Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and Veterans Brain Injury Center randomized controlled trial of two rehabilitation approaches (Vanderploeg et al. 2008)
Vanderploeg, R., Schwab, K., Walker, W., Fraser, J., Sigford, B., Date, E., . . . Warden, D. (2008). Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and Veterans Brain Injury Center randomized controlled trial of two rehabilitation approaches. Archives of Physical Medicine and Rehabilitation, 89(12), 2227-2237.
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- The study’s objective was to examine the impact of two treatments—cognitive-didactic rehabilitation and functional-experiential rehabilitation—on return to work/school and functional independence among veterans and active military with traumatic brain injury (TBI).
- The study used a randomized controlled trial design in which 366 active duty military service members or veterans with moderate-to-severe TBI were randomly assigned to receive either cognitive-didactic rehabilitation, which focuses on addressing cognitive deficits, or functional-experiential rehabilitation, which emphasizes performance of real-life tasks. Primary outcomes were measured using in-person evaluations or structured telephone interviews.
- The study found no significant differences in return to work or school or functional independence between the two types of rehabilitation.
- The quality of causal evidence presented in this report is high because it was based on a well-implemented randomized controlled trial. This means we are confident that any estimated effects would be attributable to the difference between the cognitive-didactic and functional-experiential treatments and not to other factors. However, the study did not find statistically significant effects between the two treatments.
Cognitive-didactic rehabilitation targets attention, memory, executive function, and pragmatic communication through paper-and-pencil and computer-based tasks, with the idea that addressing cognitive deficits will result in generalized functional improvement. Patients practiced these tests one-on-one with therapists in daily sessions lasting 1.5 to 2.5 hours. Therapists treating those in the cognitive-didactic rehabilitation group drew patients’ attention to their errors and prompted them to think through what had caused the error and how to correct it.
Functional-experiential rehabilitation focuses on performing real-life tasks in groups and natural environments to rebuild functional behaviors through practice. Patients participated in daily sessions lasting 1.5 to 2.5 hours. Therapists treating those in the functional-experiential rehabilitation group tried to anticipate patients’ mistakes and minimize them through providing instructional cues.
Both groups received treatment for 20 to 60 days and received assistance with activities of daily living, physical therapy, rehabilitation counseling, family/patient education, social work support services, and psychological treatment as necessary.
Features of the Study
The study was conducted in four U.S. Veterans Administration acute inpatient TBI rehabilitation programs in Minneapolis, Minnesota; Palo Alto, California; Richmond, Virginia; and Tampa, Florida. Participants were military members or veterans age 18 or older experiencing moderate-to-severe TBI within the past six months. Participants were included in the study if it was anticipated that they needed 30 or more days of acute rehabilitation. Participants who had prior inpatient acute rehabilitation for the current TBI or a history of severe conditions that impaired brain functioning were excluded from the study.
The authors randomly assigned 366 eligible military members or veterans to participate in one of two hospital-based interdisciplinary TBI rehabilitation programs; 184 were randomly assigned to receive cognitive-didactic rehabilitation and 182 were randomly assigned to receive functional-experiential rehabilitation. The authors collected data on return to work or school and functional independence through in-person evaluations or structured telephone interviews with patients conducted approximately one year after random assignment. Authors also collected data on a number of secondary outcomes including memory problems, motivation, and social withdrawal. The authors estimated the impacts of the program by comparing the average outcomes of patients in the two groups.
- There were no significant differences in return to work or school or functional independence between the two treatment groups.
Considerations for Interpreting the Findings
The study was a well-implemented randomized controlled trial testing two different treatments. Thus, the lack of any statistically significant differences in outcomes between patients receiving the treatments implies they were equally effective. However, neither was compared against a no-treatment control group, because that was deemed unethical. The authors noted that the overall rates of independent living and return to work or school at the one-year follow-up were 59 percent and 37 percent, respectively. They remarked that this was noteworthy considering that none of the patients was capable of doing either of those at the time of study enrollment.
Causal Evidence Rating
The quality of causal evidence presented in this report is high because it was based on a well-implemented randomized controlled trial. This means we are confident that any estimated effects would be attributable to the difference between the cognitive-didactic and functional-experiential treatments and not to other factors. However, the study did not find statistically significant effects between the two treatments.