{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,7,30]],"date-time":"2025-07-30T16:06:56Z","timestamp":1753891616766,"version":"3.41.2"},"reference-count":47,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,4,9]],"date-time":"2025-04-09T00:00:00Z","timestamp":1744156800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:sec><jats:title>Introduction<\/jats:title><jats:p>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).<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>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 (<jats:italic>n<\/jats:italic>\u202f=\u202f80) or SCORE (<jats:italic>n<\/jats:italic>\u202f=\u202f68) intervention arms. Outcome measures were administered at the start (T1) and end of treatment (T2), and at 3\u202fmonths post-treatment (T3). Only participants with data from all timepoints and adequate performance validity (SMART: <jats:italic>n<\/jats:italic>\u202f=\u202f51; SCORE: <jats:italic>n<\/jats:italic>\u202f=\u202f43) 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.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Mixed Analysis of Variance (ANOVA) showed a significant decrease in GDS scores from T1 to T3 (<jats:italic>p<\/jats:italic>\u202f&amp;lt;\u202f0.001, <jats:italic>\u03b7<jats:sub>p<\/jats:sub><\/jats:italic><jats:sup>2<\/jats:sup>\u202f=\u202f0.217), irrespective of intervention type (<jats:italic>p<\/jats:italic>\u202f=\u202f0.986, <jats:italic>\u03b7<jats:sub>p<\/jats:sub><\/jats:italic><jats:sup>2<\/jats:sup>\u202f=\u202f0.000). The greatest improvement occurred between T1 (SMART: <jats:italic>M<\/jats:italic>\u202f=\u202f0.70, SD\u202f=\u202f0.79; SCORE: <jats:italic>M<\/jats:italic>\u202f=\u202f0.70, SD\u202f=\u202f0.72) and T2 (SMART: <jats:italic>M<\/jats:italic>\u202f=\u202f0.29, SD\u202f=\u202f0.58; SCORE: <jats:italic>M<\/jats:italic>\u202f=\u202f0.29, SD\u202f=\u202f0.40), with scores plateauing at T3 (SMART: <jats:italic>M<\/jats:italic>\u202f=\u202f0.28, SD\u202f=\u202f0.52; SCORE: <jats:italic>M<\/jats:italic>\u202f=\u202f0.29, SD\u202f=\u202f0.57). Similarly, there was a significant decrease in NSI scores over the same period (<jats:italic>p<\/jats:italic>\u202f&amp;lt;\u202f0.001, <jats:italic>\u03b7<jats:sub>p<\/jats:sub><\/jats:italic><jats:sup>2<\/jats:sup>\u202f=\u202f0.138), regardless of intervention type (<jats:italic>p<\/jats:italic>\u202f=\u202f0.412, <jats:italic>\u03b7<jats:sub>p<\/jats:sub><\/jats:italic><jats:sup>2<\/jats:sup>\u202f=\u202f0.010). Additionally, treatment improved patient perceived functionality (KBCI) from T1 to T2 and these gains remained stable at T3 (<jats:italic>p<\/jats:italic>\u202f&amp;lt;\u202f0.001, <jats:italic>\u03b7<jats:sub>p<\/jats:sub><\/jats:italic><jats:sup>2<\/jats:sup>\u202f=\u202f0.377). CEA revealed SMART represented a 60% reduction in cost compared to SCORE.<\/jats:p><\/jats:sec><jats:sec><jats:title>Discussion<\/jats:title><jats:p>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.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fneur.2025.1541894","type":"journal-article","created":{"date-parts":[[2025,4,9]],"date-time":"2025-04-09T04:10:39Z","timestamp":1744171839000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["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"],"prefix":"10.3389","volume":"16","author":[{"given":"Andrew J.","family":"Darr","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Angela","family":"Basham","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jessica L.","family":"Ryan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Melissa","family":"Caswell","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Juan","family":"Lopez","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jennifer","family":"Zientz","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Erin","family":"Venza","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ida","family":"Babakhanyan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sandra","family":"Chapman","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jason M.","family":"Bailie","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2025,4,9]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"4391","DOI":"10.4103\/jfmpc.jfmpc_98_21","article-title":"Military TBI-what civilian primary care providers should know","volume":"10","author":"Lindberg","year":"2021","journal-title":"J Family Med Prim Care"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"720","DOI":"10.1097\/JXX.0000000000000532","article-title":"US