For more information visit www.iom.edu/CRTforTBI

REPORT BRIEF  OCTOBER 2011

Cognitive Rehabilitation Therapy for Traumatic Brain InjuryEvaluating the Evidence

Traumatic brain injury (TBI)—affecting an estimated 10 million people worldwide—results from a bump or blow to the head, or from external forces that cause the brain to move within the head, such as whiplash or exposure to blasts. TBI is a serious and growing problem, particularly among soldiers and veterans because of repeated exposure to violent environments. It can cause cognitive, physical, or psychosocial problems. One form of treatment for TBI is cognitive rehabilitation therapy (CRT), a patient-specific, goal-oriented approach to help patients increase their ability to process and interpret infor-mation. CRT involves a variety of treatments provided by health profession-als in a wide range of fields and often involves the participation of family or caregivers. Given that TBI is considered the “signature wound” of the conflicts in Iraq and Afghanistan, the Department of Defense (DoD) asked the Institute of Medicine (IOM) to conduct a study to determine the effectiveness of CRT for treatment of TBI. Specifically, the DoD asked the IOM to consider whether existing research on CRT provides a conclusive evidence base to support using specific CRT interventions and to guide the use of CRT for members of the military and veterans. The IOM appointed a committee of experts to answer the following ques-tions:

•AreCRTinterventionsproventoreduceanindividual’scognitivedeficitsacross:

• the three levels of injury (mild, moderate, and severe);

• the three phases of recovery (acute, subacute, and chronic);

TBI is a serious and growing prob-lem, particularly among soldiers and veterans because of repeated exposure to violent environments. It can cause cognitive, physical, or psychosocial problems.

2

• the cognitive functions (attention, lan-guage and communication, memory, and problem-solving abilities known as executive function) or within a com-prehensive rehabilitation program that may target more than one cognitive function?

•Are any CRT interventions associated withrisk for adverse events or harm?

•Are CRT interventions safe and effectivewhen administered through “telehealth” technologies?

The committee completed a review of the lit-erature and evaluated studies that met selection criteria in each of the cognitive functions or com-prehensive rehabilitation programs.

Understanding Cognitive Rehabilitation TherapyThe goal of CRT is to help an individual with a brain injury enhance his or her ability to move through daily life by recovering or compensating for damaged cognitive functions. A restorative approach helps the patient reestablish cognitive function, while compensatory approaches help the individual to adapt to an ongoing impairment. CRT interventions are nearly as unique and varied as the individuals they are used to treat. A comprehensive rehabilitation program may be used for individuals with multiple impairments, for example memory loss combined with difficul-ties in problem solving, while approaches focused on a single cognitive function attempt to work on each impairment in isolation. In addition to the variation in treatment, an individual’s responseto any one treatment may vary as well, depending ontheinjury,theindividual’spriorstateofhealth,and the individual’s social context. Treatmentstrategies evolve, as different treatments become necessary at different points in time. CRT is practiced by a wide range of profes-sionals in rehabilitation medicine, nursing, physi-

cal and occupational therapy, speech-language pathology, psychology, and neurology. Each pro-fession determines the training requirements for its own practitioners, and U.S. states regulate pro-fessional licensing standards. Because no national brain injury rehabilitation license and credential exist, the standards vary among rehabilitation professionals.

Shortcomings in the Research In its report, the committee concludes that current evidence provides limited support for the efficacy of CRT interventions. The evidence varies in both the quality and volume of studies and therefore is not yet sufficient to develop definitive guidelines for health professionals on how to apply CRT in practice. The variation among patient character-istics, severity of injuries, and CRT interventions has made it difficult for researchers to know with certainty how effective a specific CRT interven-tion is in the long-term recovery of a specific indi-vidual. A lack of standardized terms for the dif-ferent forms of CRT also presents a challenge for researchers. Despite the methodological shortcomings of the evidence, the committee supports the ongoing use of CRT for people suffering from a TBI while improvements are made in the standardization, design, and conduct of studies.

