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NeuroRehabilitation 26 (2010) 239–255 239

DOI 10.3233/NRE-2010-0560
IOS Press

Cognitive rehabilitation for military personnel


with mild traumatic brain injury and chronic
post-concussional disorder: Results of April
2009 consensus conference
Katherine Helmick and members of Consensus Conference (see Appendix B)
Defense Centers of Excellence for Psychological, Health and Traumatic Brain Injury, 1335 East West Highway, 9th
Floor, Suite 400, Silver Spring, MD 20910, USA
E-mail: Katherine.Helmick@tma.osd.mil

Abstract. A consensus conference on cognitive rehabilitation for mild traumatic brain injury was conducted by the Defense
Centers of Excellence for Psychological Health and Traumatic Brain Injury and the Defense and Veterans Brain Injury Center.
Fifty military and civilian subject matter experts from a broad range of clinical and scientific disciplines developed clinical
guidance for the care of Service Members with persistent post-concussion cognitive symptoms three or more months post injury.
“Cognitive rehabilitation” was identified to be a broad group of diverse services. Specific services within this rubric were
identified as effective or not, and were evaluated both as single-services and as combined integrated cognitive rehabilitation
programs. Co-morbidities were acknowledged and addressed, but the conference and ensuing guidance focused primarily
upon treatment of cognitive impairment. Guidance regarding effective services addressed the areas of assessment, intervention,
outcome measurement, and treatment program implementation.

1. Introduction Iraq since 2001 report a 15%–22% mTBI incidence


rate [25,63]. In response, military-based research and
The true incidence of military mild traumatic brain clinical programs rapidly are developing and evolving,
injury (mTBI) is unknown. Many Warriors with mT- and the “first generation” of these programs is starting
BI do not seek medical care and thus have unrecog- to reach the scientific literature [67].
nized and unrecorded injuries. Alternately, many others TBI and mTBI long have been civilian health prob-
are identified through unwitnessed and unverified self- lems and have created a large and well-established TBI
report, using questionnaires administered months fol- rehabilitation literature [22]. The civilian literature is
lowing suspected mTBI. Both approaches are plagued not without its controversies, but it has had decades to
by numerous potentially severe biases and are compli- mature and to incorporate sophisticated methodologies
cated by the unknown prevalence of multiple mTBI and such as multi-site randomized controlled trials [67].
overlapping co-morbid disorders [5,21,26,38]. Civilian rehabilitation professionals also have devel-
While the precise incidence of mTBI in Op- oped decades of expertise in rehabilitating patients with
eration Enduring Freedom/Operation Iraqi Freedom TBI and mTBI [9,44].
(OEF/OIF) remains difficult to determine, there is no The purpose of the presently reported Consensus
question that it is one of the most common injuries Conference was to integrate military and civilian mT-
sustained by our Warriors. Data from combat-exposed BI rehabilitation expertise to create guidance regard-
U.S. military personnel returning from Afghanistan and ing cognitive rehabilitation of chronic post-concussive

ISSN 1053-8135/10/$27.50  2010 – IOS Press and the authors. All rights reserved
240 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder

symptoms in military populations receiving treatment result in significant functional impairment and disabil-
within military medical settings. A key objective was to ity [62].
acknowledge differences and similarities between mil- Cognitive rehabilitation is a well-accepted and com-
itary and civilian mTBI populations, and between mil- mon component of comprehensive rehabilitation for
itary and civilian health care delivery systems. In sum, persons with moderate and severe TBI [11], and in-
the mission and overriding emphasis of the conference creasingly is used for persisting deficits following mT-
was to generate guidance immediately relevant to mili- BI [22]. Clinical management of mTBI typically fo-
tary health care systems, military health care providers, cuses on preventing “excess disability” through edu-
and Wounded Warriors. cation to promote expectations of rapid and complete
recovery; providing a “timeout” period to permit recu-
peration; avoidance of dangerous activities that could
2. Methods lead to secondary injury; and, using appropriate medi-
cal treatment to ameliorate symptoms (e.g., headache,
2.1. Target population sleep disturbance, dizziness, etc.) that can interfere
with optimal recovery ([13] www.dvbic.org). However,
the 5%–15% of mTBI with chronic symptoms and func-
Conference attendees were instructed to focus upon tional limitations (admittedly an approximation based
Service Members who have persistent cognitive symp- on civilian studies) are an increasingly large population
toms three or more months post-concussion. While of Wounded Warriors needing effective treatment.
it was understood that many of these patients would
have co-morbidities (e.g. psychological and emotion- 2.2. Conference methodology
al issues, somatic symptoms, personality factors, etc.)
needing treatment, conference members were instruct- To address this need, the Defense Centers of Excel-
ed to address the issues of where and how in the spec- lence (DCoE) for Psychological Health and Traumatic
trum of care cognitive rehabilitation should be ap- Brain Injury and the Defense and Veterans Brain Injury
plied for this defined set of patients. These constraints Center (DVBIC) convened a two-day Cognitive Reha-
were known to be artificial for many patients, but the bilitation Consensus Conference on 27–28 April 2009
complexity of the overall task appeared overwhelm- in Crystal City, Virginia and included 50 Subject Matter
ing should all of the multiple complicating factors be Experts (SMEs) from the Department of Defense, the
considered simultaneously. It therefore was decided to Department of Veterans Affairs, civilian rehabilitation
address a set of core issues and thereby increase the centers, and academia. SMEs included persons with ex-
probability of producing clear guidance. It was under- pertise in TBI for professions including nursing, neu-
stood from the outset that the present conference was a rology, psychiatry, family practice, neuropsychology,
“starting point” of an iterative process to create a clear occupational therapy (OT), speech-language pathology
and firm foundation for adding subsequent layers of (SLP), and research, and included the authors of sever-
complexity. al prominent evidence-based reviews, efficacy studies,
Preparation for the conference included a compre- and books used as references by neuropsychologists,
hensive search of the literature regarding the natural SLPs, and OTs. Military representatives were selected
history of symptom onset, duration, and resolution fol- by their respective Surgeons’ General offices. Repre-
lowing mTBI. It was understood that as a similar liter- sentatives from each of the Services as well as the Na-
ature base became available for military mTBI, reap- tional Guard, Reserves, Special Operations, and Line
praisal would be warranted. The substantial majority also participated. “Cognitive rehabilitation” in this doc-
of civilian patients with mTBI (75–90%) have symp- ument is used synonymously with terms such as neu-
toms that are transient and self-limiting, with appar- ropsychological rehabilitation, cognitive remediation
ent full recovery occurring within minutes to several and cognitive retraining.
weeks following injury [35]. However, approximately The 50 SMEs worked both as one large group and as
5%–15% of persons with acute mTBI do not show the four smaller groups addressing the areas of assessment,
expected rapid recovery and have persistent symptoms intervention, outcome measurement, and program im-
and/or functional limitations [26,48]. There is strong plementation. Since much of the evidence-based liter-
consensus in the literature that persistent mTBI symp- ature and clinical expertise had been developed within
toms include cognitive and emotional sequelae that can the civilian health care system, the “program imple-
K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder 241

