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Cognitive Rehabilitation for Traumatic Brain Injury
A Randomized Trial
Andres M. Salazar, MD;
Deborah L. Warden, MD;
Karen Schwab, PhD;
Jack Spector, PhD;
Steven Braverman, MD;
Joan Walter, PA;
Reginald Cole, MD;
Mary M. Rosner, MA;
Elisabeth M. Martin, RN;
James Ecklund, MD;
Richard G. Ellenbogen, MD;
for the Defense and Veterans Head Injury Program (DVHIP) Study Group
JAMA. 2000;283:3075-3081.
Context Traumatic brain injury (TBI) is a principal cause of death and disability in young adults. Rehabilitation for TBI has not received the same level of scientific scrutiny for efficacy and cost-efficiency that is expected in other medical fields.
Objective To evaluate the efficacy of inpatient cognitive rehabilitation for patients with TBI.
Design and Setting Single-center, parallel-group, randomized trial conducted from January 1992 through February 1997 at a US military medical referral center.
Patients One hundred twenty active-duty military personnel who had sustained a moderate-to-severe closed head injury, manifested by a Glasgow Coma Scale score of 13 or less, or posttraumatic amnesia lasting at least 24 hours, or focal cerebral contusion or hemorrhage on computed tomography or magnetic resonance imaging.
Interventions Patients were randomly assigned to an intensive, standardized, 8-week, in-hospital cognitive rehabilitation program (n=67) or a limited home rehabilitation program with weekly telephone support from a psychiatric nurse (n=53).
Main Outcome Measures Return to gainful employment and fitness for military duty at 1-year follow-up, compared by intervention group.
Results At 1-year follow-up, there was no significant difference between patients who had received the intensive in-hospital cognitive rehabilitation program vs the limited home rehabilitation program in return to employment (90% vs 94%, respectively; P=.51; difference, 4% [95% confidence interval {CI}, -5% to 14%]) or fitness for duty (73% vs 66%, respectively; P=.43; difference, 7% [95% CI, -10% to 24%]). There also were no significant differences in cognitive, behavioral, or quality-of-life measures. In a post-hoc subset analysis of patients who were unconscious for more than 1 hour (n = 75) following TBI, the in-hospital group had a greater return-to-duty rate (80% vs 58%; P=.05).
Conclusions In this study, the overall benefit of in-hospital cognitive rehabilitation for patients with moderate-to-severe TBI was similar to that of home rehabilitation. These findings emphasize the importance of conducting randomized trials to evaluate TBI rehabilitation interventions.
Author Affiliations: Defense and Veterans Head Injury Program at the Henry M. Jackson Foundation, Rockville, Md (Drs Salazar and Cole, Mss Walter, Rosner, and Martin); Uniformed Services University, Bethesda, Md (Dr Schwab); and Walter Reed Army Medical Center, Washington, DC (Drs Warden, Spector, Braverman, Ecklund, and Ellenbogen).
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