Cognitive Rehabilitation for Military Personnel NeuroRehabilitation

8/6/2019 Cognitive Rehabilitation for Military Personnel NeuroRehabilitation

1/18


2/18

NeuroRehabilitation 26 (2010) 239255 239DOI 10.3233/NRE-2010-0560IOS 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, 9thFloor, Suite 400, Silver Spring, MD 20910, USA

E-mail: [email protected]

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 primarilyupon treatment of cognitive impairment. Guidance regarding effective services addressed the areas of assessment, intervention,

outcome measurement, and treatment program implementation.

1. Introduction

The true incidence of military mild traumatic braininjury (mTBI) is unknown. Many Warriors with mT-BI do not seek medical care and thus have unrecog-

nizedand unrecordedinjuries.Alternately, manyothersare identified through unwitnessed and unverified self-

report, using questionnaires administered months fol-lowing suspected mTBI. Both approaches are plaguedby numerous potentially severe biases and are compli-cated by the unknown prevalence of multiple mTBI andoverlapping co-morbid disorders [5,21,26,38].

While the precise incidence of mTBI in Op-eration Enduring Freedom/Operation Iraqi Freedom

(OEF/OIF) remains difficult to determine, there is noquestion that it is one of the most common injuries

sustained by our Warriors. Data from combat-exposedU.S. military personnel returning from Afghanistan and

Iraq since 2001 report a 15%22% mTBI incidencerate [25,63]. In response, military-based research andclinical programs rapidly are developing and evolving,and the first generation of these programs is startingto reach the scientific literature [67].

TBI and mTBI long have been civilian health prob-lems and have created a large and well-established TBIrehabilitation literature [22]. The civilian literature isnot without its controversies, but it has had decades tomature and to incorporate sophisticated methodologiessuch as multi-site randomized controlled trials [67].Civilian rehabilitation professionals also have devel-oped decades of expertise in rehabilitating patients withTBI and mTBI [9,44].

The purpose of the presently reported ConsensusConference was to integrate military and civilian mT-BI rehabilitation expertise to create guidance regard-ing cognitive rehabilitation of chronic post-concussive

ISSN 1053-8135/10/$27.50 2010 IOS Press and the authors. All rights reserved


3/18

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

symptoms in military populations receiving treatment

within military medical settings. A key objective was toacknowledge differences and similarities between mil-

itary and civilian mTBI populations, and between mil-

itary and civilian health care delivery systems. In sum,

the mission and overriding emphasis of the conference

was to generate guidance immediately relevant to mili-

tary health care systems, military health care providers,

and Wounded Warriors.

2. Methods

2.1. Target population

Conference attendees were instructed to focus upon

Service Members who have persistent cognitive symp-

toms three or more months post-concussion. While

it was understood that many of these patients would

have co-morbidities (e.g. psychological and emotion-

al issues, somatic symptoms, personality factors, etc.)

needing treatment, conference members were instruct-

ed to address the issues of where and how in the spec-

trum of care cognitive rehabilitation should be ap-

plied for this defined set of patients. These constraints

were known to be artificial for many patients, but thecomplexity of the overall task appeared overwhelm-

ing should all of the multiple complicating factors be

considered simultaneously. It therefore was decided to

address a set of core issues and thereby increase the

probability of producing clear guidance. It was under-

stood from the outset that the present conference was a

starting point of an iterative process to create a clear

and firm foundation for adding subsequent layers of

complexity.

Preparation for the conference included a compre-

hensive search of the literature regarding the natural

history of symptom onset, duration, and resolution fol-

lowing mTBI. It was understood that as a similar liter-

ature base became available for military mTBI, reap-

praisal would be warranted. The substantial majority

of civilian patients with mTBI (7590%) have symp-

toms that are transient and self-limiting, with appar-

ent full recovery occurring within minutes to several

weeks following injury [35]. However, approximately

5%15% of persons with acute mTBI do not show the

expected rapid recovery and have persistent symptoms

and/or functional limitations [26,48]. There is strong

consensus in the literature that persistent mTBI symp-

toms include cognitive and emotional sequelae that can

result in significant functional impairment and disabil-

ity [62].Cognitive rehabilitation is a well-accepted and com-

mon component of comprehensive rehabilitation for

persons with moderate and severe TBI [11], and in-

creasingly is used for persisting deficits following mT-

BI [22]. Clinical management of mTBI typically fo-

cuses on preventing excess disability through edu-

cation to promote expectations of rapid and complete

recovery; providing a timeout period to permit recu-

peration; avoidance of dangerous activities that could

lead to secondary injury; and, using appropriate medi-

cal treatment to ameliorate symptoms (e.g., headache,

sleep disturbance, dizziness, etc.) that can interfere

with optimal recovery ([13] www.dvbic.org). However,

the 5%15%of mTBI with chronic symptoms andfunc-

tional limitations (admittedly an approximation based

on civilian studies) are an increasingly large population

of Wounded Warriors needing effective treatment.

2.2. Conference methodology

To address this need, the Defense Centers of Excel-

lence (DCoE) for Psychological Health and Traumatic

Brain Injury and the Defense and Veterans Brain Injury

Center (DVBIC) convened a two-day Cognitive Reha-

bilitation Consensus Conference on 2728 April 2009in Crystal City, Virginia andincluded50 Subject Matter

Experts (SMEs) from the Department of Defense, the

Department of Veterans Affairs, civilian rehabilitation

centers, andacademia. SMEs included persons with ex-

pertise in TBI for professions including nursing, neu-

rology, psychiatry, family practice, neuropsychology,

occupational therapy (OT), speech-language pathology

(SLP), and research, and included the authors of sever-

al prominent evidence-based reviews, efficacy studies,

and books used as references by neuropsychologists,

SLPs, and OTs. Military representatives were selected

by their respective Surgeons General offices. Repre-

sentatives from each of the Services as well as the Na-

tional Guard, Reserves, Special Operations, and Line

also participated. Cognitive rehabilitation in this doc-

ument is used synonymously with terms such as neu-

ropsychological rehabilitation, cognitive remediation

and cognitive retraining.

The 50 SMEs worked both as one large group and as

four smaller groupsaddressing the areas of assessment,

intervention, outcome measurement, and program im-

plementation. Since much of the evidence-based liter-

ature and clinical expertise had been developed within

the civilian health care system, the program imple-


4/18

K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder 241

mentation group had the specific task of developing

clinical service delivery methods suitable to militaryhealth care systems.

