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New clinical recommendations on cognitive rehabilitation for TBI released

Dr. Gregory Johnson (right), Tripler Concussion Clinic medical director, has Army Spc. Andrew Karamatic, Department of Medicine combat medic, follow his finger with his eyes during a neurologic exam at Tripler Army Medical Center, Honolulu. (U.S. Air Force photo by Staff Sgt. Christopher Hubenthal) Dr. Gregory Johnson (right), Tripler Concussion Clinic medical director, has Army Spc. Andrew Karamatic, Department of Medicine combat medic, follow his finger with his eyes during a neurologic exam at Tripler Army Medical Center, Honolulu. (U.S. Air Force photo by Staff Sgt. Christopher Hubenthal)

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The Defense and Veterans Brain Injury Center, the Defense Health Agency’s traumatic brain injury center of excellence, recently released the “Cognitive Rehabilitation for Service Members and Veterans Following Mild to Moderate Traumatic Brain Injury Clinical Recommendations.”

These recommendations build on the 2016 VA/DoD Clinical Practice Guidelines on Concussion/Mild Traumatic Brain Injury. While there has been new research on cognitive rehabilitation over the past few years, clinical practice varies widely in the MHS and throughout the VA.

To diminish this variation, DVBIC established subject matter expert work groups from the DoD, VA, civilian health care, and academia; nearly 40 experts were involved. Many of these individuals had previously been involved in developing clinical guidelines in professional settings such as the National Academies of Sciences, Engineering, and Medicine.

Drawing on both published literature and their own expertise, the working group developed a consensus opinion in August 2017 that helped shape how the specific recommendations were developed. The new DVBIC recommendations provide resources to enable consistent care delivery across the Military Health System, Veterans Health Administration, and civilian providers.

Cognitive rehabilitation focuses on improving thinking and communication skills such as attention, problem solving, planning, and memory. More generally, it provides strategies to target cognitive difficulties in daily life. For example, an individual having difficulty keeping track of appointments would work with the cognitive rehabilitation provider to develop and rehearse specific strategies, like the use of a smartphone calendar app and reminder, to track and successfully attend appointments. These types of strategies can help improve the daily functioning and independence of TBI patients. The new recommendations offer providers detailed guidance for treating service members and veterans with mild to moderate TBI and cognitive dysfunction as they move through each phase of recovery.

"These clinical recommendations are a unique contribution to the field of cognitive rehabilitation,” said Navy Capt. Scott Pyne, DVBIC division chief. “They provide an integrated source for clinicians: detailed, evidence-informed clinical guidance and links to an array of DoD/VA cognitive rehabilitation resources and tools that support state-of-the-science clinical care."

Approximately 82 percent of brain injury cases are considered mild TBIs, otherwise known as concussions. Among those who experience chronic effects from TBIs, cognitive impairment is the most persistent and disabling because it can directly affect return to duty or employment and can have a broad impact on daily living and quality of life. To address these challenges, the new recommendations outline unique considerations, including modifications, specific interventions, strategies, and best practices when providing treatment to this target population.

When developing the recommendations, the working group sought to address the needs of the end-user clinicians by incorporating their feedback and perspectives. As explained by working group member Dr. Wayne Gordon, Chief of Rehabilitation and Neuropsychology Service at Mount Sinai Hospital in New York City, cognitive rehabilitation should not be a “canned intervention” but rather “providers need to be flexible in their approach,” given the nuanced nature of how a TBI patient presents. The new recommendations allow providers to tailor their approach to the specific recovery needs of service members and veterans, which are often different from those of the general population.

The recommendations are available to download and print now via dvbic.dcoe.mil. To further support the clinical recommendations, an interactive web tool has been published on the DVBIC website. The tool outlines the clinical content and provides links to resources for cognitive rehabilitation providers, such as occupational therapists, speech-language pathologists, neuropsychologists, and other rehabilitation providers.

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