. Interventionsthat address cognitive-communication disorderscan help to improve outcomes and quality-of-life[12, 13, 18, 47, 48].

Research has identified the following cognitive-communication disorders among individuals withABI: impoverished, vague, tangential or disorganizeddiscourse (oral or written) [49–51] impaired com-prehension in the presence of length, complexity,detail, indirect content (implied, abstract, figurative,humourous), background noise, multiple speakers,rapid presentation or rapid shifts from topic to topic[52, 53]; word finding problems particularly inconversation or generative contexts [54, 55], prag-matic or social communication difficulties includingproblems related to initiation, turn taking, topicmanagement, conversational repair, self-monitoring,social perception and adapting to the needs of theconversational partner and context [17, 56–58] anddifficulties using language or communication to assistmemory and new learning [59]. Thus, the main focusof intervention is on maximizing functional commu-nication, including improving the understanding andcompetence of communication partners, in contextsthat are most relevant to the individual with ABI.Recently, improved consistency in approach andterminology for cognitive-communication evidence-based practice research has been emerging in thepublications of the Evidence Based PracticeCommittee of the Academy of Neurological

Cognitive-communication interventions: Evidence 487

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Communication Disorders (ANCDS), in conjunc-tion with the American Hearing Association (ASHA)[23, 26, 60–62].

Further challenges: Determining ‘best

evidence’

The next challenge in reviewing the evidence forcognitive-communication interventions is to deter-mine what constitutes ‘best evidence’. With well over300 studies of communication interventions afterABI [11] there is a sizeable body of evidence toreview. Systematic reviews (SR’s) and meta-analysesare a helpful resource for end users as they evaluatemultiple individual studies according to explicitprocedures and recommend practice standards,guidelines and options according to pre-definedcriteria based on levels of evidence [5]. Despite thecompelling evidence these reviews can provide, thereis still much for the end user to consider wheninterpreting their recommendations [14, 63]. Thisstudy identified over 72 practice recommendationsin an initial analysis of systematic reviews relevant toCCD’s and noted significant variance among SR’swith respect to scope, inclusion and exclusioncriteria, key search terms and ratings of the evidence.Some SR’s reviewed a broad range of multidisci-plinary interventions across the rehabilitation con-tinuum whereas others reviewed specific types ofinterventions. Some included only randomized con-trolled trials while others included studies with singlesubject designs. Outcome measures varied markedlywith over 90 indicators of outcome reported in oneSR [64]. SR’s also varied considerably in theirinclusion of participant cognitive and communica-tion profiles. These varied approaches call for an‘evidence road map’ to assist end users in integratingand applying the evidence. Thus, this paper presentsa model for the exploration, integration and clinicalapplication of evidence relating to cognitive-communication interventions.

Purpose of the study

This paper has four objectives:

(1) To provide a model for analysing the full scopeof cognitive-communication interventions fol-lowing ABI.

(2) To consolidate the existing evidence for cogni-tive and communication interventions availablein systematic reviews and meta-analyses for thepurpose of translation to clinical practice incognitive-communication interventions.

(3) To provide clinicians with a set of factors toconsider when weighing the evidence for cogni-tive-communication interventions.

(4) To provide recommendations for futureresearch and knowledge uptake; the translationof evidence into clinical practice.

The purpose of the study was not to conduct anew systematic review but rather to provide acomprehensive model for extracting, from existingreviews, knowledge that can be applied to cognitive-communication interventions. Currently there areno systematic reviews specific to cognitive-communication interventions published in thepeer-reviewed literature. This paper is an attemptto direct clinicians to the best evidence currentlyavailable regarding both communication and cogni-tive interventions that have some relevance tocognitive-communication interventions after ABI.It is hoped that the proposed framework and processfor knowledge translation will prompt further dis-cussion and research to address gaps in theliterature.

Method

Defining the search terms

The first step in searching for evidence relating tocognitive-communication interventions was todefine a set of key search terms. This was importantas cognitive-communication interventions encom-pass a wide variety of treatment domains andapproaches with a vast array of terminology thathas been used inconsistently among researchers andreviewers. Many reviews either do not includecommunication among their key search terms orthey use terms limited to one particular aspect ofcommunication (i.e. ‘speech’ and ‘language’).Significant limitations in evidence-based reviewscan occur when a limited set of key words areutilized in the initial search for evidence. Therefore,a critical first step is to identify keywords, synonyms,and related terms, based on the conceptual frame-work underlying the research question [65]

To meet the need for consistency in consolidationand translation of the evidence, the Cognitive-Communication Intervention Review Framework(CCIRF) was developed. The CCIRF frameworkidentifies 11 intervention categories as well as asso-

ciated key words to be used in the evidence search.These were based on a review of the literature incognitive-communication assessment and treatment,position statements and practice guidelines withinthe field of speech-language pathology [31, 32, 66,67] and the PsycBITE database [68]. This study alsoutilized an expert panel review including four

488 S. MacDonald & C. Wiseman-Hakes

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speech-language pathologists with expertise incognitive-communication intervention and researchwho reviewed the terms. The CCIRF is presented inTable I. The key words were then used in theliterature search which will be described below.

Search strategy

A search for all systematic reviews pertaining tocommunication and cognitive interventions in ABIpublished between 1997–2007 was then conductedusing the following search engines: Medline,PubMed, Scholars Portal, Google Scholar. As it ispossible to miss publications in specific speech-language pathology journals when a single searchengine is used, the authors also conducted manual,table-of-contents searches of specific speech-language pathology journals.

Five online resources were also used for thesearch. First, PsycBITE (www.psycBITE.com) is aweb resource designed by researchers in Australiawhich lists over 1298 intervention studies in the fieldof ABI by subject area [11]. Secondly, the website ofthe Academy of Neurological CommunicationDisorders (ANCDS) (www.ancds.org) [69] sum-marizes all of the systematic reviews and meta-analyses conducted by it’s evidence-based practicecommittee, as described by Golper et al. [5]. Next,the American Speech and Hearing Association’swebsite (www.asha.org) [70] lists systematic reviewsrelated to communication interventions. Next, aCanadian review of acquired brain injury interven-tions is entitled the Acquired Brain Injury EvidenceBased Review (www.abiebr.com) [71] and theirwebsite summarizes the systematic reviews of thatgroup. Finally, the website for the CochraneCollaboration (www.cochrane.org) [72], an interna-tional not-for-profit organization which promotesthe accessibility of systematic reviews of the effects ofhealth care interventions, was searched forcommunication-related interventions. Many of thesystematic reviews posted on these websites arepublished in peer reviewed journals, whereas othersare in various stages of submission.

