NEUROPSYCHOLOGICAL REHABILITATION

2020, VOL. 30, NO. 10, 1976–1995

https://doi.org/10.1080/09602011.2019.1623823

Current practice of cognitive rehabilitation following

traumatic brain injury: An international survey
Clare Nowell a,b, Marina Downing a,b
, Peter Bragge c
and
Jennie Ponsford a,b
a
Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monsah University,
Melbourne, Australia; bMonash-Epworth Rehabilitation Research Centre, Epworth Healthcare,
Melbourne, Australia; cBehaviourWorks Australia, Monash Sustainable Development Institute, Monash
University, Melbourne, Australia

ABSTRACT ARTICLE HISTORY

Traumatic brain injury (TBI) is a global public health issue, Received 11 February 2019
frequently resulting in impairments in the cognitive domains Accepted 20 May 2019
of attention, information processing speed, memory, executive
KEYWORDS
function, and communication. Despite the importance of Brain injury; traumatic;
rehabilitating cognitive difficulties, and the release of clinical rehabilitation; cognition;
practice guidelines (CPGs) for cognitive rehabilitation, little is clinician
known about current clinician practice. This study aimed to
explore current international clinician practice of cognitive
rehabilitation. One hundred and fifteen English-speaking allied
health professionals, including neuropsychologists and
occupational therapists, from 29 countries outside Australia,
were surveyed online about their current practice and
reflections on cognitive rehabilitation. Both cognitive
retraining and functional compensation approaches to
cognitive rehabilitation were commonly utilized. Clinicians
mostly targeted deficits in attention and executive functioning
with retraining interventions, whilst memory deficits were
mostly targeted with compensatory interventions. Clinicians
were aware of and utilized various resources for cognitive
rehabilitation, including CPGs. Clinicians considered the client’s
social support network, client engagement and motivation in
rehabilitation, multidisciplinary team collaboration, and goal
setting and implementation as highly impactful factors on the
success of cognitive rehabilitation interventions. Whilst
practice is broadly consistent with current CPG
recommendations, addressing facilitating factors can further
optimize client outcomes and quality of life following TBI.

Introduction
Traumatic brain injury (TBI) is a global public health issue, which can result in life-
long burden and disability (Corrigan, Selassie, & Orman, 2010). Moderate-to-

CONTACT Jennie Ponsford jennie.ponsford@monash.edu School of Psychological Sciences, Monash Uni-

versity, Clayton, Vic 3800, Australia
Supplemental data for this article can be accessed doi:10.1080/09602011.2019.1623823.
© 2019 Informa UK Limited, trading as Taylor & Francis Group
 NEUROPSYCHOLOGICAL REHABILITATION 1977

severe TBI, involving >20 min loss of consciousness and >24 h post-traumatic
amnesia (PTA; Campbell, 2000), commonly results in impairments of cognition,
behaviour, emotion, and social functions. Cognitive impairment is most frequent
in the domains of attention, memory and working memory, executive function-
ing, self-awareness, and communication. Such impairments can have significant
and long-lasting effects on the individual’s capacity to participate in education,
employment, social and leisure activities, and relationships (Ponsford, Downing
et al., 2014; Ponsford & Spitz, 2015; Rabinowitz & Levin, 2014; Ruet et al., 2018).
Thus, rehabilitation of cognitive impairments post-TBI is of great importance.
Cognitive rehabilitation involves interventions that address cognitive impair-
ments resulting from TBI (Rees, Marshall, Hartridge, Mackie, & Weiser, 2007). It is
generally delivered by neuropsychologists, clinical psychologists, occupational
therapists, speech pathologists, nurses, and rehabilitation physicians (Institute
of Medicine, 2011). Various approaches are taken, but most commonly they
can be classifed under the categories “cognitive retraining” and “functional com-
pensation” (Downing, Bragge, & Ponsford, 2019). Cognitive retraining aims to
restore impaired cognitive functioning, and often involves hierarchically orga-
nized training exercises that are specific and repetitive, with gradually increasing
difficulty or cognitive demand (Ben-Yishay & Diller, 1993; Institute of Medicine,
2011; Ponsford, Sloan, & Snow, 2012; Ylvisaker, Hanks, & Johnson-Greene,
2002). Cognitive retraining may involve paper-and-pencil or computerized
tasks and is most commonly used to address attentional difficulties (Barman,
Chatterjee, & Bhide, 2016). For example, Attention Process Training (APT) aims
to restore attention, and a task used for this purpose may involve an individual
listening to a long list of numbers, presented with increasing speed, and pressing
a button when a specific number is heard (Sohlberg & Mateer, 1987). Cognitive
retraining can also involve a combination of tasks developed for specific activi-
ties, such as driving (Kewman et al., 1985).
Functional compensation involves developing alternate strategies and utiliz-
ing remaining abilities to complete everyday tasks, circumventing or lessening
the burden of impairment (Institute of Medicine, 2011; Ponsford et al., 2012).
For example, a strategy utilized for memory impairment might involve the
internal process of visual imagery, to increase conscious engagement during
memory encoding (Velikonja et al., 2014). External functional compensation
strategies for memory might involve utilizing physical systems of compensation,
such as diaries and electronic devices including mobile/smart phones (Velikonja
et al., 2014; Wilson, 2009). For individuals with impairments in memory and
executive functioning, techniques such as errorless learning, which involves pro-
viding prompting to avoid making errors during training, can facilitate the learn-
ing of functional compensatory strategies (Ehlhardt et al., 2008). Modifications to
the environment or structured support provided by another person are also con-
sidered external compensatory strategies aiming to increase functional indepen-
dence or participation (Ponsford et al., 2012; Velikonja et al., 2014).
1978 C. NOWELL ET AL.

