Cognitive Rehabilitation Therapy for Traumatic Brain Injury Evaluating the Evidence (2011) / Chapter Skim
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Pages 255-270
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From page 255... ...
. However, the evidence for the therapeutic value of CRT is variable across cognitive domains and is currently insufficient overall to provide definitive guidance for translation into clinical practice guidelines, particularly with respect to selecting the most effective treatment(s)
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256 TABLE 14-1 Overall Conclusions by Cognitive Domain and Multi-Modal/Comprehensive CRT Language and Social Multi-Modal/ Domain Attention Executive Function Communication Memory Comprehensive CRT NonSubdomain Awareness Awareness TBI Moderate- ModerateSeverity Moderate-Severe Moderate-Severe Moderate-Severe Mild Moderate-Severe Severe Mild Severe Recovery Phase Subacute Chronic Chronic Chronic Chronic Subacute Chronic Approach R R R R/IC/EC R IC EC R IC EC M M M PatientCentered 0 + 0 + 0 0 N/A 0 + ++ 0 + 0 Outcomes Long-Term Treatment + 0 0 0 + + N/A 0 + N/A 0 + 0 Effect Immediate Treatment + + + + ++ + N/A 0 ++ ++ 0 + 0 Benefit NOTES: EC = external compensatory strategy; IC = internal compensatory strategy; M = mixture of treatment approaches; R = restorative strategy; Evidence Grades: 0 no or not informative, + limited, ++ modest, +++ strong. Multiple treatments intended to target cognitive (non-awareness)
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From page 257... ...
In reviewing the evidence regarding the efficacy and effectiveness of CRT, the committee found no studies addressing cognitive deficits in the acute phase of recovery following TBI, few studies addressing cognitive treatment for individuals with mild injuries -- those that did were only in the chronic phase; and few studies addressing treatment of those with moderate to severe injuries in the subacute phase. Table 14-2 provides the committee's definitions for acute, subacute, and chronic recovery phases.
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From page 258... ...
Evidence supporting the efficacy of CRT in the chronic phase of TBI for patients with moderate-severe injuries varies by cognitive domain and specific CRT treatment modality. Of note, patients with moderate to severe injuries in the chronic phase typically have deficits that can be objectively measured and have a slower rate of natural recovery.
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From page 259... ...
Practice-based evidence studies include the Congressionally Mandated Longitudinal Study on TBI (e.g., 15 Year Longitudinal Study of TBI Incurred by Members of the Armed Forces in OIF/OEF) , DVBIC Study on Cognitive Rehabilitation Effectiveness for Mild TBI (SCORE!
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From page 260... ...
The committee recommends the Department of Defense (DoD) undertake the following: • nclude measures in experimental and observational data sets that I characterize important dimensions of patient heterogeneity and factors affecting recovery and response to CRT; • mprove standardization of CRT treatments as well as TBI patient I characteristics and relevant outcome measures in clinical practice and research; • evelop a common registry or linked registries encompassing de D identified data of large numbers of consenting patients to facilitate data mining and the rationale for testing new interventions; and • rospectively follow any policy changes in coverage for CRT in the P Military Health System.
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From page 261... ...
To enhance the understanding of the optimal treatment candidates for various forms of CRT, and their relative value in affecting different outcome targets, DoD should collaborate with other rehabilitation research organizations to capture relevant patient characteristics and outcome measures, which can facilitate comparison of results across studies and treatments and support formal meta-analyses. Categorizing participants by injury severity and recovery phase may be important to create useful categories, group studies, and draw related conclusions.
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Promote Standardization and Operationalization of Patient Characteristics, Outcome Measures, and CRT Interventions Research to document efficacy of CRT will benefit from greater operational definition of the CRT interventions being evaluated. Given that no current treatment taxonomy is sufficiently mature to allow feasible coding of treatment A versus B versus C in practice, the most realistic short-term approach to defining and standardizing specific CRT interventions is to develop treatment manuals and adherence measures to verify that the defined treatment is being administered to patients.
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Measures of the relevant outcomes are also available, and the NIH's CDE effort has already made some progress in suggesting specific consensus outcome measures for patients with TBI. Outcome measures incorporated into CRT research remain variable.
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, multi disciplinary team of clinicians and researchers to finalize the selection of patient characteristics and outcome variables to be included in ex perimental and observational CRT research, and to plan a strategy to advance the common definition and operationalization of CRT interventions. In addition, researchers and clinicians should reach consensus on the appropriate timing of CRT in the course of recovery following TBI.
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Operationally defined CRT treatments (i.e., manualbased interventions) will not clear up the ambiguity of services provided via occupational therapy (such as "dressing training")
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Once a more comprehensive taxonomy of rehabilitation treatments is available, embedded CRT activities provided via occupational therapy, physical therapy, or speech-language pathology will be easier to identify due to the services provided (e.g., training, learning, adapting, and compensating)
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From page 267... ...
Recommendation 14-5: DoD should collaborate with other research and funding organizations to foster all phases of research and develop ment of CRT treatments for TBI, from pilot phase, to early efficacy research (safety, dose, duration and frequency of exposure, and durabil ity) , to large-scale randomized clinical trials, and ultimately, effective ness and comparative effectiveness studies.
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From page 268... ...
Evidence supporting the efficacy of CRT in the chronic phase of TBI for patients with moderate-severe injuries varies by cognitive domain and specific CRT treatment modality. Because the noted limitations of the evidence often were secondary to the methodological shortcomings of the studies reviewed, and do not rule out meaningful benefit of CRT for TBI, the committee supports the ongoing clinical application of CRT interventions for individuals with cognitive and behavioral deficits due to TBI.
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From page 269... ...
2009. VA/DoD Joint Executive Council Strategic Plan: Fiscal years 2009–2011.
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