Department of defense warfighter brain health initiative: maximizing performance on and off the battlefield","volume":"32","author":"Lee","year":"2020","journal-title":"J Am Assoc Nurse Pract"},{"year":"","key":"ref3"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"1571","DOI":"10.1212\/WNL.0000000000003839","article-title":"Epidemiology and prognosis of mild traumatic brain injury in returning soldiers: a cohort study","volume":"88","author":"Schwab","year":"2017","journal-title":"Neurology"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"239","DOI":"10.3233\/NRE-2010-0560","article-title":"Cognitive rehabilitation for military personnel with mild traumatic brain injury and chronic post-concussional disorder: results of April 2009 consensus conference","volume":"26","author":"Helmick","year":"2010","journal-title":"Neuro Rehabil"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"329","DOI":"10.1093\/arclin\/acu013","article-title":"Factors influencing postconcussion and posttraumatic stress symptom reporting following military-related concurrent polytrauma and traumatic brain injury","volume":"29","author":"Lange","year":"2014","journal-title":"Arch Clin Neuropsychol"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"316","DOI":"10.1155\/2012\/316575","article-title":"Possible lingering effects of multiple past concussions","volume":"2012","author":"Iverson","year":"2012","journal-title":"Rehabil Res Pract"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"1823","DOI":"10.1089\/neu.2014.3363","article-title":"The impact of multiple concussions on emotional distress, post-concussive symptoms, and neurocognitive functioning in active duty United States marines independent of combat exposure or emotional distress","volume":"31","author":"Spira","year":"2014","journal-title":"J Neurotrauma"},{"key":"ref9","doi-asserted-by":"crossref","DOI":"10.1007\/978-1-4614-7579-8_2","article-title":"The evolving definition of cognitive readiness for military operations","volume-title":"Teaching and measuring cognitive readiness","author":"Fletcher","year":"2014"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"576","DOI":"10.1017\/S1355617712000203","article-title":"The contributions of self-reported injury characteristics and psychiatric symptoms to cognitive functioning in OEF\/OIF veterans with mild traumatic brain injury","volume":"18","author":"Drag","year":"2012","journal-title":"J Int Neuropsychol Soc"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"521","DOI":"10.1682\/JRRD.2009.11.0181","article-title":"Self-reported cognitive symptoms following mild traumatic brain injury are poorly associated with neuropsychological performance in OIF\/OEF veterans","volume":"47","author":"Spencer","year":"2010","journal-title":"J Rehabil Res Dev"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"403","DOI":"10.1007\/s11682-015-9440-2","article-title":"Treatment of persistent post-concussive symptoms after mild traumatic brain injury: a systematic review of cognitive rehabilitation and behavioral health interventions in military service members and veterans","volume":"9","author":"Cooper","year":"2015","journal-title":"Brain Imaging Behav"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"E1","DOI":"10.1097\/HTR.0000000000000254","article-title":"Cognitive rehabilitation for military SMs with mild traumatic brain injury: a randomized clinical trial","volume":"32","author":"Cooper","year":"2017","journal-title":"J Head Trauma Rehabil"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"16","DOI":"10.1097\/HTR.0000000000000228","article-title":"Compensatory cognitive training for operation enduring freedom\/operation Iraqi freedom\/operation new Dawn veterans with mild traumatic brain injury","volume":"32","author":"Storzbach","year":"2017","journal-title":"J Head Trauma Rehabil"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"314","DOI":"10.3389\/fnagi.2017.00314","article-title":"Enhancing innovation and underlying neural mechanisms via cognitive training in healthy older adults","volume":"9","author":"Chapman","year":"2017","journal-title":"Front Aging Neurosci"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"69","DOI":"10.3389\/fnsys.2014.00069","article-title":"Enhancement of cognitive and neural functions through complex reasoning training: evidence from normal and clinical populations","volume":"8","author":"Chapman","year":"2014","journal-title":"Front