Cognitive Rehabilitation Therapy
for Traumatic Brain Injury
Evaluating the Evidence
Committee on Cognitive Rehabilitation Therapy for Traumatic Brain Injury
Rebecca Koehler, Erin E, Wilhelm, Ira Shoulson, Editors
Board on the Health of Select Populations
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract No. HHSP23320042509XI between the National Academy of Sciences and the U.S. Department of Defense. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
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Suggested citation: IOM (Institute of Medicine). 2011. Cognitive Rehabilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence. Washington, DC: The National Academies Press.
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COMMITTEE ON COGNITIVE REHABILITATION
THERAPY FOR TRAUMATIC BRAIN INJURY
IRA SHOULSON (Chair), Professor of Neurology, Pharmacology and Human Science, and Director, Program for Regulatory Science and Medicine, Georgetown University, Washington, DC
REBECCA A. BETENSKY, Professor of Biostatistics, Harvard School of Public Health, Harvard University, Boston, MA
PETER COMO, Lead Reviewer/Neuropsychologist, U.S. Food and Drug Administration, Silver Spring, MD
RAY DORSEY, Associate Professor of Neurology, The Johns Hopkins University, Baltimore, MD
CHARLES DREBING, Acting Mental Health Service Line Manager, Bedford VA Medical Center, Bedford, MA
ALAN I. FADEN, David S. Brown Professor, Departments of Anesthesiology, Anatomy and Neurobiology, Neurosurgery, and Neurology, Director, STAR Organized Research Center, University of Maryland School of Medicine
ROBERT T. FRASER, Professor of Rehabilitation Medicine, University of Washington/Harborview Medical Center, Seattle, WA
TAMAR HELLER, Professor and Department Head, Department of Disability and Human Development, University of Illinois at Chicago
RICHARD KEEFE, Professor of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
MARY R. T. KENNEDY, Associate Professor, Department of Speech-Language-Hearing Sciences, University of Minnesota, Minneapolis
HARVEY LEVIN, Professor and Director of Research, Department of Physical Medicine & Rehabilitation, Baylor College of Medicine; Director of the Center of Excellence for Traumatic Brain Injury, Michael E. De Bakey Veterans Affairs Medical Center, Houston, TX
CYNTHIA D. MULROW, Professor of Medicine, University of Texas Health Science Center at San Antonio, TX
HILAIRE THOMPSON, Assistant Professor, School of Nursing, University of Washington, Seattle
JOHN WHYTE, Director, Moss Rehabilitation Research Institute, Elkins Park, PA
Consultants
JENNIFER J. VASTERLING, Chief of Psychology, VA Boston Healthcare System; Professor of Psychiatry, Boston University School of Medicine, MA
BARBARA G. VICKREY, Professor and Vice Chair, Department of Neurology, University of California, Los Angeles
IOM Study Staff
REBECCA N. KOEHLER, Study Director
ERIN E. WILHELM, Associate Program Officer
ALICIA JARAMILLO-UNDERWOOD, Program Assistant
JON Q. SANDERS, Program Associate
ANDREA COHEN, Financial Associate
FREDERICK (RICK) ERDTMANN, Director, Board on the Health of Select Populations
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Charles H. Bombardier, University of Washington School of Medicine
Diana D. Cardenas, University of Miami
Keith Cicerone, JFK-Johnson Rehabilitation Institute
Chris Giza, University of California, Los Angeles
Wayne Gordon, Mount Sinai School of Medicine
Tessa Hart, Moss Rehabilitation Research Institute
Bruce Miller, University of California, San Francisco
Mark Sherer, TIRR Memorial Hermann
McKay Moore Sohlberg, University of Oregon
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions
or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Dan G. Blazer, Duke University Medical Center, and Nancy E. Adler, University of California, San Francisco. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Preface
Traumatic brain injury (TBI) is a too common and disabling occurrence in civilian and military life, estimated to annually affect 10 million people worldwide. The Institute of Medicine (IOM) has a long-standing role of providing guidance to the Department of Defense (DoD) on the health and well-being of services members and their families. At the request of DoD, the current study represents a concentrated endeavor by the Committee on Cognitive Rehabilitation Therapy for Traumatic Brain Injury to comprehensively evaluate the value of cognitive rehabilitation therapy (CRT) as a therapeutic intervention for traumatic brain injury.
