Validation of Strategic Memory Advanced Reasoning Training (SMART) as an Efficient and Effective Approach to Treating Warfighters with Persistent Cognitive Complaints Associated with Mild Traumatic Brain Injury (mTBI)

Andrew J Darr ^1* Angela Basham ¹ Jessica L Ryan ² Melissa Caswell ¹ Juan Lopez ¹ Jennifer Zientz ³ Erin Elizabeth Venza ³ Ida Babakhanyan ¹ Sandra Bond Chapman ³ Jason M Bailie ¹

• ¹ Traumatic Brain Injury Center of Excellence (TBICoE), Military Health System, Silver Spring, Maryland, United States
• ² James A. Haley Veterans' Hospital Primary Care Annex, Tampa, Florida, United States
• ³ Center for BrainHealth, School of Behavioral and Brain Sciences, The University of Texas at Dallas, Dallas, Texas, United States

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). 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). 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 Behavioral Change Index (KBCI) self-report measures of post concussive symptoms (PCS). A cost effectiveness analysis (CEA) was performed directly comparing the relative efficiencies of the two CR interventions. Mixed Analysis of Variance (ANOVA) showed a significant decrease in GDS scores from T1 to T3 (p <.001, ηp2 = .217), irrespective of intervention type (p = .986, ηp2 = .000). The greatest improvement occurred between T1 (SMART: M = .70, SD = .79; SCORE: M = .70, SD = .72) and T2 (SMART: M = .29, SD = .58; SCORE: M = .29, SD = .40), with scores plateauing at T3 (SMART: M = .28, SD = .52; SCORE: M = .29, SD = .57). Similarly, there was a significant decrease in NSI scores over the same period (p < .001, ηp2 = .138), regardless of intervention type (p=.412, ηp2 = .010). Additionally, treatment improved patient perceived functionality (KBCI) from T1 to T2 and these gains remained stable at T3 (p < .001, ηp2 = .377). CEA revealed SMART represented a 60% reduction in cost compared to SCORE. 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.