Implementing a Research AgendaThe committee recommends an investment in research to further define, standardize, and assess the outcomes of CRT interventions. Develop-ing studies that have larger sample sizes and that examine a more comprehensive set of variables regarding the injuries, patient characteristics, and outcomes will help advance knowledge about CRT. In addition, because CRT encompasses a wide range of therapies, research is needed to evaluate the effectiveness of each intervention for each cognitive function. To achieve standard-

3

sive registry of CRT interventions—a database to col-lect information about these variables. As part of an effort to advance current research, the DoD in collaboration with other research and funding agencies, should support all phases of research on CRT, including pilot stud-ies, early efficacy studies, large-scale clinical tri-als, and comparative effectiveness studies. In the future, researchers should capture information about potential adverse events as well as evalu-ate CRT interventions applied through telehealth technology, for example treating patients via voice or video calls over the Internet.

Despite the methodological short-comings of the evidence, the com-mittee supports the ongoing use of CRT for people suffering from a TBI while improvements are made in the standardization, design, and conduct of studies.

ization, the DoD should convene a conference to reach consensus among a multiagency and mul-tidisciplinary team on the variables included in future studies and the strategy to advance the common definition of CRT interventions. Once the research community develops stan-dardized variables and definitions, the committee recommends that the DoD collect clinical data in the most rigorous way possible, which will help answer questions about which patients benefit the most from which CRT interventions. The DoD also should integrate the standardized definitions into ongoing research studies and should develop a comprehen-

Incidence of TBI in the Military

0

5000

10000

15000

20000

25000

30000

35000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Inci

denc

e

Year

Not Classifiable

Penetrating

Severe

Moderate

Mild

SOURCE: Defense and Veterans Brain Injury Center, 2011

The Institute of Medicine serves as adviser to the nation to improve health. Established in 1970 under the charter of the National Academy of Sciences,

the Institute of Medicine provides independent, objective, evidence-based advice to policy makers, health professionals, the private sector, and the public.

Copyright 2011 by the National Academy of Sciences. All rights reserved.

500 Fifth Street, NW Washington, DC 20001

TEL 202.334.2352 FAX 202.334.1412

www.iom.edu

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/Neuropsycholo-gist, U.S. Food and Drug Ad-ministration, 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 Anesthesiolo-gy, Anatomy and Neurobiology, Neurosurgery, and Neurology, Director, STAR Organized Research Center, University of Maryland School of Medicine, Baltimore

Robert T. Fraser Professor of Rehabilitation Medicine, University of Wash-ington/Harborview Medical Center, Seattle, WA

Tamar Heller Professor and Department Head, Department of Disability and Human Development, Uni-versity of Illinois at Chicago

Richard Keefe Professor of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC

Mary R. T. Kennedy Associate Professor, Depart-ment of Speech-Language-Hearing Sciences, University of Minnesota, Minneapolis

Harvey Levin Professor and Director of Research, Department of Physical Medicine & Rehabilita-tion, Baylor College of Medi-cine; Director of the Center of Excellence for Traumatic Brain Injury, Michael E. De Bakey Vet-erans 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

Study Staff

Rebecca 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

Study Sponsor

U.S. Department of Defense

Consultants

Jennifer Vasterling Chief of Psychology, VA Boston Healthcare System; Professor of Psychiatry, Boston University School of Medicine, MA

Barbara Vickrey Professor and Vice Chair, Department of Neurology, University of California, Los Angeles

ConclusionEach year, 1.7 million people in the United States sustain a TBI, and the number of military service members diagnosed with a TBI nearly tripled from 2000 to 2010. The incidence of TBI is rapidly ris-ing, and while the survival rate is rising concomi-tantly—due to improved protective equipment and more effective life-saving measures—survivors of TBI may experience long-lasting physical and cog-nitive impairments. These trends point to a growing need to effectively treat the lasting consequences of traumatic brain injury. CRT interventions are promising approaches, but further development and assessment of this therapy is required. f