In Reply: Our study was inspired partly by
Dr Prigatano's work,1 and we modeled our
program partly after his. Our staff was experienced in TBI milieu therapy,
and therapeutic alliances were indeed established with our patients in both
One goal was to maximize fitness for duty after TBI, which partly dictated
the timing of therapy. Despite the severity of their injuries, participants
had improved enough to become duty candidates. However, both the less-than-optimal
return to duty in this previously fit and relatively high-functioning group
and the differential effect of the 2 treatments in a subset analysis argue
against our patients being too well to benefit from intensive rehabilitation.
Aggressive behavior is a serious problem after TBI, but it is unlikely that
our milieu therapy increased it, since our home group had a similar increase.
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