The growing emphasis on evidence-based practice in medicine has led to the

production of guidelines for clinician practice, based on evaluations of published
research. Various clinical practice guidelines (CPGs) for cognitive rehabilitation
after brain injury have been developed (e.g., Cicerone et al., 2000, 2005, 2011).
More recently, the INCOG guidelines were developed by an international
group of researchers and clinicians on the basis of previous CPGs, review of
current evidence, and expert panel consensus. Recommendations were provided
for PTA, attention and information processing speed, executive function and self-
awareness, cognitive communication, and memory following TBI (Bayley et al.,
2014; Ponsford, Bayley et al., 2014; Ponsford, Janzen et al., 2014; Tate et al.,
2014; Togher et al., 2014; Velikonja et al., 2014). A clinical algorithm to aid clinicians’
decision-making in applying recommendations was also developed by the INCOG
team. Following the publication of the INCOG CPGs, further guidelines have been
developed. One such CPG was developed by INESSS-ONF (Truchon et al., 2017),
which references the INCOG CPGs for cognitive rehabilitation. The development
process of these guidelines included a novel emphasis on user perspective and
insights, incorporating their priorities for both format and implementation tools,
important subjects (such as community life), as well as the context of healthcare
(including factors such as timing and length of care) in Canada (Bayley et al.,
2018; Bayley et al., 2018; Lamontagne et al., 2018b; Swaine et al., 2018).
There have been few investigations into current clinical practice and the
extent to which CPGs are utilized by allied health professionals working in
post-TBI cognitive rehabilitation. In two Canadian provinces, Lamontagne et al.
(2018b) found that CPG recommendations were most commonly considered
by clinicians as either “fully” or “mostly” implemented, however, Lamontagne
et al. (2018a) reported that whilst clinicians had positive opinions of CPGs,
only a small percentage of participants utilized them. This suggests that an
audit of practice remains necessary to determine levels of recommendation
implementation. Australian clinicians’ experiences, practice scope, and perceived
barriers to providing rehabilitation have also been investigated by Pagan et al.
(2015). However, this study explored post-TBI rehabilitation in general, rather
than cognitive rehabilitation specifically. Another study investigated the assess-
ment and rehabilitation of social cognition deficits, in Australian and inter-
national samples, demonstrating a gap between evidence-based
recommendations and clinical practice (Kelly, McDonald, & Frith, 2017a,
2017b). However, knowledge regarding the extent to which current clinical prac-
tice of cognitive rehabilitation aligns with CPGs more broadly remains limited, as
is the case in numerous other areas of healthcare.
Members of the INCOG project team have therefore undertaken a series of
surveys to explore clinician practice in Australian and international settings.
The results from the Australian setting have been published elsewhere
(Downing et al., 2019), with the current study focussing on the results from
countries other than Australia. The aim of this study was to survey current
 NEUROPSYCHOLOGICAL REHABILITATION 1979

practices of clinicians involved in cognitive rehabilitation post-TBI. This included

open-ended questions investigating the focus of and approaches to rehabilita-
tion, resources utlised to inform intervention, and barriers and facilitators to
the practice of cognitive rehabilitation.

Materials and methods

Design

This study utilized an online questionnaire created to examine current clinician

practice (see Appendix). The survey included 25 items covering: (A) demographic
information; (B) nature of current cognitive rehabilitation; (C) resources used to
inform TBI cognitive rehabilitation; and (D) reflections on cognitive rehabilitation,
including perceived barriers to cognitive rehabilitation, and the relative ease of
rehabilitation in each cognitive domain. Items comprised multiple-choice ques-
tions, rating scales, yes/no questions, and open-ended items. The survey was
available, in English, online from April 2014 until September 2016 on Qualtrics.

Participants
Allied health professionals currently providing cognitive rehabilitation for mod-
erate-to-severe TBI were eligible to participate. The snowball sample consisted of
115 allied health professionals with experience in cognitive rehabilitation post-
TBI. Invitation to participate and a link to an online anonymous survey were
emailed to allied health professional managers and clinicians internationally,
via a database of allied health clinicians with an interest in brain impairment
held by the Australasian Society for the Study of Brain Impairment (ASSBI) and
Neuropsychological Rehabilitation Special Interest Group of the World Federa-
tion for NeuroRehabilitation (NR-SIG-WFNR). These individuals were asked to
forward the email on to other eligible allied health professionals.
Ethical approval was granted from Epworth Healthcare’s Human Research and
Ethics Committee (Reference number LR134-13). Participants provided informed
consent by checking a box at the beginning of the survey.

Data analysis

The quantitative Qualtrics data were downloaded and collated into IBM’s Statisti-
cal Package for the Social Sciences (SPSS) version 25, and valid responses and
missing values were visually screened. Respondent demographics were exam-
ined using descriptive statistics. Open-ended qualitative response data from
Qualtrics were imported and analysed in QSR International’s NVivo 11 qualitative
data analysis Software. Responses were then coded using the six-phase thematic
process described by Braun and Clarke (2006). This included: (1) data
1980 C. NOWELL ET AL.

familiarization, through repeatedly reading transcripts; (2) data organization,

through allocating initial codes to the raw data; (3) deriving initial themes to rep-
resent research aims, through code organization; (4) theme review, by re-reading
the responses, checking codes, themes, and their interpretation against the
entire data set and relevant literature; (5) refining and defining themes; and
(6) extracting examples of responses to represent each theme. Thematic maps
for two survey questions (factors that facilitate and hinder cognitive rehabilita-
tion) were also developed. Both inductive and deductive processes were used
to identify themes. The themes were identified at a semantic level, so that the
explicit, or surface, meanings of the responses were interpreted and used to
choose themes (Boyatzis, 1998).
Independent cross-coding was conducted by author MD for 95% of respondent
data, using the same coding hierarchy, to ensure adequate coding reliability.
There was a total of 10 open-ended questions that required cross-coding.
Codes were subsequently revised following discussion (Creswell, 2009). Cohen’s
(1960) Kappa statistic was calculated to determine inter-rater reliability.

