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Multidisciplinary Postacute Rehabilitation for Moderate to Severe Traumatic Brain Injury in Adults

Comparative Effectiveness Reviews, No. 72

Investigators: Michelle Brasure, PhD, MLIS, Greg J Lamberty, PhD, LP, ABPP, Nina A Sayer, PhD, Nathaniel W Nelson, PhD, ABPP, Roderick MacDonald, MS, Jeannine Ouellette, MS, James Tacklind, BS, Michael Grove, MS, Indulis R Rutks, BS, Mary E Butler, PhD, MBA, Robert L Kane, MD, and Timothy J Wilt, MD, MPH.

Minnesota Evidence-based Practice Center
Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Jun.
Report No.: 12-EHC101-EF
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Structured Abstract

Objective:

To determine the effectiveness and comparative effectiveness of multidisciplinary postacute rehabilitation for moderate to severe traumatic brain injury (TBI) in adults.

Data Sources:

MEDLINE®, Cochrane Database of Systematic Reviews, PsycINFO, and the Physiotherapy Evidence Database (PEDro) bibliographic databases; hand searches of references of relevant systematic reviews.

Review Methods:

We screened abstracts and full text articles of identified references for eligibility and reviewed randomized controlled trials (RCTs) and prospective cohort studies to describe intervention characteristics and evaluate evidence on participation outcomes of productivity and community integration and treatment harms. We extracted data, rated quality, and graded strength of evidence. Our primary outcomes included measures of participation in employment, school, or training and select scales measuring community integration (Mayo-Portland Adaptability Inventory [MPAI] and the Craig Handicap Assessment and Reporting Technique [CHART], Craig Handicap Assessment and Reporting Technique Short Form [CHART-SF], and the Community Integration Questionnaire [CIQ]). Data were collected on secondary patient-centered outcomes as well.

Results:

We found 16 studies that met our inclusion criteria. Interventions that could be classified as comprehensive holistic day treatment programs were the most often studied model of care. These interventions are characterized as integrated intensive programs delivered to cohorts of patients focusing on cognitive rehabilitation and social functioning. Eight studies that addressed primary outcomes and were assessed to have a low or moderate risk of bias were graded to evaluate effectiveness and comparative effectiveness. We found insufficient evidence on effectiveness. We found a low level of evidence that certain interventions were no different than others in terms of productivity outcomes at 1-year post-treatment. We found a low level of evidence that a comprehensive holistic day treatment program resulted in greater productivity, but not improved community integration, than the standard treatment. However, group differences no longer existed at 6 months post-treatment because the standard rehabilitation group made significant progress during the followup period. Gains made during rehabilitation appear to be sustained at followups 6 months to 1 year post-treatment. Interpretation of community integration from scales is complicated by little attention to minimal clinically important differences. One study addressed harms and found no treatment-related harms.

Conclusions:

The body of evidence is not informative regarding effectiveness or comparative effectiveness of multidisciplinary postacute rehabilitation. Further research should address methodological flaws common in these studies and further address effectiveness research questions.

Contents

540 Gaither Road, Rockville, MD 20850; www​.ahrq.gov

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10064-I, Prepared by: Minnesota Evidence-based Practice Center, Minneapolis, MN

Suggested citation:

Brasure M, Lamberty GJ, Sayer NA, Nelson NW, MacDonald R, Ouellette J, Tacklind J, Grove M, Rutks IR, Butler ME, Kane RL, Wilt TJ. Multidisciplinary Postacute Rehabilitation for Moderate to Severe Traumatic Brain Injury in Adults. (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-2007-10064-I.) AHRQ Publication No. 12-EHC101-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.

This report is based on research conducted by the Minnesota Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10064-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.

1

540 Gaither Road, Rockville, MD 20850; www​.ahrq.gov

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