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Rehabilitation for traumatic brain injury |
Chesnut R M, Carney N, Maynard H, Patterson P, Clay Mann N, Helfand M |
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Authors' objectives To examine the evidence for effectiveness of rehabilitation methods at various phases in the course of recovery from traumatic brain injury (TBI) in adults.
Searching MEDLINE (1966 to 1997 for randomised controlled trials, otherwise 1976 to 1997), CINAHL (1982 to 1997), HealthSTAR (1995 to 1997), and PsycINFO (1984 to 1997) were searched. Four MEDLINE search strategies were used, the first for review questions (1) and (2), and one for each of the remaining three research questions. The search terms used for all search strategies are listed in an appendix. The Cochrane Collaboration made available a database of around 500 articles on brain and spinal cord injury, which was searched for articles about rehabilitation. Current Contents was referred to on a monthly basis between November 1997 and May 1998. Articles recommended by experts or identified through reference lists were also retrieved. Foreign language papers were not sought.
Study selection Study designs of evaluations included in the reviewStudies considered relevant to the review questions were retrieved for review and abstraction. Inclusion criteria were applied for each review question. These were:
1. Data specific to the question.
2. Sound scientific methods.
3. Rehabilitation as the intervention.
4. Independent variable specific to the question.
5. Dependent variable specific to the question. A three level system was used to rate individual studies.
Specific interventions included in the reviewThe authors addressed five questions about the effectiveness of:
1. Early rehabilitation in the acute care setting.
2. Intensity of acute inpatient rehabilitation.
3. Cognitive rehabilitation.
4. Supported employment.
5. Carecoordination (case management).
Studies of pharmacological interventions and acute care were excluded.
Participants included in the reviewParticipants were adults with TBI who were included in studies that examined rehabilitation methods in the course of recovery from TBI. Studies of people with carbon monoxide poisoning were excluded as were paediatric studies and studies relating to alcohol/drug use or stroke.
Outcomes assessed in the reviewNo specific inclusion/exclusion criteria relating to outcomes were given. Included papers used a variety of outcome measures, including: Rehabilitation length of stay (LOS); measures such as the Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS) and Functional Independence Measure (FIM); brain scans (MRI and CT); and various measures of physical/motor/sensory/perceptual outcomes and various measures of cognitive/language outcomes.
How were decisions on the relevance of primary studies made?Abstracts were screened independently by two reviewers. Where these two reviewers disagreed, a third reviewer examined the article and cast the deciding vote. For citations without abstracts or with an indeterminable title, full articles were retrieved. The data extraction instrument had two components: the first component applied to all articles specified for inclusion in the study and the second component applied to one of the five key questions. A reviewer could exclude an article on the basis of the first few questions of the data extraction instrument. If this was this case, the article was to be passed on to a second reviewer for confirmation.
Assessment of study quality Key studies were critically appraised using a list of 18 criteria relating to methodology, reporting of methods and outcomes, and relevance to the review. These were: prospective data collection; complete description of patient population; sample size; setting; reasons for referral to service studied; full description of methods; full description of rehabilitation technique; full description of comparison groups; conditions determining whether subjects did or did not receive the study rehabilitation technique; information about potential confounders; valid measurement of confounding variables; payer group; outcomes meaningful to survivors as well as caregivers; use of functional status and other health outcomes; valid measurement of outcome variables; timing of outcome measurements; blinded assessment of survivor characteristics and outcomes; use of multivariate statistical analysis. 'Key' articles for each research question were reviewed by a specific subcommittee, comprised of members of the research team and the local technical panel. The results were summarised by the chair. All of the critical articles for the five questions were individually read by the principal investigator. Summaries were presented and discussed with national experts at the Aspen Neurobehavioral Conference in April 1998.
Data extraction The authors do not state how many of the reviewers performed the data extraction. A data extraction instrument was designed by the research team and a panel of technical experts. This included items for patient characteristics, interventions, co-interventions, outcomes, study methods, relevance to the specific research questions, and results of the study.
Methods of synthesis How were the studies combined?Studies that met the inclusion criteria and were relevant to a particular review question were tabulated and combined by narrative review.
How were differences between studies investigated?The authors did not carry out any formal test of heterogeneity, but discussed the differences between included articles in terms of settings, outcomes and methodological quality.
Results of the review A total of 85 articles pertaining to questions 1 and 2, 73 articles for question 3, 56 articles for question 4, and 73 articles for question 5 were included.
1. One small, retrospective, single-centre, observational study supported an association between the acute institution of formalised, multidisciplinary, physiatrist-driven TBI rehabilitation and decreased length of stay (acute hospital and acute rehabilitation) and some measures of short-term physiologic (noncognitive) patient outcomes. There was no evidence from comparative studies for or against early rehabilitation in patients with mild and moderate injury.
