Cognitive Rehabilitation for Military Service Members With Mild Traumatic Brain Injury: A Randomized Clinical Trial

Objective: To compare cognitive rehabilitation (CR) interventions for mild traumatic brain injury (mTBI) with standard of care management, including psychoeducation and medical care for noncognitive symptoms. Setting: Military medical center. Participants: A total of 126 service members who received mTBI from 3 to 24 months before baseline evaluation and reported ongoing cognitive difficulties. Interventions: Randomized clinical trial with treatment outcomes assessed at baseline, 3-week, 6-week, 12-week, and 18-week follow-ups. Participants were randomly assigned to one of four 6-week treatment arms: (1) psychoeducation, (2) computer-based CR, (3) therapist-directed manualized CR, and (4) integrated therapist-directed CR combined with cognitive-behavioral psychotherapy (CBT). Treatment dosage was constant (10 h/wk) for intervention arms 2 to 4. Measures: Paced Auditory Serial Addition Test (PASAT); Symptom Checklist-90 Revised (SCL-90-R); Key Behaviors Change Inventory (KBCI). Results: No differences were noted between treatment arms on demographics, injury-related characteristics, or psychiatric comorbidity apart from education, with participants assigned to the computer arm having less education. Using mixed-model analysis of variance, all 4 treatment groups showed a significant improvement over time on the 3 primary outcome measures. Treatment groups showed equivalent improvement on the PASAT. The therapist-directed CR and integrated CR treatment groups had better KBCI outcomes compared with the psychoeducation group. Improvements on primary outcome measures during treatment were maintained at follow-up with no differences among arms. Conclusions: Both therapist-directed CR and integrated CR with CBT reduced functional cognitive symptoms in service members after mTBI beyond psychoeducation and medical management alone.