mentation” group had the specific task of developing 1. Provider determines no cognitive symptoms are
clinical service delivery methods suitable to military present with or without TBI. Education and re-
health care systems. assurance to both referring provider and patient
While evidence-based practices were emphasized, should occur.
virtually all recent reviews of the field have noted their 2. Provider determines that there are no indications
paucity [10,11]. However, as is shown below, there of TBI but cognitive symptoms are present. The
has been a recent acceleration of this type of evidence. provider should refer the patient back to the pri-
Unfortunately the time interval needed to successfully mary care provider for further evaluation of either
plan, execute and report on high quality clinical trials a medical or a mental health condition.
would not meet the clinical needs of service members 3. Provider determines that other co-morbidities or
and veterans who need these services now. Thus, while other symptoms (i.e., depression, PTSD, chron-
preference was given to evidence-based studies, clin- ic pain, or substance abuse) are too severe for
ical expertise and expert consensus of necessity was the patient to undergo valid cognitive assessment.
an essential ingredient of the ensuing guidance. More- An appropriate specialty clinic referral should be
over, since anecdotal reports indicated that techniques placed and a case manager assigned.
known to be ineffective were prevalent, the conference a. If a patient is referred to a specialty clinic,
also focused on evidence and on generating guidance the patient should be re-evaluated for cognitive
regarding “what not to do.” assessment in 4 weeks in addition to receiving
case management follow-up. This will ensure
that these patients may still receive a cognitive
3. Results assessment and that they are not lost to follow-
up.
3.1. Assessment b. If the patient is referred to a specialty clinic and
all the cognitive symptoms resolve, the patient
should be followed monthly by telephone con-
Screening for cognitive rehabilitation is required to
sultation by the case manager to ensure that the
determine eligibility and clinical indication for a pre-
symptoms remain resolved for 6 months. If
treatment comprehensive assessment. Screening in the
possible, “face-to-face” interviews are recom-
primary care setting should be by a provider with TBI
mended if there is any uncertainty concerning
experience who is also familiar with other deployment-
how the patient reports changes in symptoms.
related health conditions (e.g. nurse, nurse practitioner
or a physician assistant), may occur in different set- 4. Provider determines that the patient has symp-
tings per situational opportunities, and should occur tomatic mTBI and comprehensive cognitive as-
less than 30 days following referral. In addition to a sessment is indicated.
positive screening, comprehensive assessment may be Written communication regarding the outcome of the
initiated based on cognitive symptoms reported by the patient’s screening for cognitive rehabilitation should
family/community/line, or evidence of dysfunction in be sent to the patient’s primary care provider and the
the patient’s daily, social, or occupational functioning. referral source (if different) to ensure continuity of ef-
Initial screening should include a thorough intake fective communication and treatment coordination.
history to include a description of the injury event and Prior to cognitive assessment for cognitive rehabili-
the duration of loss of consciousness or altered mental tation, the patient must undergo a comprehensive neu-
status, confirmation of TBI diagnosis (HA Policy 07- rological examination. During this time, medical con-
030 Traumatic Brain Injury: Definition and Reporting, ditions that may result in cognitive impairment should
1 Oct 07, www.pdhealth.mil/TBI.asp), (Appendix A), be evaluated and treated. This examination also should
evaluation of ongoing symptoms [including comple- include a thorough review of the medical records to
tion of the Neurobehavioral Symptom Inventory (NSI), look for prior cognitive, mood, or behavioral disorders,
Posttraumatic Stress Disorder Checklist – Military or or events that may have resulted in increased vulnera-
Civilian Version (PCL-M, PCL-C)] [4,15], a mental bility to same. This comprehensive neurological exam-
health screening, and evaluation for acute and chronic ination does not need to be completed by a neurologist,
pain, sleep disorders and substance abuse. The follow- but rather, by a physician with sufficient expertise and
ing potential scenarios may result (see Fig. 1): knowledge in the examination as well as in the medi-
242 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder

Referral

Re-eval in 4
weeks

Intake Process

+/ - TBI No TBI + TB + TBI


No cognitive Cognitive symptoms Cognitive symptoms Cognitive
symptoms are present are present symptoms are
Severe co- present. No co-
morbidities are morbidities or co-
present morbidities are
controlled

Educate
referring Refer back to
provider primary care
Educate and provider for
reassure medical and * Case * Case
patient psychologica manager manager
evaluation assigned assigned

** Referral to specialty to
treat co-morbidity(s)
Refer back to
referring Neurological
provider Assessment

Reconsider for
cognitive
rehabilitation Cognitive
Assessment

TBI Cognitive
Rehabilitation

Fig. 1. Referral process.


