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

Department of Mental Health and Behavioral Sciences, and Defense and Veterans Brain Injury Center, James A. Haley Veterans Affairs Medical Center, Tampa, FL 33612, USA.
Archives of physical medicine and rehabilitation (Impact Factor: 2.57). 01/2009; 89(12):2227-38. DOI: 10.1016/j.apmr.2008.06.015
Source: PubMed


To determine the relative efficacy of 2 different acute traumatic brain injury (TBI) rehabilitation approaches: cognitive didactic versus functional-experiential, and secondarily to determine relative efficacy for different patient subpopulations.
Randomized, controlled, intent-to-treat trial comparing 2 alternative TBI treatment approaches.
Four Veterans Administration acute inpatient TBI rehabilitation programs.
Adult veterans or active duty military service members (N=360) with moderate to severe TBI.
One and a half to 2.5 hours of protocol-specific cognitive-didactic versus functional-experiential rehabilitation therapy integrated into interdisciplinary acute Commission for Accreditation of Rehabilitation Facilities-accredited inpatient TBI rehabilitation programs with another 2 to 2.5 hours daily of occupational and physical therapy. Duration of protocol treatment varied from 20 to 60 days depending on the clinical needs and progress of each participant.
The 2 primary outcome measures were functional independence in living and return to work and/or school assessed by independent evaluators at 1-year follow-up. Secondary outcome measures consisted of the FIM, Disability Rating Scale score, and items from the Present State Exam, Apathy Evaluation Scale, and Neurobehavioral Rating Scale.
The cognitive-didactic and functional-experiential treatments did not result in overall group differences in the broad 1-year primary outcomes. However, analysis of secondary outcomes found differentially better immediate posttreatment cognitive function (mean+/-SD cognitive FIM) in participants randomized to cognitive-didactic treatment (27.3+/-6.2) than to functional treatment (25.6+/-6.0, t332=2.56, P=.01). Exploratory subgroup analyses found that younger participants in the cognitive arm had a higher rate of returning to work or school than younger patients in the functional arm, whereas participants older than 30 years and those with more years of education in the functional arm had higher rates of independent living status at 1 year posttreatment than similar patients in the cognitive arm.
Results from this large multicenter randomized controlled trial comparing cognitive-didactic and functional-experiential approaches to brain injury rehabilitation indicated improved but similar long-term global functional outcome. Participants in the cognitive treatment arm achieved better short-term functional cognitive performance than patients in the functional treatment arm. The current increase in war-related brain injuries provides added urgency for rigorous study of rehabilitation treatments. ( ID# NCT00540020.).

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    • "Since attention plays a major role in many cognitive functions, attention has been the target of various types of rehabilitation programs for TBI survivors, for both inpatient rehabilitation and postacute or community re-entry settings [3,4]. However, treatment outcome studies for the inpatient population, especially the severely impaired population, are scarce [3,5-7]. There have been even fewer studies that might advance new treatments that can be tolerated by this population. "
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    ABSTRACT: Although common during the early stages of recovery from severe traumatic brain injury (TBI), attention deficits have been scarcely investigated. Encouraging evidence suggests beneficial effects of attention training in more chronic and higher functioning patients. Interactive technology may provide new opportunities for rehabilitation in inpatients who are earlier in their recovery. We designed a "virtually minimal" approach using robot-rendered haptics in a virtual environment to train severely injured inpatients in the early stages of recovery to sustain attention to a visuo-motor task. 21 inpatients with severe TBI completed repetitive reaching toward targets that were both seen and felt. Patients were tested over two consecutive days, experiencing 3 conditions (no haptic feedback, a break-through force, and haptic nudge) in 12 successive, 4-minute blocks. The interactive visuo-haptic environments were well-tolerated and engaging. Patients typically remained attentive to the task. However, patients exhibited attention loss both before (prolonged initiation) and during (pauses during motion) a movement. Compared to no haptic feedback, patients benefited from haptic nudge cues but not break-through forces. As training progressed, patients increased the number of targets acquired and spontaneously improved from one day to the next. Interactive visuo-haptic environments could be beneficial for attention training for severe TBI patients in the early stages of recovery and warrants further and more prolonged clinical testing.
    Full-text · Article · Aug 2013 · Journal of NeuroEngineering and Rehabilitation
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    • "; Thomas-Stonell, Johnson, Schuller, & Jutai, 1994; Tiersky et al., 2005; van Hout et al., 2008; Vanderploeg et al., 2008 "
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    ABSTRACT: We reviewed all randomised trials on cognitive rehabilitation in order to determine the effective elements in terms of patients' and treatment characteristics, treatment goals and outcome. A total of 95 random controlled trials were included from January 1980 until August 2010 studying 4068 patients in total. Most studies had been conducted on language (n = 25), visuospatial functioning (n = 24), and memory (n = 14). Stroke patients were the commonest subjects (57%; overall mean age = 52.2, SD = 15.0 years). Of the interventions 39% were offered more than 12 months after onset and 23% were offered within two months of onset. The mean (SD) number of hours of treatment actually delivered was 4.1 (3.6) per week; treatment was mostly offered individually. No papers gave specific information on the expertise or competences of the staff involved. With 95 RCTs there is a large body of evidence to support the efficacy of cognitive rehabilitation, and the current study can serve as a database for clinicians and researchers. But most studies have given little information about the actual content of the treatment which makes it difficult to use the studies when making treatment decisions in daily clinical practice. We suggest developing an international checklist to make standardised description of non-pharmacological complex interventions possible.
    Full-text · Article · Apr 2012 · Neuropsychological Rehabilitation
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    • "I : whiplash injury following an vehicle accident (grade I and II), score within the risk range (i.e. above 50 percentile) on at least one of the psychosocial measures targeted in the program, patient in one of 5 rehab clinics in eastern Canada whose staff had attended a 2- days training workshop on PGAP intervention techniques, being employed prior to their motor vehicle accident, providing informed consent participating in a functional restoration physical therapy program E: not being employed • Physical therapist • OT • Occupational health nurse • Office assistant (interviews) • RTW (primary outcome variable) • Catastrophizing • Fear of movement or reinjury • Perceived disability • Pain severity Vanderploeg et al., 2008 "
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    ABSTRACT: The primary aim of this review study was to gather evidence on the effectiveness in terms of return to work (RTW) of occupational therapy interventions (OTIs) in rehabilitation patients with non-congenital disorders. A secondary aim was to be able to select the most efficient OTI. A systematic literature review of peer-reviewed papers was conducted using electronic databases (Cinahl, Cochrane Library, Ebsco, Medline (Pubmed), and PsycInfo). The search focussed on randomised controlled trials and cohort studies published in English from 1980 until September 2010. Scientific validity of the studies was assessed. Starting from 1532 papers with pertinent titles, six studies met the quality criteria. Results show systematic reviewing of OTIs on RTW was challenging due to varying populations, different outcome measures, and poor descriptions of methodology. There is evidence that OTIs as part of rehabilitation programs, increase RTW rates, although the methodological evidence of most studies is weak. Analysis of the selected papers indicated that OTIs positively influence RTW; two studies described precisely what the content of their OTI was. In order to identify the added value of OTIs on RTW, studies with well-defined OT intervention protocols are necessary.
    Full-text · Article · Aug 2011 · BMC Public Health
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