Post-concussion symptoms improve significantly when using several forms of therapist-led rehabilitation, according to the first large-scale study of mild traumatic brain injury on active-duty personnel.
The study by researchers from several institutions, including Brooke Army Medical Center in San Antonio, looked at 126 servicemembers three to 24 months after they had concussions.
Treatments for severe traumatic brain injury, or TBI, have been studied extensively since the beginning of the Afghanistan and Iraq wars in the early 2000s. But effective treatments for persistent concussion symptoms, or mild TBI, among active military members has lagged, even as the injury has gained notoriety from media reports about athletes taking hits to the head.
About six years ago, Congress mandated further study of cognitive rehabilitation for servicemembers with post-concussion symptoms, said Dr. Amy Bowles, a co-author of the study and a brain-injury rehabilitation physician at Brooke Medical Center.
"The reason Congress wanted this studied is that there's not really a lot of great evidence to show what would help these folks," she said. "There's a lot of evidence that shows most people who have concussions get better, but for people having persistent, ongoing complaints, it's harder to figure out how to help them."
The cause and precise descriptions of symptoms of chronic concussion are still being debated.
Patients have described dizziness, fatigue, deficient memory, lack of concentration, headache and insomnia.
Cognitive rehab works on strategies to help patients function better with day-to-day tasks, such as skills to aid memory, attention span, organization and planning.
Cognitive rehab is "a traditional therapy that's done in a rehabilitation context with people with strokes, people with traumatic brain injury," said Dr. Douglas Cooper, a neuropsychologist and lead author of the study.
Other forms of treatment are medication and psychotherapy, he said.
The study divided the 126 servicemembers into four groups.
The first group received the "standard of care," during which patients see a healthcare provider every three weeks and receive "psychoeducation" adapted for servicemembers who have experienced chronic concussion symptoms, Cooper said.
The other groups received the same standard of care but were also given 60 hours of cognitive rehab over a six-week period.
Group two got that rehab exclusively by using a computer program at the medical center. No live therapist was involved, but the rehab was proctored by a staff member.
The third group received cognitive rehab that was led by a therapist, meaning they met with an occupational therapist or speech and language pathologist who worked one on one with patients on various techniques to compensate and restore cognitive ability, Cooper said.
The fourth group integrated the core features of cognitive rehab but added other elements of behavioral health intervention and psychotherapy intended to manage post-concussion symptoms.
The researchers measured the outcomes in three ways. First was performance on a neuropsychological test that formally measures things such as attention and ability to process tasks.
Second, they looked at the level of "psychological distress" a patient was experiencing, an important measurement because a high percentage of servicemembers who've had concussions are also experiencing psychiatric conditions such as post-traumatic stress syndrome and depression, Cooper said. In general, as cognitive ability increases, psychological distress decreases, he said.
The third measure -- functional cognitive ability -- was the outcome of most practical use to medical professionals involved in brain rehab, Cooper said. Examples of impaired cognitive ability are: "I made mistakes in the community and missed my appointment. I always misplace items in my house. Or my wife tells me to do things and I forget them," Cooper said.
He said the study's primary and most important finding was that the patients in groups three and four -- both of which had therapist-led treatment -- experienced better cognitive functioning.
Although the study did not examine why that was so, the researchers believe the development of rapport between patient and therapist plays a part in the recovery, Cooper said.
The researchers also found that 30 percent to 50 percent of patients in the two therapist-led groups reported lower levels of psychological distress.
The researchers chose to set up the study without a "pure" sample group of patients whose only medical complaint was a concussion, Bowles said.
"[T]hat's not really going to help in my clinical practice because I see almost nobody who has concussion and nothing else," she said.
Cooper pushed back against the general mood of despair about post-concussion treatment.
"Our hope is that this will serve as the foundation that there are treatments out there."