Original article
A Trial of Neuropsychologic Rehabilitation in Mild-Spectrum Traumatic Brain Injury

https://doi.org/10.1016/j.apmr.2005.03.013Get rights and content

Abstract

Tiersky LA, Anselmi V, Johnston MV, Kurtyka J, Roosen E, Schwartz T, DeLuca J. A trial of neuropsychologic rehabilitation in mild-spectrum traumatic brain injury.

Objective

To test the effectiveness of a neuropsychologic rehabilitation program consisting of psychotherapy and cognitive remediation in the treatment of the affective and neuropsychologic sequelae of mild-spectrum traumatic brain injury (TBI).

Design

Single-blind randomized, wait-listed controlled trial, with repeated measures and multiple baselines.

Setting

Outpatient clinic in northern New Jersey.

Participants

Twenty persons with persisting complaints after mild and moderate TBI (11 in treatment group, 9 controls).

Interventions

The experimental group received both 50 minutes of individual cognitive-behavioral psychotherapy and 50 minutes of individual cognitive remediation, 3 times a week for 11 weeks. The control group was wait-listed and received treatment after conclusion of follow-up.

Main Outcome Measures

Symptom Check List–90R General Symptom Index, plus scales of depression, anxiety, coping, attention, and neuropsychologic functioning.

Results

Compared with the control group, the treatment group showed significantly improved emotional functioning, including lessened anxiety and depression. Most significant improvements in emotional distress were noted at 1 month and 3 months posttreatment. Performance on a measure of divided auditory attention also improved, but no changes were noted in community integration scores.

Conclusions

Cognitive behavioral psychotherapy and cognitive remediation appear to diminish psychologic distress and improve cognitive functioning among community-living persons with mild and moderate TBI.

Section snippets

Objectives and Hypotheses

The primary objective of our investigation was to test the efficacy of a comprehensive outpatient neuropsychologic rehabilitation program in the treatment of persistent neuropsychologic dysfunction, emotional distress, and accompanying functional disability after mild and moderate TBI. The program was comprised of individual cognitive-behavioral psychotherapy (CBT) and individual cognitive remediation. By including a well-defined client population, using a randomized no-treatment control group,

Methods

This clinical trial used a randomized, individual baseline design by using repeated measures with 2 groups.49 The experimental group received both individual CBT and individual cognitive remediation. The no-treatment control group was wait-listed for treatment.

Results

Participant demographics and injury characteristics are described in table 2. On average, the sample was middle aged (range, 19–62y), well-educated, white, and female. There were no significant group differences on the demographic variables (all P≤.05). Most subjects suffered from mild brain injuries. The groups did not differ by injury severity (ie, percentage of mild or moderate subjects, P≤.189). As table 3 illustrates, the majority of subjects in both groups sustained their injuries because

Discussion

Results provide preliminary evidence that intensive outpatient treatment consisting of both CBT and cognitive remediation is beneficial in the treatment of persistent emotional distress and perhaps even cognitive dysfunction after mild and moderate TBI. In this randomized controlled trial (RCT), subjects in the treatment group showed less emotional distress and more improved cognitive functioning at follow-up compared with subjects who did not receive treatment. Moreover, improvement was most

Conclusions

RCTs are possible in community-living persons with TBI, and even small RCTs can provide important information. Although there are limits to the generalizability of the findings, this study shows that a readily available model for care can be implemented by trained clinicians. The treatment was well tolerated despite its intensity. No subject dropped out because of the intensity of the treatment. No clinical emergencies, such as psychiatric hospitalizations, were observed. Overall, control

References (82)

  • S.N. Macciocchi et al.

    Disability following head injury

    Curr Opin Neurol

    (1993)
  • R.W. Rimel et al.

    Disability caused by minor head injury

    Neurosurgery

    (1981)
  • D.J. Schretlen et al.

    A quantitative review of the effects of traumatic brain injury on cognitive functioning

    Int Rev Psychiatry

    (2003)
  • N. Bohnen et al.

    Neuropsychological deficits in patients with persistent symptoms six months after mild head injury

    Neurosurgery

    (1992)
  • N.I. Bohnen et al.

