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Cognitive Rehabilitation erapy
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
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
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.
International Standard Book Number 13: 978-0-309-21818-4
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Additional copies of this report are available from the National Academies Press,
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Cover credit: The middle image is a U.S. Air Force photo by Staff Sgt. Robert Barney/
Released.
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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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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search Council.
www.national-academies.org
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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
v
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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
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Reviewers
This report has been reviewed in draft form by individuals chosen for
their diverse perspectives and technical expertise, in accordance with proce-
dures approved by the National Research Council’s Report Review Commit-
tee. 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
vii
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viii REVIEWERS
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. Re-
sponsibility for the final content of this report rests entirely with the author-
ing committee and the institution.
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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 compre-
hensively 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 Free-
dom). Conflicts in these war zones have been characterized by more explo-
sive 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 re-
quire 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.
ix
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x PREFACE
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 func-
tion, 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 com-
prehensive 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 meet-
ings including scientific presentations, and an abundance of teleconferences
and email exchanges. We trust that this report assists not only DoD in its ef-
forts 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 pre-
sented 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 Re-
habilitation Institute (Philadelphia), who expertly abstracted information
from reviewed research reports. We also thank consultants to the commit-
tee, 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
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Contents
ACRONYMS AND ABBREVIATIONS xvii
SUMMARY 1
PART I: BACKGROUND
1 INTRODUCTION 21
Scope of the Report, 22
Traumatic Brain Injury, 23
Consequences of TBI, 26
Treatment, 28
The Military Health System, 30
Conclusion, 32
References, 33
2 TRAUMATIC BRAIN INJURY 37
Classification Schemes, 38
Heterogeneity, 42
Measures of Outcome, 49
Conclusion, 52
References, 52
3 FACTORS AFFECTING RECOVERY 59
Preinjury Conditions, 60
xi
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xii CONTENTS
Comorbidities, 61
Contextual Factors, 67
Conclusion, 69
References, 70
4 DEFINING COGNITIVE REHABILITATION THERAPY 75
The Breadth of Rehabilitation, 75
An Evolving Definition of CRT, 77
Conclusion, 86
References, 86
5 STATE OF PRACTICE AND PROVIDERS OF COGNITIVE
REHABILITATION THERAPY 89
State of Practice, 89
Providers, 94
Conclusion, 110
References, 110
PART II: REVIEW OF THE EVIDENCE
6 METHODS 115
Literature Review, 115
Evaluation of the Evidence, 118
Quality of Study Designs, 121
Organization of the Evidence Chapters, 123
References, 123
7 ATTENTION 125
Overview, 125
Moderate-Severe TBI, 126
Conclusions: Attention, 135
References, 136
8 EXECUTIVE FUNCTION 137
Overview, 137
Awareness, 137
Conclusions: Awareness, 152
Non-Awareness, 153
Conclusions: Non-Awareness, 158
References, 160
9 LANGUAGE AND SOCIAL COMMUNICATION 163
Overview, 163
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xiii
CONTENTS
Chronic, Moderate-Severe TBI, 164
Conclusions: Language and Social Communication, 171
References, 173
10 MEMORY 175
Overview, 175
Internal Memory Strategies, 176
External Memory Strategies, 184
Combined Memory Strategies: Internal and External, 189
Restorative Strategies, 191
Conclusions: Memory, 193
References, 211
11 MULTI-MODAL OR COMPREHENSIVE COGNITIVE
REHABILITATION THERAPY 213
Overview, 213
Subacute Phase of Recovery, 214
Conclusions: Subacute, Multi-Modal/Comprehensive CRT, 217
Chronic Phase of Recovery, 218
Conclusions: Chronic, Multi-Modal/Comprehensive CRT, 224
References, 241
12 TELEHEALTH TECHNOLOGY 243
Overview, 243
CRT Applied Through Telehealth Technology, 243
Conclusions: Telehealth Technology, 247
References, 247
13 ADVERSE EVENTS OR HARM 249
Overview, 249
Potential for Adverse Events or Harm from CRT, 249
Conclusions: Adverse Events or Harm, 251
References, 251
PART III: RECOMMENDATIONS
14 DIRECTIONS 255
Synthesis of Evidence Review, 255
Recommendations, 258
Conclusion, 268
References, 269
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xiv CONTENTS
APPENDIXES
A Comparative Effectiveness and Implementation Research
for Neurocognitive Disorders 273
B Workshop Agendas 283
C Recent and Ongoing Clinical Trials: CRT for TBI 287
D Biosketches of Committee Members and Staff 325
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Tables, Figures, and Boxes
TABLES
S-1 Conclusions by Cognitive Domain and Multi-Modal/Comprehen-
sive CRT, 11
2-1 Classification of Mild, Moderate, and Severe Traumatic Brain
Injury, 40
4-1 Definitions of Cognitive Rehabilitation Therapy by
Organization, 78
5-1 CRT Providers: Services, Practice Requirements, and Professional
Setting, 96
6-1 Definitions of Acute, Subacute, and Chronic Phases of Recovery
Post-TBI, 118
6-2 Study Design by Treatment Domain or Strategy, 119
7-1 Evidence Table: Attention, 127
8-1 Evidence Table: Executive Function, 139
9-1 Evidence Table: Language and Social Communication, 165
10-1 Evidence Table: Memory, 199
10-2 Internal Memory Strategies, 177
xv
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xvi TABLES, FIGURES, AND BOXES
10-3 External Memory Strategies, 184
10-4 Combined Memory Strategies, 189
10-5 Restorative Memory Strategies, 192
11-1 Evidence Table: Multi-Modal/Comprehensive CRT, 227
11-2 Studies in the Subacute Phase of Recovery, 214
11-3 Studies in the Chronic Phase of Recovery, 219
14-1 Overall Conclusions by Cognitive Domain and Multi-Modal/
Comprehensive CRT, 256
14-2 Definitions of Acute, Subacute, and Chronic TBI Recovery, 257
FIGURES
1-1 Number of U.S. service members with TBI, by severity, 25
1-2 WHO-IC Model of Disablement, 27
3-1 Factors affecting initial response to TBI and recovery from TBI, 60
4-1 Model for modular CRT, 81
4-2 Model for multi-modal/comprehensive CRT, 82
A-1 Model for multi-modal/comprehensive CRT, 274
A-2 Clinical research continuum, 276
A-3 Refined research-implementation pipeline, 277
BOXES
S-1 Statement of Task, 2
S-2 Evidence Grades, 10
1-1 Statement of Task, 23
1-2 Department of Defense Definition of Traumatic Brain Injury, 24
6-1 Inclusion and Exclusion Criteria, 117
6-2 Evidence Grades, 121
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Acronyms and Abbreviations
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
xvii
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xviii ACRONYMS AND ABBREVIATIONS
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
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xix
ACRONYMS AND ABBREVIATIONS
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
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xx ACRONYMS AND ABBREVIATIONS
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
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xxi
ACRONYMS AND ABBREVIATIONS
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
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xxii ACRONYMS AND ABBREVIATIONS
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
