Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2013;94:2562-4

BRIEF REPORT

Education Attenuates the Negative Impact of Traumatic

Brain Injury on Cognitive Status
James F. Sumowski, PhD,a,b Nancy Chiaravalloti, PhD,a,b,c Denise Krch, PhD,b,c
Jessica Paxton, PhD,a,b John DeLuca, PhDa,b,d
From the aNeuropsychology and Neuroscience, Kessler Foundation, West Orange, NJ; bDepartment of Physical Medicine and Rehabilitation,
RutgerseNew Jersey Medical School, Newark, NJ; cTraumatic Brain Injury Laboratory, Kessler Foundation, West Orange, NJ; and dDepartment
of Neurology and Neurosciences, RutgerseNew Jersey Medical School, Newark, NJ.

Abstract
Objective: To investigate whether the cognitive reserve hypothesis helps to explain differential cognitive impairment among survivors of
traumatic brain injury (TBI), whereby survivors with greater intellectual enrichment (estimated with education) are less vulnerable to cognitive
impairment.
Design: Cross-sectional study.
Setting: Medical rehabilitation research center.
Participants: Survivors of moderate or severe TBI (nZ44) and healthy controls (nZ36).
Interventions: Not applicable.
Main Outcome Measures: Intellectual enrichment was estimated with educational attainment. Group was defined as TBI or healthy control.
Current cognitive status (processing speed, working memory, episodic memory) was evaluated with neuropsychological tasks.
Results: TBI survivors exhibited worse cognitive status than healthy persons (P<.001), and education was positively correlated with cognitive status
in TBI survivors (rZ.54, P<.001). Most importantly, regression analysis revealed an interaction between group and education (R2 changeZ.036,
PZ.004), whereas higher education attenuated the negative impact of TBI on cognitive status. TBI survivors with lower education performed
much worse than matched healthy persons, but this TBI-related performance discrepancy was attenuated at higher levels of education.
Conclusions: Higher intellectual enrichment (estimated with education) reduces the negative effect of TBI on cognitive outcomes, thereby
supporting the cognitive reserve hypothesis in persons with TBI. Future work is necessary to investigate whether intellectual enrichment can build
cognitive reserve as a rehabilitative intervention in survivors of TBI.
Archives of Physical Medicine and Rehabilitation 2013;94:2562-4
ª 2013 by the American Congress of Rehabilitation Medicine

More than 200,000 survivors of moderate and severe traumatic
brain injury (TBI) are discharged from American hospitals
annually.1 Many of these survivors will suffer chronic cognitive
impairment,2 with negative consequences for quality of life.3
Cognitive outcomes vary across survivors with similar injuries,2
such that 2 persons with similar injuries often have discrepant
Supported by the New Jersey Commission on Brain Injury Research (grant no.
CBIR11PJT020); the National Institute on Disability and Rehabilitation Research (grant no.
H133A070037); and a fellowship training grant from the Department of Education, National
Institute on Disability and Rehabilitation Research (grant no. H133P090009).
The content of this article does not necessarily represent the policy of the Department of
Education, and one should not assume endorsement by the federal government.
No commercial party having a direct financial interest in the results of the research supporting
this article has conferred or will confer a benefit on the authors or on any organization with which
the authors are associated.
cognitive outcomes. This inconsistent relation between neurologic
insult and cognitive outcome is observed across neurologic pop-
ulations, including Alzheimer disease (AD). For instance, many
older adults without dementia meet the neuropathologic criteria
for probable or definite AD at autopsy.4 This cognitive-pathologic
discrepancy is explained in part by the cognitive reserve hypoth-
esis, which posits that higher lifetime intellectual enrichment
(often estimated with education) protects against disease-related
cognitive decline.5 Indeed, high education protects against
dementia, despite substantial AD neuropathology.6,7 The cognitive
reserve hypothesis has been extended to other neurologic diseases,
including multiple sclerosis8,9 and pediatric10 and adult TBI.11,12
Previous work with adult survivors of TBI has primarily shown
positive correlations between intellectual enrichment and

