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This article is to update the INCOG 2014 guidelines for the management of cognitive-communication disorders. Since INCOG 2014, there have been advances in the development of models of cognitive-communication,4 social cognition,14 and increased use of telehealth approaches,18,19 particularly following COVID-19.20 Changes to communication ability become evident as soon as the person emerges from coma, during the period of posttraumatic amnesia (PTA). During this time, a speech-language pathologist should identify and facilitate the optimal means of communication. INCOG 2.0 refers to cognitive-communication recommendations after the person has emerged from PTA. For further information regarding management during PTA, please refer to Ponsford et al21 in this issue (INCOG 2.0, Part I: posttraumatic amnesia). The recommendations are organized according to the model of cognitive-communication competence by MacDonald,4 which comprises 7 domains, 7 competencies, and 47 factors related to communication functioning and intervention. The model was designed to improve consistency with referrals, guide assessment and treatment, and plan service needs. The 7 domains are the individual, the contextual domain, the environmental domain, the cognitive domain, the communication domain, the physical/sensory domain, and the emotional/psychosocial domain.4 The model illustrates the complexity of cognitive-communication disorders in people with TBI and shows the importance of the context in which communication takes place, including not only the cognitive, behavioral, and sensorimotor abilities of the person, but also the central role of communication partners, and the necessary integration of all these factors to enable social competence. These concepts underpin the INCOG 2.0 cognitive-communication guidelines. METHODS Updated INCOG guidelines The reader is referred to the methods paper of this series for a complete review of the strategies used for the updated literature review (from 2014) and development of the recommendations and other tools (see INCOG 2.0 Methods, Overview, and Principles).22 The target population of this guideline is adults 18 years and older with moderate to severe TBI. In brief, the updated INCOG (with INCOG being an acronym standing for “International Cognitive”) guideline follows a thorough search, review, and critical evaluation of currently published clinical practice guidelines (from 2014) for each domain including principles of assessment, PTA, attention, memory, executive functions, and cognitive-communication. An international expert panel comprising of TBI cognitive rehabilitation researchers and clinicians, most from the first version of INCOG, formed the authors. In preparation, a detailed Internet and Medline search was conducted to identify new published TBI and cognitive rehabilitation evidence-based guidelines (from 2014). A systematic search (2014 to July 2021) of multiple databases (Medline, Embase, Cochrane, CINAHL, and PsycINFO) was also conducted to identify TBI articles and reviews. Research articles meeting inclusion but published after July 2021 were added based on the discretion of the expert panel. Two authors independently aligned the research articles within the existing INCOG guidelines and flagged areas where new guidelines may be warranted based on the research evidence. The evidence for this topic area was distributed to the cognitive-communication working group. During the series of videoconference meetings, the working group examined the recommendations matrix and updated some recommendations based on new evidence,

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#6 Individuals with severe communication disability following TBI should be provided with proper assessment to determine the appropriate augmentative and alternative communication (AAC) intervention by trained clinicians. The individual and close communication partners should be provided with training to effectively use AAC aids. This training should be ongoing as needs change and technology evolves. C (Updated from INCOG 2014,23 Cognitive-communication 6, p. 357) Cognitive communication #7 Clinicians should consider group therapy as an appropriate means of remediation of cognitive-communication training when social communication impairments exist post-TBI. Where aligned with their communication goals, clinicians should consider group therapy (updated from INCOG 2014,23 cognitive-communication 7, p. 361). A Lê et al40 Harrison-Felix et al65 Behn et al39Behn et al38Bosco et al67Copley et al64Douglas et al45Finch et al63Gabbatore et al66Keegan et al54Parola et al68Whitworth et al62 Cognitive-communication #8 Telerehabilitation is as efficacious, feasible, and acceptable for communication partner training compared with in-person intervention (INCOG 2.0). B Rietdijk et al19Rietdijk et al37 Rietdijk et al18 Social cognition #1 Clinicians should consider evaluating aspects of social cognition ability, including emotion perception, theory of mind (ToM), and emotional empathy. Interventions that aim at improving emotion perception, perspective taking, ToM, and social behavior are recommended. Computerized social cognition treatments are not recommended given lack of evidence of generalization to real life-activities (INCOG 2.0). A Cassel et al14Henry et al12McDonald91Turkstra et al92Vallat-Azouvi et al15 Bornhofen and McDonald58McDonald et al75Neumann et al80Westerhof-Evers et al73 Cassel et al72Gabbatore et al66Ownsworth et al78Rodríguez-Rajo et al79 Abbreviations: RCT, randomized controlled trial; TBI, traumatic brain injury.aRefer to