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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

  • Rodney D. Vanderploeg
    Correspondence
    Reprint requests to Rodney D. Vanderploeg, PhD, Mental Health and Behavioral Sciences—Psychology (116B), James A. Haley VAMC, 13000 N. Bruce B. Downs Blvd, Tampa, FL, 33612
    Affiliations
    Department of Mental Health and Behavioral Sciences, and Defense and Veterans Brain Injury Center, James A. Haley Veterans Affairs Medical Center, Tampa, FL

    Department of Psychiatry and Behavioral Medicine, University of South Florida, Tampa, FL

    Department of Psychology, University of South Florida, Tampa, FL
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  • Karen Schwab
    Affiliations
    Defense and Veterans Brain Injury Center, Walter Reed Army Medical Center, Washington, DC

    Uniformed Services University of the Health Sciences, Bethesda, MD
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  • William C. Walker
    Affiliations
    Defense and Veterans Brain Injury Center, Hunter H. McGuire Veterans Affairs Medical Center, Richmond, VA

    Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond, VA
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  • Jamie A. Fraser
    Affiliations
    Defense and Veterans Brain Injury Center, Walter Reed Army Medical Center, Washington, DC
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  • Barbara J. Sigford
    Affiliations
    Physical Medicine and Rehabilitation, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN; and Defense and Veterans Brain Injury Center
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  • Elaine S. Date
    Affiliations
    Comprehensive Rehabilitation Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; and Defense and Veterans Brain Injury Center

    Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA
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  • Steven G. Scott
    Affiliations
    Physical Medicine and Rehabilitation Service; Polytrauma Rehabilitation Center, James A. Haley Veterans Affairs Medical Center, Tampa, FL; and Defense and Veterans Brain Injury Center

    Physical Medicine and Rehabilitation Section, Department of Internal Medicine, University of South Florida College of Medicine, Tampa, FL
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  • Glenn Curtiss
    Affiliations
    Department of Mental Health and Behavioral Sciences, and Defense and Veterans Brain Injury Center, James A. Haley Veterans Affairs Medical Center, Tampa, FL

    Department of Psychiatry and Behavioral Medicine, University of South Florida, Tampa, FL
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  • Andres M. Salazar
    Affiliations
    Oncovir Inc, Washington, DC
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  • Deborah L. Warden
    Affiliations
    Defense and Veterans Brain Injury Center, Walter Reed Army Medical Center, Washington, DC

    Uniformed Services University of the Health Sciences, Bethesda, MD
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  • Defense and Veterans Brain Injury Center Study Group

      Abstract

      Vanderploeg RD, Schwab K, Walker WC, Fraser JA, Sigford BJ, Date ES, Scott SG, Curtiss G, Salazar AM, Warden DL, for the Defense and Veterans Brain Injury Center Study Group. 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.

      Objectives

      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.

      Design

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

      Setting

      Four Veterans Administration acute inpatient TBI rehabilitation programs.

      Participants

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

      Interventions

      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.

      Main Outcome Measures

      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.)

      Key Words

      List of Abbreviations:

      CARF (Commission for Accreditation of Rehabilitation Facilities), DRS (Disability Rating Scale), DVBIC (Defense and Veterans Brain Injury Center), PTA (posttraumatic amnesia), RCT (randomized controlled trial), RLAS (Rancho Los Amigos Scale), TBI (traumatic brain injury), VAMC (Veterans Administration Medical Centers)
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      Linked Article

      • Maximizing TBI Rehabilitation Outcomes with Targeted Interventions
        Archives of Physical Medicine and RehabilitationVol. 90Issue 3
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          Vanderploeg and colleagues1 are to be congratulated on their recent randomized controlled trial. This large multi-site study found no difference between cognitive-didactic and functional-experiential treatment on primary outcome measures: functional independence in living, and return to work or school. It did however find potentially important differences in subset outcome analysis. Younger participants (<30 years old) and those with less education who participated in the cognitive-didactic group had better work or school related outcomes at 1-year follow-up than participants in the functional-experiential group.
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