Inclusion and exclusion criteria. This study includedsystematic reviews relevant to cognitive-communication interventions from these websiteswhether they were published in peer reviewedjournals or not. The rationale for inclusion of someof these non-peer reviewed systematic reviews was3-fold: (1) There were few relevant SR’s to includeat this early stage of EBP and it was felt that analysisof contrasting approaches to SR’s would be illumi-nating; (2) Some of the SR’s published online mayultimately be published in peer reviewed journals;and (3) Third party payer decisions to fund or not

fund interventions are sometimes based on on-lineSR’s that have not yet undergone peer reviewscrutiny.

Systematic reviews were included if they met thefollowing inclusion criteria:

. Focused on ABI or TBI in the populationdescription;

. Systematically reviewed intervention studies (anyage group or severity level); and

. Included interventions relating to any of thekey words in the Cognitive-CommunicationIntervention Review Framework (CCIRF).

Exclusion criteria were studies that were:

. Not systematic reviews;

. Did not include ABI or TBI in the populationdescription;

. Were not available in the English language;

. Were published outside of the study period1997–2007,

. Included interventions that did not relate to thecommunication key words listed in the CCRIF(i.e. ADL interventions, driving interventions,etc.); and

. Were focused on pharmaceutical interventions.

Four reviewers, speech-language pathologists withrelevant expertise (i.e. familiarity with evidence-based practice in cognitive-communicationinterventions following ABI) were asked to reviewthe reviews for a determination of inclusion/exclu-sion, review the CCIRF framework and add missingreviews. There was 100% inter-rater reliability withregard to inclusion/exclusion. All reviewers also readeach paper included in the reviews. Key findings andrecommendations from each of the systematicreviews were summarized under the main interven-tion headings established in the CCIRF. Practicestandards, guidelines and options were noted whereavailable.

Consolidation of findings into an accessible format

To ensure all of the considerations previously dis-cussed were addressed, the systematic reviewswere summarized according to the followingparameters: Organization; Population; Intervention;Comparison; Outcome. This is an expanded versionof the commonly used PICO format for framingevidence review questions that was proposed bySackett et al. [1] and is recommended by ASHA[73]. The initial ‘O’ is added here and represents theOrganization of the SR, including the focus or scopeof the topic (e.g. community reintegration, cognition)and whether there was expert panel review.Population characteristics such as number of sub-jects, aetiology and age of the participants were noted.


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Interventions were summarized by listing the keysearch terms or intervention categories as describedin the SR. Comparison referred to inclusion/exclusion criteria and the number of studies reviewed

and whether a meta-analysis was conducted. Finally,the SR’s were analysed with regard to outcomemeasures, particularly inclusion of communicationevaluations as an outcome measure and whether

Table I. Cognitive-communication intervention review framework (CCIRF).

Type of intervention Definition Key words

Communication interventions

1. Social communication Treatments that target discourse, pragmatics, conversation, social com-munication, non-verbal communications (eye contact, facial expres-sion, proxemics or personal space, gesture) social perception (theory ofmind, listener’s perspective etc.). Interventions which targetself-regulation or regulation of communication behaviours.

� Discourse� Pragmatics� Social communication/

Social cognition� Social perception� Listener perspective� Theory of mind� Self-regulation

2. Verbal expression Treatments that target verbal expression, word retrieval, word finding,vocabulary, language expression, syntax or sentence formulation.

� Word finding� Word retrieval� Naming� Language formulation� Verbal expression� Sentence formulation

3. Auditory or listeningcomprehension

Interventions for auditory comprehension, auditory processing or under-standing of spoken messages, receptive language. Studies that involvecomprehension of specific types of messages (i.e. humour, inferencing,figurative language, multiple meaning words).

� Auditory comprehension� Listening comprehension� Receptive language� Auditory processing� Inferencing� Figurative language

4. Reading comprehension Interventions for reading, oral reading, reading comprehension, inter-pretation of text.

� Reading comprehension� Visual processing� Oral reading

5. Written expression Interventions targeting written expression, written formulation, spelling,functional writing of messages, note-taking or alternative means ofwriting messages.

� Written expression� Written discourse� Written formulation

Cognitive interventions to improve communication

6. Attention Interventions targeting attention in order to improve aspects of commu-nication such as listening, focusing on group discussions, reading, etc.

� Attention� Speed of information

processing� Multi-tasking

7. Memory Interventions that focus on use of external memory aids. Studies thatfocus on internal memory strategies.

� Memory� Remembering� Recall/Retention� New Learning

8. Organization, Reasoning,Problem-Solving,

Executive Functions/Metacognition &Self-regulation

Interventions that target organization, reasoning, problem-solving, exec-utive functions, metacognition or self-regulation in order to improvecommunication performance.

� Organization� Reasoning� Problem-solving� Executive Functions� Meta-cognitive� Self-regulation

Communication interventions at the level of participation

9. Community & FamilyCommunications

Provision of strategies to significant others or communication partners inorder to enhance communications.

� Communityreintegration� Community

communications� Family interaction� Partner training

10. Academic and SchoolSupports

Studies targeting academic and school performance (language, newlearning, academic communications), including interventions focusingon the supports provided by educational staff.

� Academic� School� Study strategies

11. VocationalCommunications

Studies targeting communications for work, including interventionsfocused on the supports provided by work place staff.

� Vocationalcommunications� Employment� Return to work


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outcomes were analysed in terms ofImpairment/Activity Limitations or ParticipationRestrictions [74].

Results

Twenty systematic reviews published between 1997–2007 were identified, each involving participantswith ABI that included interventions related tocommunication or cognition as defined in theCCRIF [12, 13, 34, 60, 61, 64, 75–88]. Two ofthe reviews, initially reviewed on the ANCDSwebsite prior to 2007, were later published in peerreviewed journals in 2008. One systematic review,published in a book chapter [86], was identified as itwas described in another review. The decision toinclude this review was based on the fact that it metthe inclusion criteria, was specific to social commu-nication interventions for ABI and could informclinical practice. The 20 systematic reviews aresummarized in Table II.

Overall findings

Organization and scope of reviews.

. Only two of the reviews had communicationinterventions as a primary focus. This is a reflec-tion of the literature at its current state ofevolution. The Struchen [86] review focusedspecifically on social communication andreviewed 19 social communication interventionstudies. The review by Welch-West et al. [88]analysed communication interventions broadlywithout inclusion of cognitive interventions andincluded a total of 20 studies. The main focus ofthe remaining 18 reviews is as follows: multi-disciplinary cognitive rehabilitation (five reviews);paediatric interventions (three reviews); commu-nity re-integration (one review); attention (tworeviews); instructional techniques (two reviews);memory (two reviews) behavioural interventions(two reviews); and meta-cognitive and executivefunctions (one review). Systematic reviews arerequired that include studies with communicationmeasures to evaluate their outcomes. However, asone awaits further reviews specific to cognitive-communication interventions it is both reasonableand important to turn to systematic reviews forcognitive interventions and communication inter-ventions to inform clinical practice and as a basisfor further investigation.