2. When measured as the hours of application of individual or grouped therapies, there was no indication that the intensity of acute, inpatient TBI rehabilitation is related to outcome. Because of methodological weaknesses, however, previous studies are likely to have missed a significant relationship if one exists (Type II error).
3. There was evidence from two small studies (one well-designed RCT and one observational study) that a personally adapted electronic device, a notebook, and an alarm wristwatch reduce everyday memory failures for people with TBI. There was evidence from one cohort study that compensatory cognitive rehabilitation (CCR) reduces anxiety and improves self-concept and relationships for people with TBI. Evidence from one RCT and one cohort study supported the use of computer-aided cognitive rehabilitation (CACR) to improve immediate recall on neuropsychological testing, but the clinical importance of this finding has not been validated.
4. Some evidence indicated that supported employment can improve the vocational outcomes of TBI survivors. Nearly all information about supported employment comes from two bodies of work, each which used different experimental designs and different models of supported employment. The findings have not been replicated in other settings by other centres, so the generalisability of these programmes remains untested.
5. There have been very few studies on the effectiveness of case management, and the results of these studies are mixed. One clinical trial resulted in no functional status changes among case-managed subjects, despite an extended period of rehabilitation. However, when two forms of case-management were compared, both single and multiple case-manager/insurance approaches showed significant functional improvements.
Cost information Cost data from one retrospective study of increased intensity of rehabilitation (from an average of 5.5 to 8 hours per day) was reported. This study projected an average cost saving of $16,950 for coma treatment and $18,504 for acute treatment patients.
Authors' conclusions In a journal article based on this Evidence Report (See Other Publications of Related Interest no.1), the authors conclude that in TBI rehabilitation research, there are very few studies that use standards for constructing strong experiments that are widely accepted in other areas of medical research. The strongest studies suggest positive effects of early intervention, compensatory cognitive rehabilitation, and supported employment. However, limits in research design, methods of analysis, patient selection, and relevant outcome measures render the results inappropriate for application to guidelines or standards.
They state that the proper interpretation of this report is that in the presence of a need for treatment and the absence of clearly superior alternatives, choices must be made between therapies without proven superiority over others, based on clinical pragmatism.
CRD commentary This was a fairly well-conducted review of the available literature on rehabilitation methods for TBI. The five review questions were clearly stated and were supported by inclusion and exclusion criteria. A number of databases were searched using several different search strategies and further papers were identified from experts and the reference lists of review articles. However, only English language papers were selected, so relevant material may have been omitted. Key articles were validity assessed using appropriate criteria, although it is not entirely clear how many reviewers carried out this process. The key studies were presented in reasonable detail and were combined appropriately through narrative review. Although heterogeneity was not assessed formally, the authors did discuss important differences between the included studies in their results and conclusions. The authors' conclusions and recommendations appear to follow from the findings of the review.
Implications of the review for practice and research Practice: In a journal article based on this Evidence Report (see Other Publications of Related Interest no.1), the authors conclude that in TBI rehabilitation research there are very few studies that use standards for constructing strong experiments that are widely accepted in other areas of medical research. The strongest studies suggest positive effects of early intervention, compensatory cognitive rehabilitation and supported employment. However, limitations in research design, methods of analysis, patient selection and relevant outcome measures render the results inappropriate for application to guidelines or standards.
The authors also state that the proper interpretation of this report is that, in the presence of a need for treatment and the absence of clearly superior alternatives, choices must be made between therapies without proven superiority over others, based on clinical pragmatism.
Research: Population-based studies are needed to examine the overall impact of TBI and the differences in outcomes associated with different rehabilitation strategies. Future studies of cognitive rehabilitation and case management should focus on health outcomes of importance to people with TBI and their families.
Bibliographic details Chesnut R M, Carney N, Maynard H, Patterson P, Clay Mann N, Helfand M. Rehabilitation for traumatic brain injury. Rockville, MD, USA: Agency for Health Care Policy and Research. Evidence Report/Technology Assessment; 2. 1999 Other publications of related interest 1. Chesnut R M, Carney N, Maynard H, Clay Mann N, Patterson P, Helfand M. Summary Report: Evidence for the effectiveness of rehabilitation for persons with traumatic brain injury. J Head Trauma Rehabil 1999;14(2):176-88. 2. Carney N, Chesnut R M, Maynard H, Clay Mann N, Patterson P, Helfand M. Effect of cognitive rehabilitation on outcomes for persons with traumatic brain injury: A systematic review. J Head Trauma Rehabil 1999;14(3):277-307. 3. Patterson P, Maynard H, Chesnut R M, Carney N, Clay Mann N, Helfand M. Evidence of case management effect on traumatic-brain-injured adults in rehabilitation. Care Management Journals 1999;1(2):87-97.
Indexing Status Subject indexing assigned by CRD MeSH Brain Injuries /rehabilitation AccessionNumber 12000008346 Date bibliographic record published 31/08/2001 Date abstract record published 31/08/2001 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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