Effectiveness of brain injury rehabilitation

Abstract

Despite the problems posed by diversity of condition and the lack of agreement among researchers over what outcome to measure, there is now increasingly robust evidence for the effectiveness of rehabilitation in brain-injured populations. Meta-analysis has demonstrated clearly that stroke units provide a better outcome than management on a general medical ward, at the level of survival, discharge destination and dependency. The extent of this advantage may be summarized in the following terms. For every 100 patients treated in a stroke unit, four deaths and two institutional admissions are avoided, and five patients are discharged home. This benefit appears to arise from a combination of good-quality acute management and the coordinated input of a multidisciplinary team. Therapy programmes are shown to be of benefit and intensive therapy programmes of somewhat greater benefit. Smaller numbers and heterogeneity among the head-injured population tend to confound randomized controlled trial designs, but there is no good reason to suppose that brain injury resulting from trauma should be less responsive to similar good management principles than that arising from stroke. In any event, we have progressed to a stage where the weight of evidence supports the notion that rehabilitation is effective, and nontreatment controls are ethically no longer acceptable. It is time now to unravel the threads of rehabilitation and consider which are the critical components. There are still many opportunities for comparison of different models for delivery of care, and the existing evidence for these is discussed.

Effectiveness of Multidisciplinary Rehabilitation Services in Postacute Care: State-of-the-Science. A Review

“…In contrast to the rehabilitation literature on acquired brain injury, which includes stroke and brain damage from several causes, there were too few RCTs of multidisciplinary rehabilitation specifically for traumatic brain injury to draw any conclusions. 19 Turner-Stokes et al were only able to conclude that "the majority of patients with mild traumatic brain injuries make a good recovery." 11 (p9)…”

“…11,36 Particularly for conditions in which multidisciplinary rehabilitation has become the standard of care without systematic evidence to support it in practice, 31 denying services randomly in order to conduct an RCT could be considered unethical, as has been the case with patients with spinal cord and traumatic brain injuries. 19,37 Thus, at a global health services level, restricting evidence of rehabilitation effectiveness to RCTs, unless they compare standard care to more intensive or specialized rehabilitation, may be unreasonable both ethically and practically. The best alternative may be to either prospectively or retrospectively study the real-world clinical environment using nonrandomized designs appropriately adjusting for selection bias.…”

“…30 This standard for efficacy research, however, has several methodologic challenges. 19,31,32 Designing an RCT with an adequate sample size, appropriate randomization techniques to account for variability in the diagnostic conditions (ie, level of spinal cord injury), and a combination of patient, service and/or system-level outcome measures, is impractical because of the current limitations in rehabilitation research funding. 2,29,31 In addition, rehabilitation RCTs that study long-term outcomes that occur after treatment may not be appropriate for progressive conditions-such as advanced multiple sclerosis or Parkinson's disease-that inevitably are going to worsen over time regardless of how they are managed.…”

“…In contrast to the rehabilitation literature on acquired brain injury, which includes stroke and brain damage from several causes, there were too few RCTs of multidisciplinary rehabilitation specifically for traumatic brain injury to draw any conclusions. 19 Turner-Stokes et al were only able to conclude that "the majority of patients with mild traumatic brain injuries make a good recovery." 11 (p9) Beaupre 20 and Cameron 21 and colleagues reported a similar challenge: there is no clear level 1 evidence (RCT or systematic review) with which to determine the efficacy of multidisciplinary rehabilitation for hip fracture patients.…”

The efficacy of community-based rehabilitation programmes for adults with TBI

“…Hospital-based services are excluded from this definition. The aim of community rehabilitation is to enhance the client's quality of life and functional independence in the context of their regular roles and routines (Powell, 1999;Rice-Oxley and Turner Stokes, 1999) and to minimize the practical and psychological impact on the carers (Tyerman, 1999;Wood and Worthington, 1999).…”