While evidence-based practices were emphasized,

virtually all recent reviews of the field have noted their

paucity [10,11]. However, as is shown below, there

has been a recent acceleration of this type of evidence.

Unfortunately the time interval needed to successfully

plan, execute and report on high quality clinical trials

would not meet the clinical needs of service members

and veterans who need these services now. Thus, while

preference was given to evidence-based studies, clin-

ical expertise and expert consensus of necessity was

an essential ingredient of the ensuing guidance. More-

over, since anecdotal reports indicated that techniques

known to be ineffective were prevalent, the conference

also focused on evidence and on generating guidance

regarding what not to do.

3. Results

3.1. Assessment

Screening for cognitive rehabilitation is required to

determine eligibility and clinical indication for a pre-treatment comprehensive assessment. Screening in the

primary care setting should be by a provider with TBI

experience who is also familiar with other deployment-

related health conditions (e.g. nurse, nurse practitioner

or a physician assistant), may occur in different set-

tings per situational opportunities, and should occur

less than 30 days following referral. In addition to a

positive screening, comprehensive assessment may be

initiated based on cognitive symptoms reported by the

family/community/line, or evidence of dysfunction in

the patients daily, social, or occupational functioning.

Initial screening should include a thorough intake

history to include a description of the injury event and

the duration of loss of consciousness or altered mental

status, confirmation of TBI diagnosis (HA Policy 07-

030 Traumatic Brain Injury: Definition and Reporting,

1 Oct 07, www.pdhealth.mil/TBI.asp), (Appendix A),

evaluation of ongoing symptoms [including comple-

tion of the Neurobehavioral Symptom Inventory(NSI),

Posttraumatic Stress Disorder Checklist Military or

Civilian Version (PCL-M, PCL-C)] [4,15], a mental

health screening, and evaluation for acute and chronic

pain, sleep disorders and substance abuse. The follow-

ing potential scenarios may result (see Fig. 1):

1. Provider determines no cognitive symptoms are

present with or without TBI. Education and re-assurance to both referring provider and patient

should occur.

2. Provider determines that there are no indications

of TBI but cognitive symptoms are present. The

provider should refer the patient back to the pri-

mary care provider for further evaluation of either

a medical or a mental health condition.

3. Provider determines that other co-morbidities orother symptoms (i.e., depression, PTSD, chron-

ic pain, or substance abuse) are too severe for

the patient to undergo valid cognitive assessment.

An appropriate specialty clinic referral should be

placed and a case manager assigned.

a. If a patient is referred to a specialty clinic,

the patient should be re-evaluatedfor cognitive

assessment in 4 weeks in addition to receiving

case management follow-up. This will ensurethat these patients may still receive a cognitive

assessment and that they are not lost to follow-

up.

b. If thepatient is referred to a specialty clinicand

all the cognitive symptoms resolve, the patientshould be followed monthly by telephone con-

sultation by the case manager to ensurethat the

symptoms remain resolved for 6 months. Ifpossible, face-to-face interviews are recom-

mended if there is any uncertainty concerninghow the patient reports changes in symptoms.

4. Provider determines that the patient has symp-

tomatic mTBI and comprehensive cognitive as-sessment is indicated.

Written communication regarding the outcome of the

patients screening for cognitive rehabilitation shouldbe sent to the patients primary care provider and the

referral source (if different) to ensure continuity of ef-

fective communication and treatment coordination.Prior to cognitive assessment for cognitive rehabili-

tation, the patient must undergo a comprehensive neu-rological examination. During this time, medical con-

ditions that may result in cognitive impairment should

be evaluated and treated. This examination also should

include a thorough review of the medical records to

look for prior cognitive, mood, or behavioral disorders,or events that may have resulted in increased vulnera-

bility to same. This comprehensive neurological exam-

ination does not need to be completed by a neurologist,

but rather, by a physician with sufficient expertise and

knowledge in the examination as well as in the medi-


5/18


Referral

Intake Process

+/ - TBINo cognitive

symptoms

+ TBICognitive

symptoms arepresent. No co-

morbidities or co-morbidities are

controlled

+ TBCognitive symptoms

are presentSevere co-

morbidities arepresent

No TBICognitive symptoms

are present

Educatereferringprovider

Educate andreassurepatient

Refer back to

referring

provider

Refer back to

primary care

provider for

medical and

psychologica

evaluation

* Case

manager

assigned

Neurological

Assessment

** Referral to specialty totreat co-morbidity(s)

Cognitive

Assessment

TBI Cognitive

Rehabilitation

* Case

manager

assigned

Reconsider for

cognitive

rehabilitation

Re-eval in 4

weeks

Fig. 1. Referral process.


6/18


Table 1Assessment domains

Attention

Memory

Processing Speed

Executive Functioning

* reasoning and problem solving

* organizing, planning and self-monitoring

* emotional regulation

Post-Traumatic Stress Disorder (PTSD) Screen

Post-Concussive Syndrome (PCS) Symptom Rating

Pain Screen

Symptom Validity Test

Substance Abuse Screen

Depression Screen and Suicidality Assessment

cal work-up of cognitive symptoms. If no confoundingfindings are noted, the patient should next receive a

comprehensive cognitive assessment.While a comprehensive interdisciplinary team pro-

cess may not be available at all military treatment fa-cilities (MTFs), it is essential that the cognitive assess-

ment consist of a thorough neurobehavioral and cog-nitive evaluation using standardized performance and

self-report measures, including measures of effort. Itmay be that only one or two disciplines are available

or it may be that assessment and intervention are com-

pleted by different providers. However, both the as-

sessment and intervention providers must be competentin evaluating persons with known or suspected TBI,and be capable of making appropriate differential diag-

noses in complicated cases. In all situations, regardlessof the necessary program structure, appointment of a

team leader with broad-based TBI knowledge is essen-tial to assuring communication and coordination of the

treatment team.A variety of neurobehavioral assessment tools and

approaches are available and no tool or approach is rec-ommended over another. However, it is essential that

the domains specified by the American Academy of

Clinical Neuropsychology (AACN; see Table 1) shouldbe followed [1]. The assessment should identify anddescribe strengths, deficits, and function in everyday

activities, and identify barriers to successful participa-tion in rehabilitation [7].