. The systematic reviews varied in terms of expertreview which is believed to be an importantconsideration and one which has a direct impacton the quality and merit of the review. Fourteen ofthe systematic reviews had undergone peer review

for publication in scientific journals at the time ofwriting, whereas five [79–81, 83, 87, 88] wereavailable online and one in a book chapter [86].Only nine of the studies indicated that theyutilized an expert review process to advise on thereview format, key word search terms, definitions,diagnostic categories, intervention categories orratings for outcome measures. For example, thereviews of the Academy of NeurologicalCommunication Disorders (ANCDS) evidence-based practice committee were conducted byteams of three-to-eight speech-language patholo-gists at the doctorate level who are experts in thefield of cognitive-communication disorders andalso benefited from the expertise of externalreview panels [34, 60, 61, 84, 85]. The use ofan expert review panel acknowledges that clinicalexpertise is required for interpretation of clinicalindicators, measurement of current status andanalysis of outcome [5]. Although end users suchas clinicians and researchers will likely make thedistinction between reviews that have undergonepeer review and expert panel review and those thathave not, funding sources may not be so discern-ing. The hope here is that knowledge translationwill evolve to a point where end users make suchdistinctions and where intervention will be guidedby SR’s of the highest quality (i.e. expert panelreview, defined terms for search strategy, metaanalysis, peer review).

. Only three of the reviews included a meta-analysisto measure treatment effects across studies: thereview of executive functioning by Kennedy et al.[61], the review of attention interventions by Parkand Engles [82] and the review of memoryinterventions by Kessels and DeHaan [77].Factors such as inclusion of meta-analysis and/orexpert panel involvement should be taken intoconsideration when weighing the evidence.

Participant or population characteristics.

Participant characteristics varied among reviews interms of medical diagnosis (ABI, TBI, stroke), timepost-injury, severity and age (paediatric vs adult), ascan be seen in Table II, Few of the systematicreviews listed communication features as part oftheir analysis of study participants. Although cogni-tive status of research participants is usually detailed,it is less common (although desirable) for commu-nication profiles such as comprehension and dis-course performance measures to be included inparticipant descriptors. The systematic reviews con-ducted by the Academy of NeurologicalCommunication Disorders (ANCDS) present anincreased level of specificity with regard to thedescription of baseline and post-intervention


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38

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tici

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term

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med

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ou

tcom

es


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in I

nj D

ownl

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om in

form

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y U

nive

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onto

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r pe

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CD

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ract

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mu

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edy

etal

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008)*

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NC

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AN

CD

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rven

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om

mu

nic

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est

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lsan

dd

eH

aan

(2003);

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her

lan

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27

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gin

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rven

-ti

on

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ith

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airm

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ivit

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mu

nic

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chet

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edia

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atm

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tten

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itiv

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2;

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4

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airm

ent/

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ivit

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mu

nic

atio

n:

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ipp

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etal

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007);

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ada;

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mu

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mu

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10

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al.

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ada;

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on

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007);

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mu

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adto

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esu

ffic

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td

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lfo

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fect

size

esti

mat

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com

pu

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anal

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dir

ect

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on

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spec

ific

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die

s

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pai

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tici

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o�

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mu

nic

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ily.

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wst

ud

ies

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sure

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rati

ng

of

mood

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ress

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x-ie

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ven

tori

es.

Su

bje

ctiv

era

tin

gsof

atte

nti

on

by

par

tici

pan

tan

dob

serv

ers

wer

eu

sed

on

som

e.

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set

al.

(2007);

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ada;

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IEB

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avio

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–�

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I�

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inte

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sic

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17

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die

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pai

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ctiv

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tici

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:N

o�

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mu

nic

atio

n:

No


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in I

nj D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y U

nive

rsity

of

Tor

onto

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r pe

rson

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se o

nly.

14

Soh

lber

get

al.

(2003);

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A;

AN

CD

S

Att

enti

on

p�

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ult

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ever

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n¼

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tota

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word

s�

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enti

on

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emed

iati

on

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ehab

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inin

g�

Bra

inIn

jury

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lose

dh

ead

inju

ry

9�

Imp

airm

ent/

Act

ivit

y/P

arti

cip

atio

n:

Yes

�C

om

mu

nic

atio

n:

No

15

Soh

lber

get

al.

(2005);

US

A;

AN

CD

S

Inst

ruct

ion

alte

chn

iqu

es–

�R

evie

wed

inst

ruct

ion

stu

die

sof

seve

ral

pop

u-

lati

on

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ecia

led

uca

-ti

on

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emen

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sch

izop

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nia

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BI

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evie

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ratu

re�

n¼

not

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ed

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tIn

stru

ctio

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ateg

yb

ased

inst

ruct

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pac

edre

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val

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rrorl

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g

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du

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on

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stu

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sT

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30

stu

die

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pai

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t/A

ctiv

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tici

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o�

Com

mu

nic

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16

Soh

lber

get

al.

(2007)

Mem

ory

:E

xter

nal

Aid

s

p�

AB

I�

All

ages

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veri

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267

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ajori

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tici

pan

tsw

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adu

ltm

ales

inch

ron

icst

age

post

-in

jury

Mem

ory

note

book

(9)

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age

(1)

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word

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Tra

um

atic

bra

inin

jury

�C

lose

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ead

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uir

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rain

inju

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Mem

ory

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terv

enti

on

/th

erap

y/re

med

ia-

tion

/reh

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atio

n

19

Imp

airm

ent/

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ivit

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arti

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esO

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ed:

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edm

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Fre

qu

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pan

tp

refe

ren

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om

mu

nic

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17

Str

uch

an(2

005);

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AS

oci

alco

mm

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I�

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ages

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mm

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od

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19

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mu

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18

Tu

rner

-Sto

kes

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.(2

005);

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ran

e

Mu

lti-

dis

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du

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5�

n¼

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ult

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reh

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14

RC

T’s

Qu

asi

Ran

dom

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and

Qu

asi

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pro

vid

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met

pre

def

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pai

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o�

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mu

nic

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tinued

)


Bra

in I

nj D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y U

nive

rsity

of

Tor

onto

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r pe

rson

al u

se o

nly.

Tab

leII

.C

on

tin

ued

.

Syst

em

ati

crevie

w

(Au

thors

,Y

ear,

Cou

ntr

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Co

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mu

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19

Wel

chW

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007);

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ada;

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mu

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du

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pai

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mu

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20

Ylv

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communication status of study participants. In orderfor speech-language pathologists to apply evidenceto treatment of individuals, they will need to beprovided with clear descriptions of the communica-tion profiles of study participants.

Levels of evidence.

