Sports Medicine Research: In the Lab & In the Field: Therapist-Directed Cognitive Rehabilitation Improved Functional Cognitive Outcomes (Sports Med Res)


Monday, October 10, 2016

Therapist-Directed Cognitive Rehabilitation Improved Functional Cognitive Outcomes

Cognitive Rehabilitation for Military Service Members With Mild Traumatic Brain Injury: A Randomized Clinical Trial

Cooper DB, Bowles AO, Kennedy JE, Curtiss G, French LM, Tate DF, Vanderploeg RD. J Head Trauma Rehabil. 2016;ahead of print.

Take Home Message: Four treatment strategies for chronic symptoms after a mild traumatic brain injury (mTBI) improved symptoms; however, those with therapist-directed cognitive rehabilitation demonstrated superior improvements in functional cognitive scores compared with standard of care and computer-based rehabilitation.

Many US military service members and veterans report postconcussive symptoms well beyond a normal period of recovery. Psychoeducation, behavioral health, and cognitive rehabilitation interventions for chronic postconcussive symptoms are used to treat those suffering from memory and other cognitive impairments. However, prior studies were small and only looked at acute recovery. Therefore, the authors developed a randomized control trial to compare cognitive rehabilitation interventions with standard of care management for service members who had chronic symptoms after an mTBI. The researchers assessed 126 service members who sustained an mTBI from 3 to 24 moths before baseline evaluation and reported ongoing cognitive difficulties (at least moderate severity). The service members were randomly allocated into 1 of 4, 6-week treatment programs for 10 hours a week:
1) psychoeducation (standard or care) – no specific treatment interventions; 34 participants
2) computer-based cognitive rehabilitation – computer programs for skill-specific training and cognitive activation; 30 participants
3) therapist-directed manualized cognitive rehabilitation – individual therapy sessions focusing on restorative and compensatory strategies, group therapy focusing on compensatory strategies, and computer-based “homework” for attention processing training; 30 participants
4) integrated therapist-directed cognitive rehabilitation combined with cognitive-behavioral psychotherapy – individual therapy sessions focusing on restorative, compensatory, mindfulness-based stress reduction, and stress/anxiety symptom acceptance and commitment strategies, group therapy focusing on postconcussive and depression symptoms through cognitive-behavioral psychotherapy and compensatory strategies, computer-based “homework” for mindfulness-based stress reduction training and attention processing; 32 participants
All service members received psychoeducational materials and medical management for symptoms. Blinded researchers administered 3 outcome measures 1) Paced Auditory Serial Addition test( PASAT) to assess information processing speed, sustained attention, and divided attention; 2) Symptom Checklist-90 Revisited (SCL-90R) to measure psychological problems and psychopathology; and 3) Key Behavior Change Inventory (KBCI) to measure functional cognitive and behavioral difficulties. Assessments were conducted at baseline and at 4 follow-up time points (3-, 6-, 12-, and 18-weeks). Members of each treatment group improved on all 3 outcome measures over time. All of the groups had similar improvement in neurocognitive performance. Service members in the 2 therapist-directed programs demonstrated higher functional cognitive abilities compared with service members in the psychoeducation group. Improved scores of psychological problems and psychopathology were maintained at least until the 12- and 18-week follow-up sessions.

The authors found that all 4 rehabilitation programs led to sustained improvement for the 3 primary outcome measures. When service members received treatment with therapist direction they had superior improvement in day-to-day functional cognitive abilities compared with those in the psychoeducation and computer based groups that lacked a therapist. Also, service members in the integrated therapist-directed cognitive rehabilitation demonstrated a greater positive change in reducing psychological distress or emotional symptoms compared with those in the psychoeducation group. Based on these results medical professionals should consider referring patients with persistent concussive signs and symptoms to individual and/or group therapy to improve cognitive function.

Questions for Discussion: Do you currently send patients with mTBI to a therapist? If not, would you consider therapy for those suffering post concussion signs and symptoms? Do you think there would be a difference in recovery between patients that receive individual versus group therapy?

Written by: Jane McDevitt, PhD
Reviewed by: Jeff Driban

Related Posts:

Cooper DB, Bowles AO, Kennedy JE, Curtiss G, French LM, Tate DF, & Vanderploeg RD (2016). Cognitive Rehabilitation for Military Service Members With Mild Traumatic Brain Injury: A Randomized Clinical Trial. The Journal of head trauma rehabilitation PMID: 27603763


B_Green said...

I really enjoyed this article and would like to see a study of this nature replicated in a collegiate athlete population. Because most mild traumatic injuries resolve within 7-10 days, I do not believe sports medicine clinicians encounter student-athletes with prolonged postconcussive symptoms often enough to have a game plan for how to treat those individuals. From my own experience, I have not encountered a student-athlete struggling to recover from a sport concussion and thus would be limited in how to provide the best treatment. A lack of financial resources may prevent many sports medicine departments from referring athletes to off-site facilities for treatment, so providing clinicians with best practices for treating prolonged postconcussive recovery in-house would be ideal.

Although the four treatment options in this study were time- and resource-intensive, they could be modified for utilization in other settings. A major clinical takeaway that is of importance in any setting is the benefit of therapist-directed rehabilitation. Again, referencing my own experience in a collegiate setting, I believe clinicians are often challenged to provide high-quality individualized care because of time restraints. However, I think this study rightfully draws attention back to patient-centered care. If frequent feedback, positive reinforcement, and constant instruction lead to improved outcomes following mild traumatic brain injury, or any injury for that matter, we as clinicians need to advocate for more resources that would allow us to increase the one-on-one time spent with our athletes.

Jane McDevitt said...

I agree with you the lack of resources could prevent referring concussed athletes to these specialists; however, your idea about modifying these practices to be utilized in other settings is a good idea. And, if more research is done to confirm that this is helpful then we do need to advocate for resources to provide this rehabilitation. I think at the very least medical professionals should consider engaging and networking with these therapists so they have them within their sports medicine umbrella. We can also be educating athletes on the importance of considering these treatment options.

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