National Report Points to CRT Effectiveness for TBI Cognitive rehabilitation treatment (CRT) should continue to be used to help patients with traumatic brain injury (TBI), but more research is needed to determine exactly what treatments will help which patients, according to the speech-language pathologist on an Institute of Medicine (IOM) committee that reviewed the evidence base. “Clinicians should ... Features
Free
Features  |   November 01, 2011
National Report Points to CRT Effectiveness for TBI
Author Notes
  • Carol Polovoy, assistant managing editor of The ASHA Leader , can be reached at cpolovoy@asha.org.
    Carol Polovoy, assistant managing editor of The ASHA Leader , can be reached at cpolovoy@asha.org.×
Article Information
Attention, Memory & Executive Functions / Traumatic Brain Injury / Features
Features   |   November 01, 2011
National Report Points to CRT Effectiveness for TBI
The ASHA Leader, November 2011, Vol. 16, 4. doi:10.1044/leader.FTR4.16152011.4
The ASHA Leader, November 2011, Vol. 16, 4. doi:10.1044/leader.FTR4.16152011.4
Cognitive rehabilitation treatment (CRT) should continue to be used to help patients with traumatic brain injury (TBI), but more research is needed to determine exactly what treatments will help which patients, according to the speech-language pathologist on an Institute of Medicine (IOM) committee that reviewed the evidence base.
“Clinicians should not conclude from the study that cognitive rehabilitation treatment is not effective,” said ASHA member Mary Kennedy, associate professor of speech-language pathology at the University of Minnesota. “The committee report clearly states that limited evidence does not indicate limited effectiveness and that ’the limitations of the evidence do not rule out meaningful benefit.’”
The October report also states that “the committee supports the ongoing clinical application of CRT interventions for individuals with cognitive and behavioral deficits due to TBI” and outlines a comprehensive research agenda to determine efficacy and effectiveness.
Study Purpose
The IOM study was commissioned by the U.S. Department of Defense (DoD), which is looking for ways to deal with the rising incidence of TBI among service members returning from the conflicts in Iraq and Afghanistan. Under current policy, CRT is not covered by TRICARE, the health insurance program for all service members and their families—although individual speech-language services are covered.
Current policy is based on a 2009 evidence review that found insufficient evidence that CRT is effective. That review (known as the ECRI Institute report), Kennedy said, was later criticized for its design; its strict criteria (including only randomized controlled trials) excluded much of the published literature on CRT, and examined only 18 studies.
The IOM study used broader criteria, yielding 90 studies in which the majority of the participants had a TBI, and reached a very different conclusion: There is benefit from some forms of CRT for TBI, but evidence is insufficient to develop general guidelines about which treatments work best for particular patients.
Methodology and Results
The IOM committee spent seven months reviewing the research on CRT effectiveness. In keeping with DoD parameters, the review was limited to studies that examined treatments to remediate attention, executive functions (problem solving), language and communication, and memory deficits, as well as comprehensive CRT and the use of telehealth service delivery. The studies involved participants with mild, moderate, and severe TBI across acute, subacute, and chronic recovery phases. Treatment approaches were compensatory (internal or external), restorative, or a mixture.
The review of 90 studies that met these criteria found “modest” evidence of effectiveness in three narrowly defined categories:
  • Immediate treatment benefit for language and social communication in patients with moderate–severe TBI in the chronic recovery phase (e.g., participants in small outpatient social skills groups showed immediate improvement in individualized targeted goal areas).

  • Immediate treatment benefit for internal compensatory strategies for memory in moderate–severe TBI in the chronic recovery phase (e.g., scores improved on standard memory tests in which strategies such as mnemonics were likely used).

  • Immediate treatment benefit for external compensatory strategies for memory in moderate–severe TBI in the chronic recovery phase (e.g., the use of diaries, notebooks, and other devices reduced the number of memory failures, with improved patient satisfaction).

In other categories, evidence was “limited” or “none or not informative” (because the intervention had not been studied or the studies were limited or flawed).
In other words, Kennedy said, “The report found a ’modest’ level of evidence of effectiveness for memory and for language and social communication, but clinicians should know that other types of CRT may be effective for individual patients, despite insufficient evidence in this particular review with these particular parameters.”
Clinical and Research Implications
Reports from IOM, the health arm of the National Academy of Sciences, are viewed by the medical community as an unbiased source of high-level expertise, Kennedy said. SLPs can use the report to educate physicians about CRT and the domains where the evidence is modest, limited, or not available.
The report does not, however, offer practice guidelines. Kennedy suggests other resources, including the Academy of Neurological Communication Disorders and Sciences and articles by Keith Cicerone and colleagues (see “Resources”). These sources used less strict criteria in study selection and had a broader base from which to create practice recommendations.
The committee’s roadmap for future research calls for a number of critical improvements in studies that examine CRT effectiveness: standard definitions for TBI-related impairments, uniform outcome measures, and specific methods of intervention delivery.
“Studies need to describe CRT in detail, so that reviewers know exactly, for example, what treatment was provided, in what dose, and for how long; how much the patient practiced; and how patients were instructed,” Kennedy said. “Larger sample sizes and volume of data are required, particularly to identify which patients benefit most from which treatment.”
Future Directions
The study design underscores that clinicians should pay particular attention to the focus of CRT for individual patients. “The committee used the World Health Organization’s International Classification of Functioning, Disability, and Health framework in its review because DoD asked for patient-centered outcome measures,” Kennedy explained. “These guidelines highlight that CRT and other treatments must have a rationale for eventual practical, functional, positive communication outcomes.”
These measurable outcomes go beyond assessment scores. “Gains in assessment scores don’t necessarily translate into meaningful benefits in a person’s life. For example, if a college student receives CRT to help him remember what he reads, it’s not enough if he improves on memory assessments. The treatment goal needs to be improved grades on his exams so that he passes his classes, earns a degree, and finds a job.”
In general, the message for clinicians is clear, Kennedy said: “CRT can be an effective treatment for TBI, and should be used even as research continues to advance our understanding of the precise ingredients that result in real change.”
0 Comments
Submit a Comment
Submit A Comment
Name
Comment Title
Comment


This feature is available to Subscribers Only
Sign In or Create an Account ×
FROM THIS ISSUE
November 2011
Volume 16, Issue 15