. The reviews also varied with regard to the level ofevidence included; One out of 20 systematicreviews of cognitive and communication interven-tions limited inclusion to randomized control trialsor quasi randomized experimental designs; five ofthe 20 included primarily group studies; and 14/20included all types of research design, includingsingle-subject design. There was general agree-ment across systematic reviews that RCT studiesare few in ABI research. This observation isconsistent across all areas of rehabilitation asevidenced by Perdices et al.’s [11] review of 1298ABI intervention studies wherein the largest pro-portion of studies were single-subject design(39%), followed by case series (22%), randomizedcontrol trials (21%), non-randomized control trials(11%) and systematic reviews (7%). Among thedifficulties identified with RCT’s were: heteroge-neity of the ABI population requiring individua-lized treatment approaches; averaged group resultsmasking individual treatment effects; ethical andpractical obstacles to randomization and establish-ment of control conditions; and the need formeasurement of real life or contextually-basedoutcomes that are more challenging to measurethan clinic-based measures or standardize tests[85, 86]. A compelling rationale for inclusion ofsingle-subject design studies was provided in manysystematic reviews [34, 76, 85]. Single-subjectdesign studies can be made more rigorous byincluding multiple baselines across subjects andbehaviours, randomization of the order of activetreatment phases and effect sizes [11, 89]. Awell-designed single-subject experiment offers thebest evidence that an intervention has worked foran individual patient and can be used to support asimilar intervention for patients who closely resem-ble the studied patient [27]. Furthermore,single-subject design may be the most appropriatedesign to investigate interventions in earlier phasesto build support for proceeding to group trials [89].In conclusion, research designs other than RCT’s,such as case series and single-subject design maybe better suited to the challenges of evaluating thecomplexities of ABI intervention.

. Some well-designed RCT’s have emerged tosupport social communication interventions[18, 48], yes/no communication intervention incoma or minimally responsive states [90],

communication partner training [47] and family-focused interventions [91] for individualswith ABI.

Outcome measures.

There was a consistent call across the reviews toreport measurement of outcomes in daily function-ing. Ten of the 20 included some analysis ofoutcome in terms of impairment, activity and/orparticipation measures and these were primarily theANCDS reviews. Communication outcomes werenot initially specified in ABI intervention research;however, there has been an increased focus oncommunication outcomes in recent systematicreviews. Nine out of 20 SR’s presented outcomesspecific to communication. Future evidence-basedpractice research will be most relevant to clinicalpractice in speech-language pathology if it provides:(i) analysis of communication outcomes; (ii) analysisof outcomes at the level of activity and participationin the real world and (iii) consistency in outcomemarkers to better equate the effects of interventionsacross studies [34, 51, 60, 61, 64, 82, 85, 86].

Evidence for cognitive and communication

interventions

All 20 systematic reviews provided evidence tosupport the effectiveness of a variety of communica-tion and cognitive interventions. To date theresearch of cognitive and communication interven-tions appears to be in parallel rather than integrated.That is, there are communication interventionstudies demonstrating improved communicationfunctioning and cognitive intervention studiesdemonstrating improved cognitive functioning, butthere has not yet been a systematic review todemonstrate the relative impact of interventions forone on the other.

In the next section the results of each of thereviews will be analysed according to the previouslydescribed Cognitive-Communication InterventionReview Framework in an attempt to determinewhich types of cognitive-communication interven-tions work for which types of participants underwhat conditions, and for what functional, real-lifeoutcomes.

Social communication and behavioural/self-

regulation. Social communication interventions fol-lowing ABI have taken many forms, as indicated inthe key word list in Table I. The approach to socialcommunication interventions is evolving withincreased awareness of the impact of frontal lobeimpairment on social competence including: impul-sivity, initiation, disinhibition, social imperceptions


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and impaired ability to learn from consequences[17–19, 27, 28, 34]. Initial efforts to improve socialcommunication applied a social skills trainingapproach (SST). According to Ylvisaker et al.([27], p. 261) the SST approach, ‘assumed that theidentified individuals: lacked knowledge of relevantsocial rules; were motivated to change their socialbehaviour and possessed the capacity to transfer skillsacquired in a decontextualized training setting tovaried real world environments’. For those with ABI,the problem is not a lack of social skills knowledgebut rather with self-regulation, self-awareness andsocial perception. Instead of focusing on training ofsocial skills knowledge, current practice tends tofocus on training of self-control strategies andopportunities for guided communication practice inthe real world [27, 28, 36–38].

There were eight systematic reviews that pre-sented evidence and recommendations related tointerventions for social communication. Only onereview had a primary focus on social communication[86]. One review summarized communication inter-ventions in general [88], one focused on paediatricinterventions [90], three focused on cognitive inter-ventions [12, 13, 80] and two focused on beha-vioural interventions [34, 83].

Carney et al. [64, 75] conducted two of theearliest systematic reviews in 1999, examining a totalof 32 cognitive intervention studies for adults [64]and 88 cognitive intervention studies for children[75]. Neither of these studies addressed socialcommunication specifically. However, the review ofadult interventions concluded that, based on tworandomized controlled trials and one observationalstudy, there was evidence to support specific formsof cognitive rehabilitation to reduce memory failuresand anxiety and improve self-concept and inter-personal relationships for persons with TBI. Theauthors recommended improved operational defini-tion, consistency in describing interventions andfunctional outcome measures to further evidenceresearch.

Cicerone et al. [12, 13] analysed aspects of socialcommunication interventions within two multidisci-plinary reviews of cognitive rehabilitation conductedby the Brain Injury Interdisciplinary Special InterestGroup of the American Congress of RehabilitationMedicine. The first review in 2001 [12] examined171 studies of cognitive interventions including‘language’ interventions and their 2005 review [13]examined an additional 81 studies including ‘lan-guage and communication interventions’. Thesereviews classified the evidence according topre-defined criteria and formulated practice stan-dards, guidelines and options according to a set ofdecision rules. All practice recommendations werereviewed by the expert panel to ensure consensus.

The 2005 review recommended, as a practicestandard, specific interventions for functional com-munication deficits including pragmatic conversa-tion skills [13].

Welch-West et al. [88] review focused specificallyon communication interventions and included 20studies. This was part of a larger Canadian evidencereview called the Evidence Review of Acquired BrainInjury (ERABI). The ERABI reviewed interventionsfor moderate-to-severe ABI and two reviewers ratedthe evidence according to pre-defined criteria. Thiscommunication review was presented online and hadnot had the benefit of peer review for publication orexpert panel review to advise on search key terms.The communication module included 20 interven-tion studies. The key search terms focused predo-minantly on motor speech and augmentativecommunication for individuals with minimal verbaloutput. The review identified five studies relating tosocial communication interventions and, based onthese, concluded that training in social skills, socialcommunication or pragmatics is effective in improv-ing communication following brain injury.McCormick et al. [81] conducted a review ofpaediatric interventions as part of the ERABIreview and concluded that pragmatic skills trainingmay help to improve communication in children, butmore research is required.