Results
Participant demographics

The initial sample size was 145. Of the 145 people who commenced the survey,
100% completed at least one question in Section A (demographics), 80% (n =
116) completed at least one question in Section B (cognitive rehabilitation prac-
tice), 69% (n = 100) completed at least one question in Section C (cognitive rehabi-
litation resources), and 64.8% (n = 94) completed at least one question in Section D
(reflections on cognitive rehabilitation). Of the 145 respondents, 20% (n = 29) only
completed Section A, thus they were excluded from further analysis. The overall
completion rate for the survey (defined as the percentage of participants who
met inclusion criteria and completed some, or all, of the questions in sections B,
C, and D) was therefore 80%. One additional respondent was not currently involved
in cognitive rehabilitation at the time of survey completion and was therefore also
excluded from further analysis, and thus the final sample consisted of 115 partici-
pants. For the double-coded results, the percentage of agreement was 99.94% (SD
= .11, Range = 99.09% to 100%), and the inter-coder concordance was excellent
(Mean Kappa = .83, SD = .31, Range = 0–1.00; Viera & Garrett, 2005).
Participant origins and employment characteristics are displayed in Table 1.
Participants represented a broad range of disciplines, came from 29 countries,
and worked in inpatient and outpatient settings. The majority of respondents
(78.3%) were employed full-time; 20% were employed part-time; and 1.7% in a
different capacity. Respondents had an average of 13.96 (SD = 9.85) years’
(Range: <1–40 years) experience in cognitive rehabilitation. Respondents had
an average total clinical experience of 18.14 (SD = 11.46) years (Range: <1–50
 NEUROPSYCHOLOGICAL REHABILITATION 1981

Table 1. Respondent characteristics.

Percentage (%)
Survey Respondents (n = 115)
Clinical neuropsychologist (n = 45) 39.1
Rehabilitation physician (n = 18) 15.7
Speech pathologist (n = 18) 15.7
Occupational therapist (n = 11) 9.6
Physiotherapist (n = 2) 1.7
Other (e.g., nurse) (n = 21) 18.3
Country of Respondents
United States of America (n = 27) 23.5
United Kingdom (n = 21) 18.3
France (n = 8) 7.0
The Netherlands (n = 8) 7.0
Italy (n = 7) 6.1
Norway (n = 4) 3.5
Spain (n = 4) 3.5
Sweden (n = 4) 3.5
Denmark (n = 3) 2.6
Germany (n = 3) 2.6
Finland (n = 2) 1.7
India (n = 2) 1.7
Ireland (n = 2) 1.7
Russia (n = 2) 1.7
Singapore (n = 2) 1.7
Switzerland (n = 2) 1.7
Turkey (n = 2) 1.7
Algeria (n = 1) 0.9
Belgium (n = 1) 0.9
Brazil (n = 1) 0.9
Cyprus (n = 1) 0.9
Estonia (n = 1) 0.9
Hong Kong (n = 1) 0.9
Mongolia (n = 1) 0.9
New Zealand (n = 1) 0.9
Quebec (n = 1) 0.9
Scotland (n = 1) 0.9
South Korea (n = 1) 0.9
Ukraine (n = 1) 0.9
Work Setting
Inpatient brain injury rehabilitation unit (n = 46) 40.0
Outpatient rehabilitation setting (n = 37) 32.2
Supported accommodation (n = 8) 7.0
Other (e.g., community/home-based settings) (n = 24) 20.9
Client Funding
Insurance or compensation (n = 52) 45.2
Public / Government funding (n = 44) 38.3
Private (n = 8) 7.0
Combination of sources (including private and public/government) (n = 7) 6.0
Other (e.g., university research) (n = 4) 3.5

years), and an average 13.86 (SD = 9.73) years (Range: <1–40 years) clinical experi-
ence in TBI cognitive rehabilitation. They saw approximately 21 clients with TBI per
month, of whom an average of 16 clients were seen for cognitive rehabilitation.

Current practice of cognitive rehabilitation

In an open-text response, respondents identified processes that were part of
their day-to-day clinical practice. Frequently identified clinical processes were:
cognitive retraining and functional compensation interventions, assessment,
1982 C. NOWELL ET AL.

and goal setting and implementation (see Figure 1). Six of the 115 respondents
(5%) indicated that their use of processes was within a context of providing
supervision and advice.
Approaches to cognitive rehabilitation were also identified by respondents,
with the most common including cognitive retraining; functional compensation;
and functional retraining, including preparation for return to work or study (see
Figure 2).
Respondents also identified the specific cognitive domains on which they
focused within cognitive retraining (see Figure 3), and functional compensation
approaches (see Figure 4).
When asked about cognitive domains which were the focus of cognitive
retraining, respondents frequently reported a general retraining approach to
cognitive rehabilitation (in which cognitive domains were not specified), as
well as specific domains of attention; executive functioning, problem solving
and planning; and memory (including working memory). Cognitive retraining
for attention often involved computer software and APT, whilst retraining inter-
ventions for executive functioning involved computer software, paper-and-
pencil tasks, and functional tasks, such as planning for and then cooking a
meal. Cognitive retraining memory interventions that were frequently reported
involved in computer software such as Cogmed QM, targeting working memory.
When asked about cognitive domains that were the focus of functional com-
pensation approaches, some respondents did not specify cognitive domains of
focus. Of those who did, allied health professionals commonly identified
memory (including working memory), followed by attention and executive

Figure 1. Commonly utilized processes in day-to-day cognitive rehabilitation reported by

clinicians.
Note: categories generated from open-text survey, with number of survey responses presented above each percen-
tage value bar.
 NEUROPSYCHOLOGICAL REHABILITATION 1983

Figure 2. Approaches utilized in day-to-day cognitive rehabilitation reported by clinicians.

Note: categories generated from open-text survey, with number of survey responses presented above each percen-
tage value bar.

functioning (see Figure 4). Respondents frequently identified utilizing external

aids, especially for memory, including diaries and agendas (n = 13), electronic
devices such as smartphones and tablets (n = 10), and prompts and notes (n =
5). Six of the 115 (5.2%) respondents reported the use of errorless learning to
teach strategies to deliver functional retraining as part of cognitive rehabilitation.

Figure 3. Cognitive domains of focus within cognitive retraining approaches.

Note: categories generated from open-text survey, with number of survey responses presented above each percen-
tage value bar.
1984 C. NOWELL ET AL.

Figure 4. Cognitive domains of focus within functional compensatory approaches.

Note: categories generated from open-text survey, with number of survey responses presented above each percen-
tage value bar.

