NeuroRehabilitation 26 (2010) 239–255 239

DOI 10.3233/NRE-2010-0560
IOS Press

Cognitive rehabilitation for military personnel

with mild traumatic brain injury and chronic
post-concussional disorder: Results of April
2009 consensus conference
Katherine Helmick and members of Consensus Conference (see Appendix B)
Defense Centers of Excellence for Psychological, Health and Traumatic Brain Injury, 1335 East West Highway, 9th
Floor, Suite 400, Silver Spring, MD 20910, USA
E-mail: Katherine.Helmick@tma.osd.mil

Abstract. A consensus conference on cognitive rehabilitation for mild traumatic brain injury was conducted by the Defense
Centers of Excellence for Psychological Health and Traumatic Brain Injury and the Defense and Veterans Brain Injury Center.
Fifty military and civilian subject matter experts from a broad range of clinical and scientific disciplines developed clinical
guidance for the care of Service Members with persistent post-concussion cognitive symptoms three or more months post injury.
“Cognitive rehabilitation” was identified to be a broad group of diverse services. Specific services within this rubric were
identified as effective or not, and were evaluated both as single-services and as combined integrated cognitive rehabilitation
programs. Co-morbidities were acknowledged and addressed, but the conference and ensuing guidance focused primarily
upon treatment of cognitive impairment. Guidance regarding effective services addressed the areas of assessment, intervention,
outcome measurement, and treatment program implementation.

1. Introduction Iraq since 2001 report a 15%–22% mTBI incidence

The true incidence of military mild traumatic brain
injury (mTBI) is unknown. Many Warriors with mT-
BI do not seek medical care and thus have unrecog-
nized and unrecorded injuries. Alternately, many others
are identified through unwitnessed and unverified self-
report, using questionnaires administered months fol-
lowing suspected mTBI. Both approaches are plagued
by numerous potentially severe biases and are compli-
cated by the unknown prevalence of multiple mTBI and
overlapping co-morbid disorders [5,21,26,38].
While the precise incidence of mTBI in Op-
eration Enduring Freedom/Operation Iraqi Freedom
(OEF/OIF) remains difficult to determine, there is no
question that it is one of the most common injuries
sustained by our Warriors. Data from combat-exposed
U.S. military personnel returning from Afghanistan and
rate [25,63]. In response, military-based research and
clinical programs rapidly are developing and evolving,
and the “first generation” of these programs is starting
to reach the scientific literature [67].
TBI and mTBI long have been civilian health prob-
lems and have created a large and well-established TBI
rehabilitation literature [22]. The civilian literature is
not without its controversies, but it has had decades to
mature and to incorporate sophisticated methodologies
such as multi-site randomized controlled trials [67].
Civilian rehabilitation professionals also have devel-
oped decades of expertise in rehabilitating patients with
TBI and mTBI [9,44].
The purpose of the presently reported Consensus
Conference was to integrate military and civilian mT-
BI rehabilitation expertise to create guidance regard-
ing cognitive rehabilitation of chronic post-concussive