Syst Neurosci"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"396","DOI":"10.1093\/cercor\/bht234","article-title":"Neural mechanisms of brain plasticity with complex cognitive training in healthy seniors","volume":"25","author":"Chapman","year":"2015","journal-title":"Cereb Cortex"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"338","DOI":"10.3389\/fnhum.2016.00338","article-title":"Distinct brain and behavioral benefits from cognitive vs. physical training: a randomized trial in aging adults","volume":"10","author":"Chapman","year":"2016","journal-title":"Front Hum Neurosci"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"e00687","DOI":"10.1002\/brb3.687","article-title":"Strategy-based reasoning training modulates cortical thickness and resting-state functional connectivity in adults with chronic traumatic brain injury","volume":"7","author":"Han","year":"2017","journal-title":"Brain Behav"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"497","DOI":"10.1016\/b978-0-444-63521-1.00031-5","article-title":"Language impairments in traumatic brain injury: a window into complex cognitive performance","volume":"128","author":"Vas","year":"2015","journal-title":"Handb Clin Neurol"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"1676","DOI":"10.3389\/fpsyg.2016.01676","article-title":"Enhancing executive function and neural health in bipolar disorder through reasoning training","volume":"7","author":"Venza","year":"2016","journal-title":"Front Psychol"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"176","DOI":"10.1093\/milmed\/usaa501","article-title":"Efficacy of cognitive training when translated from the laboratory to the real world","volume":"186","author":"Young","year":"2021","journal-title":"Mil Med"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"26","DOI":"10.1177\/1545968319868710","article-title":"Cognitive training reorganizes network modularity in traumatic brain injury","volume":"34","author":"Han","year":"2020","journal-title":"Neurorehabil Neural Repair"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"502","DOI":"10.1080\/09602011.2015.1044013","article-title":"Reasoning training in veteran and civilian traumatic brain injury with persistent mild impairment","volume":"26","author":"Vas","year":"2016","journal-title":"Neuropsychol Rehabil"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"P5.329","DOI":"10.1212\/WNL.82.10_supplement.P5.329","article-title":"Mid life hypometabolism in the precuneus may be associated with prior history of traumatic brain injury (TBI) (P 5.329)","volume":"82","author":"Soman","year":"2014","journal-title":"Neurology"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.neulet.2013.04.032","article-title":"Spontaneous brain activity in combat related PTSD","volume":"547","author":"Yan","year":"2013","journal-title":"Neurosci Lett"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"2955","DOI":"10.1002\/hbm.24052","article-title":"Neural correlates of reduced depressive symptoms following cognitive training for chronic traumatic brain injury","volume":"39","author":"Han","year":"2018","journal-title":"Hum Brain Mapp"},{"year":"2016","key":"ref28"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"279","DOI":"10.1097\/HTR.0b013e3181a66356","article-title":"Reliability and predictive validity of the Ohio State University TBI identification method with prisoners","volume":"24","author":"Bogner","year":"2009","journal-title":"J Head Trauma Rehabil"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"318","DOI":"10.1097\/01.HTR.0000300227.67748.77","article-title":"Initial reliability and validity of the Ohio State University TBI identification method","volume":"22","author":"Corrigan","year":"2007","journal-title":"J Head Trauma Rehabil"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"315","DOI":"10.1097\/01.HTR.0000300226.67748.3e","article-title":"Screening and identification of TBI","volume":"22","author":"Corrigan","year":"2007","journal-title":"J Head Trauma Rehabil"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"261","DOI":"10.1080\/13803395.2013.879096","article-title":"The use of the Rey 15-item test and recognition trial to evaluate noncredible effort after pediatric mild traumatic brain injury","volume":"36","author":"Green","year":"2014","journal-title":"J Clin Exp Neuropsychol"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"332","DOI":"10.1080\/13854046.2019.1643923","article-title":"Utility