Is Cognitive Therapy Effective for TBI- Evidence Still Inconclusive

by U.S. Medicine

December 7, 2011

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.”

Is Cognitive Therapy Effective for TBI? Evidence Still Inconclusive Cont.

Few Definitive Findings

While taking pains to note the limitations of their own study, IoM researchers identified 90 studies looking at CRT that met their criteria — studies looking at one or several forms of CRT to treat the effects of TBI. They evaluated the outcomes of these studies over the short-term and the long-term, as well as how it helped the patient function in the real world.

The studies showed that there was a benefit from some forms of CRT for TBI. For example, one study used speech pathology and social work professionals to conduct training sessions with TBI patients and their families. The researchers found that, after 12 weeks of the treatment, those receiving the intervention had better communication skills — improvements that were maintained through a six-month follow-up.

Another study looked at using visual imagery to improve memory. After 30 treatment sessions, those receiving treatment performed better on the immediate recall of stories, as well as other memory tests. The treatment effects were maintained three months after treatment.  

However, most findings were less definitive. Many studies had flaws in the design, and most had small sample sizes. The committee also found little evidence of CRT impact on executive function impairments — the cognitive processes that allow individuals to plan or develop goals, initiate behavior, solve problems and monitor their course of life.

The end result is a body of evidence that is inconclusive as to CRT’s effectiveness, the IoM report states. The researchers laid out a comprehensive set of recommendations directed at how DoD should proceed. They included convening a multiagency conference with VA, NIH and other stakeholders to decide what criteria should be used in studying CRT, and plan a strategy to adopt a common definition of the treatment.

DoD also should collaborate with other research agencies to foster all phases of research and development of CRT treatments. The IoM researchers noted in their report that, while there was insufficient evidence to conclusively prove effectiveness, this was a result of a lack of evidence, not evidence to the contrary. A research strategy that incorporates support for CRT treatments for TBI from pilot phase to early efficacy research to large-scale clinical trials and comparative effectiveness studies will help pave the way to more effectively judge the treatment’s worth.

Cognitive Rehabilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence

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