It is critical for the team to determine the primary

factors contributing to symptoms (i.e., is mTBI the pri-mary cause of the symptoms or is a co-morbidity such

as major depression considered the primary contribu-

tor?). Assessment should include measures of effort,

although suboptimal results should not produce auto-matic disqualificationas there are numerous factors that

may account for reduced effort.

Upon completion of the cognitive assessment, the

team should be able to determine the following:

1) identificationof cognitive deficits associated with

TBI

2) need for cognitive rehabilitation

3) optimal rehabilitation method(s) for return to

function

4) measureable short- and long-term treatmentgoals

The cognitive assessment process may determine that

a patient does not require a full cognitive rehabilitation

program but rather a more limited program that assists

with goal-setting and provides educationon developing

cognitive and emotional skills to improve day-to-dayfunctioning (modeled after the Army Center for En-

hanced Performance) or a shortreturn-to-duty refresher

training to increase confidence in ones ability to return

to full duty. Malec and Basford [34] describe a range of

postacute braininjury rehabilitation programs available

in the civilian sector. Most cases resulting from mTBI

in the military will be similar to community re-entry

or community services only programs, the latter de-

scribing a structured, supervised, and supported return

to community. Regardless, a patient should not be dis-

charged from the cognitive assessment process without

a treatment plan based on the four options in Fig. 1.

3.2. Intervention

Despite the difference in common mechanisms of

injury and environment in which the injury occurs be-

tween combat related and non-combat related mTBI,

there is presently no evidence to suggest that the re-

sulting cognitive deficits are different or require dif-

ferent interventions [3]. The following are interven-

tions with demonstrated efficacy and utility for cogni-

tive rehabilitation: direct attention training; selection

and training of external memory/organizational aids;

training in internal memory strategies; metacognitive

strategy training; social pragmatics training (targeting

self-perception, self-awareness, and social skills); en-

vironmental modification (more organizedand less dis-

tracting environments); brain injury education for pa-

tients, family, and employers; and aggressive support

during gradual reentry into community and vocation-

al/educational activities (see Table 2). Holistic re-

habilitation programs integrate the above into orga-

nized interdisciplinary or transdisciplinary programs,

and have the advantage of using group process to ad-

dress social and behavioral issues [12,22].


7/18


Table 2

InterventionsArea of cognitiveimpairment

Empirically-supportedinterventions

Specific examples References

Attention Attention processtraining

Working memorytraining

Letter cancellationtasks withdistracting noise inbackground

Completing twocognitive taskssimultaneously

Sohlberg et al., 2002Tiersky et al, 2005Novack et al., 1996Sinotte & Coelho, 2007Berg et al., 1991Cicerone, 2002Serino et al., 2007Lew et al., 2009

Memory Variousmnemonictechniques

Visual imagerymnemonics

Story methodAcronymsSentences/

acrosticsMethod of lociChunkingRepetitionImagery basedtraining

Ryan & Ruff, 1988Berg et al., 1991Thickpenny-Davis & Barker-Collow, 2007

Kaschel et al., 2002Westerberg et al., 2007Glisky & Glisky, 2002

AttentionMemoryExecutivefunctioning

Memorynotebook

External Cuing

ProstheticsPDA

Supervised livingBlackBerryCell phonePDA

Schmitter-Edgecome et al. 1995Ownsworth & McFarland, 1999Sohlberg & Mateer, 1989McKerracher et al., 2005

Wilson et al., 2005Evans et al., 1998Kime & Lamb, 1996

ExecutivefunctioningSocialpragmatics

Socialcommunicationskills traininggroups

Group cognitivetherapy

Dahlberg et al., 2007Levin et. al., 1997

AttentionMemoryExecutivefunctioningSocialpragmatics

Problem solvingtrainingErrormanagementtraining

Emotionalregulationtraining

Internal problem-solvingInternal dialogue

Individual andgroup self-awareness training

Anger management

groups

Fasotti et al., 2000Ownsworth & McFarland, 1999Vaynman & Gomez, 2005Cheng et al., 2006Goverover et al., 2007Ehlhardt et al, 2005Ownworth et al., 2000Ownsworth et al., 2006Levine et al., 2000Rath et al., 2003Cicerone et al., 2008

Medd & Tate, 2000Ruff et al., 1996

AttentionMemoryExecutivefunctioningSocialpragmatics

Integrated use ofindividual andgroup cognitive,psychologicaland functionalinterventions

Cicerone et al., 2008Rattock et al., 1992Sarajuri et al., 2005Goranson et al., 2003Carney et al., 1999Cicerone et al., 2000Cicerone et al., 2005Comper et al., 2005Gordon et al., 2006Griesbach et al., 2009Hoge et. al., 2008Kim et. al., 2009


8/18


Table 2, continued

Area of cognitiveimpairment Empirically-supportedinterventions

Specific examples References

NIH Consensus Panel, 1999Prigatano, 1999Salazar et al., 2000Serino et al. 2007Terrio et al. 2009Tsaousides & Gordon, 2009Vanderploeg et al. 2008

Interventions for persistent postconcussioncognitive

symptoms uniformly emphasize improvement in atten-

tion abilities. Attention in all its various components

(e.g., alertness, sustained attention, divided attentionand alternating attention) is the prerequisite for basic

as well as complex behaviors involving memory, judg-

ment, social perception, and executive skills. Impair-ments in attention will have direct effects on specif-

ic attention tasks, and substantial indirect effects on

all aspects of a patients behavior. Moreover, attention

deficits often can masquerade as deficits in other cog-

nitive functions. For example, memory impairment

may be the downstream result of poor attention, with

concomitant impairments for registration of informa-tion, thus degrading memory performance even in the

absence of a true memory deficit.

Attention training was one of the earliest approach-es to cognitive rehabilitation [58]. It has been the sub-

ject of a number of well-designed studies and remains

one of the cornerstones of cognitive rehabilitation inter-

ventions [10,11,56,60]. Attention training has been acore element of diverse programs, ranging from single-

service/single-provider programs to interdisciplinary

holistic programs [22] and numerous studies have

confirmed its benefit [9,59]. Moreover, attention train-

ing has been successful for remediating TBI-related

cognitive disorders apparently far removed from atten-

tion dysfunction, as illustrated by a recent case study

showing the effectiveness of attention training for read-ing difficulties secondary to mild aphasia: The posi-

tive gains noted for this individuals reading skills were

felt to be the result of improvement in allocation of at-

tentional resources rather than improvement in linguis-

tic skills [55].

