Multidisciplinary Postacute Rehabilitation for Moderate to Severe Traumatic Brain Injury in Adults : Comparative Effectiveness Review Number 72.cAgency for Healthcare Resea And Quality
Traumatic brain injury (TBI) is an alteration in brain function or other evidence of brain pathology caused by an external force. TBI is a significant public health issue in the U.S., with an estimated 1.7 million TBIs per year from 2002 to 2006. Of those injured each year from 2002 to 2006, 1.37 million were treated and released from emergency departments, 275,000 were hospitalized, and 50,000 died from their injuries. Incidence is highest among children, adolescents, and young adults, but hospitalization and death occur most often among those age 75 and older. Major causes of TBIs include falls (35.2%), motor vehicle crashes (17.3%), struck by/against events (16.5%), assaults (10%), and other/unknown (21%); and, for military personnel or survivors of terrorist attacks, explosions/blasts. Blast incidents account for the majority of combat injuries, 60% of which result in TBI. TBIs are categorized as mild, moderate, or severe according to acute injury characteristics that suggest the extent of damage to the brain. Multiple measures are used to assess severity, including structural imaging findings; duration of loss of consciousness, altered consciousness and/or post-traumatic amnesia; the Glasgow Coma Scale (GCS) score; and the Abbreviated Injury Severity Scale score. Although experts in the field believe that comprehensive multidisciplinary postacute rehabilitation is the best approach for addressing impairments from moderate to severe TBI, access to these services can be problematic. Health insurance reimbursement policies may limit the degree to which patients can participate in rehabilitation programs. Uncertainty about which patients are likely to benefit from specific rehabilitation programs contributes to lack of full coverage, and impedes advocacy efforts for appropriate care. Our review differs from prior efforts in several ways. We emphasize selected patient centered participation outcomes of productivity and community integration, thus offering an important perspective unique from other reviews. In addition, many treatments target specific functional difficulties regardless of etiology. Therefore, rehabilitation programs often enroll both TBI patients and those with non-traumatic brain injuries (primarily stroke patients). However, stroke patients differ distinctly from TBI survivors. Further, evidence suggests that TBI patients achieve greater functional outcomes than stroke patients when matched on age and demographic characteristics. Therefore, we specifically address the moderate- to severe-TBI population. Finally, our review includes prospective cohort studies in addition to RCTs. We examine evidence of effectiveness and comparative effectiveness of multidisciplinary rehabilitation programs in restoring individuals with moderate to severe TBI to participation in their communities. Our full report provides a detailed description of this systematic review. We address the following Key Questions (KQs): KQ1: How have studies characterized multidisciplinary postacute rehabilitation for TBI in adults? KQ2: What is the effectiveness and comparative effectiveness of multidisciplinary postacute rehabilitation for TBI? a. Do effectiveness and comparative effectiveness vary by rehabilitation timing, setting, intensity, duration, or composition? b. Do effectiveness and comparative effectiveness vary by injury characteristics? c. Do effectiveness and comparative effectiveness vary by patient characteristics, preinjury or postinjury? KQ3: What evidence exists to establish a minimum clinically important difference (MCID) in community reintegration as measured by the Mayo-Portland Adaptability Inventory (MPAI) for postacute rehabilitation for TBI in adults? KQ4: Are improvements in outcomes achieved via multidisciplinary postacute rehabilitation for TBI sustained over time? KQ5: What adverse effects are associated with multidisciplinary postacute rehabilitation for TBI?
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