The United States military is currently engaged in ongoing operations in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom). Conflicts in these war zones have been characterized by more explosive weaponry and other aggressive tactics, placing members of the military at greater risk for TBI, the “signature wound” of these wars. Recovering and returning service members with TBI may face long-term challenges in rehabilitation and reintegration to everyday life. These challenges to injured individuals also affect their families and communities. Survivors of TBI require ongoing support systems to care for and cope with physical injuries, cognitive impairment and coexisting disabilities such as posttraumatic stress disorders. An effective and reliable health care infrastructure and evidence-based treatment and rehabilitation policies must be in place to achieve effective recovery and a return to optimal functioning and productivity. The public increasingly is confronted with and better recognizes the often enduring and serious consequences of TBI and the need for providing the most effective treatments for those who serve our country in harm’s way.
The committee sought to provide a scientific framework to evaluate current research and practices related to CRT. To evaluate the value of CRT for TBI, the committee iteratively developed criteria for inclusion of published scientific reports and reviewed and analyzed some 88 studies to inform our findings on specific domains such as attention, executive function, language and social communication, and memory, as well as multi-modal or comprehensive CRT programs.
We are honored to have been of service in providing DoD with a comprehensive evidence-based review of CRT for TBI. This was a timely review, both in terms of the relevance of the topic and relatively brief time allocated to complete the review and our report. I am deeply appreciative of the expert work of our dedicated committee members and their extraordinary commitment and contributions to the task at hand. Over a course of about 6 months, we convened six in-person committee meetings, two open meetings including scientific presentations, and an abundance of teleconferences and email exchanges. We trust that this report assists not only DoD in its efforts to care for recovering and returning service members, but also informs the broader research community about the value of cognitive rehabilitation therapy for TBI sustained in both military and civilian settings.
The committee extends its appreciation to the many people who presented information at its open meeting and to our dedicated IOM staff: Rebecca Koehler, Erin Wilhelm, Alicia Jaramillo-Underwood, and Jon Sanders. We also thank Mary Ferraro and Andy Packel at the Moss Rehabilitation Institute (Philadelphia), who expertly abstracted information from reviewed research reports. We also thank consultants to the committee, Jennifer Vasterling and Barbara Vickrey, for their contributions in the development of several chapters of the report. A special appreciation is due to the patients, their families, and clinicians who strive together to combat and recover from the disabling and often devastating consequences of TBI.
Ira Shoulson, Chair
Committee on Cognitive Rehabilitation Therapy for Traumatic Brain Injury
Contents
Conclusions: Language and Social Communication
Combined Memory Strategies: Internal and External
11 MULTI-MODAL OR COMPREHENSIVE COGNITIVE REHABILITATION THERAPY
Conclusions: Subacute, Multi-Modal/Comprehensive CRT
Conclusions: Chronic, Multi-Modal/Comprehensive CRT
CRT Applied Through Telehealth Technology
Conclusions: Telehealth Technology
Potential for Adverse Events or Harm from CRT
Tables, Figures, and Boxes
TABLES
S-1 Conclusions by Cognitive Domain and Multi-Modal/Comprehensive CRT
2-1 Classification of Mild, Moderate, and Severe Traumatic Brain Injury
4-1 Definitions of Cognitive Rehabilitation Therapy by Organization
5-1 CRT Providers: Services, Practice Requirements, and Professional Setting
6-1 Definitions of Acute, Subacute, and Chronic Phases of Recovery Post-TBI
6-2 Study Design by Treatment Domain or Strategy
8-1 Evidence Table: Executive Function
10-3 External Memory Strategies
10-4 Combined Memory Strategies
10-5 Restorative Memory Strategies
11-1 Evidence Table: Multi-Modal/Comprehensive CRT