Attention process training [60] improves attentionskills through a set of standardized auditory and visu-

al procedures made increasingly challenging by sys-

tematically increasing task complexity and heighten-

ing the level of distractions. This intervention organizes

attention and concentration tasks into subcomponents

of sustained attention, selective attention, alternating

attention, and divided attention. Training procedures

place gradually increasing demands upon attentional

capacities.

Memory training is the most frequently prescribedform of cognitive rehabilitation. While it seems sensi-

ble to have a patient with memory impairment perform

memorizationdrills with the therapist(workon remem-bering word lists, faces, designs, etc.), recent reviews

have shown that repetitive memory drills memory

as a muscle have little or no efficacy [47,53]. How-

ever, efficacy has been demonstrated for memory train-

ing techniques derived from cognitive neuroscience.

For example, success has been shown with various

mnemonic techniques and other memory-enhancingstrategies that assist patients to develop techniques to

enhance registration and encoding of information, as

well as to develop methods for searching their memoryto improve memory retrieval [27]. Of interest, Kaschel

et al. [27], report that memory strategy training is most

effective for persons with mTBI and mild memory im-

pairment, with decreasing effectiveness as injury andmemory impairment severity increase.

External aids have been used to address both mem-

ory and executive function impairments. The majority

of more recent memory training studies have focused

upon the use of memory notebooks and electronic

equivalents, essentially serving as memory prosthet-

ics. A number of these studies have compared differ-

ent memory notebook formats and training proceduresto identify the most effective. For example [42], com-

pared two memory training procedures, one a Diary

Only condition in which patients were taught the me-

chanics of using a diary, while in the other condition

they received the diary training within a more compre-

hensive approach focusing on how the diary could beused to solve problems in daily activities, particularly

when used proactively. Thickpenny-Davis and Barker-

Collo [64] combined strategy training with memory

notebook training, using theaddedefficiency of a group

format for an eight-session program, and found im-

provement in both the use of memory strategies as well


9/18


as the use of memory prosthetics, with these improve-

ments extending into patients everyday memory func-tioning. For a review of the evidence examining ef-

ficacy of use of external aids for managing memory

impairments, see Sohlberg et al. [57]. Note that the

emphasis on memory notebooks reflects their long-

standing availability as compared to newer electronic

devices that also can serve as prosthetics.

Social pragmatics (comprehending and responding

to nonverbal social cues) are commonly impaired by

TBI. Social skills training (typically within a group for-

mat) has shown effectiveness in improving these prob-

lems. For example, Dahlberg et al. [14], describes a

successful program, citing four key components: The

first was the use of co-group leaders from different

clinical backgrounds (i.e.social work,speech-language

pathology). This allowed for two clinical perspectives,

two role models, and two clinicians collaborating and

sharing their expertise. The second component was

an emphasis on self-awareness and self-assessment,

leading to individual goal setting. A third component

was the use of the group process to foster interac-

tion, feedback, problem solving, a social support sys-

tem, and awareness that one is not alone. The final

component was a focus on generalization of skills, ad-

dressed through the involvement of family and friends,

and weekly assignments completed in the home orcommunity. . . Generally, sessions followed a consis-

tent format: (1) review of homework, (2) brief intro-

duction of the topic, (3) guided discussion, (4) small

group practice, (5) group problem solving and feed-

back, and (6) homework (pp. 15641565). A major

portion of this program utilized the Goal Attainment

Scaling procedure developed by Malec, which also has

been used in numerous other programs to positive ef-

fect. Moreover, while Dahlberg describes this program

as training of social communication skills, the above

brief description clearly indicates that the program is

much more comprehensive and holistic, with focus on

executive skills, self-awareness, and emotional and be-

havioral self-regulation. As others have noted, inter-

ventions that incorporate training in personal and social

self-regulation, self-management, and problem solving

skills also address deficits in attention, memory, com-

munication, and executive function [1,45].

A robust literature supports the use of metacogni-

tive strategy training as an intervention for executive

function impairments due to TBI. At least five RCTs

have evaluated executive function outcomes from train-

ing in the use of multiple step strategies, strategic

thinking, and/or multitasking. In an early study, pos-

itive outcomes were reported from problem solving

therapy where patients were taught to identify prob-lems and solutions, weigh the pros and cons of solu-tions and monitor performance [69]. Similarly, Rath etal. [45], showed positive effects of group therapy aimedat improving emotional self regulation by the use ofproblem-solution training. A goal attainment scalingtechnique was shown to have specific positive resultson goal setting. Fasotti and colleagues [18] showedimproved problem solving with a step by step timepressure management approach. A step by step taskcompletion strategy, Goal Management Training, wasshown to improve proofreading skills [31].

A holistic focus is seen in Tiersky et al. [65], who

focused on cognitive rehabilitation of mTBI. These au-thors employed a manualized cognitive rehabilitationprogram that was delivered in conjunction with cogni-tive behavioral therapy, comparing it to a wait-list con-trol group. The 11-week, three times per week, cogni-tive rehabilitation program focused primarily on atten-tion, informationprocessing, and memory, although theauthors note that organizational and problem-solvingskills were addressed throughout the cognitive retrain-ing program because these abilities are a corollary ofmemory and attentional skills (p. 1568). The cognitivebehavioral therapy (CBT) was a relatively traditionalapplication of CBT and focused on increasing the use

of adaptive coping, reducing levels of distress, trainingin methods of preventing relapse, and improvingaccep-tance of sadness and loss related to cognitive and phys-ical impairments. The treatment group showed signif-icantly lessened anxiety and depression, and improveddivided attention.

Clinical experience with Wounded Warriors suggestthat a comprehensive holistic approach, which pro-vides individual and group therapies within an integrat-ed therapeutic environment, addresses the functionalimpairment and disability resulting from cognitive andemotional sequelae of chronic symptomatic mTBI. In-volvement of family members and the Service Mem-

bers Command is highly encouraged to optimize re-habilitation outcomes. Group therapy in addition to in-dividual therapy provides a supportive context for re-habilitation and reinforces the concept of unit cohe-sion in military culture. The above studies are but asample of those leading the Intervention Group to itsprimary conclusions regarding cognitive rehabilitationinterventions.

3.3. Outcome measures

Adequate literature and expert-consensus exists tosupport judicious and selective use of cognitive reha-


10/18


bilitation for Service Members with persistent symp-

toms of mTBI. Nonetheless, the present Panel as wellas all recently published evidence-based reviews [10,

11,13,22,65] note the scarcity of well-designed clinical

trials in this area. The time-frame for correcting this

scarcity, however, likely is a decade or more, and even

longer if the essential element of long-term follow-up

is included.

While the situation may appear daunting, there is

much useful work that can be done in the meantime.

Studies conducted in recent years, and those current-

ly ongoing, use vastly improved methodology as com-

pared to studies published even several years ago. The

Panel learned of several in-press or ongoing literature

reviews and RCTs and it is likely that the amount of

high quality research will accelerate during the coming

years.

It also is importantfor individual programs to present

and publish theiroutcome data and clinical experiences.

While this likely will not be gold standard research,

it will enhance the field by allowing programs to fer-

tilize and learn from each other. This objective will be

facilitated greatly by using a set of common measures

for describing program and patient variables.

Capturing the complexity of the chronic mTBI popu-

lation is challenging. Many mTBIpatients have comor-

bid disorders that can result in cognitive impairment,and that can overlap, exacerbate, or mimic the cogni-

tive disorders associated with mTBI. It therefore is es-

sential that programs include data elements to capture

the nature and severity of comorbidities potentially af-

fecting cognitive status. The working group identified

several additional categories of required data elements

(see Table 3): administrative performance metrics (e.g.

number of patients seen, type and number of service

providers; range of services readily available; consis-

tent and well-defined admission criteria; consistent and

well-defined discharge criteria; clear description of the

program and interventions; sufficient documentation

to permit reasonable consistency of treatment across

providers; and, clear documentation to permit audit

of patient care); pre- post-assessment differences; pre-

post- functional differences; moderating variables that

may affect outcome; dischargeenvironmentand patient

status at time of discharge; consumer satisfaction (in-

cluding the patient but can extend to family, employ-

er/Command, and referral source; and, aggregate pro-

gram outcome data to permit evaluation of the program

rather than just the individual patient.

As seen in Table 3, formal neurocognitive as-

sessments should be reserved for pre- and post-

rehabilitation (assuming appropriate intervals between

testing to protect the integrity of these tests or the useof repeatable versions), while the ongoing monthly re-assessments should emphasize evaluation of symptomstatus and functional status.

The recommended functional outcome measures are: job performance, need for redesignation/duty restric-tions or limitations; ongoing comparisons between pre-injury fitness reports/evaluations and current function-al abilities as they improve within the program; per-formance on simulators (rifle, flight, etc.); quality oflife assessment; community participation assessment;and social-skills pragmatics assessment. Results frommonthly re-assessments of symptoms and functional

status, using tools such as Goal Attainment Scaling(GAS) [33], can assist with clinical decision-makingand goal setting. The GAS procedure prescribes thatthe goals should be objective, measurable, and time-based; that they should be generated by the treatmentteam with active involvement from the patient; andthat they should be functional, based on the patientslifestyle and needs. For outcome data to be maximal-ly meaningful, it is important to carefully describe thepatient population. Some patients may respond muchbetter than others to specific interventions, making itessential to have detailed and objective identificationof moderating variables, confounds, and comorbidi-

ties. These include pain; comorbid physical injuries;type of injury; age, rank, job duties and gender of pa-tient; psychological health and substance abuse; num-ber of deployments; date(s) of injury(s); trauma histo-ry to include life events prior to entering the military;family and broader psychosocial support system; apti-tude/education; duty status; prior neurologic illnessesor injuries; motivation for retention; expectations of re-covery; years of service; and, sources of possible sec-ondary gain. Increased understanding of who respondsto specific interventions and who does not is essential.

Discharge data elements include: accomplishmentof treatment goals; plateauing of improvement and/or

failure to improve (typically following 3 to 4 weeksof treatment and medical reevaluation to rule out treat-able reasons); worsening symptoms (again with needfor reevaluation and possible case reformulation); and,a clear but flexible definition of the maximum durationof treatment. Moreover, patient and family satisfactionmeasures are useful for identifying quality improve-ment opportunities within a program

3.4. Program implementation

Patient assessment and treatment, and outcome mea-sures for program assessment, already have been dis-


11/18


Table3

Outco

memeasures

Administrativeper-

formancemetrics

Pre-Post-assessment

differences

Pre-post-functional

differences

Moderating

Variables

Dischargecriteria

&patientstatusat

timeofdischarge

Consumer

satisfaction

Aggregateprogramo

ut-

comedata

#ofpatientsseen

#ofpatientsre-

ferredformedical

appts

duration&daily

intensityofprgm

lengthoftimepa-

tientisonlimited

duty

formalneuropsych

evaluation

symptomstatus

functionalstatus

domainstesteddurin

g

CognitiveAssessment

jobperformance

needforredesigna-

tion/dutyrestrictions

pre-injuryfitnessre-

ports/evalsvs.currentfunc-

tionalabilities

performanceonsimulators

qualityoflifeassessment

communityparticipation

assessment

degreetowhichco-morbiditymay

beresulting

incognitivesymptoms

pain

severityofassociatedphysicalin-

juries

mechanism

ofinjury

age

rank/MOS

gender

psychologicalhealthco-morbidities

substance

abuseco-morbidities

#ofdeployments

date(s)ofinjury(s)

traumahis

torytoincludelifeevents

priortoente

ringthemilitary

family/bro

aderpsychosocialsup-

portsystems

aptitude/education

militarystatus

historyof

ADHDorLD

otherprio

rneurologicillnessesor

injuries

motivation

forretention

expectationsofrecovery

yearsofse

rvice

possiblesourcesofsecondarygain

goalsattained

plateauingofim-

provementand/or

failuretoimprove

worsening

symptoms

patient,family,

employer/command,

andreferralsource

education

treatments

efficacy

typeand#ofservice

providers

rangeofservices

consistent/well-defined

entrycriteria

consistent/well-defined

dischargecriteria

cleardescriptiono

fthe

program/interventions

cleardocumentatio

n


12/18


TBI Program

Cognitive Rehabilitation

Speciality

Services

Physical Rehab

Psychological

Couseling

Vocational

Rehab

Visual Rehab

Cognitive

Rehab

Vestibular

Rehab

Neuropsychology Speech Language

Pathology

Occupational

Therapy

Mental Health

Fig. 2. Cognitive rehabilitation within TBI program.

cussed. The emphasis of the present section is on im-

plementing the prior recommendations within an MTF.

If a TBI program exists at the MTF, the cognitive

rehabilitation program should be a sub-component (see

Fig. 2). The idealcognitive rehabilitationprogram mod-el is team-based and holistic [53]. Alternately, cogni-

tive treatment can be offered within a discrete thera-

py model, usually assigned to SLP or OT, though it

may become difficult to provide consistent integration

of services. Research concerning the effectiveness of

cognitive rehabilitation tends to favor the holistic mod-

el [12,22].

Optimal delivery of the holistic model requires an

interdisciplinary or transdisciplinary team of clinicians

who are competentin brain injuryrehabilitation, under-

stand and can function within military culture, and are

capable of developing a therapeutic alliance with their

patients. Strong team leadership is required, both pro-

grammatically and medically, to ensure unified goals

and quality care. Interdisciplinary case conferences for

patient management and goal setting/review should oc-cur regularly. Coordination of care is also required with

the patients family, other medical providers, and the

unit chain of command. The program leader is expect-

ed to ensure that the team, with his/her guidance, de-

velops and monitors an appropriate treatment plan, and

updates the plan as needed; keep Line and Leader-

ship informed regarding patients goals, objectives, and

progress; provide leadership and guidance during dis-

charge planning conferences; resolve and attempt to

achieve consensus among team members regardingpo-

tential differences in patient care plans; and, manage


13/18


professional turf issues should they arise.

It will be crucial to recruit, train and retain providerswith specific TBI expertise. Thediscipline of providers

to deliver a cognitive rehabilitation program shouldinclude, but is not limited to, neuropsychologists,speech-language pathologists, occupational therapists

and mental health providers. Continued professionaleducation in the area of the assessment and treatment

of TBI and associated conditions is an on-going need.Development of a concept of operations for a cogni-

tive rehabilitation program should include attention to

space requirements (quiet treatment spaces and group

intervention spaces), equipment (to include assistive

technology and virtual reality systems), and funds to

cover transportation for community activities and so-cial networking opportunities. A program such as this

will need substantial administrative support.

4. Conclusions

1. Recommend immediate implementation of this

clinical guidance into current DoD TBI treat-ment algorithms, specifically as an extension ofthe May 2008 mTBI Clinical Guidance for non-

deployed settings. Cognitive rehabilitation clin-ical guidance will be updated and refined as re-

search in this area unfolds.2. Standardized outcome measures should be used

for DoD cognitive rehabilitation programs to

further inform future research (with appropriateInstitutional Review Board (IRB) protocol ap-

proval) and further program development.3. Provide new opportunities for ongoing provider

continuingeducation related to cognitive rehabil-

itation in the military TBI population4. Consider further discussion regarding cognitive

rehabilitation as a separate reimbursable rehabil-itation technique for the traumatic brain injured

with persistent cognitive deficits.

Acknowledgements

This work was coordinated by the Defense Cen-ters of Excellence for Psychological Health and Trau-

matic Brain Injury and its operational component, theDefense and Veterans Brain Injury Center. We thank

Joseph Bleiberg, Ph. D., for his significant contribu-tions in the conceptualization and success of the April2009 Consensus Conference. We also thank Ms. San-

dra Page for her outstanding support services.

References

[1] American Academy of Clinical Neuropsychology (AACN)clinical practice guidelines for neuropsychological evaluation,The Clinical Neuropsychologist 21 (2007), 209231.

[2] I. Berg, M. Koning-Haanstra, Deelman and G. Betto, Longterm effects of memory rehabilitation: A controlled study,

Neuropsychological Rehabilitation 1 (1991), 97111.[3] H.G. Belanger, T. Kretzmer, R. Yoash-Gantz et al., Cognitive

sequelae of blast-related versus other mechanisms of braintrauma, Journal of the International Neuropsychological So-ciety 15 (2009), 18.

[4] E.B. Blanchard, J. Jones-Alexander, T.C. Buckley et al., Psy-chometric properties of the PTSD checklist (PCL), Behavior

Research and Therapy 34 (1996), 669673.[5] L.A. Brenner, R.D. Vanderploeg, H. Terrio et al., Assessment

and diagnosis of mild traumatic brain injury, posttraumaticstress disorder, and other polytrauma conditions: burden ofadversity hypothesis, Rehabilitation Psychology 54 (2009),239246.

[6] N. Carney, R.M. Chesnut, H. Maynard et al., Effect of cog-nitive rehabilitation on outcomes for persons with traumaticbrain injury: A systematic review, Journal of Head Trauma

Rehabilitation 14 (1999), 277307.[7] L.J. Carroll, J.D. Cassidy, P.M. Peloso et al., Prognosis for

mildtraumatic brain injury: Results of the WHOcollaboratingcentre task force on mild traumatic brain injury, Journal of

Rehabilitative Medicine 43 (2004), 84105.[8] S.K.W. Cheng and D.W.K. Man, Management of impaired

self-awareness in persons with traumatic brain injury, BrainInjury 11 (2006), 621628.

[9] K.D. Cicerone, Remediation of working attention after mild

traumatic brain injury, Brain Injury 16 (2002), 185195.[10] K.D.Cicerone, C. Dahlberg, K. Kalmar et al., Evidence-Based

Cognitive Rehabilitation: Recommendations for clinical prac-tice, Archives of Physical Medicine and Rehabilitation 81

(2000), 15961615.[11] K.D. Cicerone, C. Dahlberg, J.F. Malec et al., Evidence-based

cognitive rehabilitation: Updated review of the literature from1998 through 2002, Archives of Physical Medicine and Reha-bilitation 86 (2005), 16811692.

[12] K.D. Cicerone, T. Mott, J. Azulay et al., A randomized con-trolled trial of holistic neuropsychologic rehabilitation aftertraumatic brain injury, Archives of Physical Medicine and Re-habilitation 89 (2008), 22392249.

[13] P. Comper, S.M. Bisschop, N. Carnide et al., A systematicreview of treatments for mild traumatic brain injury, Brain

Injury 19 (2005), 863880.[14] C.A. Dahlberg, C.P. Cusick, L.A. Hawley et al., Treatment ef-ficacy of social communication skills training after traumaticbrain injury: A randomized treatment and deferred treatmentcontrolled trial, Archives of Physical Medicine and Rehabili-tation 88 (2007), 15611573.

[15] R. DePompei, Y. Gillette, E. Goetz et al., Practical applica-tions for use of PDAs and smartphones with children and ado-lescents who have traumatic brain injury, NeuroRehabilitation23 (2008), 487499,

[16] L.A. Ehlhardt, M.M. Sohlberg, A. Glang et al., TEACH-M:A pilot study evaluating an instructional sequence for personswith impaired memory and executive functions, Brain Injury19 (2005), 569583.

[17] J.J. Evans, H. Emslie and B.A. Wilson, External cueing sys-tems in the rehabilitation of executive impairments of action,


14/18


Journal of the International Neurological Society 4 (1998),399408.

[18] L. Fasotti, F. Kovacs, P.A. Eling et al., Time pressure man-agement as a compensatory strategy training after closed headinjury, Neuropsychological Rehabilitation 10 (2000), 4765.

[19] E.L. Glisky and M.L. Glisky, Learning and memory impair-ments, in: Neuropsychological Interventions: Clinical Re-search and Practice, P.A. Eslinger, ed., The Guilford Press,New York, 2002, pp. 137158.

[20] T.E. Goranson, R.E. Graves, D. Allison et al., Communityintegration following multidisciplinary rehabilitation for trau-matic brain injury, Brain Injury 17 (2003), 759774.

[21] W.A. Gordon, J. Cantor, T. Ashman et al., Treatment of post-TBI executive dysfunction: Application of theory to clinicalpractice, Journal of Head Trauma Rehabilitation 21(2) (2006),156167.

[22] W.A. Gordon, R. Zafonte, K. Cicerone et al., Traumatic brain

injury rehabilitation: State of the science, American Journalof Physical Medicine and Rehabilitation 85 (2006), 343382.

[23] Y. Goverover, M.V. Johnston and J. Toglia, Treatment to im-prove self-awareness in persons with acquired brain injury,

Brain Injury 21 (2007), 913923.[24] G.S. Griesbach, R.L. Sutton, D.A. Hovda et al., Controlled

contusion injury alters molecular systems associated with cog-nitive performance, Journal of Neuroscience Research 87

(2009), 795805.[25] C.W. Hoge, D. McGurk, J.L. Thomas, et al., Mild traumatic

brain injury in U.S. soldiers returning from Iraq, New EnglandJournal of Medicine 358 (2008), 453463.

[26] G.L. Iverson, N.D. Zasler, R.T. Lange et al., Post-ConcussiveDisorder, in: Brain Injury Medicine: Principles and Practice,N.D. Zasler, D.I. Katz and R.D. Zafonte, eds, Demos Medical,New York, 2006, pp. 373405.

[27] R. Kaschel, S. Della Sala, A. Cantagallo et al., Imagerymnemonics for the rehabilitation of memory: A randomizedgroup controlled trial, Neuropsychological Rehabilitation 12(2002), 127153.

[28] Y. Kim, W. Yoo, M. Ko et al., Plasticity of the attentionalnetwork after brain injury and cognitive rehabilitation, Neu-rorehabilitation and Neural Repair23 (2009), 110.

[29] S. Kime, D. Lamb and G. Wilson, Use of a comprehensiveprogram of external cueing to enhance procedural memory ina patient with dense amnesia, Brain Injury 10 (1996), 1725.

[30] H.S. Levin, F.C. Goldstein and E.J. MacKenzie, Depression asa secondary condition following mild and moderate traumaticbrain injury, Seminars in Clinical Neuropsychology 2 (1997),207215.

[31] B. Levine, I.H. Robertson, L. Clare et al., Rehabilitation ofexecutive functioning: an experimental-clinical validation ofgoal management training, Journal of the International Neu-ropsychological Society 6 (2000), 299312.

[32] H.L.Lew,M. Grayand J.H.Poole, Simultaneousmeasurementof perceptual and motor cortical potentials: Implications forassessing information processing in traumatic brain injury,

American Journal of Physical and Medical Rehabilitation 88

(2009), 16.[33] J.F. Malec, Goal attainment scaling in rehabilitation, Neu-

ropsychological Rehabilitation 9(3/4) (1999), 253275.[34] J.F. Malec and J.R. Basford, Postacute brain injury rehabili-

tation, Archives of Physical Medicine and Rehabilitation 77

(1996), 198207.[35] M. McCrea, Mild Traumatic Brain Injury and Postconcus-

sion Syndrome: The New Evidence Base for Diagnosis and

Treatment. Oxford University Press, New York, NY, 2008.

[36] G. McKerracher, T. Powell and J.A. Oyebode, Single caseexperimental design comparing two memory notebook for-mats for a man with memory problems caused by traumat-ic brain injury, Neuropsychological Rehabilitation 15 (2005),115128.

[37] J. Medd and R.L. Tate, Evaluation of an anger managementtherapy program following ABI: a preliminary study, Neu-ropsychological Rehabilitation 10 (2000), 185201.

[38] C.S. Milliken, J.L. Auchterlonie and C.W. Hoge, Longitudinalassessment of mental health problems among active and re-serve component soldiers returning from the Iraq war, JAMA

298(18) (2007), 21412148.[39] NIH Consensus Development Panel on Rehabilitation of Per-

sons with Traumatic Brain Injury. Rehabilitation of personswith Traumatic Brain Injury, JAMA 282 (1999), 947983.

[40] T.A. Novack, S.G. Caldwell, L.W. Duke et al., Focused ver-sus unstructured intervention for attention deficits after trau-

matic brain injury, Journal of Head Trauma Rehabilitation 11(1996), 5260.

[41] T. Ownsworth, J. Fleming, J. Desbois et al., A metacognitivecontextual intervention to enhance error awareness and func-tional outcome following traumatic brain injury: A single caseexperimental design, Journal of International Neuropsycho-logical Society 12 (2006), 5463.

[42] T.L. Ownsworth and K. McFarland, Memory remediation inlong-term acquired brain injury: Two approaches in diarytraining, Brain Injury 13 (1999), 605626.

[43] T.L. Ownsworth, K. McFarland and R.D. Young, Self-awareness and psychosocial functioning following acquiredbrain injury: an evaluation of a group support program, Neu-ropsychological Rehabilitation 10 (2000), 465484.

