Cognitive rehabilitation for traumatic brain injury: A randomized trial

Context: Traumatic brain injury (TBI) is a principal cause of death and disability in young adults. Rehabilitation for TBI has not received the same level of scientific scrutiny for efficacy and cost-efficiency that is expected in other medical fields. Objective: To evaluate the efficacy of inpatient cognitive rehabilitation for patients with TBI. Design and Setting: Single-center, parallel-group, randomized trial conducted from January 1992 through February 1997 at a US military medical referral center. Patients: One hundred twenty active-duty military personnel who had sustained a moderate- to-severe closed head injury, manifested by a Glasgow Coma Scale score of 13 or less, or posttraumatic amnesia lasting at least 24 hours, or focal cerebral contusion or hemorrhage on computed tomography or magnetic 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 psychiatric 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 patients 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; difference, 7% [95% CI, -10% to 24%]). There also were no significant differences in cognitive, behavioral, or quality-of-life measures. In a post-hoc subset analysis of patients who were unconscious for more than 1 hour (n = 75) following 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 rehabilitation 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.