Cognitive rehabilitation for people with brain injury due to trauma to help them return to work

Background

Traumatic brain injuries (head injuries) are becoming increasingly common, and their impact on people's lives can be devastating. Depending on which part of the brain is injured and to what extent, impairments could be in physical functions such as walking, and use of hands and legs, or in mental functions (also known as 'cognitive functions'). Problems with mental functions can be related to memory, understanding language, using appropriate words to express oneself, analyzing options in a situation and making appropriate decisions . Problems with mental functions could lead to difficulty in 'occupational activities', a term that refers to employment, pursuing education and managing daily routines. Limitations in these activities could lead to a poor quality of life and withdrawal from social life.

'Cognitive rehabilitation' is the term used to refer to the training given to people with brain injury to address and improve the specific mental abilities that are impaired. This is usually done to improve return to work, independence in managing daily routines, and quality of life.

Review question

Does cognitive rehabilitation for people with traumatic brain injury improve their return to work, independence in daily activities, community integration and quality of life?

Study characteristics

We included nine studies with 790 participants. Seven of the studies were conducted in the US, and one each in Australia and China. Follow-up (monitoring) duration in the studies ranged between two weeks and two years.

Key findings

Cognitive rehabilitation compared to no treatment

There was insufficient evidence to conclude that cognitive rehabilitation, as compared to no other treatment, led to better return to work, community integration or quality of life in adults with traumatic brain injury. We judged the quality of this evidence as low or very low because of poor reporting of both the methods used and the results.

Cognitive rehabilitation compared to other conventional rehabilitation

There was inadequate evidence to conclude that adults with traumatic brain injury who received cognitive rehabilitation had better return to work, independence in daily living, community integration or quality of life when compared to adults who received conventional rehabilitation. We judged the quality of evidence for these outcomes to vary between moderate and very-low because of poor reporting of the methods used, different types of 'conventional' treatment and imprecise results.

Home-based cognitive rehabilitation training compared to hospital-based training

In one study on active military personnel, those who received a home programme for cognitive rehabilitation training had similar return to work when compared to those who received cognitive rehabilitation training in a hospital. We judged this evidence to be of moderate quality due to imprecise results.

Different types of cognitive rehabilitation compared against each other

One study compared trial-and-error type cognitive rehabilitation (cognitive didactic) to another type of cognitive rehabilitation that provided cues to avoid errors (functional-experiential) for veterans or active military personnel with traumatic brain injury. The study found no evidence to suggest one type of cognitive rehabilitation was better than the other in improving return to work or the ability to live independently. We judged the quality of evidence to be of moderate (return to work) and low quality (ability to live independently) because of imprecise results.

None of the studies reported information about harms from cognitive rehabilitation.

Authors' conclusions: 

There is insufficient good-quality evidence to support the role of cognitive rehabilitation when compared to no intervention or conventional rehabilitation in improving return to work, independence in ADL, community integration or quality of life in adults with TBI. There is moderate-quality evidence that cognitive rehabilitation provided as a home programme is similar to hospital-based cognitive rehabilitation in improving return to work status among active duty military personnel with moderate-to-severe TBI. Moderate-quality evidence suggests that one cognitive rehabilitation strategy (cognitive didactic) is no better than another (functional experiential) in achieving return to work in veterans or military personnel with TBI.

Read the full abstract...
Background: 

Cognitive impairment in people with traumatic brain injury (TBI) could affect multiple facets of their daily functioning. Cognitive rehabilitation brings about clinically significant improvement in certain cognitive skills. However, it is uncertain if these improved cognitive skills lead to betterments in other key aspects of daily living. We evaluated whether cognitive rehabilitation for people with TBI improves return to work, independence in daily activities, community integration and quality of life.

Objectives: 

To evaluate the effects of cognitive rehabilitation on return to work, independence in daily activities, community integration (occupational outcomes) and quality of life in people with traumatic brain injury, and to determine which cognitive rehabilitation strategy better achieves these outcomes.

Search strategy: 

We searched CENTRAL (the Cochrane Library; 2017, Issue 3), MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), and clinical trials registries up to 30 March 2017.

Selection criteria: 

We identified all available randomized controlled trials of cognitive rehabilitation compared with any other non-pharmacological intervention for people with TBI. We included studies that reported at least one outcome related to : return to work, independence in activities of daily living (ADL), community integration and quality of life.

Data collection and analysis: 

Two review authors independently selected trials. We used standard methodological procedures expected by Cochrane. We evaluated heterogeneity among the included studies and performed meta-analysis only when we could include more than one study in a comparison. We used the online computer programme GRADEpro to assess the quality of evidence, and generate 'Summary of findings' tables.

Main results: 

We included nine studies with 790 participants. Three trials (160 participants) compared cognitive rehabilitation versus no treatment, four trials (144 participants) compared cognitive rehabilitation versus conventional treatment, one trial (120 participants) compared hospital-based cognitive rehabilitation versus home programme and one trial (366 participants) compared one cognitive strategy versus another. Among the included studies, we judged three to be of low risk of bias.

There was no difference between cognitive rehabilitation and no intervention in return to work (risk ratio (RR) 1.80, 95% confidence interval (CI) 0.74 to 4.39, 1 study; very low-quality evidence). There was no difference between biweekly cognitive rehabilitation for eight weeks and no treatment in community integration (Sydney Psychosocial Reintegration Scale): mean difference (MD) -2.90, 95% CI -12.57 to 6.77, 1 study; low-quality evidence). There was no difference in quality of life between cognitive rehabilitation and no intervention immediately following the 12-week intervention(MD 0.30, 95% CI -0.18 to 0.78, 1 study; low-quality evidence). No study reported effects on independence in ADL.

There was no difference between cognitive rehabilitation and conventional treatment in return to work status at six months' follow-up in one study (RR 1.43, 95% CI 0.87 to 2.33; low-quality evidence); independence in ADL at three to four weeks' follow-up in two studies (standardized mean difference (SMD) -0.01, 95% CI -0.62 to 0.61; very low-quality evidence); community integration at three weeks' to six months' follow-up in three studies (Community Integration Questionnaire: MD 0.05, 95% CI -1.51 to 1.62; low-quality evidence) and quality of life at six months' follow-up in one study (Perceived Quality of Life scale: MD 6.50, 95% CI -2.57 to 15.57; moderate-quality evidence).

For active duty military personnel with moderate-to-severe closed head injury, there was no difference between eight weeks of cognitive rehabilitation administered as a home programme and hospital-based cognitive rehabilitation in achieving return to work at one year' follow-up in one study (RR 0.95, 95% CI 0.85 to 1.05; moderate-quality evidence). The study did not report effects on independence in ADL, community integration or quality of life.

There was no difference between one cognitive rehabilitation strategy (cognitive didactic) and another (functional experiential) for adult veterans or active duty military service personnel with moderate-to-severe TBI (one study with 366 participants and one year' follow-up) on return to work (RR 1.10, 95% CI 0.83 to 1.46; moderate-quality evidence), or on independence in ADL (RR 0.90, 95% CI 0.75 to 1.08; low-quality evidence). The study did not report effects on community integration or quality of life.

None of the studies reported adverse effects of cognitive rehabilitation.

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