When asked specifically about the type of strategies used in all cognitive
domains, of 113 respondents, 101 (89.4%) indicated that they used strategies
requiring external input, either from close others or care workers, or from elec-
tronic prompters. Ninety-seven (85.8%) indicated that they used strategies
initiated by the client, such as diary/phone use and attention strategies.
Twenty-four of 113 (21.2%) respondents indicated the use of other strategies,
such as education.
Allied health professionals most frequently assessed the effectiveness of cog-
nitive rehabilitation through self-report by client or close other regarding
improvement on functional tasks (n = 95 of 113; 82.6%). This was followed by
objective measures, such as neuropsychological re-assessment (n = 92 of 113;
81.4%), and attainment of functional goals (n = 91 of 113; 80.5%). Twenty-five
of 112 (22.3%) respondents indicated the use of other measures to determine
cognitive rehabilitation efficacy, such as clinician observation of the client and
reports from other staff in the rehabilitation setting.
The assessment for need, design, implementation and outcomes of cognitive
rehabilitation was most commonly documented in clinician reports (n = 90 of
115; 78.3%), followed by: medical files (n = 68 of 115; 59.1%); client resources,
such as diaries (n = 39 of 115; 33.9%); and departmental files (n = 33 of 115;
28.7%). Thirteen of 114 respondents (11.4%) also reported documentation in
other resources, such as interviews, client notes, and testing/assessment.
 NEUROPSYCHOLOGICAL REHABILITATION 1985

Resources for cognitive rehabilitation

The percentages of respondents who were aware of resources to inform the

practice of TBI cognitive rehabilitation are displayed in Table 2. Percentages of
use are also presented, if respondents reported awareness and use of these
resources.
Journal articles and reviews were most commonly used, followed by text-
books and CPGs. Of those who reported utilizing CPGs, 29 of 70 (41.4%) respon-
dents used them less than once per month. Journal articles or reviews were most
commonly used more than once per month by 22 of 80 (27.5%) respondents,
and textbooks were most commonly used less than once per month by 19 of
71 (26.8%) respondents. Professional association websites were not commonly
used, with 19 of 45 (42.2%) respondents reporting their use less than once per
month. Internal departmental protocols were used more than once a week by
12 of 46 (26.1%) respondents but less than once per month by 15 of 46 (32.6%).

Reflections on cognitive rehabilitation

Factors aiding cognitive rehabilitation
From 85 responses regarding factors aiding cognitive rehabilitation, three
themes were identified: (1) client factors, (2) rehabilitation setting and process
factors, and (3) clinician factors. A thematic map representing these themes,
with the most commonly identified sub-themes, is displayed in Figure 5.
For client factors, 37 (43.5%) respondents identified the client’s social support
network as an important factor:
It really helps when the whole team and the family all involve in meeting a determined
goal, and when all those persons have similar and predictable reactions … (R442)

This was followed by client engagement and motivation (n = 17 of 85; 20%):

Engagement in the process is the single most important factor. All else is secondary (R231)

Client awareness and insight into their difficulties were also reported to aid
cognitive rehabilitation by respondents (n = 15 of 85; 17.6%): Good awareness
of cognitive impairment (R271), as well as good cognitive and interpersonal

Table 2. Awareness and utilization of resources for cognitive rehabilitation.

Resource type Aware of resource (% Yes) Use of resource (% Yes)
Journal article or review 91.8 (n = 90 of 98) 96.2 (n = 76 of 79)
Textbook 87.1 (n = 81 of 93) 97.1 (n = 67 of 69)
Clinical practice guideline (CPG) 82.3 (n = 79 of 96) 84.4 (n = 65 of 77)
Departmental colleagues (outside meetings) 78.0 (n = 71 of 91) 86.7 (n = 52 of 60)
Professional association website or other resources 70.8 (n = 63 of 89) 64.4 (n = 38 of 59)
Departmental meeting 68.9 (n = 62 of 90) 84.9 (n = 45 of 53)
Internal/departmental protocol 61.8 (n = 55 of 89) 70.2 (n = 40 of 57)
Medical review website 41.4 (n = 36 of 87) 38.8 (n = 19 of 49)
Other 36.8 (n = 14 of 38) 59.1 (n = 13 of 22)
1986 C. NOWELL ET AL.

Figure 5. Thematic map of factors that facilitate cognitive rehabilitation.

functioning (n = 8 of 85; 9.4%), structural supports (n = 7 of 85; 8.2%), and the

absence of adverse factors (n = 5 of 85; 5.9%).
The most common rehabilitation setting and process factor reported to aid
cognitive rehabilitation was rehabilitation team and professional collaboration
(n = 38 of 85; 44.7%):

There is a staff member in each department and we all work together as a team and we
collaborate for each patient … It helps to brainstorm and problem-solve as well as to
share insights when one of us finds a better way to cue a patient or other relevant infor-
mation that may impact therapy (R286)

Specific and personalized rehabilitation, often involving the use of individua-

lized goals, was also identified as important by 18 of the 85 (21.2%)
respondents:

… goals of the specific patient. Personal goals for practical situations are the best to
achieve positive outcomes (R227)

Opportunities for functional assessment (n = 11 of 85; 12.9%), regular contact

with the client (n = 6 of 85; 7.1%) and having sufficient time to provide cognitive
rehabilitation (n = 5 of 85; 5.9%) were also identified as important.
The most common clinician-related factor reported to aid cognitive rehabilita-
tion was the therapeutic relationship (n = 7 of 85; 8.2%):

Staff being able to establish a good emotional contact with the patient and relatives
(R299)

Client to practitioner dialogue; Non-judgemental interactions (R256)

The presence of skilled staff was also identified by one respondent to aid cog-
nitive rehabilitation.
 NEUROPSYCHOLOGICAL REHABILITATION 1987

Factors hindering cognitive rehabilitation

Within the 81 responses received regarding factors that hinder cognitive rehabi-
litation, responses again fell into the same three themes: (1) client factors, (2)
rehabilitation setting and process factors, and (3) clinician factors. A thematic
map representing these themes, with the most commonly identified sub-
themes, is displayed in Figure 6.
For client factors hindering cognitive rehabilitation, 31 (38.3%) respondents
reported the client having a poor social support network, in terms of family,
friends, carers, employers, and teachers, as a hindrance:
lack of family/caregiver support or conflict between caregiver and client (R303)

