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

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.

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
– 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.

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

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?

Jane McDevitt, PhD
by: Jeff Driban


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