Cognitive rehabilitation for traumatic brain injury: A randomized trial. Defense and Veterans Head Injury Program (DVHIP) Study Group.
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
Available from: Jeffrey N. Motter
- "One approach beginning to receive attention is computerized cognitive training (CCT) (Morimoto et al., 2012; Porter et al., 2013), in which cognitive exercises or games are used to target specific neural networks in order to improve cognitive functioning through neuroplasticity. CCT has been used in healthy adult populations (Mahncke et al., 2006; Stern et al., 2011; Willis et al., 2006) as well as in a variety of diagnostic conditions including attention-deficit hyperactivity disorder (Rapport et al., 2013), schizophrenia (Wykes et al., 2011), bipolar disorder (Preiss et al., 2013), traumatic brain injury (Salazar et al., 2000), mild cognitive impairment (Li et al., 2011), and Alzheimer's disease (Sitzer et al., 2006). It is administered through an automated computer program , oftentimes accessible over the internet. "
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Depression is common, frequently resistant to antidepressant treatment, and associated with impairments in cognition and everyday functioning. Computerized cognitive training (CCT) paradigms offer potential to improve cognition, mood and everyday functioning, but their effectiveness is not well established. The goal of this article was to conduct a systematic review and meta-analysis to determine the efficacy of CCT in depressive disorders.
A search was conducted to identify high quality randomized controlled CCT trials per PRISMA guidelines using PsycINFO and MEDLINE with the keywords "Cognitive training" or "Cognitive remediation" or "Cognitive rehabilitation" and "Depression". 9 randomized trials for depressed adults met inclusion criteria. Effect sizes (Hedge's g) were calculated for key outcome measures of mood symptom severity, daily functioning, and cognition. A 3-level Bayesian hierarchical linear model was used to estimate effect sizes for each domain and study. Publication bias was assessed using Classic Fail Safe N's and homogeneity was evaluated using Q and I(2) indexes.
Significant small-moderate effects for Symptom Severity (0.43) and Daily Functioning (0.72), and moderate-large effects for Attention (0.67), Working Memory (0.72), and Global Functioning (1.05) were found. No significant effects were found for Executive Functioning or Verbal Memory. Moderator variable analysis revealed decreased effect of CCT with age. Gender and concurrent medication treatment did not affect the results.
Small sample size, short duration, pseudo-specificity, and high heterogeneity for Verbal Memory measures.
CCT is associated with improvement in depressive symptoms and everyday functioning, though produces inconsistent effects on cognition.
Available from: Ignacio Bernabeu
- "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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ABSTRACT: Neuroendocrine dysfunction, long recognized as a consequence of traumatic brain injury (TBI), is a major cause of disability that includes physical and psychological involvement with long-term cognitive, behavioral, and social changes. There is no standard procedure regarding at what time after trauma the diagnosis should be made. Also there is uncertainty on defining the best methods for diagnosis and testing and what types of patients should be selected for screening. Common criteria for evaluating these patients are required on account of the high prevalence of TBI worldwide and the potential new cases of hypopituitarism. The aim of this review is to clarify, based on the evidence, when endocrine assessment should be performed after TBI and which patients should be evaluated. Additional studies are still needed to know the impact of post-traumatic hypopituitarism and to assess the impact of hormone replacement in the prognosis.
- " 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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ABSTRACT: This review was aimed at systematically investigating the treatment efficacy and clinical effectiveness of neurobehavioral rehabilitation programs for adults with acquired brain injury and making evidence-based recommendations for the adoption of these rehabilitation trainings. Using a variety of search procedures, 63 studies were identified and reviewed using a set of questions about research methods, treatments, results and outcomes for the 1,094 participants. The 63 studies included treatments falling into three general categories: approaches based on applied behavior analysis, interventions based on cognitive-behavior therapy (CBT), and comprehensive-holistic rehabilitation programs (CHRPs). Considerable heterogeneity exists in the reviewed literature among treatment methods and within reported sample subjects. Despite the variety of methodological concerns, results indicate that the greatest overall improvement in psychosocial functioning is achieved by CHRP that can be considered a treatment standard for adults with behavioral and psychosocial disorders following acquired brain injury. Both approaches based on applied behavior analysis and CBT can be said to be evidence-based treatment options. However, findings raise questions about the role of uncontrolled factors in determining treatment effects and suggest the need for rigorous inclusion/exclusion criteria, with greater specification of theoretical basis, design, and contents of treatments for both interdisciplinary-comprehensive approaches and single-case methodologies.
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