THIS EVIDENCE REPORT IS OUTDATED AND IS NO LONGER VIEWED AS GUIDANCE FOR CURRENT MEDICAL PRACTICE. IT IS MAINTAINED FOR ARCHIVAL PURPOSES ONLY.

Evidence Report/Technology Assessment

Number 2

Prepared for:
Agency for Health Care Policy and Research

Department of Health and Human Services
U.S. Public Health Service
2101 East Jefferson Street
Rockville, MD 20852
http://www.ahcpr.gov

Contract No. 290-97-0018

Prepared by:
Oregon Health Sciences University, Portland, OR
Randall M. Chesnut, MD
Principal Investigator

Nancy Carney, PhD
Hugo Maynard, PhD
Patricia Patterson, PhD
N. Clay Mann, PhD
Mark Helfand, MD, EPC Director

AHCPR Publication No. 99-E006

February 1999

The authors thank the members of the Brain Injury Support Group of Portland for their support and the use of their library. They also thank the Portland State University Capstone students who volunteered their time to help with the project: Heather Brooks, Samantha Cohen, Justin Davis, Cynthia Davis-O'Reilly, Julie Geil, Cheryl Matsumura, and Jeana Schoonover.

The American Academy of Family Practice provided the model, its Clinical Policy Review Form, on which the authors based their review form for this report.

The Agency for Health Care Policy and Research (AHCPR), through its Evidence-based Practice Centers (EPCs), sponsors the development of evidence reports and technology assessments to assist public- and private-sector organizations in their efforts to improve the quality of health care in the United States. The reports and assessments provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies. The EPCs systematically review the relevant scientific literature on topics assigned to them by AHCPR and conduct additional analyses when appropriate prior to developing their reports and assessments.

To bring the broadest range of experts into the development of evidence reports and health technology assessments, AHCPR encourages the EPCs to form partnerships and enter into collaborations with other medical and research organizations. The EPCs work with these partner organizations to ensure that the evidence reports and technology assessments they produce will become building blocks for health care quality improvement projects throughout the nation. The reports undergo peer review prior to their release.

AHCPR expects that the EPC evidence reports and technology assessments will inform individual health plans, providers, and purchasers as well as the health care system as a whole by providing important information to help improve health care quality.

We welcome written comments on this evidence report. They may be sent to: Director, Center for Practice and Technology Assessment, Agency for Health Care Policy and Research, 6010 Executive Blvd., Suite 300, Rockville, MD 20852.

Douglas B. Kamerow, M.D. Director, Center for Practice and Technology Assessment Administrator Agency for Health Care Policy and Research	John M. Eisenberg, M.D. Administrator Agency for Health Care Policy and Research

The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Health Care Policy and Research or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or other clinical service.

Objective. To examine the evidence for effectiveness of rehabilitation methods at various phases in the course of recovery from traumatic brain injury (TBI) in adults. Specifically, we 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, and (5) care coordination (case management).

Search Strategy. A MEDLINE search (1976 to 1997), supplemented by searches of HealthSTAR (1995 to 1997), CINAHL (1982 to 1997), PsycINFO (1984 to 1997), and reference lists of key articles.

Selection Criteria. Broad inclusion criteria were defined for screening eligible abstracts. Two reviewers read each abstract to determine its eligibility. Full articles were included if they met methodologic criteria and were relevant to one of the causal links identified for each major question. Specifically, we included all comparative (controlled) studies, as well as uncontrolled series that had information about the short- or long-term outcomes associated with rehabilitation for traumatic brain injury.

Data Collection and Analysis. We developed an instrument to record data abstracted from each eligible article. The instrument includes items for patient characteristics, interventions, co-interventions, outcomes, study methods, relevance to the specific research questions, and results of the study. We used a three-level system to rate individual studies. Well-designed randomized controlled trials (RCTs) were rated as Class I. RCTs with design flaws, well-done, prospective, quasiexperimental or longitudinal studies, and case-control studies were rated as Class II. Case reports, uncontrolled case series, and expert or consensus opinion were generally rated Class III. Comparative studies that met inclusion criteria were critically appraised and summarized in evidence tables.

Main Results. A total of 3,098 references were specified for inclusion. After removal of duplicates, 569 applied to questions 1 and 2, 600 applied to question 3, 392 applied to question 4, and 975 applied to question 5. Eighty-seven articles pertaining to questions 1 and 2, 114 articles for question 3, 93 articles for question 4, and 69 articles for question 5 passed the eligibility screen. Sixty-seven additional articles were recommended for inclusion by experts or were obtained from reference lists of review articles. There was weak evidence from Class III studies that early rehabilitation during the acute admission reduces the rehabilitation length of stay. Studies of the intensity of acute inpatient rehabilitation had inconsistent results and used study designs that, despite appropriate use of statistical methods to adjust for severity, had serious limitations because of confounders. Controlled trials of cognitive rehabilitation had mixed results, with the strongest evidence (Class I) supporting the use of prosthetic aids to memory. Well-done, prospective observational studies (Class II) support the use of supported employment within the context of well-designed, well-coordinated programs. From one Class II clinical trial, there was no support for case management, but two well-done Class III studies support the use of case management to produce functional improvements.

Conclusions. 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.

This document is in the public domain and may be used and reprinted without permission.

Suggested Citation:

Chesnut RM, Carney N, Maynard H, et al. Rehabilitation for traumatic brain injury. Evidence report no. 2 (Contract 290-97-0018 to Oregon Health Sciences University). Rockville, MD: Agency for Health Care Policy and Research. February 1999.