Navigating cognitive rehabilitation: a review of the updated INCOG 2.0 guidelines

BIS Services have provided specialist cognitive rehabilitation assistants for nearly 17 years, to provide support and rehabilitation to individuals living with brain injury and neurological conditions.

As a cognitive rehabilitation therapist, I am often asked what my role is, and how it sits apart from other therapist or clinicians.

A cognitive rehabilitation therapist plays a crucial role in helping individuals who have experienced cognitive impairment due to injury, illness, or chronic conditions. We implement targeted therapeutic strategies designed to improve or restore cognitive functions such as memory, attention, language, and problem-solving. We conduct comprehensive cognitive assessments, create personalised rehabilitation plans, and facilitate cognitive exercises.

Our role is to track progress, adjust therapeutic interventions as necessary, and work closely with other healthcare professionals to ensure comprehensive input.

The role also involves providing education and support to clients and their families, helping them understand the nature of cognitive impairments and strategies for managing them in day-to-day life.

Cognitive Rehabilitation Therapy (CRT) follows a step-by-step process, tailored specifically to each client’s unique needs and goals. The primary steps in the process typically include:

1. Evaluation:

The first step of CRT involves a thorough evaluation of the client’s cognitive abilities and deficits. This assessment may include formal neuropsychological testing, medical evaluations, and interviews with the client and their family.

2. Goal setting:

Once the evaluation is complete, therapy goals are identified in collaboration with the client and their family, and the wider MDT, if there is one. These goals are often functional in nature, relating to activities of daily living that have been impacted by the cognitive impairment.

3. Therapy:

The therapy phase involves targeted activities and exercises designed to improve cognitive functions. This can involve retraining intact cognitive skills, teaching compensatory strategies for impaired abilities, and cognitive exercises to challenge and strengthen cognitive abilities. We focus on the key cognitive domains, often commencing with attentional processes.

4. Re-evaluation and adjustment:

Progress towards therapy goals is regularly monitored, and the rehabilitation plan is adjusted as necessary based on the client’s progress and evolving needs.

5. Transition and maintenance:

As the client meets their therapy goals, they may transition from intensive therapy to maintenance therapy, with a focus on continuing to use and reinforce learned strategies and skills in their daily life.

The intervention incorporates four core strategies, forming an integrated approach to rehabilitate individuals with cognitive impairments.

1. Education:

This approach enlightens clients and their families about the nature and effects of cognitive impairments. It involves learning about the brain, understanding how the injury has affected cognitive functioning, and what to expect throughout the rehabilitation process. I create bespoke education packages for each client, utilising medical reports and family feedback. Education is ongoing around specific areas of cognition, with fatigue management playing a large role.

2. Functional training:

This focuses on specific skills that a person needs in their daily life. It is highly personalised and can include skills such as managing finances, cooking, or using public transportation to more complex processes related to vocational goals.

3. Process training:

This strategy aims to improve the cognitive processes underlying these daily life skills. Exercises might be undertaken to enhance memory, attention, perception or problem-solving skills, with the aim of improving overall cognitive functionality. These are informed by initial assessments and other neuropsychological assessments that have been undertaken.

4. Strategy training:

This teaching method involves implementing compensatory strategies to help clients manage their cognitive difficulties. For instance, techniques for memory enhancement—such as the use of reminders— might be taught, or organisation strategies might be shared to help manage time more effectively.

The list is often endless and the strategy toolbox full to the brim when it comes to new strategies.

There is a considerable body of research in cognitive rehabilitation that underpins the development and application of various therapeutic strategies. This was not always the case.

CRT was not; for a long time recognised as a valid intervention. Often it was included in the work of neuropsychologists or specialised occupational therapists. The guidelines refined their stance on the role of various therapeutic modalities, such as cognitive stimulation, cognitive training, and cognitive rehabilitation therapy. These are now considered as complementary parts of a holistic therapy plan, rather than standalone treatments.

Research evidence overwhelmingly supports the efficacy of cognitive rehabilitation in brain injury cases. Numerous studies have demonstrated significant improvement in clients who undergo cognitive rehabilitation therapy, particularly in the areas of memory, attention, and executive functioning. This is further bolstered by metaanalyses that have highlighted the positive impact of cognitive rehabilitation on overall cognitive function and quality of life

The INCOG 2.0 guidelines, published in early 2023 in The Journal of Head Trauma Rehabilitation, underscore the significance of addressing executive functioning in cognitive rehabilitation. They advocate for the use of interventions that enhance problem-solving skills, strategic thinking, and self-regulation. This includes practical strategies such as goal management training and metacognitive strategy instruction, which aim to help clients manage daily tasks more effectively.

