Validation of Strategic Memory Advanced Reasoning Training as an efficient and effective approach to treating warfighters with persistent cognitive complaints associated with mild traumatic brain injury.

INTRODUCTION

This study directly compared the relative effectiveness of Strategic Memory Advanced Reasoning Training (SMART), which focuses on metacognitive strategies, to a traditional cognitive rehabilitation (CR) program previously developed and validated for the Study of Cognitive Rehabilitation Effectiveness study (SCORE), in treating warfighters with a history of mild traumatic brain injury (mTBI) and persistent post-concussive symptoms (PCS).

METHODS

A total of 148 active-duty service members (SMs) were recruited for this randomized controlled trial (RCT). Participants were randomly assigned to either the SMART (n = 80) or SCORE (n = 68) intervention arms. Outcome measures were administered at the start (T1) and end of treatment (T2), and at 3 months post-treatment (T3). Only participants with data from all timepoints and adequate performance validity (SMART: n = 51; SCORE: n = 43) were used in analyses. The primary outcome measure was the Global Deficit Scale (GDS), a composite of seven different objective measures of cognitive performance. Secondarily, participants completed the Neurobehavioral Symptom Inventory (NSI) and Key Behaviors Change Inventory (KBCI) self-report measures of post concussive symptoms (PCS). Lastly, a cost effectiveness analysis (CEA) was performed directly comparing the relative efficiencies of the two CR interventions.

RESULTS

Mixed Analysis of Variance (ANOVA) showed a significant decrease in GDS scores from T1 to T3 (p < 0.001, ηp 2 = 0.217), irrespective of intervention type (p = 0.986, ηp 2 = 0.000). The greatest improvement occurred between T1 (SMART: M = 0.70, SD = 0.79; SCORE: M = 0.70, SD = 0.72) and T2 (SMART: M = 0.29, SD = 0.58; SCORE: M = 0.29, SD = 0.40), with scores plateauing at T3 (SMART: M = 0.28, SD = 0.52; SCORE: M = 0.29, SD = 0.57). Similarly, there was a significant decrease in NSI scores over the same period (p < 0.001, ηp 2 = 0.138), regardless of intervention type (p = 0.412, ηp 2 = 0.010). Additionally, treatment improved patient perceived functionality (KBCI) from T1 to T2 and these gains remained stable at T3 (p < 0.001, ηp 2 = 0.377). CEA revealed SMART represented a 60% reduction in cost compared to SCORE.

DISCUSSION: This study demonstrates that SMART is an effective strategy for reducing cognitive deficits and PCS in SMs with a history of mTBI, producing comparable outcomes to a traditional CR program in less time and with improved cost efficiencies.