Also when parents do not involve (themselves) in treatment, do not understand the
child’(s) impairments or how to help them, it is a very important limitation, which
can sometimes lead the treatment to failure, especially when children go back home
and need further adaptations and treatments in the community (R442)

This was followed by a client’s lack of awareness or insight into their cognitive
impairments (n = 19 of 81; 23.5%):
Poor insight and motivation of clients. Makes it hard for them to recognise their pro-
blems, accept need for cognitive rehabilitation and have the cognitive ability to use
them consistently (R270)

Poor, or lack of, engagement and motivation by the individual with a TBI was
also identified as a hinderance (n = 16 of 81; 19.8%): poor attendance by clients
can reduce input (R245). The presence of mental health and neuropsychiatric
issues, such as depression (R263), … anxiety … (R275), persistent neuropsychiatric
disorders (R280) and premorbid personality issues (narcissistic, borderline, paranoid
personality) (R284) were also identified as hindering rehabilitation (n = 11 of 81;
13.6%), as well as the presence of client behavioural issues (n = 9 of 81;
11.1%). Greater severity of client injury and of cognitive impairment were also

Figure 6. Thematic map of factors that hinder cognitive rehabilitation.

1988 C. NOWELL ET AL.

identified by seven (8.6%) respondents as factors impeding cognitive

rehabilitation.
A commonly reported rehabilitation setting and process factor impeding cog-
nitive rehabilitation was financial constraints (n = 18 of 81; 22.2%):
Lack of funding in my public hospital role prohibits the provision of cognitive rehab
(R248)

A lack of time to provide rehabilitation to clients and early client discharge

were similarly reported as impediments (n = 18 of 81; 22.2%):
Time! Many people need a lot of repetition and intensive work to fully use strategies
and implement ‘good habits’ to manage their difficulties (R270)

Poor team and professional collaboration and cohesion were also reported as
hindering rehabilitation outcomes (n = 12 of 81; 14.8%):
broader team don’t always recognise the importance of cognitive strategies – not sup-
porting use of diary etc (R310)

The approach taken towards rehabilitation and the process structure were
also identified as impediments to rehabilitation if they were inappropriate or
inconsistent (n = 9 of 81; 11.1%):

Less structures and to(o) much stimuli towards the patient is negative (R246)

Cog Rehab not connected with (client) personality and environment (R282)

Clinicians also reported lack of resources for rehabilitation (n = 7 of 81;

8.6%) as hindering optimal rehabilitation outcomes for clients, along with poor
client contact (n = 4 of 81; 4.9%), and a lack of effective treatments (n = 4 of
81; 4.9%).
Of factors relating to clinicians, the most commonly reported impediment to
cognitive rehabilitation was poor communication (n = 10 of 81; 12.3%): some
difficulties with communication where staff work part time (R245) and poor com-
munication within the team (R305). Following this, a lack of rehabilitation staff
skill, knowledge, and experience in required areas was also identified (n = 9 of
81; 11.1%):

lack of training from staff, who think that cognitive rehab is equal to cognitive restor-
ation (R284)

Other clinician factors reported to hinder rehabilitation outcomes included a

poor-quality therapeutic relationship (n = 2 of 81; 2.5%), clinicians lacking time (n
= 1 of 81; 1.2%), and lacking motivation (n = 1 of 81; 1.2%).

Ranking of cognitive domains for ease of rehabilitation

Respondents ranked attention and information processing speed (n = 31 of 86;
36%) and memory (n = 22 of 86; 25.6%) as the easiest domains in which to
 NEUROPSYCHOLOGICAL REHABILITATION 1989

provide cognitive rehabilitation. The reasons given for this ranking of attention
and information processing speed included:

there are many exercises available to enhance attention and a lot can be done using the
computer (R228)

… many and easily administered methods and tasks, and is quite clear to handle via
psychoeducation (R312)

The reasons given for the ranking of memory included:

There is much evidence in the literature for the usefulness of external compensatory
memory strategies and many different types that can be taught. They are easily trans-
lated into everyday functioning (R303)

Memory is something that patients generally agree is something they’d like to improve
… (R286)

Survey respondents ranked executive functioning (n = 29 of 87; 33.3%) and

PTA (n = 23 of 86; 26.7%) as the most difficult domains in which to provide cog-
nitive rehabilitation. Reasons for this ranking of executive functioning included:
… remains the worst and most difficult area, as it is precisely the self monitoring and
strategy implementation that is impaired and sometimes impossible to improve (with
meaningful progress in untrained tasks and generalisation to everyday life I mean,
not on just improving tests …) (R442)

executive dysfunctioning often co-occurs with deficits of awareness, which makes

patients less intrinsic(ally) motivated (R236)

The reasons given for the ranking of PTA included:

it depends on the person’s awareness, however, often times when the person has ano-
sognosia and are in denial, then providing any cognitive rehabilitation is dif(f)icult for
generalization of tasks (R307)

Another participant also responded: seems little relevant literature (R229).

Discussion
This study aimed to explore current clinician practice in cognitive rehabilitation
following TBI across countries, excluding Australia. It was found that day-to-day
cognitive rehabilitation most commonly involved cognitive retraining and func-
tional compensation interventions, consistent with findings in an Australian clin-
ician sample (Downing et al., 2019). Cognitive domains frequently addressed by
retraining interventions were attention, executive function, and memory (includ-
ing working memory). This is mostly consistent with recommendations from
INCOG (Ponsford, Bayley et al., 2014; Tate et al., 2014), and again generally
aligns Australian clinician reports (Downing et al., 2019). Non-Australian clinicians
reported addressing attentional deficits with cognitive retraining more than
1990 C. NOWELL ET AL.

