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Introduction

In October 2011, the Institute of Medicine (IOM) released the report Cognitive Rehabilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence, assessing the published evidence for the effectiveness of using cognitive rehabilitation therapy (CRT) to treat people with traumatic brain injury (TBI) (see Box 1-1 for a statement of task for the report). TBI has gained increasing attention in the past 15 years because of its status as the signature wound of American military conflicts in Iraq and Afghanistan (DVBIC, 2011; Snell and Halter, 2010). Growing numbers of U.S. service members are suffering traumatic brain injuries and are surviving them, given that (a) the majority of traumatic brain injuries are mild and (b) life-saving measures for more severe injuries have significantly improved. People with any level of injury can require ongoing health care in their recovery, helping them to regain (or compensate for) their losses of function and supporting their full integration into their social structure and an improved quality of life.

One form of treatment for TBI is CRT, a systematic, goal-oriented approach to helping patients overcome cognitive impairments. The Department of Defense (DoD) asked the IOM to evaluate CRT for traumatic brain injury in order to guide the DoD’s use and coverage in the Military Health System. Cognitive Rehabilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence was the IOM’s resulting study of the evidence. The report’s conclusions revolved around the fact that there is little continuity among research studies of the effectiveness of different types of CRT, and there exist only small amounts of evidence (or, in many cases, none) demonstrating the effectiveness of using CRT to treat TBI—although



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1 Introduction In October 2011, the Institute of Medicine (IOM) released the report Cognitive Rehabilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence, assessing the published evidence for the effectiveness of using cognitive rehabilitation therapy (CRT) to treat people with traumatic brain injury (TBI) (see Box 1-1 for a statement of task for the report). TBI has gained increasing attention in the past 15 years because of its status as the signature wound of American military conflicts in Iraq and Afghanistan (DVBIC, 2011; Snell and Halter, 2010). Growing numbers of U.S. service members are suffering traumatic brain injuries and are surviving them, given that (a) the majority of traumatic brain injuries are mild and (b) life- saving measures for more severe injuries have significantly improved. People with any level of injury can require ongoing health care in their recovery, helping them to regain (or compensate for) their losses of function and supporting their full integration into their social structure and an improved quality of life. One form of treatment for TBI is CRT, a systematic, goal-oriented approach to helping patients overcome cognitive impairments. The De- partment of Defense (DoD) asked the IOM to evaluate CRT for traumatic brain injury in order to guide the DoD’s use and coverage in the Military Health System. Cognitive Rehabilitation Therapy for Traumatic Brain In- jury: Evaluating the Evidence was the IOM’s resulting study of the evi- dence. The report’s conclusions revolved around the fact that there is little continuity among research studies of the effectiveness of different types of CRT, and there exist only small amounts of evidence (or, in many cases, none) demonstrating the effectiveness of using CRT to treat TBI—although 1

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2 COGNITIVE REHABILITATION THERAPY FOR TBI BOX 1-1 Statement of Task for the Committee That Authored Cognitive Rehabilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence A consensus committee shall design and perform a methodology to review, synthesize, and assess the salient literature and determine if there exists suffi- cient evidence for effective treatment using cognitive rehabilitation therapy (CRT) for three categories of traumatic brain injury (TBI) severity—mild, moderate, and severe—and will also consider the evidence across three phases of recovery— acute, subacute, and chronic. In assessing CRT treatment efficacy, the committee will consider comparison groups such as no treatment, sham treatment, or other non-pharmacological treatment. The committee will determine the effects of spe- cific CRT treatment on improving (1) attention, (2) language and communication, (3) memory, (4) visuospatial perception, and (5) executive function (e.g., problem solving and awareness). The committee will also evaluate the use of multi-modal CRT in improving cognitive function as well as the available scientific evidence on the safety and efficacy of CRT when applied using telehealth technology devices. The committee will further evaluate evidence relating CRT’s effectiveness on the family and family training. The goal of this evaluation is to identify specific CRT interventions with sufficient evidence base to support their widespread use in the MHS, including coverage through the TRICARE benefit. The committee shall gather and analyze data and information that addresses: 1.  comprehensive literature review of studies conducted, including but not a limited to studies conducted on MHS or VA wounded warriors; 2.  assessment of current evidence supporting the effectiveness of specific an CRT interventions in specific deficits associated with moderate and severe TBI; 3.  assessment of current evidence supporting the effectiveness of specific an CRT interventions in specific deficits associated with mild TBI; 4.  assessment of (1) the state of practice of CRT and (2) whether require- an ments for training, education and experience for providers outside the MHS direct-care system to deliver the identified evidence-based interventions are sufficient to ensure reasonable, consistent quality of care across the United States; and 5.  independent assessment of the treatment of traumatic brain injury by an cognitive rehabilitation therapy within the MHS if time or resources permit. the evidence that does exist generally indicates that CRT interventions have some effectiveness. OBJECTIVES OF THE WORKSHOP The workshop brought together experts in health services administra- tion, research, and clinical practice from the civilian and military arenas in