K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder 243

Table 1
Assessment domains
Upon completion of the cognitive assessment, the
team should be able to determine the following:
– Attention
– Memory 1) identification of cognitive deficits associated with
– Processing Speed TBI
– Executive Functioning
2) need for cognitive rehabilitation
* reasoning and problem solving
3) optimal rehabilitation method(s) for return to
* organizing, planning and self-monitoring
* emotional regulation function
– Post-Traumatic Stress Disorder (PTSD) Screen 4) measureable short- and long-term treatment goals
– Post-Concussive Syndrome (PCS) Symptom Rating
The cognitive assessment process may determine that
– Pain Screen
– Symptom Validity Test
a patient does not require a full cognitive rehabilitation
– Substance Abuse Screen program but rather a more limited program that assists
– Depression Screen and Suicidality Assessment with goal-setting and provides education on developing
cognitive and emotional skills to improve day-to-day
cal work-up of cognitive symptoms. If no confounding functioning (modeled after the Army Center for En-
findings are noted, the patient should next receive a hanced Performance) or a short return-to-duty refresher
comprehensive cognitive assessment. training to increase confidence in one’s ability to return
While a comprehensive interdisciplinary team pro- to full duty. Malec and Basford [34] describe a range of
cess may not be available at all military treatment fa- postacute brain injury rehabilitation programs available
cilities (MTFs), it is essential that the cognitive assess- in the civilian sector. Most cases resulting from mTBI
ment consist of a thorough neurobehavioral and cog- in the military will be similar to “community re-entry”
nitive evaluation using standardized performance and or “community services only” programs, the latter de-
self-report measures, including measures of effort. It scribing a structured, supervised, and supported return
may be that only one or two disciplines are available to community. Regardless, a patient should not be dis-
or it may be that assessment and intervention are com- charged from the cognitive assessment process without
pleted by different providers. However, both the as- a treatment plan based on the four options in Fig. 1.
sessment and intervention providers must be competent
in evaluating persons with known or suspected TBI, 3.2. Intervention
and be capable of making appropriate differential diag-
noses in complicated cases. In all situations, regardless
Despite the difference in common mechanisms of
of the necessary program structure, appointment of a
injury and environment in which the injury occurs be-
team leader with broad-based TBI knowledge is essen-
tial to assuring communication and coordination of the tween combat related and non-combat related mTBI,
treatment team. there is presently no evidence to suggest that the re-
A variety of neurobehavioral assessment tools and sulting cognitive deficits are different or require dif-
approaches are available and no tool or approach is rec- ferent interventions [3]. The following are interven-
ommended over another. However, it is essential that tions with demonstrated efficacy and utility for cogni-
the domains specified by the American Academy of tive rehabilitation: direct attention training; selection
Clinical Neuropsychology (AACN; see Table 1) should and training of external memory/organizational aids;
be followed [1]. The assessment should identify and training in internal memory strategies; metacognitive
describe strengths, deficits, and function in everyday strategy training; social pragmatics training (targeting
activities, and identify barriers to successful participa- self-perception, self-awareness, and social skills); en-
tion in rehabilitation [7]. vironmental modification (more organized and less dis-
It is critical for the team to determine the primary tracting environments); brain injury education for pa-
factors contributing to symptoms (i.e., is mTBI the pri- tients, family, and employers; and aggressive support
mary cause of the symptoms or is a co-morbidity such during gradual reentry into community and vocation-
as major depression considered the primary contribu- al/educational activities (see Table 2). “Holistic” re-
tor?). Assessment should include measures of effort, habilitation programs integrate the above into orga-
although suboptimal results should not produce auto- nized interdisciplinary or transdisciplinary programs,
matic disqualification as there are numerous factors that and have the advantage of using group process to ad-
may account for reduced effort. dress social and behavioral issues [12,22].
244 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder

Table 2
Interventions
Area of cognitive Empirically- Specific examples References
impairment supported
interventions
Attention Attention process Letter cancellation Sohlberg et al., 2002
training tasks with Tiersky et al, 2005
distracting noise in Novack et al., 1996
background Sinotte & Coelho, 2007
Working memory Berg et al., 1991
training Completing two Cicerone, 2002
cognitive tasks Serino et al., 2007
simultaneously Lew et al., 2009
Memory Various Story method Ryan & Ruff, 1988
mnemonic Acronyms Berg et al., 1991
techniques Sentences/ Thickpenny-Davis & Barker-Collow, 2007
acrostics
Method of loci
Chunking
Visual imagery Repetition Kaschel et al., 2002
mnemonics Imagery based Westerberg et al., 2007
training Glisky & Glisky, 2002
Attention Memory Prosthetics Schmitter-Edgecome et al. 1995
Memory notebook PDA Ownsworth & McFarland, 1999
Executive Sohlberg & Mateer, 1989
functioning McKerracher et al., 2005

External Cuing Supervised living


BlackBerry Wilson et al., 2005
Cell phone Evans et al., 1998
PDA Kime & Lamb, 1996
Executive Social Group cognitive Dahlberg et al., 2007
functioning communication therapy Levin et. al., 1997
Social skills training
pragmatics groups
Attention Problem solving Internal problem- Fasotti et al., 2000
Memory training solving Ownsworth & McFarland, 1999
Executive Error Internal dialogue Vaynman & Gomez, 2005
functioning management Cheng et al., 2006
Social training Goverover et al., 2007
pragmatics Individual and Ehlhardt et al, 2005
group self- Ownworth et al., 2000
awareness training Ownsworth et al., 2006
Emotional Levine et al., 2000
regulation Rath et al., 2003
training Anger management Cicerone et al., 2008
groups Medd & Tate, 2000
Ruff et al., 1996
Attention Integrated use of Cicerone et al., 2008
Memory individual and Rattock et al., 1992
Executive group cognitive, Sarajuri et al., 2005
functioning psychological Goranson et al., 2003
Social and functional Carney et al., 1999
pragmatics interventions Cicerone et al., 2000
Cicerone et al., 2005
Comper et al., 2005
Gordon et al., 2006
Griesbach et al., 2009
Hoge et. al., 2008
Kim et. al., 2009
K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder 245