ISSN 1053-8135/10/$27.50  2010 – IOS Press and the authors. All rights reserved
240 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder
symptoms in military populations receiving treatment
within military medical settings. A key objective was to
acknowledge differences and similarities between mil-
itary and civilian mTBI populations, and between mil-
itary and civilian health care delivery systems. In sum,
the mission and overriding emphasis of the conference
was to generate guidance immediately relevant to mili-
tary health care systems, military health care providers,
and Wounded Warriors.
2. Methods
2.1. Target population
Conference attendees were instructed to focus upon
Service Members who have persistent cognitive symp-
toms three or more months post-concussion. While
it was understood that many of these patients would
have co-morbidities (e.g. psychological and emotion-
al issues, somatic symptoms, personality factors, etc.)
needing treatment, conference members were instruct-
ed to address the issues of where and how in the spec-
trum of care cognitive rehabilitation should be ap-
plied for this defined set of patients. These constraints
were known to be artificial for many patients, but the
complexity of the overall task appeared overwhelm-
ing should all of the multiple complicating factors be
considered simultaneously. It therefore was decided to
address a set of core issues and thereby increase the
probability of producing clear guidance. It was under-
stood from the outset that the present conference was a
“starting point” of an iterative process to create a clear
and firm foundation for adding subsequent layers of
complexity.
Preparation for the conference included a compre-
hensive search of the literature regarding the natural
history of symptom onset, duration, and resolution fol-
lowing mTBI. It was understood that as a similar liter-
ature base became available for military mTBI, reap-
praisal would be warranted. The substantial majority
of civilian patients with mTBI (75–90%) have symp-
toms that are transient and self-limiting, with appar-
ent full recovery occurring within minutes to several
weeks following injury [35]. However, approximately
5%–15% of persons with acute mTBI do not show the
expected rapid recovery and have persistent symptoms
and/or functional limitations [26,48]. There is strong
consensus in the literature that persistent mTBI symp-
toms include cognitive and emotional sequelae that can
result in significant functional impairment and disabil-
ity [62].
Cognitive rehabilitation is a well-accepted and com-
mon component of comprehensive rehabilitation for
persons with moderate and severe TBI [11], and in-
creasingly is used for persisting deficits following mT-
BI [22]. Clinical management of mTBI typically fo-
cuses on preventing “excess disability” through edu-
cation to promote expectations of rapid and complete
recovery; providing a “timeout” period to permit recu-
peration; avoidance of dangerous activities that could
lead to secondary injury; and, using appropriate medi-
cal treatment to ameliorate symptoms (e.g., headache,
sleep disturbance, dizziness, etc.) that can interfere
with optimal recovery ([13] www.dvbic.org). However,
the 5%–15% of mTBI with chronic symptoms and func-
tional limitations (admittedly an approximation based
on civilian studies) are an increasingly large population
of Wounded Warriors needing effective treatment.
2.2. Conference methodology
To address this need, the Defense Centers of Excel-
lence (DCoE) for Psychological Health and Traumatic
Brain Injury and the Defense and Veterans Brain Injury
Center (DVBIC) convened a two-day Cognitive Reha-
bilitation Consensus Conference on 27–28 April 2009
in Crystal City, Virginia and included 50 Subject Matter
Experts (SMEs) from the Department of Defense, the
Department of Veterans Affairs, civilian rehabilitation
centers, and academia. SMEs included persons with ex-
pertise in TBI for professions including nursing, neu-
rology, psychiatry, family practice, neuropsychology,
occupational therapy (OT), speech-language pathology
(SLP), and research, and included the authors of sever-
al prominent evidence-based reviews, efficacy studies,
and books used as references by neuropsychologists,
SLPs, and OTs. Military representatives were selected
by their respective Surgeons’ General offices. Repre-
sentatives from each of the Services as well as the Na-
tional Guard, Reserves, Special Operations, and Line
also participated. “Cognitive rehabilitation” in this doc-
ument is used synonymously with terms such as neu-
ropsychological rehabilitation, cognitive remediation
and cognitive retraining.
The 50 SMEs worked both as one large group and as
four smaller groups addressing the areas of assessment,
intervention, outcome measurement, and program im-
plementation. Since much of the evidence-based liter-
ature and clinical expertise had been developed within
the civilian health care system, the “program imple-
 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder
mentation” group had the specific task of developing
clinical service delivery methods suitable to military
health care systems.
While evidence-based practices were emphasized,
virtually all recent reviews of the field have noted their
paucity [10,11]. However, as is shown below, there
has been a recent acceleration of this type of evidence.
Unfortunately the time interval needed to successfully
plan, execute and report on high quality clinical trials
would not meet the clinical needs of service members
and veterans who need these services now. Thus, while
preference was given to evidence-based studies, clin-
ical expertise and expert consensus of necessity was
an essential ingredient of the ensuing guidance. More-
over, since anecdotal reports indicated that techniques
known to be ineffective were prevalent, the conference
also focused on evidence and on generating guidance
regarding “what not to do.”
3. Results
3.1. Assessment
Screening for cognitive rehabilitation is required to
determine eligibility and clinical indication for a pre-
treatment comprehensive assessment. Screening in the
primary care setting should be by a provider with TBI
experience who is also familiar with other deployment-
related health conditions (e.g. nurse, nurse practitioner
or a physician assistant), may occur in different set-
tings per situational opportunities, and should occur
less than 30 days following referral. In addition to a
positive screening, comprehensive assessment may be
initiated based on cognitive symptoms reported by the
family/community/line, or evidence of dysfunction in
the patient’s daily, social, or occupational functioning.
Initial screening should include a thorough intake
history to include a description of the injury event and
the duration of loss of consciousness or altered mental
status, confirmation of TBI diagnosis (HA Policy 07-
030 Traumatic Brain Injury: Definition and Reporting,
1 Oct 07, www.pdhealth.mil/TBI.asp), (Appendix A),
evaluation of ongoing symptoms [including comple-
tion of the Neurobehavioral Symptom Inventory (NSI),
Posttraumatic Stress Disorder Checklist – Military or
Civilian Version (PCL-M, PCL-C)] [4,15], a mental
health screening, and evaluation for acute and chronic
pain, sleep disorders and substance abuse. The follow-
ing potential scenarios may result (see Fig. 1):
241
1. Provider determines no cognitive symptoms are
present with or without TBI. Education and re-
assurance to both referring provider and patient
should occur.
2. Provider determines that there are no indications
of TBI but cognitive symptoms are present. The
provider should refer the patient back to the pri-
mary care provider for further evaluation of either
a medical or a mental health condition.
3. Provider determines that other co-morbidities or
other symptoms (i.e., depression, PTSD, chron-
ic pain, or substance abuse) are too severe for
the patient to undergo valid cognitive assessment.
An appropriate specialty clinic referral should be
placed and a case manager assigned.
a. If a patient is referred to a specialty clinic,
the patient should be re-evaluated for cognitive
assessment in 4 weeks in addition to receiving
case management follow-up. This will ensure
that these patients may still receive a cognitive
assessment and that they are not lost to follow-
up.
b. If the patient is referred to a specialty clinic and
all the cognitive symptoms resolve, the patient
should be followed monthly by telephone con-
sultation by the case manager to ensure that the
symptoms remain resolved for 6 months. If
possible, “face-to-face” interviews are recom-
mended if there is any uncertainty concerning
how the patient reports changes in symptoms.
4. Provider determines that the patient has symp-
tomatic mTBI and comprehensive cognitive as-
sessment is indicated.
Written communication regarding the outcome of the
patient’s screening for cognitive rehabilitation should
be sent to the patient’s primary care provider and the
referral source (if different) to ensure continuity of ef-
fective communication and treatment coordination.
Prior to cognitive assessment for cognitive rehabili-
tation, the patient must undergo a comprehensive neu-
rological examination. During this time, medical con-
ditions that may result in cognitive impairment should
be evaluated and treated. This examination also should
include a thorough review of the medical records to
look for prior cognitive, mood, or behavioral disorders,
or events that may have resulted in increased vulnera-
bility to same. This comprehensive neurological exam-
ination does not need to be completed by a neurologist,
but rather, by a physician with sufficient expertise and
knowledge in the examination as well as in the medi-
242 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder

Referral

Re-eval in 4
weeks

Intake Process

+/ - TBI No TBI + TB + TBI

No cognitive Cognitive symptoms Cognitive symptoms Cognitive
symptoms are present are present symptoms are
Severe co- present. No co-
morbidities are morbidities or co-
present morbidities are
controlled

Educate
referring Refer back to
provider primary care
Educate and provider for
reassure medical and * Case * Case
patient psychologica manager manager
evaluation assigned assigned

** Referral to specialty to
treat co-morbidity(s)
Refer back to
referring Neurological
provider Assessment

Reconsider for
cognitive
rehabilitation Cognitive
Assessment

TBI Cognitive
Rehabilitation

Fig. 1. Referral process.

 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder
Table 1
Assessment domains
– Attention
– Memory
– Processing Speed
– Executive Functioning
* reasoning and problem solving
* organizing, planning and self-monitoring
* emotional regulation
– Post-Traumatic Stress Disorder (PTSD) Screen
– Post-Concussive Syndrome (PCS) Symptom Rating
– Pain Screen
– Symptom Validity Test
– Substance Abuse Screen
– Depression Screen and Suicidality Assessment
cal work-up of cognitive symptoms. If no confounding
findings are noted, the patient should next receive a
comprehensive cognitive assessment.
While a comprehensive interdisciplinary team pro-
cess may not be available at all military treatment fa-
cilities (MTFs), it is essential that the cognitive assess-
ment consist of a thorough neurobehavioral and cog-
nitive evaluation using standardized performance and
self-report measures, including measures of effort. It
may be that only one or two disciplines are available
or it may be that assessment and intervention are com-
pleted by different providers. However, both the as-
sessment and intervention providers must be competent
in evaluating persons with known or suspected TBI,
and be capable of making appropriate differential diag-
noses in complicated cases. In all situations, regardless
of the necessary program structure, appointment of a
team leader with broad-based TBI knowledge is essen-
tial to assuring communication and coordination of the
treatment team.
A variety of neurobehavioral assessment tools and
approaches are available and no tool or approach is rec-
ommended over another. However, it is essential that
the domains specified by the American Academy of
Clinical Neuropsychology (AACN; see Table 1) should
be followed [1]. The assessment should identify and
describe strengths, deficits, and function in everyday
activities, and identify barriers to successful participa-
tion in rehabilitation [7].
It is critical for the team to determine the primary
factors contributing to symptoms (i.e., is mTBI the pri-
mary cause of the symptoms or is a co-morbidity such
as major depression considered the primary contribu-
tor?). Assessment should include measures of effort,
although suboptimal results should not produce auto-
matic disqualification as there are numerous factors that
may account for reduced effort.
243
Upon completion of the cognitive assessment, the
team should be able to determine the following:
1) identification of cognitive deficits associated with
TBI
2) need for cognitive rehabilitation
3) optimal rehabilitation method(s) for return to
function
4) measureable short- and long-term treatment goals
The cognitive assessment process may determine that
a patient does not require a full cognitive rehabilitation
program but rather a more limited program that assists
with goal-setting and provides education on developing
cognitive and emotional skills to improve day-to-day
functioning (modeled after the Army Center for En-
hanced Performance) or a short return-to-duty refresher
training to increase confidence in one’s ability to return
to full duty. Malec and Basford [34] describe a range of
postacute brain injury rehabilitation programs available
in the civilian sector. Most cases resulting from mTBI
in the military will be similar to “community re-entry”
or “community services only” programs, the latter de-
scribing a structured, supervised, and supported return
to community. Regardless, a patient should not be dis-
charged from the cognitive assessment process without
a treatment plan based on the four options in Fig. 1.
3.2. Intervention
Despite the difference in common mechanisms of
injury and environment in which the injury occurs be-
tween combat related and non-combat related mTBI,
there is presently no evidence to suggest that the re-
sulting cognitive deficits are different or require dif-
ferent interventions [3]. The following are interven-
tions with demonstrated efficacy and utility for cogni-
tive rehabilitation: direct attention training; selection
and training of external memory/organizational aids;
training in internal memory strategies; metacognitive
strategy training; social pragmatics training (targeting
self-perception, self-awareness, and social skills); en-
vironmental modification (more organized and less dis-
tracting environments); brain injury education for pa-
tients, family, and employers; and aggressive support
during gradual reentry into community and vocation-
al/educational activities (see Table 2). “Holistic” re-
habilitation programs integrate the above into orga-
nized interdisciplinary or transdisciplinary programs,
and have the advantage of using group process to ad-
dress social and behavioral issues [12,22].
244 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder

Table 2
Interventions
Area of cognitive Empirically- Specific examples References
impairment supported
interventions
Attention Attention process Letter cancellation Sohlberg et al., 2002
training tasks with Tiersky et al, 2005
distracting noise in Novack et al., 1996
background Sinotte & Coelho, 2007
Working memory Berg et al., 1991
training Completing two Cicerone, 2002
cognitive tasks Serino et al., 2007
simultaneously Lew et al., 2009
Memory Various Story method Ryan & Ruff, 1988
mnemonic Acronyms Berg et al., 1991
techniques Sentences/ Thickpenny-Davis & Barker-Collow, 2007
acrostics
Method of loci
Chunking
Visual imagery Repetition Kaschel et al., 2002
mnemonics Imagery based Westerberg et al., 2007
training Glisky & Glisky, 2002
Attention Memory Prosthetics Schmitter-Edgecome et al. 1995
Memory notebook PDA Ownsworth & McFarland, 1999
Executive Sohlberg & Mateer, 1989
functioning McKerracher et al., 2005

External Cuing Supervised living

BlackBerry Wilson et al., 2005
Cell phone Evans et al., 1998
PDA Kime & Lamb, 1996
Executive Social Group cognitive Dahlberg et al., 2007
functioning communication therapy Levin et. al., 1997
Social skills training
pragmatics groups
Attention Problem solving Internal problem- Fasotti et al., 2000
Memory training solving Ownsworth & McFarland, 1999
Executive Error Internal dialogue Vaynman & Gomez, 2005
functioning management Cheng et al., 2006
Social training Goverover et al., 2007
pragmatics Individual and Ehlhardt et al, 2005
group self- Ownworth et al., 2000
awareness training Ownsworth et al., 2006
Emotional Levine et al., 2000
regulation Rath et al., 2003
training Anger management Cicerone et al., 2008
groups Medd & Tate, 2000
Ruff et al., 1996
Attention Integrated use of Cicerone et al., 2008
Memory individual and Rattock et al., 1992
Executive group cognitive, Sarajuri et al., 2005
functioning psychological Goranson et al., 2003
Social and functional Carney et al., 1999
pragmatics interventions Cicerone et al., 2000
Cicerone et al., 2005
Comper et al., 2005
Gordon et al., 2006
Griesbach et al., 2009
Hoge et. al., 2008
Kim et. al., 2009
 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder
Table 2, continued
Area of cognitive Empirically- Specific examples
impairment supported
interventions
Interventions for persistent postconcussion cognitive
symptoms uniformly emphasize improvement in atten-
tion abilities. Attention in all its various components
(e.g., alertness, sustained attention, divided attention
and alternating attention) is the prerequisite for basic
as well as complex behaviors involving memory, judg-
ment, social perception, and executive skills. Impair-
ments in attention will have direct effects on specif-
ic attention tasks, and substantial indirect effects on
all aspects of a patient’s behavior. Moreover, attention
deficits often can masquerade as deficits in other cog-
nitive functions. For example, “memory impairment”
may be the downstream result of poor attention, with
concomitant impairments for registration of informa-
tion, thus degrading memory performance even in the
absence of a true memory deficit.
Attention training was one of the earliest approach-
es to cognitive rehabilitation [58]. It has been the sub-
ject of a number of well-designed studies and remains
one of the cornerstones of cognitive rehabilitation inter-
ventions [10,11,56,60]. Attention training has been a
core element of diverse programs, ranging from single-
service/single-provider programs to interdisciplinary
“holistic” programs [22] and numerous studies have
confirmed its benefit [9,59]. Moreover, attention train-
ing has been successful for remediating TBI-related
cognitive disorders apparently far removed from atten-
tion dysfunction, as illustrated by a recent case study
showing the effectiveness of attention training for read-
ing difficulties secondary to mild aphasia: “The posi-
tive gains noted for this individual’s reading skills were
felt to be the result of improvement in allocation of at-
tentional resources rather than improvement in linguis-
tic skills [55].”
Attention process training [60] improves attention
skills through a set of standardized auditory and visu-
al procedures made increasingly challenging by sys-
tematically increasing task complexity and heighten-
ing the level of distractions. This intervention organizes
attention and concentration tasks into subcomponents
of sustained attention, selective attention, alternating
245
References
NIH Consensus Panel, 1999
Prigatano, 1999
Salazar et al., 2000
Serino et al. 2007
Terrio et al. 2009
Tsaousides & Gordon, 2009
Vanderploeg et al. 2008
attention, and divided attention. Training procedures
place gradually increasing demands upon attentional
capacities.
“Memory training” is the most frequently prescribed
form of cognitive rehabilitation. While it seems sensi-
ble to have a patient with memory impairment perform
memorization drills with the therapist (work on remem-
bering word lists, faces, designs, etc.), recent reviews
have shown that repetitive memory drills – “memory
as a muscle” – have little or no efficacy [47,53]. How-
ever, efficacy has been demonstrated for memory train-
ing techniques derived from cognitive neuroscience.
For example, success has been shown with various
mnemonic techniques and other memory-enhancing
strategies that assist patients to develop techniques to
enhance registration and encoding of information, as
well as to develop methods for searching their memory
to improve memory retrieval [27]. Of interest, Kaschel
et al. [27], report that memory strategy training is most
effective for persons with mTBI and mild memory im-
pairment, with decreasing effectiveness as injury and