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INTRODUCTION 3 order to discuss the barriers for evaluating the effectiveness of CRT care and for identifying suggested taxonomy, terminology, timing, and ways for- ward for CRT researchers. The workshop consisted of individuals and was not intended to constitute a comprehensive group. Select decision makers in the Military Health System and Veterans Affairs (VA) and researchers were invited to participate. The workshop was designed to spur thinking about (1) the types of research necessary to move the field forward toward evidence-based clinical guidelines, (2) what the translational pipeline looks like and what its current deficiencies are, and (3) considerations that de- cision makers may choose to use as they decide what research they will support and decide how they will balance the urgency of the need with the level of evidence for CRT interventions. Warren Lockette, Chief Medical Officer for TRICARE, offered a per- spective from the DoD aimed to guide the workshop discussions toward DoD’s primary challenges in its efforts to help service members suffering from TBIs. He described how the Military Health System’s coverage of CRT treatments is in need of a portfolio of interventions whose effective- ness has been scientifically determined. Slightly upstream is the pressing need of DoD program managers, who would greatly benefit from a clear understanding of the major research needs that must be met in order for the DoD to obtain such a portfolio of proven interventions. The DoD seeks scientifically based guidance about what CRT interventions are ef- fective, and for whom. Lockette emphasized the critical need for research that, while scientifically rigorous, also takes into account the budgetary environment in which CRT treatments are delivered—an environment very cost-constrained. He asked workshop participants to consider what kinds of techniques need to be pursued as part of a research agenda and what the standards for research programs should be to effectively and efficiently move the field toward specific, scientifically based guidance for CRT prac- titioners charged with helping injured service members regain functionality and improve their quality of life. ORGANIZATION OF THIS SUMMARY The workshop consisted of three types of discussion: formal presenta- tions, question/answer periods, and small-group discussions followed by the groups’ reporting back and subsequent large-group discussion. Small-group discussions were focused on sets of questions designed by members of the planning committee, and each small-group discussion was moderated by a planning committee member. This document was prepared by rapporteur Karin Matchett for the Board on the Health of Select Populations of the IOM as a factual summary of what occurred at the workshop Cognitive

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4 COGNITIVE REHABILITATION THERAPY FOR TBI Rehabilitation Therapy for Traumatic Brain Injury: Model Study Protocols and Frameworks to Advance the State of the Science. This workshop summary begins with summaries of the three formal presentations: an overview of the original IOM report, Cognitive Reha- bilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence (Chapter 2), an overview of the translational pipeline for using CRT for TBI, and a discussion about finding optimal ways of describing CRT in- tervention (both in Chapter 3). Chapter 4 summarizes the suggestions and recommendations of the workshop participants, organized by theme. The recommendations expressed in Chapter 4 are in no way a consensus; rather, they are meant to inform and guide, where relevant or helpful, health ser- vices administrators as they map out future research directions and clinical guidelines for using CRT to treat TBI. In accordance with the policies of the IOM, the summary does not at- tempt to establish any conclusions or recommendations about needs and future directions, focusing instead on issues identified by the speakers and workshop participants. Whenever possible, ideas presented at the workshop are attributed to the individual who expressed them. Any opinions, conclu- sions, or recommendations discussed in this workshop summary are solely those of the individual participants and should not be construed as reflect- ing consensus or endorsement by the workshop, the Board on the Health of Select Populations, the IOM, or the National Academies.