The review by Struchen [86] focused more specif-ically on social communication interventions foradults with TBI and identified 19 studies that metinclusion criteria. Struchen reviewed the method-ological weaknesses among the various studies,pointing out that only one of 19 provided Class 1evidence from an RCT; while five of 19 werenon-RCT group studies and 13/19 were case seriesincluding single-subject design. Struchen concludedthat social communication interventions could beconsidered evidence-based, but advised that morecaution is required before formulating practicerecommendations with these data. Behavioural inter-ventions are included in this section due to theintegral nature of behavioural self-regulation andsocial communication [27]. Cognitive, social andbehavioural dimensions of disability are within thescope of speech-language pathology practice as aresult of their impact on communicative competence[27, 33, 34]. The evidence from three systematicreviews of behavioural interventions indicates thatsocially unsuccessful behaviours can be decreased ina variety of types of interventions. Based on a reviewof 65 studies with 171 participants, Cicerone et al.[12] concluded that there was sufficient evidence torecommend behavioural intervention in general forboth children and adults as a practice guideline inboth the acute and post-acute stages of recovery.Rees et al. [83] conducted a review of behavioural


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interventions as part of the ERABI evidence reviewsand concluded that there was sufficient evidence tosupport the use of antecedent management, feedbackor consequences, anger management and social skillstraining to reduce undesirable or aggressive beha-viours. Ylvisaker et al.’s [34] review of 65 studiesincluding 172 participants (adults and children)concluded that behavioural interventions should beconsidered a practice guideline. The review revealedan increasing trend toward the positive behaviouralsupports approach which focuses on control ofantecedents, positive daily routines and increasedchoice and control and positive communications.However, there was not sufficient evidence torecommend one form of behavioural interventionover another. Maintenance and transfer of positivecommunication behaviours to real world commu-nications appears to require a treatment focus on self-regulation [34].

Finally, an important area of social communica-tion intervention that has received inadequate atten-tion is social perception. Individuals with ABI havebeen found to be significantly impaired in terms ofthe ability to read social cues accurately and conductsocial problem-solving [38, 48]. There is now at leastone well controlled RCT investigating interventionmethods for social perception [48]. Use of a consis-tent framework such as the CCIRF may result inincreased consideration of previously ignored areasof social communication intervention.

Overall the evidence supports the use of socialcommunication interventions; however, it indicatesthat more evidence is required to recommendspecific forms of social communication intervention[12, 13, 34, 86, 88]. Evidence to date suggests thatsocial communication interventions are most likelyto be effective when they are: individualized, con-textualized, involve practice in real world commu-nications, focus on self regulation or meta-cognitiveapproaches and incorporate provision of naturalfeedback, videotaping self-monitoring. An RCT byDahlberg et al. [18], published since these system-atic reviews, utilized similar techniques and addsfurther support to these approaches to social com-munication [69].

Verbal expression. Verbal expression interventionsinclude treatments that target word retrieval, vocab-ulary, language expression or sentence formulation.Interventions of this type have been widely studied ina number of populations. Three systematic reviewswere identified that included review of languageexpression interventions for ABI [12, 13, 78]. Thereviews by Cicerone et al. [12, 13] reviewedlanguage interventions for adults, after ABI, includ-ing stroke. The 2000 review concluded that there

was sufficient evidence from two well-controlledprospective (Class I) studies to support the use ofintervention for language formulation following TBI.The 2005 review analysed sufficient evidence torecommend as a practice standard ‘cognitive-linguistic therapies’ during acute and post-acuterehabilitation for persons with language deficits dueto left hemisphere stroke. Interventions for specificlanguage impairments such as language formulationdifficulties after TBI were recommended as a prac-tice guideline. Specifically, Cicerone et al. concludedthere is evidence supporting the use of cueingtechniques and semantic analysis to improvenaming ability by people with aphasia and TBI(traumatic brain injury). However, there was noevidence to indicate that one method is moreeffective than another [13]. Laatsch et al. [78]conducted a systematic review of paediatric inter-ventions which reviewed 28 studies involving a totalof 366 participants. Although their review revealedClass II–IV paediatric studies that showed positivetrends toward effectiveness of language and prag-matic interventions, there was insufficient evidenceto form practice standards or guidelines.

Overall there is general support for interventionsto assist verbal expression or language formulationafter ABI in adults. Further research is required todelineate the most effective methods from a range oflanguage formulation and word retrieval techniques.Although there was insufficient evidence to formpractice guidelines for children with ABI, there is awell established body of evidence for languageinterventions among children with a variety ofaetiologies [92]. Also, there is an established bodyof evidence for language interventions for adults withaphasia or language deficits due to stroke [12, 13,93–95]. Converging evidence in the aphasia and ABIliterature suggests that ‘active ingredients’ in lan-guage interventions include individualized goal-setting, context-sensitive intervention, opportunitiesfor practice in daily communications and communi-cation partner training [18, 34, 47, 61, 84, 86, 91,94–97]. These would be reasonable components tolanguage intervention as one awaits more definitivestudies providing evidence to support specifictechniques for individuals with ABI.

Auditory comprehension and information

processing. Auditory comprehension was an area ofintervention that was significantly under-representedin the systematic reviews for ABI. None of thereviews discussed studies of auditory comprehensionor information processing from the perspective oflanguage comprehension. As will be discussed infuture sections, there are several reviews thatapproached information processing, but from the


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perspective of attention and memory interventions.Until research is available for the ABI population,clinicians will need to infer from research of auditorycomprehension interventions for other populationssuch as stroke or learning disability. It is possible thatcomprehension interventions have not beenreviewed separately, but rather incorporated withininterventions targeting improved activity or partici-pation level communications. For example, inter-ventions directed at improving socialcommunication, academic success or vocationalsuccess may have focused on aspects of comprehen-sion or as part of a global set of treatment goals (i.e.understanding telephone conversations; comprehen-sion of the language of instruction; followingdirections at work, etc.). Evaluation of interventiontechniques for auditory comprehension and infor-mation processing after ABI is an important area forfuture research.

Reading comprehension. Two systematic reviewsprovided recommendations specific to interventionsfor reading comprehension after ABI. The review byCicerone et al. [12] analysed evidence from twowell-controlled prospective (Class 1) studies tosupport the use of intervention for specific areas oflanguage impairment including reading comprehen-sion after TBI to form a practice guideline. Theirreview in 2005 [13], which added to the earlierevidence, also formulated a practice guideline forinterventions for specific language impairments suchas reading comprehension after left hemispherestroke or TBI. As with the other areas of cognitive-communication intervention, the evidence for read-ing comprehension treatment is broadly supportivebut requires more specific details for practicingclinicians. Recommendations for specific readinginterventions after ABI, including reading interven-tions for primary school students, reading interven-tions for the college curriculum and readingassistance for vocational purposes, would bebeneficial.