memory impairment severity increase.
External aids have been used to address both mem-
ory and executive function impairments. The majority
of more recent memory training studies have focused
upon the use of “memory notebooks” and electronic
equivalents, essentially serving as “memory prosthet-
ics.” A number of these studies have compared differ-
ent memory notebook formats and training procedures
to identify the most effective. For example [42], com-
pared two memory training procedures, one a Diary
Only condition in which patients were taught the me-
chanics of using a diary, while in the other condition
they received the diary training within a more compre-
hensive approach focusing on how the diary could be
used to solve problems in daily activities, particularly
when used proactively. Thickpenny-Davis and Barker-
Collo [64] combined strategy training with memory
notebook training, using the added efficiency of a group
format for an eight-session program, and found im-
provement in both the use of memory strategies as well
246 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder
as the use of memory prosthetics, with these improve-
ments extending into patients’ everyday memory func-
tioning. For a review of the evidence examining ef-
ficacy of use of external aids for managing memory
impairments, see Sohlberg et al. [57]. Note that the
emphasis on memory “notebooks” reflects their long-
standing availability as compared to newer electronic
devices that also can serve as prosthetics.
Social pragmatics (comprehending and responding
to “nonverbal” social cues) are commonly impaired by
TBI. Social skills training (typically within a group for-
mat) has shown effectiveness in improving these prob-
lems. For example, Dahlberg et al. [14], describes a
successful program, citing four key components: “The
first was the use of co-group leaders from different
clinical backgrounds (i.e. social work, speech-language
pathology). This allowed for two clinical perspectives,
two role models, and two clinicians collaborating and
sharing their expertise. The second component was
an emphasis on self-awareness and self-assessment,
leading to individual goal setting. A third component
was the use of the group process to foster interac-
tion, feedback, problem solving, a social support sys-
tem, and awareness that one is not alone. The final
component was a focus on generalization of skills, ad-
dressed through the involvement of family and friends,
and weekly assignments completed in the home or
community. . . Generally, sessions followed a consis-
tent format: (1) review of homework, (2) brief intro-
duction of the topic, (3) guided discussion, (4) small
group practice, (5) group problem solving and feed-
back, and (6) homework (pp. 1564–1565).” A major
portion of this program utilized the Goal Attainment
Scaling procedure developed by Malec, which also has
been used in numerous other programs to positive ef-
fect. Moreover, while Dahlberg describes this program
as “training of social communication skills,” the above
brief description clearly indicates that the program is
much more comprehensive and holistic, with focus on
executive skills, self-awareness, and emotional and be-
havioral self-regulation. As others have noted, inter-
ventions that incorporate training in personal and social
self-regulation, self-management, and problem solving
skills also address deficits in attention, memory, com-
munication, and executive function [1,45].
A robust literature supports the use of metacogni-
tive strategy training as an intervention for executive
function impairments due to TBI. At least five RCTs
have evaluated executive function outcomes from train-
ing in the use of multiple step strategies, strategic
thinking, and/or multitasking. In an early study, pos-
itive outcomes were reported from problem solving
therapy where patients were taught to identify prob-
lems and solutions, weigh the pros and cons of solu-
tions and monitor performance [69]. Similarly, Rath et
al. [45], showed positive effects of group therapy aimed
at improving emotional self regulation by the use of
problem-solution training. A goal attainment scaling
technique was shown to have specific positive results
on goal setting. Fasotti and colleagues [18] showed
improved problem solving with a step by step time
pressure management approach. A step by step task
completion strategy, Goal Management Training, was
shown to improve proofreading skills [31].
A “holistic” focus is seen in Tiersky et al. [65], who
focused on cognitive rehabilitation of mTBI. These au-
thors employed a manualized cognitive rehabilitation
program that was delivered in conjunction with cogni-
tive behavioral therapy, comparing it to a wait-list con-
trol group. The 11-week, three times per week, cogni-
tive rehabilitation program focused primarily on atten-
tion, information processing, and memory, although the
authors note that organizational and problem-solving
skills were addressed throughout the cognitive retrain-
ing program “because these abilities are a corollary of
memory and attentional skills (p. 1568).” The cognitive
behavioral therapy (CBT) was a relatively traditional
application of CBT and focused on increasing the use
of adaptive coping, reducing levels of distress, training
in methods of preventing relapse, and improving accep-
tance of sadness and loss related to cognitive and phys-
ical impairments. The treatment group showed signif-
icantly lessened anxiety and depression, and improved
divided attention.
Clinical experience with Wounded Warriors suggest
that a comprehensive holistic approach, which pro-
vides individual and group therapies within an integrat-