Togher et al23 for evidence contributing to the recommendations prior to 2014. Cognitive-communication #1: Rehabilitation staff should recognize that levels of communication competence and communication characteristics may vary as a function of their communication partners, environment, communication demands, communication priorities, fatigue, physical and sensory issues (eg, vision, hearing), psychosocial variables, behavioral dyscontrol, emotional variables, and other personal factors (updated from INCOG 2014,23Cognitive-communication 1, p. 356). Level B evidence. This recommendation is similar to INCOG 2014, except for the addition of physical, sensory, and psychosocial variables. These were added in recognition of the frequently reported physical co-occurring or comorbid factors. Dysarthria is a persistent motor speech disorder arising after TBI,24 with estimated prevalence varying from 6% to 60%25 (see Togher et al26 for overview). Dysarthria should be considered when designing cognitive-communication interventions, with inclusion of modifications and augmentative and alternative communication, where indicated (AAC) to facilitate rehabilitation (see Cognitive-communication #6 regarding AAC). Other comorbid physical sequelae such as balance disorders, dizziness or vestibular issues, visual disturbances, hearing deficits, sleep-wake disorders, and pain can impede participation in conversation and should be addressed by the multidisciplinary team. Hearing and vision screening should be routinely conducted to ensure these sensory issues are not confounding communication outcomes.27 It is imperative that accommodations are made for sensory loss or disturbance, including availability of eyeglasses and hearing aids to ensure accurate assessment and interventions. Psychosocial, behavioral dyscontrol and emotional variables can also impact cognitive-communication competence. Anxiety,28 depression, and posttraumatic stress disorders may be

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Articulated novel recommendations based on the evidence available, and considered the clinical applicability of recommendations to enhance outcomes for individuals with TBI. For each recommendation, the cumulative evidence (studies used in the original guidelines and new articles) was evaluated by the panel in terms of study design and study quality, to determine the level of evidence grading (see Table 1). TABLE 1 - INCOG level of evidence grading system A: Recommendation supported by at least one meta-analysis, systematic review, or randomized controlled trial of appropriate size with relevant control group. B: Recommendation supported by cohort studies that at minimum have a comparison group (includes small randomized controlled trials) and well-designed single-case experimental designs. C: Recommendation supported primarily by expert opinion based on their experience, though uncontrolled case studies or series may also be included here. All relevant references after 2014 were consolidated into a reference library that was made available to the author teams, as they drafted the manuscript and finalized the recommendations. Consensus of the working group was reached when members unanimously agreed to the wording and evidence grading assignment of all the recommendations. By the end, 26 new references related to cognitive-communication disorders (from 2014 forward) and 12 references for the new recommendation for social cognition (from 2000 forward) were included in the recommendations of this article. The clinical algorithm was updated accordingly in the management areas of cognitive-communication and social cognition. LIMITATIONS OF USE AND DISCLAIMER These recommendations are informed by evidence for TBI cognitive rehabilitation interventions that was current at the time of publication. Relevant evidence published after the INCOG guideline could influence the recommendations contained herein. Clinicians must also consider their own clinical judgment, patient preferences, and contextual factors such as resource availability in their decision-making processes about implementation of these recommendations. The INCOG developers, contributors, and supporting partners shall not be liable for any damages, claims, liabilities, costs, or obligations arising from the use or misuse of this material, including loss or damage arising from any claims made by a third party. RESULTS Recommendations and literature review The full details of the recommendations, level of evidence (grade), and supporting references categorized into systematic reviews or meta-analyses, randomized controlled trials (RCTs), and non-RCTs are tabulated in Table 2. The INCOG guidelines include 8 recommendations regarding best practice for the assessment and management of cognitive-communication disorders following TBI and 1 recommendation regarding social cognition management (see Table 2). For cognitive-communication, 3 recommendations represent principles of practice, which are embodied in current international practice standards for the speech-language pathology profession, determined by consensus expert opinion, and, therefore, represent level C evidence; 2 recommendations are based on level B evidence and 4 recommendations are based on level A evidence. For social cognition, there is 1 recommendation based on level A evidence. TABLE 2 - INCOG 2.0 guideline recommendations for cognitive-communication and social cognition and new supporting evidencea Guideline recommendations to improve cognitive-communication and social cognition Grade Reviews RCTs Other Cognitive-communication #1 Rehabilitation staff should recognize that levels of