While awaiting more specific recommendationsfor those with ABI, clinicians may turn to evidencefrom similar populations. It may be that cognitive(i.e. attention deficits; visual scanning deficits) orcommunication factors (vocabulary deficits) aremore important than factors relating to aetiology(ABI, learning disability, cerebral palsy, etc.). Asystematic review that reviews trends across readinginterventions for a number of populations could bemore beneficial than a narrow focus on readingevidence for the ABI population alone. For example,a review of the National Reading Panel [98] in theUS identified 205 experimental studies of readingcomprehension instruction, yielding 16 kinds of

effective procedures, several of which are supportedby firm scientific evidence. Validated strategiesincluded the following: comprehension monitoring,co-operative learning, graphic and semantic organi-zers, story structure and story maps, questionanswering, question generation and summarizing.The panel emphasized the importance of activeinvolvement of learners, natural learning or readingcontexts and flexible use of a number of strategiesintegrated into the curriculum. Additional researchis required to investigate beneficial components ofinterventions for reading comprehension after ABI.

Written expression. Current systematic reviews ofABI interventions tend not to identify a specificcategory for interventions relating to written expres-sion. Key search terms specific to written expressionor written formulation need to be utilized in orderfor reviewers to capture these studies. The tworeviews by Cicerone et al. [12, 13] were the onlyreviews that provided recommendations relating tospecific language interventions; however, they didnot specifically describe written expression. Untilreviews of written expression interventions for ABIare available, clinicians would benefit from reviewingthe evidence from similar populations. Glang et al.[45] summarized evidence from over 36 studies,including the results of a meta analysis, that supportthe use of self-regulated strategy development anduse of advance organizers to assist individuals withwritten expression and other learning needs. Thesefindings may promote additional analysis of writtenexpression interventions for those with ABI.

Attention. Although the relationship between atten-tion deficits and communication impairment is wellunderstood clinically, the impact of attention inter-ventions on communication after ABI has yet to beexplored scientifically. A first step in understandingthe potential effects of attention training on commu-nication is to review the evidence for attentiontraining as a whole. To this end, interventions forattention were evaluated in two systematic reviewsthat focused specifically on attention [60, 82], as wellas three general reviews of cognitive rehabilitation[12, 13, 80]. Park and Ingles’ [82] 2001 reviewincluded a meta analysis to measure the efficacy ofattention interventions across 30 studies with a totalof 359 participants. They concluded that there wasnot strong evidence for attention training throughrepetitive drill exercises. There was some support forthe specific skill approach that focuses on training ofspecific skills of functional significance (i.e. driving).The systematic review by Sohlberg et al. [60]considered the findings of Park and Ingles and thenreviewed an additional nine studies of interventions


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for attention involving 208 participants. This reviewalso attempted to sort through the heterogeneitywithin the studies by analysing nine participantcharacteristics; six intervention characteristics, twooutcome characteristics and three aspects of studydesign. They concluded that direct attention trainingcould be considered a practice guideline for use withindividuals in the post-acute stage who are mildlyinjured and have intact vigilance. Further theyadvised that direct attention training is best providedin an individualized manner in conjunction withmeta-cognitive training (feedback, self-monitoring,strategy training, self-reflective logs and anticipation/prediction activities).

The main themes emerging from these reviews arethat intervention for attention is best begun in thepost-acute stage of intervention, utilizing an indivi-dualized approach, within contextualized or func-tional tasks, with inherent training of strategies ormeta-cognitive approaches, varying levels of com-plexity, and with measurement of functional, gen-eralizable outcomes. Computer training forattention, particularly without clinician support orfunctional targets, appears not to be supported bythe reviews.

Although none of the reviews of attention trainingexplored the impact of attention interventions oncommunication specifically, these themes provide agood basis for future research of the impact ofattention remediation on communication. Thesereviews indicate that attention is best trained in thecontext of functional, complex tasks that requiredregulation of attention. Communication is a func-tional complex task. A reasonable approach based onthese reviews could be to train attention usingmeta-cognitive strategies and to utilize functionalcommunication indicators as outcome measures (i.e.eye contact, conversational response times and notetaking accuracy). Future research exploring theimpact of cognitive interventions on functionalcommunication would be beneficial.

Memory and new learning. There were three sys-tematic reviews of memory interventions after ABI[76, 77, 84]. In addition, memory interventions werereviewed as part of three broad reviews of cognitiveinterventions [12, 13, 80]. Sohlberg et al. [85], aspart of the ANCDS evidence-based practice reviews,conducted a systematic review of 19 studies relatingto use of external memory aids and concluded thatthere was sufficient evidence to recommend externalmemory aid use as a practice guideline. Marshallet al. [80], as part of the ERABI project, conducted asystematic review of cognitive interventions andidentified 26 studies involving the use of externalmemory aids. Nineteen of these 26 studies reported

improvements in everyday memory functioning(fewer memory problems on self-report, increasedsuccess in achieving their self-selected target beha-viours, successful task achievement, decreasedhuman prompts required, increased recall of goals,improved task completion, increased homeworkcompletion, increased arrivals to appointments,fewer reminders and self-report of improvements).These reviews did not analyse the impact of com-pensatory memory strategies on communication.However, the practice of utilizing external memoryaids to facilitate recall of appointments, homeworkcompletion and recall of daily events has consider-able relevance to cognitive-communication interven-tion both in terms of promoting recall of currentevents and new information for social communica-tion and in terms of attendance at therapy andgeneralization and maintenance of communicationtargets. These findings support current cognitive-communication intervention practices such as theuse of day planners or electronic devices.

Another area of memory intervention relevant tocognitive-communication treatment is instructionalpractices. Clinicians from all disciplines can benefitfrom learning how to present new information orstrategies in a manner that facilitates recall and theiradoption within the individual’s daily routines.Kessels and de Haan [77] conducted a meta analysisof 27 studies to examine the effects of errorlesslearning and vanishing cues methods in memoryrehabilitation. A large and statistically significanteffect size was demonstrated for errorless learningtreatment, but no significant effect size for thevanishing cues method. This support for the error-less learning method prompts questions as to howerrorless learning techniques can be applied tocognitive-communication intervention. A recentstudy has demonstrated positive effects of anerrorless learning approach to improve social com-munication [99].

Ehlhardt et al. [76] conducted a systematic reviewof instructional techniques used to assist individualswith memory impairment. They reviewed 51 studiesincluding 38 studies with participants with ABI. Thisreview systematically analysed 17 population char-acteristics, seven intervention parameters, five studydesign features and five treatment outcome factors.The authors noted considerable variance amongstudies in terms of instructional methods, descriptivedetail of treatment procedures, treatment targets andoutcome measures. This detailed analysis highlightsthe many factors that need to be evaluated in orderfor a systematic review to guide clinical practice. Theinstructional techniques reviewed fell into two broadcategories: (a) systematic instructional methods (e.g.method of vanishing cues, errorless learning andspaced retrieval) and (b) conventional methods


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(e.g. errorful learning or trial and error learning).The authors concluded that across studies there isstrong research support for use of a number of keyinstructional practices to promote learning forindividuals with acquired memory impairments.