ed therapeutic environment, addresses the functional
impairment and disability resulting from cognitive and
emotional sequelae of chronic symptomatic mTBI. In-
volvement of family members and the Service Mem-
ber’s Command is highly encouraged to optimize re-
habilitation outcomes. Group therapy in addition to in-
dividual therapy provides a supportive context for re-
habilitation and reinforces the concept of unit cohe-
sion in military culture. The above studies are but a
sample of those leading the Intervention Group to its
primary conclusions regarding cognitive rehabilitation
interventions.
3.3. Outcome measures
Adequate literature and expert-consensus exists to
support judicious and selective use of cognitive reha-
 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder
bilitation for Service Members with persistent symp-
toms of mTBI. Nonetheless, the present Panel as well
as all recently published evidence-based reviews [10,
11,13,22,65] note the scarcity of well-designed clinical
trials in this area. The time-frame for correcting this
scarcity, however, likely is a decade or more, and even
longer if the essential element of long-term follow-up
is included.
While the situation may appear daunting, there is
much useful work that can be done in the meantime.
Studies conducted in recent years, and those current-
ly ongoing, use vastly improved methodology as com-
pared to studies published even several years ago. The
Panel learned of several in-press or ongoing literature
reviews and RCTs and it is likely that the amount of
high quality research will accelerate during the coming
years.
It also is important for individual programs to present
and publish their outcome data and clinical experiences.
While this likely will not be “gold standard” research,
it will enhance the field by allowing programs to “fer-
tilize” and learn from each other. This objective will be
facilitated greatly by using a set of common measures
for describing program and patient variables.
Capturing the complexity of the chronic mTBI popu-
lation is challenging. Many mTBI patients have comor-
bid disorders that can result in cognitive impairment,
and that can overlap, exacerbate, or mimic the cogni-
tive disorders associated with mTBI. It therefore is es-
sential that programs include data elements to capture
the nature and severity of comorbidities potentially af-
fecting cognitive status. The working group identified
several additional categories of required data elements
(see Table 3): administrative performance metrics (e.g.
number of patients seen, type and number of service
providers; range of services readily available; consis-
tent 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); pre- post-assessment differences; pre-
post- functional differences; moderating variables that
may affect outcome; discharge environment and patient
status at time of discharge; consumer satisfaction (in-
cluding the patient but can extend to family, employ-
er/Command, and referral source; and, aggregate pro-
gram outcome data to permit evaluation of the program
rather than just the individual patient.
As seen in Table 3, formal neurocognitive as-
sessments should be reserved for pre- and post-
247
rehabilitation (assuming appropriate intervals between
testing to protect the integrity of these tests or the use
of repeatable versions), while the ongoing monthly re-
assessments should emphasize evaluation of symptom
status and functional status.
The recommended functional outcome measures are:
job performance, need for redesignation/duty restric-
tions or limitations; ongoing comparisons between pre-
injury fitness reports/evaluations and current function-
al abilities as they improve within the program; per-
formance on simulators (rifle, flight, etc.); quality of
life assessment; community participation assessment;
and social-skills pragmatics assessment. Results from
monthly re-assessments of symptoms and functional
status, using tools such as Goal Attainment Scaling
(GAS) [33], can assist with clinical decision-making
and goal setting. The GAS procedure prescribes that
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. For outcome data to be maximal-
ly meaningful, it is important to carefully describe the
patient population. Some patients may respond much
better than others to specific interventions, making it
essential to have detailed and objective identification
of moderating variables, confounds, and comorbidi-
ties. These include pain; comorbid physical injuries;
type of injury; age, rank, job duties and gender of pa-
tient; psychological health and substance abuse; num-
ber of deployments; date(s) of injury(s); trauma histo-
ry to include life events prior to entering the military;
family and broader psychosocial support system; apti-
tude/education; duty status; prior neurologic illnesses
or injuries; motivation for retention; expectations of re-
covery; years of service; and, sources of possible sec-
ondary gain. Increased understanding of who responds
to specific interventions and who does not is essential.
Discharge data elements include: accomplishment
of treatment goals; plateauing of improvement and/or
failure to improve (typically following 3 to 4 weeks
of treatment and medical reevaluation to rule out treat-
able reasons); worsening symptoms (again with need
for reevaluation and possible case reformulation); and,
a clear but flexible definition of the maximum duration
of treatment. Moreover, patient and family satisfaction
measures are useful for identifying quality improve-
ment opportunities within a program
3.4. Program implementation
Patient assessment and treatment, and outcome mea-
sures for program assessment, already have been dis-
 248

