Military Service Members (SM) who have experienced a mild traumatic brain injury (mTBI) are typically expected to have a full resolution of symptoms; however, many will experience persistent complaints, particularly related to cognitive functioning. Traditional approaches to cognitive rehabilitation have only shown modest efficacy in terms of symptom resolution as well as improvement in cognitive performance. For rehabilitation of the warfighter, the goal is to return to full active duty, which includes the ability to operate in dynamic combat environments and use of advanced military equipment. To date, little is known about the impact of cognitive rehabilitation on warfighter performance. The objective of this study is to investigate the complex relationship between cognitive rehabilitative interventions and actual warfighter performance.

Participants were recruited from a military treatment facility. All patients had at least one diagnosed mTBI with persistent cognitive complaints at enrollment. A total of 36 participants were enrolled in one of two manualized cognitive rehabilitation treatment programs and consented to have a direct supervisor rate their performance. One treatment was Strategic Memory and Advanced Reasoning Training (SMART) which is a 40 hour clinician directed treatment focused on executive functioning. The second treatment was SCORE, a 60 hour treatment which is a combination of traditional cognitive rehabilitation and computer training. Sixteen participants were randomized to SMART and 20 to SCORE. Warfighter performance was measured by the Checklist of Military Activities of Daily Living (M-ADL) which was completed by a direct supervisor. The M-ADL includes 15 military-related tasks. Each item is rated on a Likert scale from “1: Unsatisfactory” to “5: Excellent”. Total score was used as the primary variable of interest. Assessments were completed pre-treatment and post treatment cognitive rehabilitation. In addition, participants self-reported symptoms (Neurobehavioral Symptom Inventory; NSI) and self-reported functional deficits (Key Behavioral Change Index; KBCI) were assessed.  Scores are presented as change scores.

Post-treatment There was a reduction in overall self-reported symptoms on the NSI (average change -5.25, SD =10.33, p = 0.002, d =.52) and KBCI (average change -10.33, SD =18.52, p <0.001, d =.56). Neither cognitive rehabilitation intervention had a significant change on the M-ADL (p= p=.383). The type of intervention did not impact outcomes (SCORE M= -1.05, SD = 6.34, p =.618; SMART M -0.12; SD = 4.129 p = 0.618). For the patients in SMART condition, there seemed to be a trend emerging between emotional scores and M-ADL ratings. For SMART, there was moderate correlation between m-ADL change and change on the Affective subscale of the NSI (r=0.303) as well as the Apathy portion of the KBCI  (r =-0.338).

The results demonstrate that cognitive rehabilitation interventions may be effective in reducing self-reported symptoms and functional complaints, but do not necessarily lead to greater military performance as rated by superiors. There was no relationship to patients’ changes in functioning the change in ratings by their superiors indicating these are independent constructs. In exploratory analyses, there was a correlation between emotional health and warfighter performance but this was only observed in small subsample of participants. This may indicate that warfighter performance may be more directly connected to the emotional symptoms related to mTBI then other symptoms. Future efforts should look into advances in cognitive rehabilitation interventions that have a more meaningful effect on warfighter performance.