11-2 Studies in the Subacute Phase of Recovery
11-3 Studies in the Chronic Phase of Recovery
14-1 Overall Conclusions by Cognitive Domain and Multi-Modal/Comprehensive CRT
14-2 Definitions of Acute, Subacute, and Chronic TBI Recovery
FIGURES
1-1 Number of U.S. service members with TBI, by severity
1-2 WHO-IC Model of Disablement
3-1 Factors affecting initial response to TBI and recovery from TBI
4-2 Model for multi-modal/comprehensive CRT
A-1 Model for multi-modal/comprehensive CRT
A-2 Clinical research continuum
A-3 Refined research-implementation pipeline
BOXES
1-2 Department of Defense Definition of Traumatic Brain Injury
AAD |
Assessment of awareness of disability |
AANN |
American Association of Neuroscience Nurses |
ACBIS |
Academy of Certified Brain Injury Specialists |
ACFI |
Assessment of Client Functioning Inventory |
ACOTE |
Accreditation Council for Occupational Therapy Education |
ACRM |
American Congress of Rehabilitation Medicine |
ADHD |
Attention deficit hyperactivity disorder |
ADL |
Activities of daily living |
AIM |
Assessment of Intentional Memory |
AIP |
Awareness Intervention Program |
AMPS |
Assessment of Motor and Process Skills |
ApoE |
Apolipoprotein E |
APT |
Attention Process Training |
ARN |
Association of Rehabilitation Nurses |
ASHA |
American Speech-Language-Hearing Association |
BI-ISIG |
Brain Injury Interdisciplinary Special Interest Group |
BINT |
Blast-induced neurotrauma |
BRISS–R |
Behaviorally Referenced Rating System of Intermediary Social Skills–Revised |
bTBI |
Blast-induced traumatic brain injury |
BVRT |
Benton Visual Retention Test |
CAA |
Council on Academic Accreditation |
CACR |
Computer-assisted cognitive rehabilitation |
CAMG |
Computer-Assisted Memory Training Group |
CAPTE |
Commission on Accreditation of Physical Therapy Education |
CBIS |
Certified Brain Injury Specialist |
CBT |
Cognitive behavioral therapy |
CDC |
Centers for Disease Control and Prevention |
CDE |
Common data element |
CFT |
Rey-Osterrieth Complex Figure Test |
CG |
Control group |
CHART–R |
Craig Handicap Assessment and Reporting Technique–Revised |
CHART–SF |
Craig Handicap Assessment and Reporting Technique– Short Form |
CIQ |
Community Integration Questionnaire |
CNRN |
Certified Neuroscience Registered Nurse |
CO |
Cognitive orthosis |
COPM |
Canadian Occupational Performance Measure |
COWAT |
Controlled Oral Word Association Test |
CP |
Clinical psychologist |
CPT |
Continuous Performance Test |
CRBC |
Cognitive Retraining Behavior Checklist |
CRRN |
Certified Rehabilitation Registered Nurse |
CRT |
Cognitive Rehabilitation Therapy |
CS |
Constraint seeking |
CSG |
Cognitive skills group |
CT |
Computed tomography |
CVLT |
California Verbal Learning Test |
DARE |
Database of Reviews of Effects |
DASS |
Depression, Anxiety and Stress Scale |
DMDC |
Defense Manpower Data Center |
DO |
Diary only |
DoD |
Department of Defense |
DRS |
Disability Rating Scale |
DSIT |
Diary and Self-Instructional Training |
DTI |
Diffusion Tensor Imaging |
DVBIC |
Defense and Veterans Brain Injury Center |
ECRI |
Emergency Care Research Institute |
EEG |
Electroencephalogram |
EL |
Errorless learning |
EMF |
Everyday memory failures |
EMQ |
Everyday Memory Questionnaire |
ERIC |
Education Resources Information Center |
FAM |
Functional assessment measure |
FANCI |
First Steps Acute Neurobehavioral and Cognitive Intervention |
FCSUS |
Frequency of Cognitive Strategy Usage Scale |
FIM |
Functional independence measure |
FITBIR |
Federal Interagency Traumatic Brain Injury Research |
fMRI |
Functional magnetic resonance imaging |
FNM |
Face-name method |
FRsBe |
Frontal Systems Behavior Scale |
GAS |
Goal Attainment Scaling |
GCS |
Glasgow Coma Scale |
GMT |
Goal Management Training |
GOS |
Glasgow Outcome Scale |
GOS-E |
Extended Glasgow Outcome Scale |
GST |
General Stimulation Training |
HKLLT |
Hong Kong List Learning Test |
HRTB |
Halstead-Reitan Neuropsychological Test Battery |
HVLT–R |
Hopkins Verbal Learning Test–Revised |
IADL |
Instrumental activities of daily living |
ICF |
International Classification of Functioning, Disability, and Health |
ICIDH |
International Classification of Impairments, Disabilities and Handicaps |
IED |
Improvised explosive device |
IRB |
Institutional review board |
IOM |
Institute of Medicine |
ISMT |
Interactive strategy modeling training |
