Cognitive Rehabilitation Therapy for Traumatic Brain Injury Evaluating the Evidence (2011) / Chapter Skim
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One form of treatment for the cognitive and behavioral deficits associated with TBI is cognitive rehabilitation therapy (CRT) , a systematic, goal-oriented approach to overcoming cognitive impairments.
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whether require ments for training, education and experience for providers outside the MHS direct-care system to deliver the identified evidence-based interventions are sufficient to ensure reasonable, consistent quality of care across the United States; and 5. An independent assessment of the treatment of traumatic brain injury by cognitive rehabilitation therapy within the MHS if time or resources permit.
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After extensive deliberation, the committee determined it was beyond its charge to interpret its assessment of the evidence with respect to policy recommendations or clinical practice guidelines. In addition to reviewing the literature, the committee heard from experts in the fields of cognitive rehabilitation research and practice, investigators of major research studies of traumatic brain injury in military and civilian settings, and advocates for the role of families and communities in providing ongoing support to injured members of the military and veterans.
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The more severe the injury, the more severe and persistent the cognitive deficits -- though clinical measurements do not always concur. Severity measures graded during the acute phase sometimes reflect variance due to medications used during resuscitation, substance use, and communication
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TREATMENT Determining the appropriate method and timing of treatment for an individual with TBI depends on a number of factors, including severity of injury, stage in recovery, and premorbid, comorbid, and environmental conditions, unique to every individual. The focus of treatment changes as a patient progresses from the acute, immediate phase after injury to more 1 The term "executive function" represents a set of integrated cognitive processes necessary to perform or accomplish everyday life activities.
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In the chronic stage of recovery, the goals of rehabilitation are functional recovery of long-lasting physical, cognitive, and emotional impairments. Cognitive Rehabilitation Therapy CRT is a collection of treatments, generally tailored to an individual depending on the pattern of the impairments and activity limitations, related disorders (e.g., preexisting conditions or comorbidities)
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While there has been some movement to standardize CRT, wide variations between the expectations of practitioners within different professions still exist, reflecting the fact that the respective accreditation organizations for these professions separately determine the educational and licensing requirements for these practitioners. EVALUATION OF THE EVIDENCE The IOM committee iteratively developed a protocol to address the following questions: • o cognitive rehabilitation interventions improve function and D reduce cognitive deficits in adults with mild, or moderate to severe TBI?
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Another limitation is that objective measures sensitive to the cognitive complaints of patients with mild TBI are lacking in many instances and the use of subjective self-report measures as an alternative is problematic when studying treatments that cannot be blinded. Also, studies of subacute treatments require relatively large samples because the ability to gauge the impact of a treatment regimen in individual patients is diminished in the context of rapid and variable natural recovery.
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It is important to note that evidence ruled "limited" does not mean the intervention was inadequate; it may simply mean a better-designed or -executed study is necessary to show meaningful short- or long-term treatment effect. 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 -- of those, only in the chronic phase -- and few studies addressing treatment of those with moderate to severe injuries in the subacute phase.
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Table S-1 summarizes the committee's conclusions for CRT, reflected in Chapters 7 through 11 in narrative form following detailed descriptions of individual studies. In its conclusions, the committee separated evidence grades by cognitive domain and multi-modal/comprehensive CRT, further subdividing by reported injury severity, recovery phase, and the treatment approach (i.e., restorative or compensatory)
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TABLE S-1 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.
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In fact, the committee supports the ongoing clinical application of CRT interventions for individuals with cognitive and behavioral deficits due to TBI. One way policy could reflect the provision of CRT is to facilitate the application of best-supported techniques in TBI patients in the chronic phase (where natural recovery is less of a confound)
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Practice-based evidence studies include the Congressionally Mandated Longitudinal Study on TBI, DVBIC Study on Cognitive Rehabilitation Effectiveness for Mild TBI (SCORE!
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and key premorbid conditions, comorbidities, and environmental factors that may influence recovery and treatment response; 2. Identify and select uniform TBI outcome measures, including standard measures of cognitive and global/functional out comes; and 3.
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2003. Outcome 3 to 5 years after moderate to severe traumatic brain injury.
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2009. Cognitive rehabilitation for the treatment of traumatic brain injury.
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2009a. VA/ DoD clinical practice guideline: Management of concussion/mild traumatic brain injury.
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