provides an overview of the committee’s conclusions based on the review of literature of modular, domain-specific treatments as well as multimodal/comprehensive CRT programs.

In most cases the evidence provides limited, and in some cases modest, support for the efficacy of CRT interventions. The committee defined limited evidence as “Interpretable results from a single study or mixed results from two or more studies” and modest evidence as “Two or more studies reporting interpretable, informative, and largely similar results” (see Box 6-2 for all evidence grades and definitions). The committee emphasizes that conclusions based on the limited evidence regarding the effectiveness of CRT does not indicate that the effectiveness of CRT treatments are “limited”; the limitations of the evidence do not rule out meaningful benefit. In fact, the committee supports the ongoing clinical application of CRT interventions for individuals with cognitive and behavioral deficits due to TBI. To acquire more specific and meaningful results from future research the committee has laid out a comprehensive research agenda to overcome challenges in determining efficacy and effectiveness. 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), with the proviso that objectively measurable functional goals are articulated and tracked and that treatment continues only so long as gains are noted.

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. The dearth of evidence in these areas is multi-factorial, but the committee recognized specific practical and methodological limitations. One 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

TABLE 14-2 Definitions of Acute, Subacute, and Chronic TBI Recovery

  Mild TBI Moderate-Severe TBI
Acute < 3 months Acute hospital care
Subacute > 3 months < 6 months Inpatient rehabilitation
Chronic > 6 months < 12 months Outpatient rehabilitation

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