Cognitive rehabilitation for traumatic brain injury - A randomized trial

Context Traumatic brain injury (TBI) is a principal cause of death and disa bility in young adults. Rehabilitation for TBI has not received the same le vel of scientific scrutiny for efficacy and cost-efficiency that is expecte d in other medical fields. Objective To evaluate the efficacy of inpatient cognitive rehabilitation fo r patients with TBI. Design and Setting Single-center, parallel-group, randomized trial conducte d from January 1992 through February 1997 at a US military medical referral center. Patients One hundred twenty active-duty military personnel who had sustaine d a moderate-to-severe closed head injury, manifested by a Glasgow Coma Sca le score of 13 or less, or posttraumatic amnesia lasting at least 24 hours, or focal cerebral contusion or hemorrhage on computed tomography or magnet ic resonance imaging. Interventions Patients were randomly assigned to an intensive, standardized , 8-week, in-hospital cognitive rehabilitation program (n=67) or a limited home rehabilitation program with weekly telephone support from a psychiatri c nurse (n=53). Main Outcome Measures Return to gainful employment and fitness for military duty at 1-year follow-up, compared by intervention group. Results At 1-year follow-up, there was no significant difference between pa tients who had received the intensive in-hospital cognitive rehabilitation program vs the limited home rehabilitation program in return to employment (90% vs 94%, respectively; P=.51; difference, 4% [95% confidence interval { CI}, -5% to 14%]) or fitness for duty (73% vs 66%,respectively; P=.43; diff erence, 7% [95% CI, -10% to 24%]). There also were no significant differenc es in cognitive, behavioral, or quality-of-life measures. In a post-hoc sub set analysis of patients who were unconscious for more than 1 hour (n=75) f ollowing TBI, the in-hospital group had a greater return-to-duty rate (80% vs 58%; P=.05). Conclusions In this study, the overall benefit of in-hospital cognitive reh abilitation for patients with moderate-to-severe TBI was similar to that of home rehabilitation. These findings emphasize the importance of conducting randomized trials to evaluate TBI rehabilitation interventions.