Interventions Following Moderate to Severe TB

A number of problems are encountered when attempting to judge the efficacy of interventions for more severe TBI. Randomised controlled trials (RCTs) are commonly taken to be the “gold standard” for evaluating the strength of evidence for medical interventions. However this type of evidence is very difficult to obtain with the TBI population because of practical and ethical restraints on withholding treatments for severely injured patients, who do not have recourse to alternatives. Another problem is that TBI is very complex and heterogeneous and two individuals with the same injury- severity may have very different patterns of impairment, with different prognoses and different rehabilitation needs. This is complicated by a lack of agreement on

instruments and measures, even in areas as basic as injury-severity (see chapter 2). Rehabilitation after TBI is a long-term process taking months or even years, which makes measurement of outcome difficult in practical terms. There are also significant problems in judging outcome. Although most health professionals would agree that the best measure is quality of life, this is difficult to measure; most studies revert to less satisfactory, but more measurable, outcomes such as productivity or work (Chesnut, 1999).

A number of recent reviews of the rehabilitation field have helped to draw together the evidence for progress made, and highlight areas of weakness that need to be addressed. In USA, a National Institutes of Health (NIH) consensus conference

(National Institutes of Health Consensus Development Panel on Rehabilitation of Persons With Traumatic Brain Injury, 1999) identified a need to confirm which rehabilitation interventions are effective through well-designed and controlled studies and the characteristics of individuals who will benefit from them—“what works for whom”. The focus of the conference was the evaluation of rehabilitative measures for

the cognitive and behavioural consequences of TBI. While pointing out that research in this area was limited, the conference report stated that scientific evidence supports the use of certain cognitive and behavioural rehabilitation strategies, and that effective interventions share a number of certain characteristics: They are structured, systematic, goal-directed and individualised; and involved learning, practice, social contact and a relevant context. The consensus panel also pointed out that the epidemiological data suffer from ascertainment bias, since they are based exclusively on information about hospitalised patients. As a result mTBI is significantly under-diagnosed and early intervention is often neglected.

A systematic review of the effectiveness of TBI rehabilitation (Chesnut, 1999) highlighted limitations in research design, methods of analysis, patient selection, and relevant outcome measures, but reported that the strongest studies suggest positive effects from early intervention on recovery after TBI (Cope & Hall, 1982),

compensatory cognitive rehabilitation (Carney et al., 1999) and supported-employment (Haffey & Abrams, 1991). These researchers also pointed out that the limitations highlighted call into question the results of the many studies with negative findings: lack of observed treatment effect may be due to inadequate design and not to lack of treatment efficacy.

A review of evidence-based recommendations for the clinical practice of cognitive rehabilitation (Cicerone, et al., 2000) found clear evidence supporting its effectiveness for the impairments of attention, functional communication, memory and problem solving after TBI in eight prospective RCTs. This type of program has been shown to improve community functioning (Cicerone, Mott, Azulay, & Friel, 2004; Goranson, Graves, Allison, & La Freniere, 2003; Malec, 2001; Seale et al., 2002), while specific neuropsychological interventions for deficits in memory, attention, and

executive functioning have also been found to be effective; (Fasotti, Kovacs, Eling, & Brouwer, 2000; Gordon, et al., 2006; Sohlberg, McLaughlin, Pavese, Heidrich, & Posner, 2000)

A review of TBI rehabilitation research by Gordon et al (2005) examined literature published between 1998 and 2004. The authors addressed some of the questions arising from the NIH consensus conference, and reported that a clearer understanding of who gets injured and some of the factors relating to their recovery had emerged. However in terms of evaluating the efficacy of interventions, or of

developing new treatments, less had been accomplished. Previous findings that comprehensive holistic cognitive rehabilitation improves community functioning were confirmed, and it was noted that specific neuropsychological interventions for deficits in memory, attention, and executive functioning had also been found to be effective. Weaknesses highlighted include the finding that in studies of outcome, samples were often small, and rarely representative of the TBI population. Furthermore, although strong evidence was found to suggest that TBI results in disturbances of mood (depression and anxiety disorders) and antisocial behaviour (for example substance abuse) information on interventions, be they psychological, behavioural or

pharmaceutical, was found to be inadequate to guide effective practice.

In 2005 a Cochrane review (Turner-Stokes, et al., 2005) looked at the evidence, from RCTs for the effectiveness of multidisciplinary rehabilitation following acquired brain injury (ABI) in adults of working age, across a range of injury severities. It is important to note that this review was of acquired brain injury, which includes non- traumatic injuries such as those from stroke. However, the majority of studies were of TBI (9 out of a total of14 trials were of TBI). For moderate to severe brain injury this review found strong evidence of benefit from formal intervention—more intense in-

patient programmes were associated with earlier functional gains—and there was moderate evidence that continued outpatient therapy can help continue the gains made in early post-acute rehabilitation. Some recommendations from the review were that patients presenting acutely to hospital with moderate to severe injuries should be routinely followed-up to assess their need for rehabilitation, and patients discharged from in-patient rehabilitation should have access to out-patient, or community-based services, appropriate to their needs. It also found strong evidence that most individuals with milder injuries make a good recovery with provision of appropriate information and advice. A subsequent review (Turner-Stokes, 2008) of non-trial based methods— such as cohort analyses and qualitative studies—found strong evidence supporting and extending the Cochrane Review findings, indicating that there is now a substantial body of high-quality research evidence for the effectiveness, including cost effectiveness (Khan, Khan, & Feyz, 2002; Murphy et al., 2006; Wood, McCrea, Wood, & Merriman, 1999) of rehabilitation for TBI.