Cognitive Rehabilitation for Mild Traumatic Brain Injury

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Cognitive Rehabilitation for Mild Traumatic Brain Injury


Mild traumatic brain injury (mTBI), also known as concussion, is one of the invisible injuries of the current conflicts in Afghanistan and Iraq. The true incidence of military mTBI is unknown. This is similar to the civilian sector as some individuals with mTBI do not seek medical care or are not properly diagnosed. However, of the combat exposed U.S. military personnel who have served in Afghanistan and Iraq since 2001, there is a 15%-22% mTBI incidence rate by self report (Hoge et al., 2008, Terrio et al., 2009).
In the mTBI literature, it is reported that a substantial majority of civilian patients with mTBI (75-90%) have symptoms that are transient and self-limiting, with apparent full recovery occurring within minutes to several weeks following injury (Levin et al., 1997). However, approximately 5%-15% of persons with mTBI do not show the expected rapid and uneventful recovery and have persistent symptoms and/or functional limitations (Iverson et al., 2006; Ruff et al., 1996). Given the incidence of mTBI in the military, and the suspected high frequency of repeated mTBI, this percentage may represent a substantial number of warriors.
Differences exist between military and civilian populations regarding mTBI. There is no evidence to determine if the recovery trajectory for mTBI sustained in combat replicates that of the civilian cohort. Additionally, the high incidence of blast-related mTBI as well as the psychologically traumatic component of the source of the wartime injuries further complicates comparisons to civilians. Thus, it is possible that the number of patients with persistent symptoms is greater than 5% of all those sustaining mTBI in the military population.
There is strong consensus in the literature that persistent mTBI symptoms include cognitive and
emotional sequelae that can result in significant functional impairment and disability. Cognitive
rehabilitation is a well-accepted and common component of comprehensive rehabilitation for persons with moderate and severe TBI (Cicerone et al, 2005). A parallel situation does not exist in the area of mTBI. Clinical management for patients with mTBI symptoms typically has focused on prevention of "excess disability" through education to promote expectations of rapid and complete recovery; providing a "timeout" period to permit recuperation; avoidance of dangerous activities that could lead to secondary injury; and, using aggressive medical treatment to ameliorate symptoms (e.g., headache, sleep disturbance, dizziness, etc.) that can interfere with optimal recovery (Comper et al., 2005; DVBIC/BIAA educational references). However, clinicians currently face an increasingly large population of Wounded Warriors who have sustained mTBI and go on to develop chronic symptoms and functional limitations, including cognitive impairment.