Australian clinicians (21.7% versus 6.8% of respondents, respectively; Downing

et al., 2019). Unlike Australian clinicians (Downing et al., 2019), non-Australian
clinicians also rated attention and information processing speed as one of the
easiest cognitive domains in which to provide cognitive rehabilitation. There
appeared to be greater use of computer training for attention, despite the
lack of strong evidence surrounding interventions for attention (Ponsford,
Bayley et al., 2014). Non-Australian clinicians also reported a use of retraining
interventions addressing memory to a greater extent than recommended by
guidelines (Velikonja et al., 2014) and compared to Australian clinicians (16.5%
versus 2.7% of respondents; Downing et al., 2019). This may reflect working
memory being included within the domain of memory by participants in the
survey, as computer programmes targeting working memory (such as Cogmed
QM), are gaining popularity in clinical practice and research, although presently
the level of empirical support remains limited (Velikonja et al., 2014). However,
such use of computer training for attention and memory may also reflect a
need for greater training of clinicians and the use of empirically supported
interventions.
Within functional compensation interventions, memory was the cognitive
domain most frequently targeted. Consistent with evidence-based recommen-
dations and Australian clinician practice, the use of external memory aids,
such as diaries and agendas, smartphones and tablets, and prompts and notes
were often identified (Downing et al., 2019; Velikonja et al., 2014). Similarly, align-
ing with findings regarding Australian clinicians, memory was rated as one of the
easiest cognitive domains in which to provide cognitive rehabilitation. A general
compensatory approach to cognitive rehabilitation (where respondents did not
specify cognitive domains) was also regularly identified, in line with INCOG rec-
ommendations (Ponsford, Bayley et al., 2014; Tate et al., 2014; Togher et al., 2014;
Velikonja et al., 2014). Clinicians also reported that common processes of day-to-
day cognitive rehabilitation included assessment, goal setting and implemen-
tation. Furthermore, clinicians identified the use of specific and appropriate
goals for cognitive rehabilitation as an important factor in the success of cogni-
tive rehabilitation. This aligns with practices of Australian clinicians (Downing
et al., 2019; Pagan et al., 2015), and previous findings that goal setting and
assessment are core elements of brain injury rehabilitation (Doig, Fleming, Corn-
well, & Kuipers, 2009; Evans, 2012; Sander, Raymer, Wertheimer, & Paul, 2009).
However, the use of goals was reported less commonly than retraining and com-
pensation interventions by clinicians. This may suggest that some clinicians do
not consider goal setting to be a cognitive rehabilitation practice, perhaps sig-
nifying a need for further training. Further investigation of the importance of
goal setting in cognitive rehabilitation is warranted.
Consistent with reports by Australian clinicians, executive functioning was
rated one of the most difficult domains in which to provide cognitive rehabilita-
tion, due to lack of client self-awareness. However, PTA was also rated as difficult
 NEUROPSYCHOLOGICAL REHABILITATION 1991

due to a lack of literature. Downing et al. (2019) reported that PTA was identified
as one of the easiest domains in which to provide cognitive rehabilitation by
Australian clinicians, likely reflecting the existence of relatively well-defined pro-
tocols for PTA assessment and management in Australian settings. There appears
to be a need for such protocols in other countries (Ponsford, 2017; Ponsford,
Janzen et al., 2014). The effectiveness of interventions and cognitive rehabilation
was most frequently assessed by self-report and objective measures (such as
neuropsychological re-assessment), whilst Australian clinicians also commonly
identified attainment of functional goals (Downing et al., 2019). Respondents
most commonly used journal articles and reviews to inform their cognitive reha-
bilitation practice, although they were also more aware of and more likely to
utilize CPGs than Australian and Canadian clinicians (Downing et al., 2019;
Lamontagne et al., 2018a). This discrepancy may reflect the fact that inter-
national respondents were sampled from a database of clinicians engaged in
conferences, who therefore were likely to have been made aware of the guide-
lines. However, CPGs were most commonly used less than once per month.
Lamontagne et al. (2018a) reported that clinicians felt ill-equipped to utilized
CPGs. Thus, as CPGs are up-to-date resources for clinicians, based on appraised
evidence and involve international input from researchers and clinicians, further
education regarding CPGs may be required.
Rehabilitation team and professional collaboration was commonly identified
by participants as important in optimizing cognitive rehabilitation. The quality
of clients’ social support network was also considered highly significant by a
number of respondents, as well as their motivation and engagement with inter-
ventions, and self-awareness. There has been a very limited formal investigation
of the impact of such factors on cognitive rehabilitation, and therefore empirical
identification of their impact is required. Clinicians also need to consider these
factors when selecting appropriate interventions. Other factors identified as
important to consider include the quality of the therapeutic relationship and
communication with the client, as well as the availability of time and
finances. These findings generally align with other similar investigations into
clinician practice and experience (Downing et al., 2019; Kelly, McDonald, &
Frith, 2017b; Pagan et al., 2015), highlighting that effectiveness of interventions
cannot be evaluated in isolation from other considerations relating to the client,
clinician and rehabilitation setting. Thus, there is a need for formal examination
of the impact of these factors on response to therapy. Furthermore, the devel-
opment of future CPGs should utilize clinician reflections, as the recent INESSS-
ONF guidelines have. Such insights can make explicit the tacit knowledge of
clinicians providing care, identifying opportunities to fully realize the potential
of CPGs.
This research is not without limitations. The snowball sampling method used
likely created bias in this study, as the mailing list used had a bias toward clini-
cians more engaged in the field, and, as there is no denominator for this survey,
1992 C. NOWELL ET AL.

the response rate is unknown. Whilst this research aimed to explore international
clinician practice, the survey required respondents to complete the questions in
English. The generalisability of these findings is therefore limited and may only
represent English-speaking clinicians interested in brain impairment and
engaged with conferences. Many clinicians in poorly resourced countries do
not have the resources to deliver cognitive rehabilitation and they would not
have responded to the survey. Thus, further research needs to be conducted
with larger samples of varied international clinicians, to more successfully
reflect current international practice. Such research, utilizing a less restricted
and biased sample, may also allow for comparison across countries, advancing
current knowledge of clinician practice. However, this limitation also reflects a
general imbalance between recommendations for practice and measures of
actual practice. Across many areas of medicine, including cognitive rehabilita-
tion, there is a relative dearth of studies examining current clinical practice
and its drivers when compared to the availability of CPGs and other evidence-
informed recommendations. This may be due to the difficulty and resource-
intensity of auditing and qualitatively exploring the clinical practice. Similarly,
a self-report measure was relied on to explore the current practice of cognitive
rehabilitation by respondents and conducting a broad-based audit of client files
remains necessary to document actual practice.
This research demonstrates that, based on the survey, the domains of atten-
tion, executive functioning, and memory are most commonly addressed by inter-
national clinicians engaged in cognitive rehabilitation. Whilst both cognitive
retraining and functional compensation approaches are utilized to address
impairments, there was somewhat greater use of computerized approaches to
retraining of attention and working memory in the present survey, compared
to the previously published survey of Australian clinicians. Broadly, practice
appears to be consistent with the current recommendations and evidence.
However, there is a significant gap in the current literature concerning the
impact of client, clinician, and rehabilitation setting and process factors on the
success of specific cognitive rehabilitation approaches. This research has there-
fore highlighted the need for clinicians to be more heavily involved in the devel-
opment of CPGs.

