Practice Profile

Psychologist Keith D. Cicerone, PhD, is convinced that current military policy is failing service members with traumatic brain injury (TBI).

“Everybody talks about the sacrifice people are making and how we should honor service men and women,” says Cicerone, director of neuropsychology and cognitive rehabilitation at the JFK Johnson Rehabilitation Institute in Edison, N.J. “But I think you honor those in the service by providing them with the services that they need.”

Cicerone and others are convinced the military isn’t living up to that obligation when it comes to treating soldiers with TBI, one of the hallmark injuries of the wars in Iraq and Afghanistan. An investigation by NPR and the nonprofit news organization ProPublica last year revealed that the military medical system — both on the battlefield and on the home front — often fails to diagnose and treat TBI. Since the wars began, more than 200,000 troops have experienced mild TBI, and the military acknowledges that that number is likely an underestimate.

Now Cicerone is working to ensure that soldiers with TBI get the cognitive rehabilitation that can help them overcome the lingering physical and mental after-effects of an injury that often leaves no visible scar. Cicerone, who has a neuropsychology doctorate from the City University of New York, specializes in helping patients with TBI return to fully functional, independent lives. That practical experience, coupled with his research as a clinical professor of physical medicine and rehabilitation at the Robert Wood Johnson Medical School, has made Cicerone a leading expert on treating head injuries. That’s why when the military needed help developing guidelines for treating TBI, it called on Cicerone.

Cicerone participated in a major consensus conference in 2009, for example, and now he’s participating in a similar effort conducted by the Institute of Medicine.

“Dr. Cicerone’s work has directly contributed to the knowledge base that the Department of Defense is acquiring that will impact both clinical care, policy and future research agendas,” says Katherine Helmick, deputy director for TBI at the Defense Centers of Excellence for Psychological Health and TBI.

Consulting with the military

The NPR/ProPublica reporting, which quoted Cicerone, found that soldiers who experienced TBI while serving in Iraq or Afghanistan often receive little or no treatment for it. At special risk are those who have suffered mild TBI, an injury that can be caused by shock waves from roadside bombs. Belying the term “mild,” this kind of TBI can lead to devastating symptoms such as memory and reasoning problems, headaches and dizziness months or even years after the initial injury.

Nonetheless, the military’s TRICARE insurance program, which allows approximately 4 million active-duty service members, retirees and their families to obtain health care from civilian providers, won’t pay for cognitive rehabilitation.

To Cicerone, that’s just wrong. In 2009, he participated in a conference convened by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and the Defense and Veterans Brain Injury Center. The conference, which brought together 50 military and civilian brain injury experts, was designed to produce a consensus on cognitive rehabilitation for military personnel with mild TBI.

“There was overwhelming consensus that the military should be using cognitive rehabilitation,” says Cicerone. The resulting consensus document, published in NeuroRehabilitation (Vol. 26, No. 3) in 2010, draws extensively on Cicerone’s research and literature reviews to note such proven interventions as attention and working memory training and anger management groups. The paper also highlights Cicerone’s work demonstrating the key role of holistic programs that integrate a variety of cognitive rehab techniques. In one randomized controlled trial published in the Archives of Physical Medicine and Rehabilitation (Vol. 89, No. 12), for instance, Cicerone and colleagues found that a holistic neuropsychologic rehab program was more effective than standard rehab in which patients receive occupational therapy, physical therapy and other services separately.

In fact, says Helmick, lead author of the consensus document, Cicerone’s presentation on the state of cognitive rehab laid the groundwork for the group’s work over the two-day conference. He was also instrumental in the group that developed the empirically based set of interventions aimed at specific cognitive domains affected by TBI, she says.

“This was a major contribution to both the military TBI work and the field of cognitive rehab,” says Helmick.

Helmick is also convinced Cicerone has had an impact on military policy. “I believe his work contributed to the current policy that has mandated a standardized approach to cognitive rehab in 13 military treatment facilities throughout the U.S.,” she says. This new “clinical guidance” document puts into practice the consensus committee’s recommendations for treating mild TBI. These facilities are collecting data on the treatment’s effectiveness so that the Pentagon can decide whether to implement the guidelines at additional facilities.

But while the consensus conference findings are improving care for patients with mild TBI at certain facilities, TRICARE remains unmoved. Instead, it commissioned its own scientific review, contracting with a nonprofit research group called the ECRI Institute. Its final report, which came out in 2009, concluded that the evidence supporting cognitive rehabilitation for TBI was too inconclusive to justify its coverage.

“I’ve been criticized in the past for saying that I think one of the driving factors here is financial, but I continue to think so,” says Cicerone, adding that cognitive rehab isn’t necessarily that expensive. “I take the position that good care centered on the nature of the illness the person is experiencing — even if it’s more expensive in the short term — is going to be more effective and therefore is going to be less expensive in the long term.”

Cicerone is one of many who criticized the ECRI report. In a letter to TRICARE’s behavioral medicine division in 2009, he argued that methodological decisions — such as only reviewing findings from randomized controlled trials — meant the study ignored valuable information about cognitive rehabilitation’s merits and limited the usefulness of its findings.

“In fact, if one applies the standards of the ECRI report to other aspects of rehabilitation, I believe that one must reach the conclusion that there is insufficient evidence to support the effectiveness of neurologic management, psychiatric treatment, physical medicine interventions or pharmacologic treatments for traumatic brain injury,” Cicerone wrote. “And yet I suspect it would not be acceptable to suggest that our wounded warriors ... should simply go untreated.”

Now the IOM has launched its own study, and once again Cicerone is involved. At the kick-off of the yearlong evaluation of cognitive rehabilitation therapy for TBI, Cicerone offered an overview of cognitive rehabilitation and highlighted key studies for the members’ consideration — a task made easier by the fact that he and colleagues had just reviewed the literature for the Archives of Physical Medicine and Rehabilitation (Vol. 92, No. 4). Cicerone hopes the IOM evaluation will help the Pentagon decide once and for all whether TRICARE will cover cognitive rehabilitation for TBI.

Does Cicerone believe his advocacy is having an impact? “I think change is coming,” he says, “but I think it’s very slow.”

Broader advocacy efforts

Cicerone’s next advocacy target? Getting increased federal funding for research on TBI in the civilian population.

“There are 10 times as many civilian TBIs, but probably a tenth of the amount of federal research funding being allocated to civilian TBIs,” says Cicerone, who testified before the Congressional Brain Injury Task Force in March.

That’s not a popular message right now, he admits, explaining that some believe that pointing out the discrepancy in funding means failing to support the troops. But, he says, somewhere between 1.5 million and 2 million TBIs occur among civilians each year, compared with 25,000 among military personnel. Both populations, he says, deserve the highest quality services.

Says Cicerone, “Traumatic brain injury is the signature injury of Iraq and Afghanistan, while it remains the silent epidemic in the civilian population.”

Rebecca A. Clay is a writer in Washington, D.C.