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INCOG Recommendations for Management of Cognition Following Traumatic Brain Injury, Part III: Executive Function and Self-Awareness

Tate, Robyn PhD; Kennedy, Mary PhD; Ponsford, Jennie PhD; Douglas, Jacinta PhD; Velikonja, Diana PhD; Bayley, Mark MD, FRCPC; Stergiou-Kita, Mary PhD

Section Editor(s): Bayley, Mark Theodore MD; Bragge, Peter PhD; Ponsford, Jennie PhD

Journal of Head Trauma Rehabilitation: July/August 2014 - Volume 29 - Issue 4 - p 338–352
doi: 10.1097/HTR.0000000000000068
Original Articles

Introduction: Traumatic brain injury (TBI) results in complex cognitive (and other) sequelae. Impairments in executive function and self-awareness are among the most characteristic neuropsychological sequelae and can exert a profound effect on resuming previous life roles. An international group of researchers and clinicians (known as INCOG) convened to develop recommendations for interventions to improve impairments in executive functioning and self-awareness after TBI.

Methods: The team reviewed the available literature and ensured the recommendations were current. To promote implementation, the team developed decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials. The team then prioritized the recommendations for implementation and developed audit criteria to evaluate the adherence to the best practice recommendations.

Results: Intervention programs incorporating metacognitive strategy instruction for planning, problem-solving, and other cognitive-executive impairments have a solid evidence base. New evidence supports the use of strategies to specifically improve reasoning skills. Substantial support exists for use of direct corrective feedback to improve self-awareness.

Conclusions: An increasing number of scientifically well-designed studies are available that demonstrate the effectiveness of a variety of interventions for the remediation of impairments in executive function and self-awareness after TBI.

Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School—Northern, University of Sydney, Australia (Dr Tate); Royal Rehabilitation Centre Sydney, Australia (Dr Tate); NHMRC Centre of Research Excellence in Traumatic Brain Injury Psychosocial Rehabilitation, Australia (Drs Tate, Ponsford, and Douglas); Department of Communicative Sciences and Disorders, Chapman, University Orange, California, United States (Dr Kennedy); School of Psychology and Psychiatry, Monash University and Epworth Hospital, Melbourne, Australia (Dr Ponsford); National Trauma Research Institute, Monash University and the Alfred Hospital, Victoria, Australia (Dr Ponsford); School of Human Communication Sciences, La Trobe University, Melbourne, and Summer Foundation, Victoria, Australia (Dr Douglas); Neuropsychology, Acquired Brain Injury Program, Hamilton Health Sciences, Hamilton, Canada (Dr Velikonja); Department of Psychiatry and Behavioural Neurosciences, DeGroote School of Medicine, McMaster University, Hamilton, Canada (Dr Velikonja); UHN-Toronto Rehabilitation Institute, and Division of Physiatry, department of Medicine, University of Toronto, Toronto, Ontario, Canada (Dr Bayley); and University of Toronto and Toronto Rehabilitation Institute, Toronto, Ontario, Canada (Dr Stergiou-Kita).

Corresponding Author: Robyn Tate, PhD, Rehabilitation Studies Unit, University of Sydney, Level 9, Kolling Institute of Medical Research, Sydney Medical School - Northern, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia (

The authors declare no conflicts of interest.

We gratefully acknowledge the support of the Victorian Transport Accident Commission through its Victorian Neurotrauma Initiative, Monash University and the Ontario Neurotrauma Foundation for their support of this project.

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins