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CogSMART compensatory cognitive training for traumatic brain injury: Effects over 1 year (Twamley et al. 2014)

Absence of conflict of interest.

Citation

Twamley, E. W., Thomas, K. R., Gregory, A. M., Jak, A. J., Bondi, M. W., Delias, D. C., & Lohr, J. B. (2014). CogSMART compensatory cognitive training for traumatic brain injury: Effects over 1 year. Journal of Head Trauma Rehabilitation, 30(6), 391-401.

Highlights

  • The study’s objective was to examine the impact of Cognitive Symptom Management and Rehabilitation Therapy (CogSMART) and enhanced supported employment (ESE) on employment, earnings, and health outcomes.
  • The authors conducted a randomized controlled trial that randomly assigned participants to the intervention and comparison groups. Employment data came from weekly reports on job attainment, hours worked, and wages earned.
  • The study did not find any statistically significant relationships between CogSMART plus ESE and employment, earnings, or health outcomes.
  • The quality of causal evidence presented in this report is low because the study had a confounding factor. Specifically, one interventionist delivered CogSMART plus ESE and another interventionist implemented services to the comparison group, which makes it impossible to separate the effect of CogSMART plus ESE from the effect of the individual interventionists. This means we are not confident that the estimated effects are attributable to CogSMART plus ESE; other factors are likely to have contributed to the findings.

Intervention Examined

CogSMART Plus ESE

Features of the Intervention

CogSMART is a cognitive symptom and rehabilitative therapy approach designed to improve post concussive symptoms, prospective memory, attention, learning and memory, and executive functioning in people with traumatic brain injury (TBI). The intervention provides instruction on strategies and habits related to handling post-concussive symptoms and enhancing attention, learning, memory, and executive functioning. Examples of strategies and habits include headache management, daily calendar use, name-learning strategies, self-talk, and self-monitoring. People in the intervention group received CogSMART instruction for two hours per week for one year.

ESE provides work rehabilitation that focuses on rapid searching for competitive employment in the community, tailored to individual interests and preferences. People in the intervention group engaged with ESE for two hours a week for one year.

Features of the Study

The authors used a randomized controlled trial design and statistical models to examine the impact of CogSMART plus ESE on employment and health outcomes among veterans with mild to moderate TBI.

The study included 50 veterans in the VA San Diego Healthcare System: 25 veterans were randomly assigned to be in the CogSMART plus ESE group and 25 veterans were randomly assigned to be in the ESE group. People were referred to the study from the VA San Diego Healthcare System Wellness and Vocational Enrichment Clinic, TBI Cognitive Rehabilitation Clinic, Polytrauma Clinic, and Neuropsychological Assessment Unit. Eligible participants included veterans of Operation Iraqi Freedom or Operation Enduring Freedom who have a history of mild to moderate TBI; who have an impairment in attention, processing speed, working memory, learning, memory, or executive functioning; who are unemployed but willing to work; who are abstinent from drugs and alcohol; and who did not participate in any other intervention studies.

People in the study were, on average, 32 years old. The majority were male and about one-third were White. They had 13 to 14 years of education.

The authors used statistical models and data from multiple measures to compare the intervention and comparison groups on employment, earnings, and health outcomes. The authors did not include control variables in their statistical models to assess the effects of the intervention on competitive employment. They did include, however, controls for age and education in their statistical models to assess the effects of the intervention on the length of employment outcome as well as for the earnings and health outcomes.

Findings

Employment

  • The study found no statistically significant relationships between CogSMART plus ESE and employment.

Earnings

  • The study found no statistically significant relationships between CogSMART plus ESE and earnings.

Causal Evidence Rating

The quality of causal evidence presented in this report is low because the study had a confounding factor. One employment specialist implemented CogSMART plus ESE and a different employment specialist implemented the condition, and we are unable to determine how much of the effects could be attributable to the employment specialist or the intervention. This means we are not confident that the estimated effects are attributable to CogSMART plus ESE; other factors are likely to have contributed to the findings.

Reviewed by CLEAR

May 2020

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