Table 2, continued
Area of cognitive Empirically- Specific examples References
impairment supported
interventions
NIH Consensus Panel, 1999
Prigatano, 1999
Salazar et al., 2000
Serino et al. 2007
Terrio et al. 2009
Tsaousides & Gordon, 2009
Vanderploeg et al. 2008

Interventions for persistent postconcussion cognitive attention, and divided attention. Training procedures
symptoms uniformly emphasize improvement in atten- place gradually increasing demands upon attentional
tion abilities. Attention in all its various components capacities.
(e.g., alertness, sustained attention, divided attention “Memory training” is the most frequently prescribed
and alternating attention) is the prerequisite for basic form of cognitive rehabilitation. While it seems sensi-
as well as complex behaviors involving memory, judg- ble to have a patient with memory impairment perform
ment, social perception, and executive skills. Impair- memorization drills with the therapist (work on remem-
ments in attention will have direct effects on specif- bering word lists, faces, designs, etc.), recent reviews
ic attention tasks, and substantial indirect effects on have shown that repetitive memory drills – “memory
all aspects of a patient’s behavior. Moreover, attention as a muscle” – have little or no efficacy [47,53]. How-
deficits often can masquerade as deficits in other cog- ever, efficacy has been demonstrated for memory train-
nitive functions. For example, “memory impairment” ing techniques derived from cognitive neuroscience.
may be the downstream result of poor attention, with For example, success has been shown with various
concomitant impairments for registration of informa- mnemonic techniques and other memory-enhancing
tion, thus degrading memory performance even in the strategies that assist patients to develop techniques to
absence of a true memory deficit. enhance registration and encoding of information, as
Attention training was one of the earliest approach- well as to develop methods for searching their memory
es to cognitive rehabilitation [58]. It has been the sub- to improve memory retrieval [27]. Of interest, Kaschel
ject of a number of well-designed studies and remains et al. [27], report that memory strategy training is most
one of the cornerstones of cognitive rehabilitation inter- effective for persons with mTBI and mild memory im-
ventions [10,11,56,60]. Attention training has been a pairment, with decreasing effectiveness as injury and
core element of diverse programs, ranging from single- memory impairment severity increase.
service/single-provider programs to interdisciplinary External aids have been used to address both mem-
“holistic” programs [22] and numerous studies have ory and executive function impairments. The majority
confirmed its benefit [9,59]. Moreover, attention train- of more recent memory training studies have focused
ing has been successful for remediating TBI-related upon the use of “memory notebooks” and electronic
cognitive disorders apparently far removed from atten- equivalents, essentially serving as “memory prosthet-
tion dysfunction, as illustrated by a recent case study ics.” A number of these studies have compared differ-
showing the effectiveness of attention training for read- ent memory notebook formats and training procedures
ing difficulties secondary to mild aphasia: “The posi- to identify the most effective. For example [42], com-
tive gains noted for this individual’s reading skills were pared two memory training procedures, one a Diary
felt to be the result of improvement in allocation of at- Only condition in which patients were taught the me-
tentional resources rather than improvement in linguis- chanics of using a diary, while in the other condition
tic skills [55].” they received the diary training within a more compre-
Attention process training [60] improves attention hensive approach focusing on how the diary could be
skills through a set of standardized auditory and visu- used to solve problems in daily activities, particularly
al procedures made increasingly challenging by sys- when used proactively. Thickpenny-Davis and Barker-
tematically increasing task complexity and heighten- Collo [64] combined strategy training with memory
ing the level of distractions. This intervention organizes notebook training, using the added efficiency of a group
attention and concentration tasks into subcomponents format for an eight-session program, and found im-
of sustained attention, selective attention, alternating provement in both the use of memory strategies as well
246 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder

as the use of memory prosthetics, with these improve- itive outcomes were reported from problem solving
ments extending into patients’ everyday memory func- therapy where patients were taught to identify prob-
tioning. For a review of the evidence examining ef- lems and solutions, weigh the pros and cons of solu-
ficacy of use of external aids for managing memory tions and monitor performance [69]. Similarly, Rath et
impairments, see Sohlberg et al. [57]. Note that the al. [45], showed positive effects of group therapy aimed
emphasis on memory “notebooks” reflects their long- at improving emotional self regulation by the use of
standing availability as compared to newer electronic problem-solution training. A goal attainment scaling
devices that also can serve as prosthetics. technique was shown to have specific positive results
Social pragmatics (comprehending and responding on goal setting. Fasotti and colleagues [18] showed
to “nonverbal” social cues) are commonly impaired by improved problem solving with a step by step time
TBI. Social skills training (typically within a group for- pressure management approach. A step by step task
mat) has shown effectiveness in improving these prob- completion strategy, Goal Management Training, was
lems. For example, Dahlberg et al. [14], describes a shown to improve proofreading skills [31].
A “holistic” focus is seen in Tiersky et al. [65], who
successful program, citing four key components: “The
focused on cognitive rehabilitation of mTBI. These au-
first was the use of co-group leaders from different
thors employed a manualized cognitive rehabilitation
clinical backgrounds (i.e. social work, speech-language
program that was delivered in conjunction with cogni-
pathology). This allowed for two clinical perspectives,
tive behavioral therapy, comparing it to a wait-list con-
two role models, and two clinicians collaborating and
trol group. The 11-week, three times per week, cogni-
sharing their expertise. The second component was tive rehabilitation program focused primarily on atten-
an emphasis on self-awareness and self-assessment, tion, information processing, and memory, although the
leading to individual goal setting. A third component authors note that organizational and problem-solving
was the use of the group process to foster interac- skills were addressed throughout the cognitive retrain-
tion, feedback, problem solving, a social support sys- ing program “because these abilities are a corollary of
tem, and awareness that one is not alone. The final memory and attentional skills (p. 1568).” The cognitive
component was a focus on generalization of skills, ad- behavioral therapy (CBT) was a relatively traditional
dressed through the involvement of family and friends, application of CBT and focused on increasing the use
and weekly assignments completed in the home or of adaptive coping, reducing levels of distress, training
community. . . Generally, sessions followed a consis- in methods of preventing relapse, and improving accep-
tent format: (1) review of homework, (2) brief intro- tance of sadness and loss related to cognitive and phys-
duction of the topic, (3) guided discussion, (4) small ical impairments. The treatment group showed signif-
group practice, (5) group problem solving and feed- icantly lessened anxiety and depression, and improved
back, and (6) homework (pp. 1564–1565).” A major divided attention.
portion of this program utilized the Goal Attainment Clinical experience with Wounded Warriors suggest
Scaling procedure developed by Malec, which also has that a comprehensive holistic approach, which pro-
been used in numerous other programs to positive ef- vides individual and group therapies within an integrat-
fect. Moreover, while Dahlberg describes this program ed therapeutic environment, addresses the functional
as “training of social communication skills,” the above impairment and disability resulting from cognitive and
brief description clearly indicates that the program is emotional sequelae of chronic symptomatic mTBI. In-
much more comprehensive and holistic, with focus on volvement of family members and the Service Mem-
executive skills, self-awareness, and emotional and be- ber’s Command is highly encouraged to optimize re-
havioral self-regulation. As others have noted, inter- habilitation outcomes. Group therapy in addition to in-
ventions that incorporate training in personal and social dividual therapy provides a supportive context for re-
self-regulation, self-management, and problem solving habilitation and reinforces the concept of unit cohe-
skills also address deficits in attention, memory, com- sion in military culture. The above studies are but a
sample of those leading the Intervention Group to its
munication, and executive function [1,45].
primary conclusions regarding cognitive rehabilitation
A robust literature supports the use of metacogni-
interventions.
tive strategy training as an intervention for executive
function impairments due to TBI. At least five RCTs 3.3. Outcome measures
have evaluated executive function outcomes from train-
ing in the use of multiple step strategies, strategic Adequate literature and expert-consensus exists to
thinking, and/or multitasking. In an early study, pos- support judicious and selective use of cognitive reha-
K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder 247