Additionally, the guidelines recommend the implementation of personalised task practice, emphasising real-world application and meaningful engagement. The use of computerised cognitive training programs is also encouraged, given their potential to target specific executive functions.

Since their initial release in 2014, the INCOG guidelines have undergone significant revisions in their 2.0 version, reflecting the evolving landscape of cognitive rehabilitation following traumatic brain injury.

These changes reflect INCOG's commitment to staying abreast of the latest research and clinical practices in cognitive rehabilitation following traumatic brain injury. They showcase the evolution of the guidelines from their 2014 version to the present, highlighting both the refinements made and the avenues yet to be explored in this vital field of therapy.

One notable change is the enhanced focus on personalised, client-centred rehabilitation plans. This adjustment emphasises the importance of tailoring treatments to individual needs, taking into account the client’s unique circumstances and recovery goals.

The INCOG 2.0 guidelines understand the necessity of personalised plans. They provide a framework that allows for individualisation, understanding that each client’s journey is unique. The guidelines also emphasise the importance of ongoing reassessment and adjustment of treatment plans, promoting an approach that optimises client outcomes.

The new reviews of the INCOG 2.0 guidelines provide fresh insights, further enriching their utility. They highlight the inclusion of both client and caregiver perspectives as central to effective treatment plans.

This human-centric approach individualises therapies, and this shift aims to foster an improved therapeutic alliance, enhancing the efficacy of cognitive rehabilitation strategies. This empowers the clients in their rehabilitation journeys, allowing for increased motivation, as well as improved outcomes.

Another key change in the INCOG 2.0 guidelines is the endorsement of a multi-modal approach to treatment. The guidelines suggest the potential benefits of combining cognitive rehabilitation with other interventions, such as physical exercise and medication, depending on the client’s specific circumstances and needs.

This multi-pronged approach is a substantial departure from the 2014 guidelines, which focused primarily on cognitive rehabilitation alone. The guidelines also provide clinicians with detailed information on how to assess a person's cognitive needs and the strategies that should be put in place in order to maximise their recovery potential.

In addition, it provides details on when and how to refer clients for more specialist interventions if required. By providing clear direction on how to assess clients and tailor interventions, it allows practitioners to focus their efforts effectively and ensure the best possible outcomes for those affected by neurological conditions. Additionally, it provides an important starting point for designing new programmes which can benefit from evidence-based approaches.

In order to ensure that cognitive rehabilitation efforts are successful, clinicians must be sure to familiarise themselves with the INCOG 2.0 guidelines and use them as a reference when creating new programmes.

Despite the significant updates and improvements in the INCOG 2.0 guidelines, the current state of their implementation presents both progress and challenges. On one hand, there's a growing adoption of these guidelines, particularly in rehabilitation units where they recognise the importance of personalised and multi-modal treatments.

However, several challenges persist.

The most common of these include variance in resource allocation, lack of standardised training for healthcare professionals, and the absence of robust monitoring and evaluating systems to measure guideline adherence and effectiveness.

Translating to community settings continues to be of great challenge. While the guidelines highlight the need for an individualised approach, translating this into practice can be complex and time-consuming, particularly given the nuanced nature of traumatic brain injury.

One potential area for improvement in future updates could be increased attention to the role of technology in cognitive rehabilitation. With the rapid advancements in digital health technologies, there are ever more tools available that could potentially be incorporated into treatment plans.

Additionally, despite the endorsement of a multi-modal approach, there is a need for further research to understand the optimal combination of treatments for different client profiles.

Ultimately, while the INCOG 2.0 guidelines represent a significant step forward, their effective implementation remains an ongoing challenge that necessitates further research, resources, and concerted efforts from all stakeholders involved.

In summary, the INCOG 2.0 Cognitive Rehabilitation Guidelines are useful resource that equips healthcare professionals with the knowledge and tools to effectively manage cognitive impairments, with specific domain specific recommendation.

By implementing the strategies and interventions outlined in these guidelines, healthcare professionals can make significant strides in improving patient outcomes and enhancing overall quality of life in individuals living with brain injury neurological conditions.

For further information regarding how our services can support your clients, or for CRT training information contact us at www. thebiss.co.uk or call 01622 584456