    Late neurobehavioural symptoms after mild head injury

    Brain Inj

    (1995)
  • K.D. Cicerone

    Attention deficits and dual task demands after mild traumatic brain injury

    Brain Inj

    (1996)
  • B.E. Leininger et al.

    Neuropsychological deficits in symptomatic minor head injury patients after concussion and mild concussion

    J Neurol Neurosurg Psychiatry

    (1990)
  • R.M. Ruff et al.

    Selected cases of poor outcome following a minor brain traumacomparing neuropsychological and positron emission tomography assessment

    Brain Inj

    (1994)
  • D.J. Hellawell et al.

    Cognitive and psychosocial outcome following moderate or severe traumatic brain injury

    Brain Inj

    (1999)
  • S.R. Millis et al.

    Long-term neuropsychological outcome after traumatic brain injury

    J Head Trauma Rehabil

    (2001)
  • R.W. Rimel et al.

    Moderate head injurycompleting the clinical spectrum of brain trauma

    Neurosurgery

    (1982)
  • S.S. Dikmen et al.

    Neuropsychological outcome at 1-year post head injury

    Neuropsychology

    (1995)
  • F. Andrasik et al.

    Emotional and psychosocial aspects of mild head injury

    Semin Neurol

    (1994)
  • M.D. Lezak

    Relationships between personality disorders, social disturbances, and physical disability following traumatic brain injury

    J Head Trauma Rehabil

    (1987)
  • J.R. Fann et al.

    Psychiatric illness following traumatic brain injury in an adult health maintenance organization population

    Arch Gen Psychiatry

    (2004)
  • K.D. Cicerone

    Psychotherapy after mild traumatic brain injuryrelation to the nature and severity of subjective complaints

    J Head Trauma Rehabil

    (1991)
  • R.E. Jorge et al.

    Major depression following traumatic brain injury

    Arch Gen Psychiatry

    (2004)
  • G. Mooney et al.

    The association between mild traumatic brain injury and psychiatric conditions

    Brain Inj

    (2001)
  • R.S. Parker

    The spectrum of emotional distress and personality changes after minor head injury incurred in a motor vehicle accident

    Brain Inj

    (1996)
  • C.F. Bontke et al.

    Do patients with mild brain injuries have posttraumatic stress disorder too?

    J Head Trauma Rehabil

    (1996)
  • T.M. McMillan

    Post-traumatic stress disorder following minor and severe closed head injury10 single cases

    Brain Inj

    (1996)
  • A. Ohry et al.

    Post-traumatic stress disorder in brain injury patients

    Brain Inj

    (1996)
  • G. Fenton et al.

    The postconcussional syndromesocial antecedents and psychological sequelae

    Br J Psychiatry

    (1993)
  • J.M. Uomoto et al.

    Traumatic brain injury and chronic paindifferential types and rates by head injury severity

    Arch Phys Med Rehabil

    (1993)
  • A.I. Drake et al.

    Factors predicting return to work following mild traumatic brain injurya discriminant analysis

    J Head Trauma Rehabil

    (2000)
  • C. Paniak et al.

    A randomized trial of two treatments for mild traumatic brain injury

    Brain Inj

    (1998)
  • W. Mittenberg et al.

    Treatment of post-concussion syndrome following mild head injury

    J Clin Exp Neuropsychol

    (2001)
  • D.T. Wade et al.

    Does routine follow up after head injury help? A randomised controlled trial

    J Neurol Neurosurg Psychiatry

    (1997)
  • D.T. Wade et al.

    Routine follow up after head injurya second randomised controlled trial

    J Neurol Neurosurg Psychiatry

    (1998)
  • Y. Ben-Yishay et al.

    Cognitive rehabilitation

  • G.P. Prigatano et al.

    Neuropsychological rehabilitation after brain injury

    (1986)
  • Cited by (202)

    • Clinical Updates in Mild Traumatic Brain Injury (Concussion)

      2023, Neuroimaging Clinics of North America
    View all citing articles on Scopus

    Supported by the National Institute on Disability and Rehabilitation Research (grant no. H133A980030) and the Henry Kessler Foundation (grant no. 20.1).

    No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated.

    View full text