1. Traumatic Brain Injury (TBI) in the Military - Cognitive Rehabilitation
The views expressed in this presentation are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

2. Cognitive Rehabilitation
Other terms for Cognitive Rehabilitation
Neurorehabilitation
Neuropsychological rehabilitation
Cognitive remediation
Cognitive retraining
Speech Pathology
Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and Defense and Veterans Brain Injury Center consensus conference

3. Cog Rehab Goal
To provide guidance regarding cognitive rehabilitation of chronic post-concussive symptoms in service members and veterans receiving treatment within military medical settings
Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and Defense and Veterans Brain Injury Center cognitive rehabilitation for mild traumatic brain injury summary of clinical recommendations
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

4. Recommendation
If SM has three months or more post concussive injury and persistent cognitive symptoms
1. Assessment 2. Interventions 3. Outcome measures 4. Program implementation.
If SM or veteran is 3 months or more post-concussive injury and has persistent cognitive symptoms.
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

5. Assessment: Part 1 – Initial Evaluation Purpose
To determine if the individual has a history of mild traumatic brain injury (mTBI) (also known as concussion) with persistent cognitive symptoms or signs of cognitive impairment and to determine if any co-morbidities exist that may affect cognitive function
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

6. Initial Evaluation Performed by a TBI-experienced provider.
Referral can be made by any provider.
Reasons for referral: cognitive symptoms observed by the provider or reported by the patient, family, or leadership.
SM displays evidence of cognitive dysfunction in daily social or occupational functioning.
Any suspicion of mild TBI with persistent cognitive symptoms warrants further cognitive evaluation
Primary Care Manager (PCM) is also familiar with other deployment related health conditions.
Even if the SM does not report cognitive difficulties
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

7. Assessment: Part 2 – Comprehensive Cognitive Evaluation Purpose
To determine:
Primary factor(s) contributing to symptom
2) Cognitive deficits
3) Need for cognitive rehabilitation
4) Type of rehabilitation needed
5) Short- and Long-term goals.
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

8. Comprehensive Cognitive Evaluation
Performed by an interdisciplinary team: neuropsychologist, occupational therapist, speech-language pathologist.
Includes a comprehensive neurological evaluation performed by a neurologist or physician
Includes a review of the medical records, education level, GT score, etc.
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

9. Intervention
Based on a holistic approach and include individual as well as group therapies
Target attention, memory, executive functioning and social pragmatics
these are the most common cognitive domains affected by TBI.
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

10. Outcome Measures To advance the published science
Administrative performance metrics
Pre- and post-assessment differences
Pre- and post-functional differences
Moderating variables
Discharge criteria
Consumer satisfaction
Aggregate program outcome data
Evidenced-based medicine has become the cornerstone to informing quality care and identifying advances in therapies
number of patients seen; number of patients referred for medical appointments; length of stay in the program, both in terms of treatment duration and daily intensity; length of time the patient is on profile or limited duty; and, return to duty/return to work rates
not be limited to formal neurocognitive evaluation, but include and emphasize assessment of symptom status and functional status as well
refers to changes in the ability of an individual to function within important areas of daily life - the goals should be objective, measurable, and time-based; that they should be generated by the treatment team with active involvement from the patient; and that they should be functional, based on the patient's lifestyle and needs
pain; comorbid physical injuries; type of injury; age, rank, job duties and gender of patient; psychological health and substance abuse; number of deployments; date(s) of injury(s); trauma history to include life events prior to entering the military; family and broader psychosocial support system; aptitude/education; duty status; prior neurologic illnesses or injuries; motivation for retention; expectations of recovery; years of service; and, possible sources of secondary gain.
accomplishment of the goals of treatment; plateauing of improvement and/or failure to improve
useful for identifying quality improvement possibilities within a program and also are extremely important for identifying whether the program improves the quality of life and functional outcome for the patient and family
overlap with the administrative evaluation of the program - type and number of service providers; range of services readily available; consistent and well-defined admission criteria; consistent and well-defined discharge criteria; clear description of the program and interventions; sufficient documentation to permit reasonable consistency of treatment across providers; and, clear documentation to permit audit of patient care against these definitions.
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

11. Program Implementation
Assessment prior to treatment
Identification of individualized cognitive rehabilitation goals that target symptom reduction through restoration and compensation functional improvements/gains, and a therapeutic alliance
Development of an interdisciplinary individualized treatment plan
Periodic cognitive reassessment and review of goals
Development of a well defined discharge plan
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

