To determine the effectiveness and comparative effectiveness of multidisciplinary postacute rehabilitation for moderate to severe traumatic brain injury (TBI) in adults.
MEDLINE®, Cochrane Database of Systematic Reviews, PsycINFO, and the Physiotherapy Evidence Database (PEDro) bibliographic databases; hand searches of references of relevant systematic reviews.
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.
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.
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.