Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and Veterans Brain Injury Center randomized controlled trial of two rehabilitation approaches.
OBJECTIVE
To determine the relative efficacy of 2 different acute traumatic brain injury (TBI) rehabilitation approaches: cognitive didactic versus functional-experiential, and secondarily to determine relative efficacy for different patient subpopulations.


METHODS
Randomized, controlled, intent-to-treat trial comparing 2 alternative TBI treatment approaches.


METHODS
Four Veterans Administration acute inpatient TBI rehabilitation programs.


METHODS
Adult veterans or active duty military service members (N=360) with moderate to severe TBI.


METHODS
One and a half to 2.5 hours of protocol-specific cognitive-didactic versus functional-experiential rehabilitation therapy integrated into interdisciplinary acute Commission for Accreditation of Rehabilitation Facilities-accredited inpatient TBI rehabilitation programs with another 2 to 2.5 hours daily of occupational and physical therapy. Duration of protocol treatment varied from 20 to 60 days depending on the clinical needs and progress of each participant.


METHODS
The 2 primary outcome measures were functional independence in living and return to work and/or school assessed by independent evaluators at 1-year follow-up. Secondary outcome measures consisted of the FIM, Disability Rating Scale score, and items from the Present State Exam, Apathy Evaluation Scale, and Neurobehavioral Rating Scale.


RESULTS
The cognitive-didactic and functional-experiential treatments did not result in overall group differences in the broad 1-year primary outcomes. However, analysis of secondary outcomes found differentially better immediate posttreatment cognitive function (mean+/-SD cognitive FIM) in participants randomized to cognitive-didactic treatment (27.3+/-6.2) than to functional treatment (25.6+/-6.0, t332=2.56, P=.01). Exploratory subgroup analyses found that younger participants in the cognitive arm had a higher rate of returning to work or school than younger patients in the functional arm, whereas participants older than 30 years and those with more years of education in the functional arm had higher rates of independent living status at 1 year posttreatment than similar patients in the cognitive arm.


CONCLUSIONS
Results from this large multicenter randomized controlled trial comparing cognitive-didactic and functional-experiential approaches to brain injury rehabilitation indicated improved but similar long-term global functional outcome. Participants in the cognitive treatment arm achieved better short-term functional cognitive performance than patients in the functional treatment arm. The current increase in war-related brain injuries provides added urgency for rigorous study of rehabilitation treatments. (http://ClinicalTrials.gov ID# NCT00540020.).
Vanderploeg
Rodney D
RD
Department of Mental Health and Behavioral Sciences, and Defense and Veterans Brain Injury Center, James A. Haley Veterans Affairs Medical Center, Tampa, FL 33612, USA. Rodney.Vanderploeg@va.gov
Schwab
Karen
K
Walker
William C
WC
Fraser
Jamie A
JA
Sigford
Barbara J
BJ
Date
Elaine S
ES
Scott
Steven G
SG
Curtiss
Glenn
G
Salazar
Andres M
AM
Warden
Deborah L
DL
D000328:Adult; D001930:Brain Injuries / Q000150:complications / Q000534:rehabilitation*; D003071:Cognition; D003072:Cognition Disorders / Q000209:etiology / Q000534:rehabilitation*; D004651:Employment; D005260:Female; D006801:Humans; D008297:Male; D008889:Military Personnel; D009788:Occupational Therapy / Q000379:methods; D026741:Physical Therapy Modalities; D011446:Prospective Studies; D020127:Recovery of Function; D016037:Single-Blind Method; D014481:United States; D014728:Veterans