1. DISCUSSION & CONCLUSIONS
Benefits of Complex Reasoning Training in Veterans and Civilians with Chronic Traumatic Brain Injury
Nellie Evenson M.S. CCC-SLP, Stephanie Tuthill M.A. CCC-SLP, Asha Vas PhD OT, Daniel Krawczyk Ph.D., Sandra Chapman Ph.D. CCC-SLP
Center for BrainHealth at the University of Texas at Dallas, University of Texas Southwestern Medical Center at Dallas
BACKGROUND
Traumatic brain injuries (TBI) resulting from motor vehicle accidents, high-impact sports, and war-related events affect both civilian and military populations
TBI significantly affects complex frontal functions including higher order reasoning, resulting in impairments in daily functions months and years after initial injury1,2
A limited number of rehabilitative programs mitigate higher-order reasoning deficits, a target crucial for resuming pre-injury levels of daily functioning in individuals with TBI3
Previous research has demonstrated that complex reasoning training labeled SMART (Strategic Memory Advanced Reasoning Training) in civilians with moderate to severe TBI can result in improved higher-order cognition and significant functional gains4
METHODS (Training)
SMART: Strategic Memory Advanced Reasoning Training
Goal is to improve complex reasoning skills using frontal lobe strategies
Training sessions consisted of 18 hours over an 8-week period
Groups involved mix of 5-7 civilians & veterans led by 2 clinicians
Application of strategies to daily life tasks consisted of processing information (movies, TV shows, reading materials, lectures), task planning and organization, school and job performance, conversations, and leisure pursuits
Aim 3: Military and Civilian Differences
Preliminary comparisons between military and civilians subgroups revealed:
Significant gains for each subgroup in the trained domain of complex reasoning (coherence), and generalized executive functions including working memory, cognitive flexibility, and innovation
No significant gains in either subgroup for the generalized domains of daily function as measured by the FSE or the GOS-E
No significant gains unique to the military population
Significant gains unique to civilians in the trained area of complex reasoning (lessons), along with generalized domains of memory and daily function as measured by the BDI
Strategic attention- Block less relevant details, focus on important information, and avoid multitasking.
Integrated reasoning- Construct meaning by combining information at hand with past experiences to generate abstract themes. Bind themes to generate big ideas.
Innovation- Flexibly create novel ideas. Make connections by examining various perspectives
AIMS
To determine whether higher-order reasoning can be enhanced in civilians and veterans with mild TBI through the SMART program, designed to build strategic thinking and advanced reasoning skills
To examine the benefits of SMART on executive functions, memory, and daily functions immediately post-training and 3 months post-training
To compare the military versus civilian response to SMART on both cognitive and functional performance
Table 1: Cognitive measures and domains
Trained Benefits Specific to Civilians:
Complex Reasoning- Lessons
Generalized Benefits Specific to Civilians:
Memory & Daily Function
RESULTS
Within-subjects t-test analyses show significant gains post-SMART and 3-months post SMART in trained areas of complex reasoning (coherence), along with generalized domains of executive functioning
Cognitive Domain
Measures
Description
Complex Reasoning (Trained Domain)
TOSL5 (Test of Strategic Learning)
Coherence
Lessons
Number of abstracted ideas in a cohesive summary of complex texts
Number of interpretive statements abstracted from complex texts
Executive Functions
 Innovation
Cognitive Flexibility
Working Memory
D-KEFS (Delis-Kaplan Executive Function System) Sorting Task
Number of different sorts made according to conceptual categorization
D-KEFS Trails- Condition 4 Raw
Completion time for switching between alphabet & numbers
Listening Span
(Daneman & Carpenter 1980)
Recall of last word in a sentence after answering related questions
Memory
WMS (Wechsler Memory Scale) –Delayed Recall
Recall of details given a story after a short delay
Daily Function
BDI (Beck Depression Inventory)
FSE (Functional Status Exam)
GOS-E (Glasgow Outcome Scale-Extended)
Self-report inventory of depression-like symptoms
Self-report inventory measuring changes in daily life following TBI
Self-report inventory of general functional recovery after TBI
DISCUSSION & CONCLUSIONS
SMART training improves complex reasoning skills in military and civilian populations with chronic traumatic brain injury
Improvements post-SMART in associated areas of cognition including flexibility and memory suggests the top-down benefits of enhanced higher order reasoning for individuals with TBI
Maintenance of gains three months after training demonstrates sustained benefits of SMART
Civilian populations showed increased response to training in specific areas of abstract reasoning, memory, and daily function measures relative to military veterans, thereby implicating population-specific treatment targets
Rehabilitation efforts should adopt training paradigms that target complex brain functions which have generalized benefits in order to enhance functional recovery even in chronic stages of TBI
Aim 1: Trained Benefits: Complex Reasoning
METHODS (Participants)
Subset analysis of double-blinded randomized controlled study
Participants: N = 19 (male=9, female= 10)
Military n = 7; Civilian n = 12
Table 2: Participant demographic variables
Aim 2: Generalized Benefits: Executive Function
REFERENCES
1 Cicerone ,K.D., Dahlberg, C., Malec, J.F., et al Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002. Arch Phys Med Rehabil. 86:1681–1692.
2 Cicerone, K.D., Mott, T., Azulay, J., et al A randomized controlled trial of holistic neuropsychologic rehabilitation after traumatic brain injury. Arch Phys Med Rehabil. 89:2239–2249.
3 Chen, A.J.W., Abrams, G.M., D’Esposito, M Functional reintegration of prefrontal neural networks for enhancing recovery after brain injury. J Head Trauma Rehabil. 21:107–118.
4 Vas, A.K., Chapman, S.B., Cook, L.G., Elliott, A.C. & Keebler, M Higher-Order Reasoning Training Years After Traumatic Brain Injury in Adults. The Journal of head trauma rehabilitation , 26, no. 3: 224.
5 Chapman, S.B., Hart, J.M., Levin, H.S., Cook, L.G. & Gamino, J.F. under review. The Test of Strategic Learning.
Listening Span
p=.009*
Working Memory
2.39
3.05
3.03
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
Pre
Post
3month
Variable
Mean (SD)
Range
Current Age
42.0 (14.7)
20- 65
Current IQ
111.5 (10.6)
97-129
Years of Education
15.4 (2.3)
12-20
GOS-E
6.1 (.8)
4-7
SES
45.7 (8.0)
35-63
Pre-morbid IQ
109.4 (7.3)
94-121
FSE
22.6 (6.6)
11-34
Age at Injury
34.8 (14.3)
17-64
Years since Injury
7.2 (6.4)
1-24
ACKNOWLEDGMENTS
Supported by US Department of Defense CDMRP Program in Psychological Health and TBI and Meadows Foundation