INTRODUCTION

Evidence-Based Practice for Cognitive-Communication

Disorders after Traumatic Brain Injury

A s clinicians, we sincerely believe that our sociation (ASHA), Division 2, Neurophysiol-

intervention improves the lives of those we
serve. In the case of neurogenic communication
disorders, however, this belief is not always
supported by data. The disability rights move-
ment in the 1980s led us to consider client
outcomes beyond clinical settings, and we had
little measurable evidence that our intervention
made a meaningful difference in these contexts.
Reimbursement limitations further forced us to
ogy and Neurogenic Speech and Language
Disorders, and the Department of Veterans
Affairs.
The ANCDS guidelines project has
proved to be a Herculean task. It has required
the efforts of several teams of individuals,
including students who have participated in
collecting and summarizing data as well as
colleagues who have provided peer reviews of

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scrutinize our practice for evidence of both
efficacy (a significant benefit demonstrated in
a clinical trial) and effectiveness (benefit to an
individual in clinical practice). At the same
time, there was a movement toward evidence-
based practice in medicine, led in part by the
Evidence-Based Medicine Working Group at
McMaster University in Ontario, Canada.
Thus, we joined a community of health care
practitioners engaged in the process of creating
evidence-based guidelines for intervention.
The Academy of Neurologic Communica-
tion Disorders and Sciences (ANCDS) has
been working since 1997 to develop evidence-
based practice guidelines specifically for ac-
quired neurogenic communication disorders.
LeeAnn Golper summarized the goals of the
project in the initial publication of the guide-
lines group, stating that ‘‘The goal of this
project is to improve the quality of services of
individuals with neurologic communication
disorders by assisting clinicians in decision-
making about the management of specific pop-
ulations through ‘guidelines’ based on research
evidence’’.1 Additional support for the ANCDS
evidence-based practice project has come from
the American Speech-Language-Hearing As-
numerous documents. Evidence reviews are
published or under way in the areas of dysarth-
ria, dementia, aphasia, childhood apraxia of
speech, and, as in the clinical focus articles
included in this issue, cognitive-communica-
tion disorders associated with traumatic brain
injury (TBI) . There are two excellent sources
of updated information about the guidelines
project: the ANCDS Web site (www.ancds.
org) and the regular ANCDS column included
in the ASHA Division 2 quarterly Perspectives
publication. Readers are referred to these for
more comprehensive information about the
project and its products.
The cognitive-communication disorders
writing group chose to present results in several
formats, in accordance with deficits typically
encountered by persons with TBI.2 Thus, we
took a modular approach to reviewing the
literature and current practice for the following
areas: intervention for attention disorders,3
standardized assessment,4 nonstandardized as-
sessment, the use of external memory aids,
intervention for deficits of executive function
and metacognition, intervention for social and
behavioral disorders, and intervention that in-
cludes direct instruction. To reach the widest

Evidence-Based Practice for Cognitive-Communication Disorders after Traumatic Brain Injury; Editors in Chief, Audrey
L. Holland, Ph.D., and Nan Bernstein Ratner, Ed.D.; Guest Editor, Lyn S. Turkstra, Ph.D. Seminars in Speech and
Language, volume 26, number 4, 2005. 1Guest editor; Department of Communicative Disorders, University of Wisconsin-
Madison, Madison, Wisconsin; 2Chair, ANCDS Writing Committee on Evidence-Based Practice Guidelines for
Cognitive Communication Disorders; Associate Professor, Speech-Language-Hearing Sciences, University of Minnesota,
Minneapolis, Minnesota. Copyright # 2004 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY
10001, USA. Tel: +1(212) 584-4662. 0734-0478,p;2005,26,04,213,214,ftx,en;ssl00248b.
213
214 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 26, NUMBER 4
readership, several formats have been used,
including technical reports, posted on the
ANCDS Web site; comprehensive guidelines
papers, some of which have been published in
the Journal of Medical Speech-Language Pathol-
ogy with others forthcoming; and a series of
‘‘clinical focus’’ articles, several of which are
presented in this special issue.
In the first article, Turkstra, Coelho, and
Ylvisaker review standardized, norm-refer-
enced tests that are currently used by clinicians
to evaluate language and cognitive-communi-
cation disorders. Coelho, Ylvisaker, and Turk-
stra then discuss the evidence related to the use
of nonstandardized approaches to assessment,
particularly for outcomes at the level of com-
munication activities and participation as a
preview to the technical report and recommen-
dations
Kennedy and Coelho focused their review
on the evidence for the use of self-regulation in
intervention for memory and problem solving,
which is part of a broader review of intervention
for disorders of executive function and meta-
cognition. In the next article, Ylvisaker, Turk-
stra, and Coelho discuss intervention for social
and behavioral problems affecting communica-
tion. The final article, by Sohlberg, Ehlhardt,
and Kennedy, discusses the use of direct in-
struction as a strategy for changing behavior.
Anyone who has ever tried to evaluate the
‘‘evidence’’ and make clinical recommendations
realizes immediately that it is a dynamic process
that can change from year to year. One year
there may be limited evidence that only sug-
gests that an intervention is efficacious, but in
subsequent years the evidence may be mount-
ing. The need for more evidence is obvious.
Regardless of what the evidence suggests, each
clinician must ultimately make decisions about
the best intervention for each client, and to do
that, clinicians must balance the evidence with
2005
the client’s own goals, needs, and values. As the
Evidence-Based Medicine Working Group5
noted, there is no substitute for clinical judg-
ment in choosing the most appropriate assess-
ment and intervention for an individual client.
Lyn Turkstra, Ph.D.1
Mary Kennedy, Ph.D.2
ACKNOWLEGMENTS
In addition to the committee members who
served as authors for this issue, the authors wish
to acknowledge Kathryn Yorkston for her ex-
perience in creating guidelines and committee
member Jack Avery for his contribution to
several technical reports and guideline papers.
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REFERENCES
1. Golper LC, Wertz RT, Frattali CM, et al. Evi-
dence-based practice guidelines for the management
of communication disorders in neurologically-
impaired individuals: project introduction. In:http://
www.ancds.duq.edu/guidelines.html; 2001
2. Kennedy M, Avery J, Coelho C, et al. Evidence-
based practice guidelines for cognitive-communica-
tion disorders after traumatic brain injury: initial
report of the Academy of Neurologic Communica-
tion Disorders and Sciences Writing Committee for
practice guidelines in cognitive-communication dis-
orders after traumatic brain injury. J Med Speech
Lang Pathol 2002;10:ix–xiii
3. Sohlberg MM, Avery J, Kennedy M, et al. Practice
guidelines for attention training. J Med Speech Lang
Pathol 2003;(in press)
4. Turkstra L, Coelho C, Ylvisaker M, et al. Practice
guidelines for standardized assessment for persons
with traumatic brain injury. J Med Speech Lang
Pathol 2005;13:ix–xxviii
5. Guyatt GH, Haynes RB, Jaeschke RZ, et al. for the
Evidence Based Medicine Working Group. Users’
guide to the medical literature. JAMA 2000;284:
1290–1296