Table 3
Outcome measures
Administrative per- Pre-Post- assessment Pre-post- functional Moderating Variables Discharge criteria Consumer Aggregate program out-
formance metrics differences differences & patient status at satisfaction come data
time of discharge
• # of patients seen • formal neuropsych • job performance • degree to which co-morbidity may • goals attained • patient, family, • type and # of service
• # of patients re- evaluation • need for redesigna- be resulting in cognitive symptoms • plateauing of im- employer/ command, providers
ferred for medical • symptom status tion/duty restrictions • pain provement and/or and referral source • range of services
appts • functional status • pre-injury fitness re- • severity of associated physical in- failure to improve • education • consistent/ well-defined
• duration & daily • domains tested during ports/evals vs. current func- juries • worsening • treatments entry criteria
intensity of prgm Cognitive Assessment tional abilities • mechanism of injury symptoms • efficacy • consistent/ well-defined
• length of time pa- • performance on simulators • age discharge criteria
tient is on limited • quality of life assessment • rank/MOS • clear description of the
duty • community participation • gender program/ interventions
assessment • psychological health co-morbidities • clear documentation
• substance abuse co-morbidities
• # of deployments
• date(s) of injury(s)
• trauma history to include life events
prior to entering the military
• family/broader psychosocial sup-
port systems
• aptitude/education
• military status
• history of ADHD or LD
• other prior neurologic illnesses or
injuries
• motivation for retention
• expectations of recovery
• years of service
• possible sources of secondary gain
K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder
 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder
Visual Rehab
Speciality
Services
TBI Program
Physical Rehab
Vestibular
Rehab
Cognitive
Rehab
Fig. 2. Cognitive rehabilitation within TBI program.
cussed. The emphasis of the present section is on im-
plementing the prior recommendations within an MTF.
If a TBI program exists at the MTF, the cognitive
rehabilitation program should be a sub-component (see
Fig. 2). The ideal cognitive rehabilitation program mod-
el is team-based and holistic [53]. Alternately, cogni-
tive treatment can be offered within a discrete thera-
py model, usually assigned to SLP or OT, though it
may become difficult to provide consistent integration
of services. Research concerning the effectiveness of
cognitive rehabilitation tends to favor the holistic mod-
el [12,22].
Optimal delivery of the holistic model requires an
interdisciplinary or transdisciplinary team of clinicians
who are competent in brain injury rehabilitation, under-
stand and can function within military culture, and are
249
Psychological
Couseling
Vocational
Rehab
Occupational
Therapy
Cognitive Rehabilitation
Neuropsychology Speech Language
Pathology
Mental Health
capable of developing a therapeutic alliance with their
patients. Strong team leadership is required, both pro-
grammatically and medically, to ensure unified goals
and quality care. Interdisciplinary case conferences for
patient management and goal setting/review should oc-
cur regularly. Coordination of care is also required with
the patient’s family, other medical providers, and the
unit chain of command. The program leader is expect-
ed to ensure that the team, with his/her guidance, de-
velops and monitors an appropriate treatment plan, and
updates the plan as needed; keep Line and Leader-
ship informed regarding patients goals, objectives, and
progress; provide leadership and guidance during dis-
charge planning conferences; resolve and attempt to
achieve consensus among team members regarding po-
tential differences in patient care plans; and, manage
250 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder
professional “turf” issues should they arise.
It will be crucial to recruit, train and retain providers
with specific TBI expertise. The discipline of providers
to deliver a cognitive rehabilitation program should
include, but is not limited to, neuropsychologists,
speech-language pathologists, occupational therapists
and mental health providers. Continued professional
education in the area of the assessment and treatment
of TBI and associated conditions is an on-going need.
Development of a concept of operations for a cogni-
tive rehabilitation program should include attention to
space requirements (quiet treatment spaces and group
intervention spaces), equipment (to include assistive
technology and virtual reality systems), and funds to
cover transportation for community activities and so-
cial networking opportunities. A program such as this
will need substantial administrative support.
4. Conclusions
1. Recommend immediate implementation of this
clinical guidance into current DoD TBI treat-
ment algorithms, specifically as an extension of
the May 2008 mTBI Clinical Guidance for non-
deployed settings. Cognitive rehabilitation clin-
ical guidance will be updated and refined as re-
search in this area unfolds.
2. Standardized outcome measures should be used
for DoD cognitive rehabilitation programs to
further inform future research (with appropriate
Institutional Review Board (IRB) protocol ap-
proval) and further program development.
3. Provide new opportunities for ongoing provider
continuing education related to cognitive rehabil-
itation in the military TBI population
4. Consider further discussion regarding cognitive
rehabilitation as a separate reimbursable rehabil-
itation technique for the traumatic brain injured
with persistent cognitive deficits.
Acknowledgements
This work was coordinated by the Defense Cen-
ters of Excellence for Psychological Health and Trau-
matic Brain Injury and its operational component, the
Defense and Veterans Brain Injury Center. We thank
Joseph Bleiberg, Ph. D., for his significant contribu-
tions in the conceptualization and success of the April
2009 Consensus Conference. We also thank Ms. San-
dra Page for her outstanding support services.
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 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder 253

