An Examination of Clinically Meaningful Change Among Veterans with Mild Traumatic Brain Injury Following Compensatory Cognitive Training

Kate Shirley, Oregon Health & Science University, Portland, United States
Kate Clauss, Veteran Affairs Portland Health Care System, Portland, United States
David Cameron, Oregon Health & Science University, Portland, United States
Emily Sano, Veteran Affairs Portland Health Care System, Portland, United States
Maya O'Neil, Veteran Affairs Portland Health Care System, Portland, United States


High prevalence of mild traumatic brain injury (mTBI) among Veterans and associated cognitive impairments (e.g., executive functioning, verbal delayed memory, and processing speed) necessitate effective cognitive rehabilitation procedures. Compensatory Cognitive Training (CCT) is a group-based comprehensive behavioral intervention that teaches practical, generalizable compensatory strategies. CCT consists of ten 120-minute weekly sessions with interactive didactic presentations, in-class discussions, and activities that introduce a variety of cognitive strategies and external aids. Although CCT has been shown to reduce the cognitive difficulties associated with mTBI in Veterans, statistically significant changes do not always reflect clinically meaningful differences. Therefore, we present a secondary analysis of clinical trial data published by Storzbach and colleagues (2017) using clinically relevant cut scores to determine which variables were associated with qualitatively meaningful change in impairment following participation in CCT. We anticipated that CCT would result in more meaningful improvement compared to the control condition.

Participants and Methods:

Veterans with mTBI recruited from three VA medical centers (Portland, Puget Sound, and San Diego) were randomized to 10 weeks of CCT (n = 50) or treatment as usual (n = 69). Assessments (e.g., subjective cognitive complaints, cognitive strategies, psychological functioning, objective cognitive performance) were administered at baseline and 10 weeks. Using established cut scores or scores > 2 standard deviations above the mean, we categorized outcome variables as impaired or unimpaired.


We examined descriptive statistics to determine what portion of the CCT group experienced meaningful improvements across measures. The majority of participants endorsed impairing posttraumatic stress disorder and depressive symptoms at baseline. Across study measures, a minority of participants changed from impaired to unimpaired over the course of CCT. However, nearly one fourth of participants in the CCT group experienced improvements in depressive symptoms such that their scores shifted from impaired to unimpaired.


The present study used clinically relevant cut scores to examine improvements in subjective and objective functioning in Veterans with mTBI who participated in CCT compared to treatment as usual. The largest changes were observed in the CCT group, where nearly a quarter of the sample shifted from impaired to unimpaired with regard to depressive symptoms. Thus, although the primary purpose of CCT is to improve cognitive functioning, it may also have beneficial effects on depressive symptoms. While clinically meaningful change was only observed in a small portion of the sample, in Storzbach and colleagues’ (2017) examination of the continuous outcomes in this dataset, they found that participants reported greater use of cognitive strategies and fewer cognitive and memory complaints following CCT relative to treatment as usual. Although we did not observe clinically meaningful changes, participants’ perceptions of their cognitive functioning improved. Previous research has demonstrated that cognitive rehabilitation interventions commonly improve participants knowledge and use of compensatory strategies but have less consistent effects on objective cognitive functioning. Thus, it may be that subjective improvements overshadow improvements in objective cognitive functioning regarding overall functioning and satisfaction with cognitive rehabilitation interventions.

Category: Cognitive Intervention/Rehabilitation

Keyword 1: cognitive rehabilitation
Keyword 2: concussion/ mild traumatic brain injury
Keyword 3: cognitive functioning