of the D-KEFS color word interference test as an embedded measure of performance validity","volume":"34","author":"Eglit","year":"2020","journal-title":"Clin Neuropsychol"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"62","DOI":"10.1080\/13803395.2022.2073334","article-title":"D-KEFS trail making test as an embedded performance validity measure","volume":"44","author":"Jurick","year":"2022","journal-title":"J Clin Exp Neuropsychol"},{"key":"ref35","doi-asserted-by":"publisher","first-page":"707","DOI":"10.3109\/02699052.2013.775484","article-title":"Let the games begin: a preliminary study using attention process training-3 and luminosity brain games to remediate attention deficits following traumatic brain injury","volume":"27","author":"Zickefoose","year":"2013","journal-title":"Brain Inj"},{"key":"ref36","doi-asserted-by":"publisher","first-page":"234","DOI":"10.1080\/13854040490501448","article-title":"Initial validation of a screening battery for the detection of HIV-associated cognitive impairment","volume":"18","author":"Carey","year":"2004","journal-title":"Clin Neuropsychol"},{"volume-title":"Revised comprehensive norms for an expanded Halstead-Reitan battery: demographically adjusted neuropsychological norms for African American and Caucasian adults","year":"2004","author":"Heaton","key":"ref37"},{"volume-title":"Hopkins verbal learning test-revised","year":"1998","author":"Brandt","key":"ref38"},{"volume-title":"Delis-Kaplan executive function system (D-KEFS)","year":"2001","author":"Delis","key":"ref39"},{"key":"ref40","doi-asserted-by":"publisher","first-page":"367","DOI":"10.2466\/pms.1977.44.2.367","article-title":"Paced auditory serial-addition task: a measure of recovery from concussion","volume":"44","author":"Gronwall","year":"1977","journal-title":"Percept Mot Skills"},{"key":"ref41","doi-asserted-by":"publisher","first-page":"53","DOI":"10.1016\/j.acn.2005.07.006","article-title":"A comprehensive review of the paced auditory serial addition test (PASAT)","volume":"21","author":"Tombaugh","year":"2006","journal-title":"Arch Clin Neuropsychol"},{"volume-title":"Symbol digits modalities test: manual","year":"2007","author":"Smith","key":"ref42"},{"key":"ref43","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1097\/00001199-199510030-00002","article-title":"Persistent postconcussion syndrome: the structure of subjective complaints after mild traumatic braininjury","volume":"10","author":"Cicerone","year":"1995","journal-title":"J Head Trauma Rehabil"},{"key":"ref44","doi-asserted-by":"publisher","first-page":"1063","DOI":"10.1080\/13854046.2016.1193632","article-title":"Interpreting change on the neurobehavioral symptom inventory and the PTSD checklist in military personnel","volume":"30","author":"Belanger","year":"2016","journal-title":"Clin Neuropsychol"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"614","DOI":"10.1080\/13854046.2014.894576","article-title":"Normative data for the neurobehavioral symptom inventory (NSI) and post-concussion symptom profiles among TBI, PTSD, and nonclinical samples","volume":"28","author":"Soble","year":"2014","journal-title":"Clin Neuropsychol"},{"key":"ref46","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1097\/HTR.0000000000000009","article-title":"The structure of postconcussion symptoms on the neurobehavioral symptom inventory: a comparison of alternative models","volume":"30","author":"Vanderploeg","year":"2015","journal-title":"J Head Trauma Rehabil"},{"key":"ref47","doi-asserted-by":"publisher","first-page":"277","DOI":"10.1053\/apmr.2003.50100","article-title":"Development of the key behaviors change inventory: a traumatic brain injury behavioral outcome assessment instrument","volume":"84","author":"Kolitz","year":"2003","journal-title":"Arch Phys Med Rehabil"}],"container-title":["Frontiers in Neurology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2025.1541894\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,4,9]],"date-time":"2025-04-09T04:10:41Z","timestamp":1744171841000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2025.1541894\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,4,9]]},"references-count":47,"alternative-id":["10.3389\/fneur.2025.1541894"],"URL":"https:\/\/doi.org\/10.3389\/fneur.2025.1541894","relation":{},"ISSN":["1664-2295"],"issn-type":[{"type":"electronic","value":"1664-2295"}],"subject":[],"published":{"date-parts":[[2025,4,9]]},"article-number":"1541894"}}