12. Potential Team Members
Cognitive Rehabilitation
for the SM
Neuro-psychology
Mental Health
Speech Pathology
Occupational Therapy
Audiologist
Case manager
Neurologist
Neuropsychologist
Occupational therapist
Ophthalmologist
Physical therapist
Primary Care Manager
Psychiatrist
Speech-Language Pathologist
Family members are also a vital part of the cognitive rehab process as we invite them into individual as well as group sessions to provide education and instruction to better support their loved one. Just like the sacrifices of war impact not only the SM but also their families, participation in the road to recovery from a concussion will involve care from family members.
Cognitive Rehabilitation for Military Personnel with Mild Traumatic Brain Injury and Chronic Post-Concussional Disorder: Results of April 2009 Consensus Conference.
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

13. Comorbidity of Symptoms
PTSD or Acute Stress Reaction
Mild TBI or Post Concussive Syndrome
Stress symptoms Emotional numbing
Avoidance
Intrusive symptoms
Insomnia
Impaired Memory
Poor concentration
Depression
Anxiety
Irritability
Headache
Dizziness
Fatigue
Noise/Light intolerance
Symptoms attributable to other factors: demographic, psychosocial, medical, situational. Other reasons for persisting symptoms may include limited cognitive reserve, expectation, somatoform disorder, malingering
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.
Post-Traumatic Stress Disorder and TBI in Returning Service Members & Veterans, Collins, 2009.

14. Cognitive Symptoms
Memory
Attention
Processing
Speed
Communication
Executive Function
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

15. Memory Memory Long-Term Memory Explicit (Declarative)
Episodic Memory (Events)
Semantic Memory (Facts)
Implicit (Non-declarative)
Procedural Memory
Classical Conditioning
Short-Term (Working) Memory
Different types of memory can be used in therapy to teach strategies to patients. For instance, using active rehearsal or repetition in procedural memory to reinforce recall (i.e. shrine, creating a routine, develop organization)
Key Elements of Functional Memory for Those with Brain Injury: Linking Neuroscience to Clinical Practice, Burns, 2010.
Key Elements of Functional Memory for Those with Brain Injury: Linking Neuroscience to Clinical Practice, Burns, 2010.

16. Executive Functions Multi-tasking Problem Solving Planning
Organization
Multi-tasking
Planning
Problem Solving
Self-Monitoring
Intervention for Executive Functions after Traumatic Brain Injury: A Systematic Review, Meta-Analysis and Clinical Recommendations, Kennedy et al, 2008.
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

17. Attention
Attention
Sustained
Divided
Alternating
Selective
Evaluation of Attention Process Training and Brain Injury Education in Persons with Acquired Brain Injury, Sohlberg et al, 2000.
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

18. Speed of Processing
Processing time
Response time
Listening & Distractions
Archives of Clinical Neuropsychology, Tombaugh et al, 2007.
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

19. Communication
Oral Expression
Reading Comprehension
Written Expression
Auditory comprehension
Social pragmatics
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.
Evidence-Based Cognitive Rehabilitation: Recommendations for Clinical Practice, Cicerone et al, 2000.

20. Memory Aids External Aids Internal Aids Alarms Timers Notebooks
Datebooks
Calendars
Answering machines
Electronic organizers
Tape recorders
Watches with beepers
Medication dispensers
Highlighters
Journals
Computers
Repetition
Creating rhymes
Making associations
First-letter cues
Chunking
Mnemonics
Visualization
Categorization
Active observation
Evidence-Based Practice for the Use of External Aids as a Memory Compensation Technique, Sohlberg et al, 2007.
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

21. mTBI Cognitive-Communication Group
Offer support through group discussion, counseling, and therapeutic activities designed to maximize compensatory and facilitative strategies.
Invite guest speakers on topics of interest (e.g., sleep, nutrition, executive functions, meditation/relaxation, coping strategies, transition to school/work, community resources) and involve interdisciplinary care.
Group activities: focus on memory, critical thinking, problem solving, attention, organization, planning community outings.
Members include SB TBI group via VTC – offer peer support.
Provides supportive context and unit cohesion in the military culture.
Focus on IDT and the inviting family involvement in SM ‘s care.
Cognitive Rehabilitation for Military Personnel with Mild Traumatic Brain Injury and Chronic Post-Concussional Disorder: Results of April 2009 Consensus Conference, Helmick et al, 2010.
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

22. mTBI Cognitive-Communication Group
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

23. mTBI Cognitive-Communication Group
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

24. TBI Resources Brainline (DVBIC-sponsored): www.brainline.org
Brain Injury Association of America:
Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury:
Defense and Veterans Brain Injury Center:
CDC’s National Center for Injury Prevention and Control:
National Institute of Neurological Disorders and Stroke (NINDS) Traumatic Brain Injury Information Page:
Traumatic Brain Injury National Resource Center:
VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.