bilitation for Service Members with persistent symp- rehabilitation (assuming appropriate intervals between
toms of mTBI. Nonetheless, the present Panel as well testing to protect the integrity of these tests or the use
as all recently published evidence-based reviews [10, of repeatable versions), while the ongoing monthly re-
11,13,22,65] note the scarcity of well-designed clinical assessments should emphasize evaluation of symptom
trials in this area. The time-frame for correcting this status and functional status.
scarcity, however, likely is a decade or more, and even The recommended functional outcome measures are:
longer if the essential element of long-term follow-up job performance, need for redesignation/duty restric-
is included. tions or limitations; ongoing comparisons between pre-
While the situation may appear daunting, there is injury fitness reports/evaluations and current function-
much useful work that can be done in the meantime. al abilities as they improve within the program; per-
Studies conducted in recent years, and those current- formance on simulators (rifle, flight, etc.); quality of
ly ongoing, use vastly improved methodology as com- life assessment; community participation assessment;
pared to studies published even several years ago. The and social-skills pragmatics assessment. Results from
monthly re-assessments of symptoms and functional
Panel learned of several in-press or ongoing literature
status, using tools such as Goal Attainment Scaling
reviews and RCTs and it is likely that the amount of
(GAS) [33], can assist with clinical decision-making
high quality research will accelerate during the coming
and goal setting. The GAS procedure prescribes that
years.
the goals should be objective, measurable, and time-
It also is important for individual programs to present
based; that they should be generated by the treatment
and publish their outcome data and clinical experiences. team with active involvement from the patient; and
While this likely will not be “gold standard” research, that they should be functional, based on the patient’s
it will enhance the field by allowing programs to “fer- lifestyle and needs. For outcome data to be maximal-
tilize” and learn from each other. This objective will be ly meaningful, it is important to carefully describe the
facilitated greatly by using a set of common measures patient population. Some patients may respond much
for describing program and patient variables. better than others to specific interventions, making it
Capturing the complexity of the chronic mTBI popu- essential to have detailed and objective identification
lation is challenging. Many mTBI patients have comor- of moderating variables, confounds, and comorbidi-
bid disorders that can result in cognitive impairment, ties. These include pain; comorbid physical injuries;
and that can overlap, exacerbate, or mimic the cogni- type of injury; age, rank, job duties and gender of pa-
tive disorders associated with mTBI. It therefore is es- tient; psychological health and substance abuse; num-
sential that programs include data elements to capture ber of deployments; date(s) of injury(s); trauma histo-
the nature and severity of comorbidities potentially af- ry to include life events prior to entering the military;
fecting cognitive status. The working group identified family and broader psychosocial support system; apti-
several additional categories of required data elements tude/education; duty status; prior neurologic illnesses
(see Table 3): administrative performance metrics (e.g. or injuries; motivation for retention; expectations of re-
number of patients seen, type and number of service covery; years of service; and, sources of possible sec-
providers; range of services readily available; consis- ondary gain. Increased understanding of who responds
tent and well-defined admission criteria; consistent and to specific interventions and who does not is essential.
well-defined discharge criteria; clear description of the Discharge data elements include: accomplishment
program and interventions; sufficient documentation of treatment goals; plateauing of improvement and/or
to permit reasonable consistency of treatment across failure to improve (typically following 3 to 4 weeks
providers; and, clear documentation to permit audit of treatment and medical reevaluation to rule out treat-
of patient care); pre- post-assessment differences; pre- able reasons); worsening symptoms (again with need
post- functional differences; moderating variables that for reevaluation and possible case reformulation); and,
may affect outcome; discharge environment and patient a clear but flexible definition of the maximum duration
of treatment. Moreover, patient and family satisfaction
status at time of discharge; consumer satisfaction (in-
measures are useful for identifying quality improve-
cluding the patient but can extend to family, employ-
ment opportunities within a program
er/Command, and referral source; and, aggregate pro-
gram outcome data to permit evaluation of the program 3.4. Program implementation
rather than just the individual patient.
As seen in Table 3, formal neurocognitive as- Patient assessment and treatment, and outcome mea-
sessments should be reserved for pre- and post- sures for program assessment, already have been dis-
248