The combined evidence presented in these sys-tematic reviews for memory interventions point to anumber of best practices including: use of externalmemory aids, clear delineation of interventiontargets, errorless learning, provision of sufficient,distributed practice, multiple exemplars, strategytraining and ecologically valid targets. All of thesepractices can be applied to cognitive-communicationinterventions, although further research willbe required to delineate the impact of specifictechniques (i.e. errorless learning) on dailycommunications.

Organization, reasoning, problem-solving, executive

function and self-regulation. Deficits in organization,reasoning, problem-solving, executive functions andself-regulation are linked to difficulties with com-munication after ABI [34, 37, 100–102]. Cognitive-communication interventions usually incorporatestrategies and procedures designed to improvethese aspects of functioning. Organization, reason-ing, problem-solving, executive functioning andbehavioural self-regulation are integrated conceptsand until there are evidence-based operationaldefinitions to distinguish them, it is reasonable toreview them as one area of intervention.

A thorough systematic review with meta analysis,conducted by Kennedy et al. [61], focused specifi-cally on interventions for executive functions. Twosystematic reviews relating to behavioural interven-tions or self-regulation were discussed previouslyunder social communication [34, 83]. Three sys-tematic reviews relating to general cognitive rehabil-itation for adults [12, 13, 80] and one SR forpaediatric [78] cognitive rehabilitation presentedrecommendations relevant to this area.

Kennedy et al.’s [61] review of executive functionsinterventions analysed 15 studies that met searchcriteria. Variance among the studies was analysedincluding: 27 population characteristics, 14 studydesign variables, four types of outcome, a range ofinterventions times (i.e. 30 minutes–48 hours),treatment settings (home, clinic, university, school)and types of intervention. Three kinds of interven-tion were used across studies including: (1) Trainingof multiple steps which included meta-cognitivestrategy instruction (11 studies); (2) Training ofstrategic thinking (two studies); and (3) Training ofmulti-tasking (two studies). The authors noted thatapproaches to problem-solving in most studiesincluded self-regulation through the use of meta-

cognitive strategies. All of the studies reportedimmediate positive treatment outcomes and 12/15reported activity or participation outcomes in addi-tion to impairment level outcomes. Nine studies(60%) reported maintenance of positive treatmenteffects over time and eight studies (53%) reportedgeneralization of treatment effects to other settingsor activities. The researchers concluded there wassufficient evidence to recommend meta-cognitivestrategy instruction as a practice standard withyoung-to-middle aged adults with TBI for difficultywith problem-solving, planning and organization.Evidence was also found in support of strategicthinking interventions for verbal reasoning in middleaged adults with chronic disability. Overall theauthors recommended provision of real world prac-tice and a focus on self-regulation and self-monitoring, as well as participation level outcomemeasures, as opposed to sole reliance on standar-dized test measures at the impairment level. Theserecommendations were consistent with those pre-sented in an earlier systematic review by Ciceroneet al. [12], who recommended cognitive interven-tions that promote internalization of self regulationstrategies through use of verbal self-instruction,self-questioning and self-monitoring as a PracticeOption for the remediation of deficits in executivefunctioning.

The evidence for executive functions interventionsfor children was less conclusive, as both reviews ofpaediatric studies concluded there was insufficientevidence of the effectiveness of interventions used toimprove executive functioning in children [78].

A general review of cognitive interventions byMarshall et al. [80] concluded that cognitive inter-ventions may be effective for improving executivefunctions.

Overall these reviews indicate that cognitive inter-ventions, including interventions for organization,reasoning, executive functioning and self-regulation,are beneficial whether offered in group or individualformat. Although further research into the specificcomponents of intervention are required, somepotential ‘active ingredients’ or successful character-istics of intervention are: individualized goal-setting,use of meta-cognitive approaches that encourageself-regulation or self-monitoring, internalization orself-instruction, structure and practice in a variety ofreal-life environments; and explicit feedback ortraining in self-evaluation systems (i.e. videotaping)[61]. Also, further research into the effectiveness ofexecutive functions interventions in children andadolescents is necessary [61, 78].

Community and family communication. Six of thesystematic reviews provided analysis and


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recommendations related to interventions for com-munity and family communications. These includedthe review by Lippert et al. [79] on communityre-integration, the Turner-Stokes et al. [87] reviewof multidisciplinary intervention; the Laatch et al.[78], McCormick et al. [81] and Carney et al. [75]reviews on paediatric interventions; and theWelch-West et al. [88] review on communicationinterventions. Involvement of family members ininterventions after ABI was recommended in three ofthese reviews [75, 78, 81]. In the area of commu-nication interventions the involvement of family andsignificant others has progressed from provision ofgeneral education to empowering communicationpartners in active training and provision of skills.Communication partner training has been shown tobe effective in aphasia [96], child language [97] andABI [47]. The systematic review by Welch-Westet al. [88] concluded that training of communicationpartners can improve the communication efficiencyof people with severe TBI.

Community involvement has also been shown tobe a beneficial adjunct to therapy. The systematicreview by Lippert et al. [77] recommended that arehabilitation programme with a focus on socialsupport and integration is effective in promotinggains in independence and productivity in patientswith ABI. This finding supports the practice ofextending intervention beyond individual therapysessions toward building of social networks andproductive activity. Such approaches as ‘Participateto Learn’ [103] and Context Sensitive therapy [36]advise that interventions for those with ABI will bemost effective when individuals are meaningfullyengaged in productive activities and have regularopportunities to interact. Evidence in this directionsuggests that speech-language pathologists will bemore effective in improving cognitive-communication functioning if they incorporate com-munication practice in real world environmentsduring meaningful activities.

Evidence reviews of comprehensive therapies fol-lowing ABI have provided strong evidence of benefitfrom formal intervention [87] and strong evidence ofmore intensive programmes [87]. Future evidencereviews will be most beneficial if they can providepractice recommendations analysing the contexts ofintervention such as communication partner train-ing, community integration opportunities and com-munity communications.

Academic communications and school supports. Thesystematic review by Carney et al. [75] analysedstudies to answer five key questions, two of whichwere relevant to the provision of academic supports

for students following ABI, and these questions wereas follows:

(1) Among children diagnosed with TBI, how manyare provided with special education that isdesigned to accommodate the needs of TBI?

(2) Do children with TBI who receive specialeducation designed to accommodate the needsof TBI have better outcomes than those who areprovided with special education that is not sodesigned and those who do not receive specialeducation?

Carney et al. analysed the effects of special educationprogrammes for children with TBI in onenon-randomized comparative study, one small caseseries, one survey and five case studies. Theyconcluded that the evidence at that time wasprimarily exploratory and the study designs ingeneral were not capable of providing evidence foreffectiveness of interventions for children andadolescents with TBI. They recommended lookingto literature in related fields by identifying sharedcharacteristics and incorporating what has beenlearned in other fields when designing interventions.