Disclosure statement
No potential conflict of interest was reported by the authors.

Ethical standards
All authors assert that all procedures contributing to this work were conducted
with formal approval of the relevant institutional and national committees, and
comply with the principles of the Helsinki Declaration of 1975, as revised in 2013.
 NEUROPSYCHOLOGICAL REHABILITATION 1993

ORCID
Clare Nowell http://orcid.org/0000-0003-2263-0153
Marina Downing http://orcid.org/0000-0002-3126-6632
Peter Bragge http://orcid.org/0000-0003-0745-5131
Jennie Ponsford http://orcid.org/0000-0003-0430-125X

References
Barman, A., Chatterjee, A., & Bhide, R. (2016). Cognitive impairment and rehabilitation strat-
egies after traumatic brain injury. Indian Journal of Psychological Medicine, 38(3), 172–181.
Bayley, M. T., Lamontagne, M.-T., Kua, A., Marshall, S., Marier-Deschenes, P., Allaire, A.-S., …
Swaine, B. (2018). Unique features of the INESSS-ONF rehabilitation guidelines for moderate
to severe traumatic brain injury: Responding to users’ needs. Journal of Head Trauma
Rehabilitation, 33(5), 296–305.
Bayley, M. T., Tate, R. L., Douglas, J. M., Turkstra, L. S., Ponsford, J. L., Stergiou-Kita, M., … Bragge,
P. (2014). INCOG guidelines for cognitive rehabilitation following traumatic brain injury:
Methods and overview. Journal of Head Trauma Rehabilitation, 29(4), 290–306.
Ben-Yishay, Y., & Diller, L. (1993). Cognitive remediation in traumatic brain injury: Update and
issues. Archives of Physical Medicine and Rehabilitation, 74(2), 204–213.
Boyatzis, R. E. (1998). Transforming qualitative information: Thematic analysis and code develop-
ment. Thousand Oaks, CA: Sage Publications.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in
Psychology, 3(2), 77–101.
Campbell, M. (2000). Rehabilitation for traumatic brain injury: Physical therapy practice in
context.. Enginburgh: Churchill Livingstone.
Cicerone, K. D., Dahlberg, C., Kalmar, K., Langenbahn, D. M., Malec, J. F., Bergquist, T., …
Harrington, D. E. (2000). Evidence-based cognitive rehabilitation: Recommendations for
clinical practice. Archives of Physical Medicine and Rehabilitation, 81(12), 1596–1615.
Cicerone, K. D., Dahlberg, C., Malec, J. F., Langenbahn, D. M., Felicetti, T., Kneipp, S., …
Catanese, J. (2005). Evidence-based cognitive rehabilitation: Updated review of the litera-
ture from 1998 through 2002. Archives of Physical Medicine and Rehabilitation, 86(8),
1681–1692.
Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J., Kalmar, K., Fraas, M., … Ashman, T.
(2011). Evidence-based cognitive rehabilitation: Updated review of the literature from
2003 through 2008. Archives of Physical Medicine and Rehabilitation, 92(4), 519–530.
Cohen, J. (1960). A coefficient of agreement for nominal scales. Educational and Psychological
Measurement, 20(1), 37–46.
Corrigan, J. D., Selassie, A. W., & Orman, J. A. (2010). The Epidemiology of traumatic brain injury.
Journal of Head Trauma Rehabilitation, 25(2), 72–80.
Creswell, J. W. (2009). Research design: Qualitative, quantitative, and mixed methods approaches
(3rd ed). Thousand Oaks, CA: Sage Publications.
Doig, E., Fleming, J., Cornwell, P. L., & Kuipers, P. (2009). Qualitative exploration of a client-cen-
tered, goal-directed approach to community-based occupational therapy for adults with
traumatic brain injury. American Journal of Occupational Therapy, 63(5), 559–568.
Downing, M., Bragge, P., & Ponsford, J. (2019). Cognitive rehabilitation following traumatic
brain injury: A survey of current practice in Australia. Brain Impairment, 20(1), 24–36.
Ehlhardt, L. A., Sohlberg, M. M., Kennedy, M., Coelho, C., Ylvisaker, M., Turkstra, L., & Yorkston, K.
(2008). Evidence-based practice guidelines for instructing individuals with neurogenic
1994 C. NOWELL ET AL.

memory impairments: What have we learned in the past 20 years? Neuropsychological

