Article

Cognitive rehabilitation for traumatic brain injury: A randomized trial. Defense and Veterans Head Injury Program (DVHIP) Study Group.

Defense and Veterans Head Injury Program, Bldg 1, Room B210, Walter Reed Army Medical Center, Washington, DC 20307-5001, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 07/2000; 283(23):3075-81.
Source: PubMed

ABSTRACT Traumatic brain injury (TBI) is a principal cause of death and disability in young adults. Rehabilitation for TBI has not received the same level of scientific scrutiny for efficacy and cost-efficiency that is expected in other medical fields.
To evaluate the efficacy of inpatient cognitive rehabilitation for patients with TBI.
Single-center, parallel-group, randomized trial conducted from January 1992 through February 1997 at a US military medical referral center.
One hundred twenty active-duty military personnel who had sustained a moderate-to-severe closed head injury, manifested by a Glasgow Coma Scale score of 13 or less, or posttraumatic amnesia lasting at least 24 hours, or focal cerebral contusion or hemorrhage on computed tomography or magnetic resonance imaging.
Patients were randomly assigned to an intensive, standardized, 8-week, in-hospital cognitive rehabilitation program (n=67) or a limited home rehabilitation program with weekly telephone support from a psychiatric nurse (n=53).
Return to gainful employment and fitness for military duty at 1-year follow-up, compared by intervention group.
At 1-year follow-up, there was no significant difference between patients who had received the intensive in-hospital cognitive rehabilitation program vs the limited home rehabilitation program in return to employment (90% vs 94%, respectively; P=.51; difference, 4% [95% confidence interval ¿CI¿, -5% to 14%]) or fitness for duty (73% vs 66%, respectively; P=. 43; difference, 7% [95% CI, -10% to 24%]). There also were no significant differences in cognitive, behavioral, or quality-of-life measures. In a post-hoc subset analysis of patients who were unconscious for more than 1 hour (n = 75) following TBI, the in-hospital group had a greater return-to-duty rate (80% vs 58%; P=. 05).
In this study, the overall benefit of in-hospital cognitive rehabilitation for patients with moderate-to-severe TBI was similar to that of home rehabilitation. These findings emphasize the importance of conducting randomized trials to evaluate TBI rehabilitation interventions. JAMA. 2000;283:3075-3081

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    • "In young adults TBI is considered one of the main causes of death (Hodgson et al., 2000). Moreover, it is a major cause of disability that includes physical and psychological involvement with long-term cognitive, behavioral, and social changes (Salazar et al., 2000; Khan et al., 2003). Neuroendocrine dysfunction has long been recognized as a consequence of TBI (Cyran, 1914), particularly in moderate and severe cases, although the last 10 years have witnessed a better understanding of the frequency of TBI-mediated hypopituitarism and its clinical implications, with the publication of an increasing number of studies (Benvega et al., 2000; Kelly et al., 2000; Lieberman et al., 2001; Agha et al., 2004; Bondanelli et al., 2004; Popovic et al., 2004; Aimaretti et al., 2005; Leal-Cerro et al., 2005; Herrmann et al., 2006; Schneider et al., 2006; Tanriverdi et al., 2006). "
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    • " al . ( 2000 ) —one of the only five RCTs - Class I studies rated in the present review—as an example of what he defines as the " dogma that randomized controlled studies provide the most convincing evidence regarding the efficiency of an intervention " . Prigatano ( 2003 ) stated the following reasons for the putatively misleading con clusions of Salazar et al . ( 2000 ) on the ineffectiveness of MORP in TBI individuals : ( 1 ) the program was designed for postacute rather than acute patients ( within the first month from injury in this study ) ; ( 2 ) the working alliance between the patient and the rehabilitation team as a predictive value for those benefiting from such treatment was neither mention"
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    • "In their exhaustive review, Carney et al [32] concluded that ''specific forms of cognitive rehabilitation reduce memory failures (notebook training/electronic cueing devices—results didn't hold 6 months post treatment) and anxiety, and improve self-concept and interpersonal relationships for persons with TBI.'' A recent Defense and Veteran's Head Injury program study did not find any significant improvement on their measures as a result of cognitive rehabilitation (compared with control group) in patients with moderate to severe TBI [34]. In conclusion, no definitive scientific evidence indicates that cognitive rehabilitation leads to sustained improvements in memory. "
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