Trial compares methods for brain injury rehab
January 6, 2009
Researchers from the Defense and
Veterans Brain Injury Center (DVBIC) have
published the results of one of the first
studies of its kind: a randomized clinical trial
comparing different treatment approaches
for those with traumatic brain injury (TBI).
The study appeared in the December
issue of the Archives of Physical Medicine
and Rehabilitation. It compared two
rehabilitation approaches: "cognitive
didactic" versus "functional-experiential."
The study appeared in the December
issue of the Archives of Physical Medicine
and Rehabilitation. It compared two
rehabilitation approaches: "cognitive
didactic" versus "functional-experiential."
While the findings suggest pluses to both
methods, the cognitive approach resulted in
better short-term gains in mental function and
was more effective in helping younger
patients return to work or school. The
functional method led to higher rates of
independent living among older patients. Both
methods had been validated in prior research
but had never been tested head-to-head.
Long-term gains from both approaches
"Our results show long-term functional
improvements in both groups," said lead
author Rodney Vanderploeg, PhD, a
research psychologist at the Tampa VA
Medical Center and University of South
Florida. At one year after treatment, he said,
about 6 in 10 study participants overall were
employed and living independently. "This is
remarkable," wrote Vanderploeg and
colleagues, "given that none were capable
of work or independent living at baseline"
and 90 percent had brain injuries that were
considered severe.
The study included 360 veterans or activeduty
troops, mostly men, with moderate to
severe TBI. Enrollment for the study ran
from 1996 to May 2003, shortly after the
onset of the war in Iraq. As such, most of the
participants sustained their injuries not in
combat but in vehicle crashes, falls or other
incidents.
Meanwhile, though, TBI has come to be
known as the "signature injury" of the wars
in Iraq and Afghanistan, affecting some 20
percent of injured troops. So the results of
the DVBIC study are highly relevant for
Department of Defense and VA, although
there may be ways in which TBI caused by
blasts—the most common scenario in the
current wars—differs from brain injuries
sustained otherwise.
The trial was conducted at VA's four
main polytrauma centers, in Tampa,
Richmond, Palo Alto and Minneapolis.
Patients, all in the acute phase of
rehabilitation, were randomly assigned to
one of two approaches:
- In the cognitive-didactic approach, the
emphasis was on helping study participants
relearn thinking skills.
-
In the functional-experiential approach,
the focus was on giving participants handson
practice doing everyday tasks.
Younger patients fare better
with 'cognitive' method
Over a month or two, each group
received about two hours per day of therapy
specific to their study arm. For example, the
cognitive group worked on paper-and-pencil
or computerized tests that became
progressively more difficult, with the
explicit goal of sharpening their mental
skills. The functional group, on the other
hand, received extra help going through the
physical motions of everyday activities such
as dining and grooming.
Each group also received additional
physical, occupational and speech therapy
in which the therapists used either a
cognitive or functional approach. In the
cognitive group, therapists offered more
verbal instruction and encouraged learning
through trial and error. They asked
questions such as "How do you think you
did?" or "What do you need to do now?" to
promote thinking and self awareness. In the
functional group, therapists did less verbal
teaching and emphasized "learning by
doing." They offered more hands-on, step-by-step support to help patients successfully
complete tasks. The aim was to ingrain the
physical movements and thereby promote
implicit learning.
The researchers tested participants'
cognitive abilities and everyday functioning
before and after treatment and one year
later. Among the findings:
-
Overall function was similar between
the two groups after one year. For
example, in the cognitive study arm, 65 out
of 167 participants (38.9 percent) were
working or in school. In the functional
group, the rate was 68 out of 164 (35.4
percent). The difference was not statistically
significant. (Follow-up data were not
available on all 360 study participants.)
- Immediate posttreatment cognitive
function was better in the cognitive
group. This was measured with tests in
areas such as comprehension, expression,
social interaction, problem solving and
memory. Cognitive-arm participants also
reported fewer memory problems after one
year.
-
Younger patients (those age 30 or
under) in the cognitive arm had a higher
rate of return to work or school than their
age peers in the functional arm. On the
other hand, older patients and those with
more years of education in the functional
arm were more likely to be living
independently at one year than similar
participants in the cognitive group.
The study authors offered a tentative
analysis of why younger and older patients
may have benefited differently from the two
approaches:
"…These findings suggest that the
cognitive treatment not only better enhances
cognitive recovery but also lays a stronger
foundation for the development of workrelated
cognitive skills. This effect appears
to be most prominent in younger patients,
who may benefit more from the higher level
of structure and teaching provided in the
cognitive approach to treatment. The
functional approach generally provided less
structure and did not offer problem-solving
strategies and approaches. Older or more
educated persons, who may already have
internalized structure and independence,
seemed to benefit more from the direct
living skills emphasized in the functional
interventions."
The DVBIC (www.dvbic.org) is a multisite
center for medical care, clinical
research and education on TBI. Funded by
the Department of Defense, the program
involves clinicians and investigators from
DoD, VA, and academic and private
medical centers. Since 2007, the center has
been part of the newly established Defense
Centers of Excellence for Psychological
Health and Traumatic Brain Injury.
This article originally appeared in the January 2009 issue of VA Research Currents.