In their review of instructional practices, Glanget al. [45] analysed techniques shown to be effectivefor other student populations. They concluded thattwo instructional practices, direct instruction andcognitive strategy intervention, have significant evi-dence supporting their use with many populations ofchildren. They postulated that the efficacy of theseapproaches with students with similar learning andbehavioural characteristics presented a good basis forfurther research of these methods with students withABI. A systematic review of current practices intransitioning students back to school would be ahelpful addition to the literature in evidence-basedpractice. In the meantime, a helpful resource is areport by Ylvisaker et al. [37] which summarizes 20years of paediatric rehabilitation and ongoing sup-ports after TBI, including an analysis of educationalsupports. Increasingly the evidence points to thebenefits of strategy training within natural contexts[37]. A beneficial next step in evidence-basedresearch would be a SR that analyses the effective-ness of cognitive-communication strategy trainingwithin the academic context.

Vocational communication. There were no system-atic reviews of the impact of cognitive-communication interventions on vocational re-entry.The review of interventions for community reinte-gration by Lippert et al. [79] was most relevant tothis area of practice. They concluded that interven-tions incorporating cognitive strategies increase thenumber of individuals with ABI that return to full


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time vocational activity. They also concluded thatvocational rehabilitation strategies are most effectivewhen implemented earlier after ABI. They alsonoted that supported employment interventionsimprove job placement and retention followingABI. Scollon [104] reviewed 600 articles onreturn-to-work issues as part of a review of factorsthat affect return-to-work following TBI. Althoughthe review is not a systematic review of interventions,the review makes 19 practice recommendationsrelated to vocational re-entry that are of someclinical utility as one awaits systematic reviewsspecific to vocational communication interventions.Scollon’s review concluded that communicationskills are an important determinant of successfulreturn to work. Scollon’s review also noted improvedvocational re-integration as a function of earlierintervention. Given that communication skills are animportant factor in vocational success [46, 104, 105]further research into the impact of cognitive-communication interventions on vocational reinte-gration is necessary.

Conclusion

Evidence to support cognitive-communication

interventions

There is a growing body of evidence to support theeffectiveness of interventions for deficits in thefollowing areas related to cognitive-communicationfunctioning after ABI: social communication; beha-vioural self-regulation, verbal expression, attention,external memory aids, instructional techniques,executive functions/meta-cognitive training andcommunication partner/family training. The follow-ing approaches appear to be helpful across interven-tion domains: individualization of goals, feedbackand outcome measures; context sensitive interven-tions that are embedded in the communications andenvironments of daily life; self-evaluation andself-regulation techniques; use of meta-cognitivestrategies; focus on activity and participation levelsof intervention and outcome rather than impairmentlevel drill and training; and employment of instruc-tional techniques that have been validated on manypopulations (i.e. errorless learning and directinstruction).

Future research directions

While additional research is required in all areas, thisanalysis revealed considerable need for research inthe following areas of intervention for those withABI: comprehension and information processing,written expression, academic and vocationalcommunications.

Challenges in translating the evidence to clinical

practice

Cognitive-communication interventions present par-ticular challenges in translating evidence to clinicalpractice due to: (1) the broad spectrum of cognitiveand communication presentations and interventions;(2) the evolution of terminology and clinicalapproaches over time, (3) the complex interplaybetween cognition, communication, emotion andbehavioural self-regulation prompting considerationof a wide range of therapeutic approaches, (4) theheterogeneity of the ABI population (i.e. age, sever-ity and neurobehavioural presentation), (5) discre-pancies in what constitutes strong evidence for aparticular type of treatment and (6) variation in theextent to which communication is included in thepopulation description, intervention and evaluationof outcomes.

Recommendations for knowledge transfer and application

of evidence

This review of the reviews has generated a number ofrecommendations for knowledge transfer and appli-cation of clinical evidence. To improve consistencyand clinical application, intervention studies need tospecify participant characteristics, cognitive-communication profiles, individualized treatmentgoals, treatment characteristics and real worldoutcome measures, including communication out-comes. End users (clinicians, researchers, policy-makers, survivors) can be guided in their analysis ofevidence by the OPICO guiding questions (Overallfocus, Population, Intervention, Comparison andOutcome). Also, consistent use of a peer reviewedframework for evidence search and consolidationis recommended to promote comparisonacross reviews. The Cognitive-CommunicationIntervention Review Framework is one approach todefining key search terms and consolidating evidencein a consistent manner that allows for comparison ofintervention recommendations over time. Expertpanel review is increasingly being used to ensureoptimal definition of search terms, as well as searchand evaluation approaches. Finally many studiesadvised the review of a broader range of designmethodologies including single-subject design,rather than exclusive attention to randomized con-trol trials. Although RCTs have been considered tobe the ‘gold standard’ of evidence, there have been anumber of critiques of RCT’s as a measure of treat-ment effectiveness [26, 63, 106, 107]. Single-subjectdesign (SSD) studies are the most prevalent studymethodology used in ABI rehabilitation research[11], owing to the heterogeneous ABI population,the need for individualized goal-setting, individuallytailored treatment techniques such as self-regulation


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and use of real life, activity and participation basedoutcome measures. Until ABI research has evolvedto a stage where multiple RCT’s are available, itseems prudent to consider the findings of singlesubject design studies in evidence reviews. Finally,those wishing to apply evidence to clinical practicecan be greatly assisted in their search for interventionstudies and systematic reviews by two databases.PsycBITE (www.psycBITE.com) [68] categorizesand reviews all studies of psychologically-basedinterventions after ABI and SpeechBITE (www.speechBITE.com) [108] categorizes and reviews allcommunication interventions for speech-languagepathologists. These databases will be invaluable toend users, particularly the majority of clinicians whoare not affiliated with institutional library services.

As end users grapple with the task of integratingand implementing evidence from a variety ofsources, consistent approaches are required forknowledge exchange, transfer and application, TheCCIRF provides a model for consolidating theevidence for cognitive-communication interventions.It is hoped that additional efforts to consolidate andapply available evidence will help to bridge the gapbetween research produced and evidence applied,with the ultimate end of improving communicationoutcomes for those with acquired brain injuries.

Acknowledgements

The authors wish to express sincere gratitude to DrLyn Turkstra and Dr Mark Ylvisaker for theireditorial expertise in reviewing this paper at variousstages of its evolution. Appreciation is also extendedto Dr Mary Kennedy and Dr Leanne Togher whoprovided resources during the earlier stages of thepaper. The second author gratefully acknowledgesthe support of the Canadian Institutes for HealthResearch through a Fellowship in Clinical Research,and the Toronto Rehabilitation Institute who receivefunding under the Provincial RehabilitationResearch Program from the Ministry of Health andLong-Term Care in Ontario. The views expresseddo not necessarily reflect those of the Ministry.

Declaration of interest: The authors declare noconflicts of interest. The authors alone are respon-sible for the content and writing of the paper.

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Knowledge translation in ABI rehabilitation: A model for ... · ASHA’s definition of CCD’s, developed though an expert consensus panel, is as follows: Cognitive-communication