More Research Needed on Effectiveness of Rehabilitation for Traumatic Brain Injury

Press Release Date: December 15, 1998

More research is needed on the effectiveness of rehabilitation for traumatic brain injury (TBI), according to an exhaustive analysis of the scientific literature by Oregon Health Sciences University (OHSU). The year-long study, conducted by OHSU in its capacity as an Agency for Health Care Policy and Research (AHCPR) Evidence-based Practice Center, found no strong evidence supporting one rehabilitation strategy over another.

TBI results from motor vehicle accidents, gunshot wounds, falls and other traumas to the head. Advances in medical technology and improvements in regional trauma services have increased the number of survivors of TBI. Each year, about 80,000 TBI survivors will have some disability or require increased medical care, leading to annual direct medical costs of an estimated $48.3 billion (including the costs of acute care hospitalization and the costs of various rehabilitation services).

In conducting its analysis, OHSU explored five research questions related to the phases of recovery from TBI in adults. The questions address the timing of interdisciplinary rehabilitation; the intensity of inpatient interdisciplinary rehabilitation; the effectiveness of cognitive rehabilitation; the use of supported employment (on-site aid and advocacy at the place of employment, with the goal of enabling people with severe or long-term or permanent deficit to resume a productive life); and the provision of long-term care coordination (case management).

Following are OHSU's main findings:

• There is evidence that a form of cognitive rehabilitation that provides environmental cues and assistance (for example, personally adapted electronic devices that provide reminders to perform certain tasks) improves everyday memory function, and that other forms reduce anxiety and improve self-concept and relationships.
• Although the evidence is weak, it may be of benefit to patients, the health care system and payers to initiate coordinated, multidisciplinary rehabilitation for patients with severe TBI as soon as possible after their admission to the trauma center.
• There is insufficient evidence on which to base decisions regarding the application of intensive inpatient rehabilitation. Currently, studies use "number of hours of therapy" as a measure of treatment intensity, which does not take into account the quality or productivity of each session. A better measure of intensity must be developed, and new studies conducted, to address this issue.
• Supported employment appears to be a promising way to increase the success of survivors of TBI in the workplace, but the studies do not give definitive proof of its effectiveness and do not provide enough clarity on why it works or its best application and use.
• At this time there is no clear research evidence for or against the effectiveness of case management for people with TBI and their families.

"This study demonstrates that the present state of research in traumatic brain injury is rather weak. In terms of practice, we cannot state that any one treatment approach is markedly superior to another. Most treatments appear to have some beneficial effect," according to Randall M. Chesnut, M.D., principal investigator for the project. "The major implication of this study is that all those involved in TBI rehabilitation—including caregivers, payers and government agencies—must seriously begin working together to improve our ongoing research efforts so that future evidence-based reviews will not find shortcomings such as this one. "OHSU's evidence report has laid the substantial groundwork necessary for continued evidence-based research and quality improvement efforts in the important area of traumatic brain injury," said AHCPR Administrator John M. Eisenberg, M.D. "We are very pleased that the evidence already is being translated into improved medical practice by the International Brain Injury Association as it develops TBI guidelines for children and adolescents, and by the National Institutes of Health (NIH) Consensus Development Conference."

OHSU was aided in its research by the planning committee for the NIH Consensus Development Conference on Rehabilitation of Persons with Traumatic Brain Injury and by the Brain Injury Association, Inc., Panel members of the Consensus Development Conference reviewed the OHSU draft evidence report as part of their year-long review of medical literature related to rehabilitation of people with TBI. Dr. Chesnut presented the findings of the evidence report at the consensus conference, which was held October 26-28, 1998.

The TBI evidence report is part of a new series of evidence reports and technology assessments sponsored by AHCPR to provide public- and private-sector organizations with comprehensive, science-based information on common, costly medical conditions and health care technologies. OHSU is one of 12 AHCPR Evidence-based Practice Centers in the United States and Canada under contract to review all the relevant literature on designated topics related to prevention, diagnosis, treatment and management of common diseases and clinical conditions, and where appropriate, use of alternative/complementary therapies, and technology assessments of specific medical procedures or health care technologies.

Select to access the online summary of Evidence Report on Rehabilitation for Traumatic Brain Injury (AHCPR 99-E005). Print copies are available from AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907; telephone 1-800-358-9295 within the United States, and (703) 437-2078 outside the United States.

The full report will be posted in late January 1999, on the National Library of Medicine's HSTAT database. Also at that time, printed copies will become available from the AHCPR Publications Clearinghouse.

Forthcoming AHCPR evidence reports and technology assessments examine drug therapy for alcohol dependence, evaluation of abnormal cervical cytology, depression treatment with new drugs, treatment of attention deficit/hyperactivity disorder, diagnosis and treatment of acute sinusitis, testosterone suppression treatment for prostatic cancer and other topics. Recently assigned topics include management of acute chronic obstructive pulmonary disease, management of cancer pain, criteria for weaning from mechanical ventilation and management of chronic hypertension during pregnancy. Additionally, OHSU will conduct a systematic review of the literature on TBI among children and adolescents.

AHCPR's first evidence report—Diagnosis of Sleep Apnea—was released December 8, and its summary is available online.

Note to Editors: For further details about the TBI evidence report, including the respective roles of OHSU and its partner organizations, call OHSU News and Publications Office, (503) 494-8231.

For additional information, contact AHCPR Public Affairs: Karen Migdail, (301) 427-1855 (KMigdail@ahrq.gov).

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Internet Citation:

More Research Needed on Effectiveness of Rehabilitation for Traumatic Brain Injury. Press Release, December 15, 1998. Agency for Health Care Policy and Research, Rockville, MD. http://www.ahrq.gov/news/press/tbipr3.htm

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