Cognitive Rehabilitation Therapy for Traumatic Brain Injury Evaluating the Evidence (2011) / Chapter Skim
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11 Multi-Modal or Comprehensive Cognitive Rehabilitation Therapy
11 Multi-Modal or Comprehensive Cognitive Rehabilitation Therapy
Pages 213-242
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From page 213... ...
Only one trial targeted mild TBI; three focused on the subacute phase while the other three focused on the chronic phase of recovery. Four of the six RCTs had some form of CRT in both trial arms.
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From page 214... ...
1999) of multi-modal/comprehensive CRT included patients in the subacute phase of recovery from mild, moderate, and severe TBI.
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Participants were randomly assigned to a comprehensive, 8-week in-hospital cognitive rehabilitation program or, after receiving some inpatient memory training, were discharged to home for a program of education and counseling via weekly telephone calls from a psychiatric nurse. During the telephone calls, which were described as lasting 30 minutes, nurses inquired about the week's events, offered support and advice in addressing problems, and checked on use of memory aids.
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From page 216... ...
The study reported no difference in primary outcomes of independent living or employment, and no difference on any secondary outcome measures including the FIM, measures of mood and behavior, the Disability Rating Scale, or a self-rating of memory. In subgroup analyses, patients younger than age 30 had better school or work outcomes in the cognitive-didactic arm, while those with higher education and older than age 30 did better in the functional-experiential arm on that primary outcome.
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From page 217... ...
of multi-modal/ comprehensive CRT delivered in the subacute phase (Bowen et al. 1999; Salazar et al.
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From page 218... ...
Of six nonrandomized, parallel group design studies identified and described in this review of chronic phase TBI patients, three studies compared comprehensive CRT to a non-CRT program, and three were comparative effectiveness studies of alternate CRT approaches. Implications of study results are markedly different for studies that compare CRT to an inert comparison or to a non-CRT comparator group, as these studies provide knowledge about efficacy, versus the stud
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From page 219... ...
Table 11-3 presents all chronic phase studies by design and treatment comparator. Comparator Group: Non-CRT Content The committee reviewed one RCT of comprehensive CRT in patients with chronic TBI (Tiersky et al.
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The intervention arm received about equal amounts of cognitive remediation (i.e., attention, information processing, memory) and individual cognitive behavioral therapy in two 50-minute sessions, 3 days per week over 11 weeks; the total intervention time is estimated at 55 hours.
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From page 221... ...
In the Parente and Stapleton (1999) study, outcomes were assessed among 33 TBI patients who had been referred to a rehabilitation program and given a program that included cognitive skills group sessions, computer training, training in use of electronic aids such as tape recorders or personal organizers, interviewing skills training, and peer teaching.
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From page 222... ...
Of note, however, most of the patients in the comparator "no rehabilitation" group did not meet inclusion criteria for the CRT program and thus were different from the group that did receive the CRT program. The study sample was in the chronic phase of recovery for mild TBI, on average 12 to 13 months postinjury.
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From page 223... ...
to a 288-hour standard inpatient neurorehabilitation program of physical, occupational, and neuropsychological therapies that "incorporated many of the principles of comprehensive neuro-psychological rehabilitation" but in a less structured, less intense fashion. The intensive CRT treatment arm had significantly better Community Integration Questionnaire scores after program completion, despite being in the chronic phase (mean = 34 months from injury)
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on patient centered outcomes of multi-modal/comprehensive CRT delivered to patients with mild TBI in the chronic phase of recovery. One small but well-conducted trial demonstrated meaningful beneficial effects on
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. There is limited evidence about the sustainment of treatment effects on the general symptom index through 3 months posttreatment of multi modal/comprehensive CRT delivered to patients with mild TBI in the chronic phase of recovery (Tiersky et al.
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Therefore, there is preliminary evidence that an 11-week outpatient program of about 55 hours of both CRT and cognitive behavioral therapy is beneficial in patients with mild TBI in the chronic phase. However, while showing favorable findings on several primary outcomes, the study was a pilot, exploratory trial; no larger, follow-on trials were identified in this literature review.
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· Rey Complex Figure ▪ Perceived self-efficacy ▪ Community-based employment · Vocational Integration Scale Ruff and 24 NR The effectiveness of Y Katz Adjustment Scale (KAS) There was no significant Niemann cognitive remediation subscales: difference between groups, 1990 versus day treatment Other CRT • Social Obstreperousness with both groups reporting was compared in this Content: Sessions • Acute Psychoticism decreased symptoms of study of emotional and emphasizing • Withdrawn Depression psycho-emotional distress, psychosocial adjustment psychosocial i.e., lessened social in subjects.
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From page 228... ...