Rehabilitation, 18(3), 300–342.
Evans, J. J. (2012). Goal setting during rehabilitation early and late after acquired brain injury.
Current Opinion in Neurology, 25(6), 651–655.
Institute of Medicine. (2011). Cognitive rehabilitation therapy for traumatic brain injury:
Evaluating the evidence. Washington, DC: The National Academies Press.
Kelly, M., McDonald, S., & Frith, M. H. J. (2017a). Assessment and rehabilitation of social cogni-
tion impairment after brain injury: Surveying practices of clinicians. Brain Impairment, 18(1),
11–35.
Kelly, M., McDonald, S., & Frith, M. H. J. (2017b). A survey of clinicians working in brain injury
rehabilitation: Are social cognition impairments on the radar? The Journal of Head Trauma
Rehabilitation, 32(4), E55–E65.
Kewman, D. G., Seigerman, C., Kintner, H., Chu, S., Henson, D., & Reeder, C. (1985). Simulation
training of psychomotor skills: Teaching the brain-injured to drive. Rehabilitation
Psychology, 30(1), 11–27.
Lamontagne, M.-T., Bayley, M., Marshall, S., Kua, A., Marier-Deschenes, P., Allaire, A.-S., …
Swaine, B. (2018a). Assessment of users’ needs and expectations toward clinical practice
guidelines to support the rehabilitation of adults with moderate to severe traumatic
brain injury. Journal of Head Trauma Rehabilitation, 33(5), 288–295.
Lamontagne, M.-T., Gargaro, J., Marier-Deschenes, P., Truchon, C., Bayley, M., Marshall, S., …
Swaine, B. (2018b). A survey of perceived implementation gaps for a clinical practice guide-
line for the rehabilitation of adults with moderate to severe traumatic brain injury. Journal of
Head Trauma Rehabilitation, 33(5), 306–316.
Pagan, E., Ownsworth, T., McDonald, S., Fleming, J., Honan, C., & Togher, L. (2015). A survey of
multidisciplinary clinicians working in rehabilitation for people with traumatic brain injury.
Brain Impairment, 16(3), 173–195.
Ponsford, J. (2017). International growth of neuropsychology. Neuropsychology, 31(8), 921–933.
Ponsford, J. L., Bayley, M. T., Wiseman-Hakes, C., Togher, L., Velikonja, D., McIntyre, A., … Tate, R.
L. (2014). INCOG recommendations for management of cognition following traumatic brain
injury, part II: Attention and information processing speed. Journal of Head Trauma
Rehabilitation, 29(4), 321–337.
Ponsford, J. L., Downing, M. G., Olver, J., Ponsford, M., Acher, R., Carty, M., & Spitz, G. (2014).
Longitudinal follow-up of patients with traumatic brain injury: Outcome at two, five, and
ten years post-injury. Journal of Neurotrauma, 31(1), 64–77.
Ponsford, J. L., Janzen, S., McIntyre, A., Bayley, M. T., Velikonja, D., & Tate, R. L. (2014).
INCOG recommendations for management of cognition following traumatic brain injury,
part I: Posttraumatic amnesia/delirium. Journal of Head Trauma Rehabilitation, 29(4),
307–320.
Ponsford, J. L., Sloan, S., & Snow, P. (2012). Traumatic brain injury: Rehabilitation for everyday
adaptive living (2nd ed.). New York, NY: Psychology Press.
Ponsford, J. L., & Spitz, G. (2015). Stability of employment over the first 3 years following trau-
matic brain injury. The Journal of Head Trauma Rehabilitation, 30(3), E1–E11.
Rabinowitz, A. R., & Levin, H. S. (2014). Cognitive sequelae of traumatic brain injury. The
Psychiatric Clinics of North America, 37(1), 1–11.
Rees, L., Marshall, S., Hartridge, C., Mackie, D., & Weiser, M. (2007). Cognitive interventions post
acquired brain injury. Brain Injury, 21(2), 161–200.
Ruet, A., Jourdan, C., Bayen, E., Darnoux, E., Sahridj, D., Ghout, I., … Azouvi, P. (2018).
Employment outcome four years after a severe traumatic brain injury: Results of the Paris
severe traumatic brain injury study. Disability and Rehabilitation, 40(18), 2200–2207.
 NEUROPSYCHOLOGICAL REHABILITATION 1995

Sander, A. M., Raymer, A., Wertheimer, J., & Paul, D. (2009). Perceived roles and collaboration
between neuropsychologists and speech-language pathologists in rehabilitation. The
Clinical Neuropsychologist, 23(7), 1196–1212.
Sohlberg, M. M., & Mateer, C. A. (1987). Effectiveness of an attention-training program. Journal
of Clinical and Experimental Neuropsychology, 9(2), 117–130.
Swaine, B., Bayley, M., Marshall, S., Kua, A., Marier-Deschenes, P., Allaire, A.-S., … Lamontagne,
M.-T. (2018). Why do we need a new clinical practice guideline for moderate to severe trau-
matic brain injury? Journal of Head Trauma Rehabilitation, 33(5), 285–287.
Tate, R. L., Kennedy, M., Ponsford, J. L., Douglas, J. M., Velikonja, D., Bayley, M. T., & Stergiou-Kita,
M. (2014). INCOG recommendations for management of cognition following traumatic
brain injury, part III: Executive function and self-awareness. Journal of Head Trauma
Rehabilitation, 29(4), 338–352.
Togher, L., Wiseman-Hakes, C., Douglas, J. M., Stergiou-Kita, M., Ponsford, J. L., Teasell, R., …
Turkstra, L. S. (2014). INCOG recommendations for management of cognition following
traumatic brain injury, part IV: Cognitive communication. Journal of Head Trauma
Rehabilitation, 29(4), 353-368.
Truchon, C., Kagan, C., Bayley, M., Swaine, B., Lamontagne, M.-E., Marshall, S., … Gargaro, J.
(2017). INESSS-ONF clinical practice guidelines for the rehabilitation of adults having sus-
tained a moderate-to-severe TBI. Brain Injury, 31(6-7), 741–741.
Velikonja, D., Tate, R. L., Ponsford, J. L., McIntyre, A., Janzen, S., & Bayley, M. T. (2014). INCOG
recommendations for management of cognition following traumatic brain injury, part V:
Memory. Journal of Head Trauma Rehabilitation, 29(4), 369–386.
Viera, A. J., & Garrett, J. M. (2005). Understanding interobserver agreement: The kappa statistic.
Family Medicine, 37(5), 360–363.
Wilson, B. A. (2009). Memory rehabilitation: Integrating theory and practice. New York, NY:
Guilford Press.
Ylvisaker, M., Hanks, R., & Johnson-Greene, D. (2002). Perspectives on rehabilitation of individ-
uals with cognitive impairment after brain injury: Rationale for reconsideration of theoreti-
cal paradigms. The Journal of Head Trauma Rehabilitation, 17(3), 191–209.
Copyright of Neuropsychological Rehabilitation is the property of Taylor & Francis Ltd and
its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.