[44] G.P. Prigatano, Principles of Neuropsychological Rehabilita-tion, Oxford University Press, New York, NY, 1999.

[45] J.F. Rath, D.M. Langenbahn, D. Simon et al., Group treatmentof problem-solving deficits in outpatients with traumatic braininjury: A randomized outcome study,Neuropsychological Re-habilitation 13 (2003), 341488.

[46] J. Rattok, Y. Ben-Yishay, O. Ezrachi et al., Outcome of differ-ent treatment mixes in a multidimensional neuropsychologicalrehabilitation program, Neuropsychology 6 (1992), 395415.

[47] L. Rees, S. Marshall, C. Hartridge et al., Cognitive interven-tions post acquired brain injury, Brain Injury 21 (2007), 161200.

[48] R. Ruff, L. Camenzuli and J. Mueller, Miserable minority:emotional risk factors that influence the outcome of a mildtraumatic brain injury, Brain Injury 10 (1996), 551565.

[49] T.V. Ryan and R.M. Ruff, The efficacy of structured memoryretraining in a group comparison of head trauma patients,

Archives of Clinical Neuropsychology 3 (1988), 165179.[50] A.M. Salazar, D.L. Warden et al., Cognitive rehabilitation

for traumatic brain injury: A randomized trial. Defense andveterans head injury program (DVHIP) study group, JAMA283 (2000), 30753081.

[51] J.M. Sarajuuri, M.L. Kaipio, S.K. Koskinen et al., Outcomeof a comprehensive neurorehabilitation program for patientswith traumatic brain injury, Archives of Physical Medicine and

Rehabilitation 86 (2005), 22962302.[52] M. Schmitter-Edgecombe, J.F. Fahy, J.P. Whelan et al., Mem-

ory remediation after severe closed head injury: Notebooktraining versus supportive therapy, Journal of Consulting andClinical Psychology 63 (1995), 484489.

[53] L.E. Schutz and K. Trainor, Evaluation of cognitive rehabili-tation as a treatment paradigm, Brain Injury 21 (2007), 545557.


15/18


[54] A. Serino, E. Ciaramelli and A.D. Santantonio, A pilot studyof rehabilitation of central executive deficits after traumaticbrain injury, Brain Injury 21 (2007), 1119.

[55] M. Sinotte and C.A. Coelho, Attention training for readingimpairment in mild aphasia: A follow-up study, Journal of

Medical Speech Pathology 11 (2003), 1939.[56] M.M. Sohlberg, J. Avery, M.R.T. Kennedy et al., Practice

guidelines for direct attention training, Journal of MedicalSpeech-Language Pathology 11 (2003).

[57] M.M. Sohlberg, M.R.T. Kennedy, J. Avery et al., Evidencebased practice for the use of external aids as a memory reha-bilitation technique, Journal of Medical Speech Pathology 15

(2007).[58] M.M. Sohlberg and C.A. Mateer, Training use of compensato-

ry memory books: A three stage behavioral approach, Journalof Clinical Experimental Psychology 11 (1989), 871891.

[59] M.M. Sohlberg and C.A. Mateer, Cognitive Rehabilitation:

An Integrative Approach, The Guilford Press, New York, NY,2001.

[60] M.M. Sohlberg,K.A.McLaughlin, A.Pavese etal., Evaluationof attention process training and brain injury education inpersons with acquired brain injury, Journal of Clinical and

Experimental Neuropsychology 22 (2002), 656676.[61] G.E. Strangman, R. Goldstein, T. ONeil-Pirozzi et al., Neu-

ropsychological alterationsduringstrategy-basedverbal learn-ing in TBI, Journal of Neurorehabilitation and Neural Repair23 (2009), 226236.

[62] M.B. Stein and T.W. McAllister, Exploring the convergence ofposttraumatic stress disorder and mild traumatic brain injury,

American Journal of Psychiatry 166 (2009), 768776.[63] H. Terrio, L.A. Brenner, B.J. Ivins et al., Traumatic brain

injury screening: preliminary findings in a US Army BrigadeCombat Team, Journal of Head Trauma Rehabilitation 24

(2009), 1423.[64] K.L. Thickpenny-Davis and S.L. Barker-Collow, Evaluation

of a structured group format memory rehabilitation programfor adults following brain injury, Journal of Head Trauma

Rehabilitation 22 (2007), 303313.[65] L.A. Tiersky, V. Anselmi, M.V. Johnston et al., A trial of

neuropsychologic rehabilitation in mild-spectrum traumaticbrain injury, Archives of Physical Medicine and Rehabilitation86 (2005), 15651574.

[66] T. Tsaousides and W.A. Gordon, Cognitive rehabilitationfollowing traumatic brain injury: Assessment to treatment,

Mount Sinai School of Medicine 76 (2009), 173181.[67] R.D. Vanderploeg, K. Schwab, W.C. Walker et al., Rehabil-

itation of traumatic brain injury in active duty military per-sonnel and veterans: Defense and veterans brain injury centerrandomized controlled trial of two rehabilitation approaches,

Archives of Physical Medicine and Rehabilitation 89 (2008),22272238.

[68] S. Vaynman and F. Gomez-Pinilla, License to run: Exercise

impacts functional plasticity in the intact and injured centralnervous system by using neurotrophins, Neurorehabilitationand Neural Repair19 (2005), 283295.

[69] D.Y. Von Cramon et al., Problem solving deficits in braininjured patients: A therapeutic approach, Neuropsychological

Rehabilitation 1 (1991), 4564.[70] F.W. Weathers, B.T. Litz, D.S. Herman et al., The PTSD

Checklist (PCL): Reliability, Validity and Diagnostic Utility,Paper presented at the Ninth Annual Meeting of the Interna-tional Society for Traumatic Stress Studies, San Antonio, TX,October 1993.

[71] P.M. Webb and R.L. Gluecauf, The effects of direct involve-mentin goal setting onrehabilitation outcome for persons withtraumatic brain injuries, Rehabilitation Psychology 39 (1994),179188.

[72] H. Westerberg, H. Jacobaeus, T. Hirvikoski et al., Comput-

erized working memory training after stroke A pilot study,Brain Injury 21 (2007), 2129.


16/18


Appendix A: DoD TBI definition


17/18



18/18


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.

Cognitive Rehabilitation for Military Personnel NeuroRehabilitation

Documents

Transcript of Cognitive Rehabilitation for Military Personnel NeuroRehabilitation