IT |
Information Technology |
IVA-CPT |
Integrated Visual and Auditory Continuous Performance Test |
KAS |
Katz Adjustment Scale |
KAS–R |
Katz Adjustment Scale–Relative Report Form |
KAS-R1 |
Katz Adjustment Scale, modified form R1 |
LAP |
Learning activities packet |
LCFS |
Levels of Cognitive Functioning Scale |
LCSW |
Licensed Clinical Social Worker |
LM |
Logical memory |
LOC |
Loss of consciousness |
LTM |
Long-term memory |
MAC–F |
Memory Assessment Clinics ratings scales–Family |
MAC–S |
Memory Assessment Clinics ratings scales–Self |
MANOVA |
Multivariate analysis of variance |
MCI |
Mild cognitive impairment |
MCQ |
Memory Compensation Questionnaire |
MEPSM |
Means-Ends Problem-Solving Measure |
MHS |
Military Health System |
MI |
Metacomponential Interview |
MOL |
Method of loci |
MPAI-3 |
Mayo-Portland Adaptability Inventory III |
MRI |
Magnetic resonance imaging |
MTBI |
Mild traumatic brain injury |
MSW |
Master of Social Work |
NART |
National Adult Reading Test |
NCLEX-RN |
National Council Licensure Examination for Registered Nurses |
NCSE |
Neurobehavioral Cognitive Status Examination |
NFI |
Neurobehavioral Functioning Inventory |
NICHD |
National Institute of Child Health and Human Development |
NIDRR |
National Institute on Disability and Rehabilitation Research |
NIH |
National Institutes of Health |
NR |
Neurorehabilitation program |
OEF |
Operation Enduring Freedom |
OIF |
Operation Iraqi Freedom |
ORM |
Orientation Remedial Module |
OT |
Occupational therapist |
OTR |
Occupational therapist registered |
PASAT |
Paced Auditory Serial Addition Test |
PASAT–R |
Paced Auditory Serial Addition Test–Revised |
PCS |
Post-concussion syndrome |
PCSS |
Personal Conversational Style Scale |
PDA |
Personal digital assistant |
PDBS |
Partner Directed Behavior Scale |
PET |
Positron emission tomography |
PFIC |
Profile of Functional Impairment in Communication |
PQOL |
Perceived Quality of Life |
PQRST |
Preview, Question, Repeat, State, and Test |
PROM |
Patient Reported Outcome Measures |
PRPP |
Perceive, Recall, Plan, and Perform |
PSQ |
Problem Solving Questionnaire |
PTA |
Posttraumatic amnesia |
PTSD |
Posttraumatic stress disorder |
QCIQ |
Quality of Community Integration Questionnaire |
RAPS |
Rapid Assessment of Problem Solving |
RAVLT–M |
Rey Auditory Verbal Learning Test–Modified |
RBMT |
Rivermead Behavioural Memory Test |
RCT |
Randomized controlled trial |
RIS |
Ridiculously imaged story |
RITS |
Rehabilitation Intensity of Therapy Scale |
RLTLT |
Ruff-Light Trail Learning Test |
RN |
Registered nurse |
RPM |
Raven’s Progressive Matrices |
SADI |
Self Awareness of Deficits Interview |
SART |
Sustained Attention to Response Test |
SCL–90 R |
Symptom Checklist–90 Revised |
SCSQ–A |
Social Communication Skills Questionnaire–Adapted |
SES |
Socioeconomic status |
SIT |
Self-instruction training |
SLP |
Speech-language pathologist |
SPRS |
Sydney Psychosocial Reintegration Scale |
SPRS–Relative |
Sydney Psychosocial Reintegration Scale–Relative Ratings |
SPRS–Self |
Sydney Psychosocial Reintegration Scale–Self Ratings |
SPSS |
Social Performance Survey Schedule |
SPSVM |
Social Problem-Solving Video Measure |
SR |
Spaced Retrieval |
SRSI |
Self-regulation skills interview |
SS/MB |
Single-subject, multiple baseline |
SUD |
Substance use disorders |
SWLS |
Satisfaction with Life Scale |
TAI |
Traumatic axonal injury |
TAMG |
Therapist Administered Memory Training Group |
TAP |
Test for Attentional Performance |
TASIT |
The Awareness of Social Interference Test |
TBI |
Traumatic brain injury |
TMS |
Transcranial magnetic stimulation |
TPM |
Time Pressure Management |
TOT |
Temporal Orientation Test |
UCSS |
Usefulness of Cognitive Strategy Scale |
USUHS |
Uniformed Services University of the Health Sciences |
VA |
Department of Veterans Affairs |
VAMC |
Veterans Affairs’ Medical Center |
VHA |
Veterans Health Administration |
VPA |
Visual paired associates |
WA |
Working alliance |
WAIS |
Wechsler Adult Intelligence Scale |
WAIS–R |
Wechsler Adults Intelligence Scale–Revised |
WCST |
Wisconsin Card Sorting Test |
WHO |
World Health Organization |
WHO-ICF |
World Health Organization’s International Classification of Functioning, Disability, and Health |
WMS–R |
Wechsler Memory Scale–Revised |
WMT |
Working Memory Training |
WRAMC |
Walter Reed Army Medical Center |