Appendix A: DoD TBI definition

254 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder
 K. Helmick / Cognitive rehabilitation for military personnel with mTBI and chronic post-concussional disorder 255

Appendix B: April 2009 Consensus Conference Participants

Dr. Sonja Batten, Lt Col Sarah Beal, Dr. Joseph Bleiberg, CPT Paul Boccio, Ms. Theresa Boyd, Dr. Keith
Cicerone, Dr. Paul Comper, Dr. Douglas Cooper, Dr. Micaela Cornis-Pop, LT Tara Cozzarelli, Maj David Dickey,
Ms. Selina Doncevic, CDR Kim Ferland, Ms. Elizabeth Findling, Dr. Louis French, COL Nancy Fortuin, CDR John
Golden, Dr. Matthew Gonzalez, Dr. Wayne Gordon, Ms. Kathy Helmick, CDR David Jones, CDR Frederick Kass,
Dr. James Kelly, LCDR Carrie Kennedy, Dr. Jan Kennedy, Dr. Kathleen Kortte, CAPT Karen Kreutzberg, LTC
Lynne Lowe, Dr. James Malec, Ms. Pauline Mashima, Dr. Cate Miller, Dr. Maria Mouratidis, Dr. George Prigatano,
Dr. Carole Roth, LTC Michael Russell, LT Rick Schobitz, Dr. Joel Scholten, CAPT Edward Simmer, Dr. McKay
Moore Sohlberg, LTC Benjamin Solomon, MAJ Matthew St. Laurent, Ms. Elizabeth Thomson, CDR Jack Tsao, Dr.
Rodney Vanderploeg, Maj Megumi Vogt, Dr. Therese Walden, Col Christopher Williams, Mr. Michael Wilmore,
LTC Yvette Woods, BG (ret) Stephen Xenakis.