Table 3
Outcome measures
Administrative per- Pre-Post- assessment Pre-post- functional Moderating Variables Discharge criteria Consumer Aggregate program out-
formance metrics differences differences & patient status at satisfaction come data
time of discharge
• # of patients seen • formal neuropsych • job performance • degree to which co-morbidity may • goals attained • patient, family, • type and # of service
• # of patients re- evaluation • need for redesigna- be resulting in cognitive symptoms • plateauing of im- employer/ command, providers
ferred for medical • symptom status tion/duty restrictions • pain provement and/or and referral source • range of services
appts • functional status • pre-injury fitness re- • severity of associated physical in- failure to improve • education • consistent/ well-defined
• duration & daily • domains tested during ports/evals vs. current func- juries • worsening • treatments entry criteria
intensity of prgm Cognitive Assessment tional abilities • mechanism of injury symptoms • efficacy • consistent/ well-defined
• length of time pa- • performance on simulators • age discharge criteria
tient is on limited • quality of life assessment • rank/MOS • clear description of the
duty • community participation • gender program/ interventions
assessment • psychological health co-morbidities • clear documentation
• substance abuse co-morbidities
• # of deployments
• date(s) of injury(s)
• trauma history to include life events
prior to entering the military
• family/broader psychosocial sup-
port systems
• aptitude/education
• military status
• history of ADHD or LD
• other prior neurologic illnesses or
injuries
• motivation for retention
• expectations of recovery
• years of service
• possible sources of secondary gain
K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder
K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder 249

Visual Rehab

Speciality Psychological
Services Couseling

TBI Program
Physical Rehab
Vestibular Vocational
Rehab Rehab

Cognitive
Rehab

Occupational
Therapy

Cognitive Rehabilitation

Neuropsychology Speech Language


Pathology

Mental Health

Fig. 2. Cognitive rehabilitation within TBI program.

cussed. The emphasis of the present section is on im- capable of developing a therapeutic alliance with their
plementing the prior recommendations within an MTF. patients. Strong team leadership is required, both pro-
If a TBI program exists at the MTF, the cognitive grammatically and medically, to ensure unified goals
rehabilitation program should be a sub-component (see and quality care. Interdisciplinary case conferences for
Fig. 2). The ideal cognitive rehabilitation program mod- patient management and goal setting/review should oc-
el is team-based and holistic [53]. Alternately, cogni- cur regularly. Coordination of care is also required with
tive treatment can be offered within a discrete thera- the patient’s family, other medical providers, and the
py model, usually assigned to SLP or OT, though it unit chain of command. The program leader is expect-
may become difficult to provide consistent integration ed to ensure that the team, with his/her guidance, de-
of services. Research concerning the effectiveness of velops and monitors an appropriate treatment plan, and
cognitive rehabilitation tends to favor the holistic mod- updates the plan as needed; keep Line and Leader-
el [12,22]. ship informed regarding patients goals, objectives, and
Optimal delivery of the holistic model requires an progress; provide leadership and guidance during dis-
interdisciplinary or transdisciplinary team of clinicians charge planning conferences; resolve and attempt to
who are competent in brain injury rehabilitation, under- achieve consensus among team members regarding po-
stand and can function within military culture, and are tential differences in patient care plans; and, manage
250 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder

professional “turf” issues should they arise. References


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K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder 253

Appendix A: DoD TBI definition


254 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder
K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder 255

Appendix B: April 2009 Consensus Conference Participants

Dr. Sonja Batten, Lt Col Sarah Beal, Dr. Joseph Bleiberg, CPT Paul Boccio, Ms. Theresa Boyd, Dr. Keith
Cicerone, Dr. Paul Comper, Dr. Douglas Cooper, Dr. Micaela Cornis-Pop, LT Tara Cozzarelli, Maj David Dickey,
Ms. Selina Doncevic, CDR Kim Ferland, Ms. Elizabeth Findling, Dr. Louis French, COL Nancy Fortuin, CDR John
Golden, Dr. Matthew Gonzalez, Dr. Wayne Gordon, Ms. Kathy Helmick, CDR David Jones, CDR Frederick Kass,
Dr. James Kelly, LCDR Carrie Kennedy, Dr. Jan Kennedy, Dr. Kathleen Kortte, CAPT Karen Kreutzberg, LTC
Lynne Lowe, Dr. James Malec, Ms. Pauline Mashima, Dr. Cate Miller, Dr. Maria Mouratidis, Dr. George Prigatano,
Dr. Carole Roth, LTC Michael Russell, LT Rick Schobitz, Dr. Joel Scholten, CAPT Edward Simmer, Dr. McKay
Moore Sohlberg, LTC Benjamin Solomon, MAJ Matthew St. Laurent, Ms. Elizabeth Thomson, CDR Jack Tsao, Dr.
Rodney Vanderploeg, Maj Megumi Vogt, Dr. Therese Walden, Col Christopher Williams, Mr. Michael Wilmore,
LTC Yvette Woods, BG (ret) Stephen Xenakis.