WASHINGTON — While there is evidence that cognitive rehabilitation therapy (CRT) has a positive impact on TBI, it is not sufficient to develop guidelines on how to apply this type of therapy to specific patients, according to a recent report from the Institute of Medicine (IoM).

CRT is an umbrella term that covers a range of approaches to overcoming or compensating for cognitive impairments such as those caused by TBI. In the last decade, the number of servicemembers diagnosed with TBI rose from 11,000 to nearly 31,000. In that time, clinicians have struggled to find ways to treat these patients, especially over the long-term. To help determine the effectiveness of CRT as a path toward TBI recovery, DoD asked IoM to evaluate it as a treatment.

Lack of Standardization

One difficulty IoM found in evaluating CRT is that the therapy is not easily classified. It is practiced in a wide variety of settings, and those conducting the treatment are found in a wide range of fields, such as physical therapy, rehabilitation, speech-language pathology, occupational therapy, psychology, neuropharmacology and vocational rehabilitation.

Consequently, CRT as a treatment has not been standardized, and there are wide variations in practice. According to the IoM researchers, “The heterogeneity of the possible interventions makes it challenging to narrowly define the concept of CRT, or how to effectively apply it, challenging.”

Rather than describe the course of treatment, current definitions of CRT focus on the intent to improve one or more aspects of impaired cognitive function. For example, VA’s definition of CRT is that it’s, “one component of a comprehensive brain injury rehabilitation program [that] focuses not only on the specific cognitive deficits of the individual with brain injury but also on their impact on social, communication, behavior and academic/vocational performance.” VA’s definition goes on to list some of the interventions that might fall under CRT, which include modeling, guided practice, errorless learning, communication skills and computer-assisted retraining programs, but this results in making the definition broader, not more specific.

The IoM report takes great pains to list and compare the different types of CRT treatments — restorative vs. compensatory, contextualized vs. decontextualized, modular vs. comprehensive — and note that such heterogeneity in treatment makes it difficult to assess CRT as a whole.

However, the researchers suggest that the heterogeneity of treatment is a direct reflection of the reality of TBI. No traumatic brain injury is exactly like another one, and a patient’s treatment plan should be equally unique.

“A one-size-fits-all method of treatment may not be effective because of the heterogeneity of injuries, differences in personal, social and environmental circumstances, and differences in the activities of importance to individual patients,” the report states. “Heterogeneity of TBI further complicates studies of CRT impact and may mask benefit in subgroups that the study cannot detect due to small sample size or other limitations in study design.”