0003-9993/13/$36 - see front matter ª 2013 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2013.07.023
Cognitive reserve in TBI
cognitive outcomes (ie, a main effect),11 but herein we evaluate
the cognitive reserve hypothesis in TBI by investigating whether
educational attainment differentially impacts cognitive impair-
ment after TBI (ie, an interaction effect).
Methods
Participants
The sample included 44 survivors of moderate (nZ3) or severe
(nZ41) TBI (mean age  SD, 39.310.6y; 12 women) and 36
healthy controls (mean age  SD, 43.711.3y; 24 women).
Survivors were at least 1 year postinjury (median, 5.9y; mean 
SD, 9.07.1y). Glasgow Coma Scale data were only available for
a subset of TBI survivors (nZ20; median, 4; mean  SD,
5.22.9). The TBI sample was marginally younger (t78Z1.79,
PZ.078), with a higher proportion of men (72.7% vs 33.3%;
c2Z12.42, P<.001). Age and sex were controlled in subsequent
analyses. The Kessler Foundation Institutional Review Board
approved data collection, and written informed consent was ob-
tained from all subjects.
Cognitive reserve
Lifetime intellectual enrichment was estimated with educational
attainment (healthy controls: 14.771.93y; TBI: 13.841.94y).5
Educational attainment was unrelated to time since injury
(rZ.074) or Glasgow Coma Scale scores (rZ.093) for TBI
survivors. As such, any protective effects of intellectual enrich-
ment are not explained/confounded by any chance relation
between educational attainment and injury severity.
Cognitive status
The most common cognitive deficits among TBI survivors include
slowed processing speed, poor working memory, and episodic
memory impairment.3 We assessed processing speed with the
Symbol Digit Modalities Test (oral version), working memory
with Letter-Number Sequencing, and episodic memory with the
Selective Reminding Test (total learning). Performance on each
measure was entered into a principal components analysis to
create a single cognitive status score used in subsequent analyses
(71.8% of variance).
Statistical analysis
We tested if intellectual enrichment (estimated with education)
moderates the deleterious effect of TBI on cognitive status
(interaction effect) by performing a hierarchical regression pre-
dicting cognitive status, with age, sex, group, and education in
step 1, and the interaction between group and education in step 2.
We expected a group by education interaction, where TBI survi-
vors with lower education would show cognitive deficits relative
to healthy persons, but such deficits would be attenuated in
patients with higher education.
List of abbreviations:
AD Alzheimer disease
TBI traumatic brain injury
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Results
Cognitive status was lower among TBI survivors ( .70.72) than
healthy persons (.85.50, t78Z10.92, P<.001). Significant (all
Ps<.001) raw score differences also existed for each of the 3
cognitive scores contributing to the cognitive status composite:
Symbol Digit Modalities Test (healthy: 64.399.76; TBI:
37.211.5), Letter-Number Sequencing (healthy: 12.442.57;
TBI: 9.252.3), and Selective Reminding Test (healthy:
141.445.7; TBI: 113.2723).
The full regression model was significant (F5,74Z10.91,
P<.001, R2Z.691). After controlling for age, sex, group, and
education, there was an interaction between group and education
(R2 changeZ.036, PZ.004). TBI survivors with lower education
performed worse than healthy persons, but this TBI-related
performance discrepancy was attenuated at higher levels of
education (fig 1A).
The cognitive reserve hypothesis predicts that intellectual
enrichment will be more related to cognitive status within
neurologic samples than healthy persons. This is because among
healthy persons, there are no deleterious effects of neurologic
disease processes on cognitive status for intellectual enrichment to
protect against. Indeed, there was a strong positive relation
between education and cognitive status among TBI survivors
(rZ.538, P<.001), but there was no relation among healthy
persons (rZ.035, PZ.841). We provide the raw data demon-
strating this divergent relation (fig 1B).
Discussion
Higher education attenuated the deleterious effect of moderate to
severe TBI on cognitive status, thereby supporting the cognitive
reserve hypothesis in TBI. This finding helps to explain the variable
cognitive outcomes across TBI survivors with similar injuries2
because survivors with higher education can sustain a given injury
with lesser cognitive decline than a person with less education. Our
findings extend earlier work linking higher premorbid intelligence
(another proxy of cognitive reserve) with better cognitive perfor-
mance in adult survivors of TBI11 and lesser cognitive decline after
penetrating head injuries12; however, we add to the literature by
directly testing the cognitive reserve hypothesis with an interaction
between TBI and intellectual enrichment (education).
Study limitations
Although limited by a relatively small sample size, our study
provides a proof of concept for cognitive reserve in TBI. The
small sample size may limit the generalizability of our findings
because our small samples may not adequately represent the
populations of healthy persons and survivors of TBI. For instance,
we confirmed our hypothesis that educational attainment would be
more related to cognitive status in survivors of TBI than in healthy
persons; however, one might expect at least a small positive
correlation between education and cognitive status in healthy
persons. This is one way in which our healthy sample may differ
from the general population. Another limitation relates to our sole
use of educational attainment as an estimate of intellectual
enrichment because the construct validity of education as an
independent contributor to reserve has been questioned,9,13 in part
because of the correlation between education and other proxies of
reserve (ie, intelligence). Finally, similar to work in AD6,7 and
2564
Fig 1 Plot of the interaction between group (TBI, healthy) and
educational attainment on the cognitive status component score.
Solid line indicates TBI group; dashed line, healthy control group (A).
Scatterplot of the relation between years of educational attainment
and cognitive status for TBI patients and healthy persons. Red indi-
cates TBI group; blue, health control group (B).
multiple sclerosis,8,9 future research should investigate whether
intellectual enrichment moderates/attenuates the negative effect of
disease-related neuropathologic changes (ie, cerebral atrophy) on
cognitive outcomes in TBI survivors.
Conclusions
Ultimately, consideration of lifetime intellectual enrichment
through proxies, such as education or vocabulary knowledge, may
J.F. Sumowski et al
help identify TBI survivors at greatest risk of cognitive impair-
ment (ie, survivors with lower cognitive reserve), who can then be
targeted for early intervention cognitive rehabilitation. Also,
encouraging survivors to engage in intellectually enriching
activities may help protect against cognitive decline, although
future experimental work is necessary to draw a causal link
between enrichment and neurocognitive protection.
Keywords
Brain injuries; Cognitive disorders; Cognitive reserve;
Neuropsychology; Rehabilitation
Corresponding author
James F. Sumowski, PhD, Neuropsychology and Neuroscience,
Kessler Foundation Research Center, 300 Executive Dr, Ste
70, West Orange, NJ 07052. E-mail address: jsumowski@
kesslerfoundation.org.
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