1999 who had recovered Home-based • Halstead-Reitan based CRT program sufficiently from a recent rehabilitation with Neuropsychological groups in return to gainful Warden moderate-severe closed TBI education Impairment Index employment or fitness for et al. 2000 head injury (within 3 and individual • Katz Adjustment Scale duty; furthermore, there were months of randomization)
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2008 Severe cognitive rehabilitation at 1-year follow-up: difference in primary approaches, cognitive Other CRT ▪ Functional independence outcomes of independent didactic and functional- Content: in living living or employment, and no experimental, to Cognitive didactic ▪ Return to work and/or difference on any secondary determine efficacy overall or functional- school outcome measures including and relative effectiveness experimental • Secondary outcome the FIM, measures of mood to specific subpopulations. measures: and behavior, the Disability ▪ FIM Rating Scale, or a self-rating ▪ Disability Rating Scale of memory.
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This finding is statistically significant, suggesting that early intensive inpatient rehabilitation including CRT may hasten recovery, with similar longer-term outcomes.
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From page 231... ...
superior outcome for and family support nurse) interdisciplinary • Logical Memory 1 both intervention groups, in addition to usual- services • Logical Memory 2 compared to the control care services was more (occupational • Occupational status group, in some but not all beneficial for improving therapy alone)
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processes. speech therapy ▪ Block design and occupational ▪ Object assembly therapy • Category test • Trail Making Test • Wisconsin Card Sorting test • WMS and WMS-R • Digit span forward, backward • Logical memory immediate, delayed • Visual reproduction immediate, delayed • Paired associates immediate, delayed
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Middleton et 36 NR Investigates outcomes Y • WAIS-R, Digit Span There was significant al. 1991 following computer- • Wechsler Paired Associates improvement on five of six delivered cognitive Other CRT • Knox's cube measures by both groups rehabilitation therapy, Content: • Block Counting at 8-week follow-up; no comparing two forms Control received • Concept formation differential effect was of computer-assisted computer-assisted • Shipley Abstraction observed in the treatment neuropsychological training on group.
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TABLE 11-1 Continued 234 TBI Severity Study N Level Brief Narrative Comparator Outcome Measures Findings Parente and 33 NR In a pilot study, evaluated Y Return to work Participants in the CSG had Stapleton the effectiveness of a 76 percent vocational 1999 the Cognitive Skills Other CRT rehabilitation rate, i.e., Group (CSG) providing Content: placement in competitive thinking skill training as Similar services but employment; 58 percent of a precursor to vocational not within CSG the baseline participants placement.
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. Cognitive remediation stressed small involved task and curing group interpersonal hierarchies, constructional exercises; Group 3 praxis, visual information involved cognitive processing, and logical remediation reasoning.
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TABLE 11-1 Continued 236 TBI Severity Study N Level Brief Narrative Comparator Outcome Measures Findings Pre-Post Single Group Braunling- 205 Severe Investigators examined N Functional Area Outcome There were significant Mcmorrow the effect multifaceted Menu: functional gains of et al. 2010 rehabilitation services had • Behavioral and Emotional approximately 1.5 levels, on functional outcomes Status using the rehabilitation for participants with • Community Participation treatment model, for major physical and • Educational Endeavors neuropsychologically cognitive difficulties • Global Quality of Life impaired participants, both (n = 129)
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▪ California Verbal areas of complex attention Learning Test and information-processing ▪ Rey Immediate Recall speed. Participants who • Higher cognitive function were not able to resume ▪ Rey Copy productive functioning ▪ WCST Perseveration showed decline in functioning ▪ Category Test on various measures at 1 ▪ Mazes and 6-month follow-up.
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• PTSD Checklist impairment, no change in • Satisfaction with Life Scale PTSD symptoms, no change • Severity of Dependence in community integration Scale levels, and a trend toward • TBI self-efficacy scale increased self-efficacy. • Usefulness of Cognitive Strategy Scale (UCSS)
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From page 239... ...
• Work/school status Mills et al. 42 Severe Examines outcomes of N • Functional evaluation Patients' functional outcomes 1992 a 6-week, structured ▪ Identifying community improved significantly outpatient rehabilitation resources post treatment; the overall program, individualized ▪ Consumer skills percentage of goals achieved to each patient, including ▪ Health was 67.5 percent.
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▪ Depression, Anxiety, and Stress Scales ▪ General Well-Being Questionnaire ▪ European Brain Injury Questionnaire, family rating
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2004. Community integration and satisfac tion with functioning after intensive cognitive rehabilitation for traumatic brain injury.
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2008. Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and Veterans Brain Injury Center randomized controlled trial of two rehabilitation approaches.
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