1. Introduction and Methodology
ABI Acquired Brain Injury
ERABI Evidence-Based Review of Moderate to Severe Acquired Brain Injury
GCS Glasgow Coma Scale
GOS Glasgow Outcome Score
LOC Loss of Consciousness
PCT Prospective Controlled Trial
PEDro Physiotherapy Evidence Database
PTA Post-Traumatic Amnesia
RCT Randomized Controlled Trial
TBI Traumatic Brain Injury
No Key Points in this Module
The Evidence-Based Review of Moderate to Severe Acquired Brain Injury (ERABI) is designed to comprehensively review current scientific literature on acquired brain injury (ABI) rehabilitation in the acute and post-acute phase of recovery. ERABI aims to identify all currently described rehabilitation interventions with their associated evidence, while identifying gaps in the literature deserving further research, where appropriate.
ERABI aspires to descriptively report and compare existing rehabilitation interventions such that the evidence can be used to inform and change practice in a way that benefits the patient and the caregiving team. As of 2017, ERABI was primarily used by individuals in the United States of America, and most users were physicians. Though this is a Canadian based project, it has a large international audience.
ERABI is the first step in a larger process known as knowledge translation, which ultimately seeks to incorporate new evidence into evidence-based practice. Evidence-based practice as a model, facilitates flow between the most current research and encourages its application to patient care. The primary goals of evidence-based practice are to increase knowledge and awareness of new interventions, and integrate them into practice in a clinically meaningful and significant way.
1.2 Objective of the Evidence Based Review of Acquired Brain Injury
The aim of this project was to conduct a comprehensive, evidence-based review of the research literature regarding rehabilitation interventions for moderate to severe ABI. The authors systematically reviewed the research evidence to create a review that had direct benefit and relevance to both clinicians and researchers. Clinicians are able to objectively evaluate the current body of evidence for a given intervention, and use that to guide their practice if they so choose. The conclusions made in ERABI regarding the efficacy of interventions help both clinicians and patients be more informed about which interventions are supported by scientific evidence, and at what strength. From this review, we have developed a mechanism for continued collection and dissemination of the research evidence for moderate to severe brain injury. This allows for the incorporation of new evidence regarding a specific intervention as well as provides a mechanism for the introduction of new interventions altogether.
Evidence-based practice, because of its potential to improve patient care, has become a priority in the healthcare system. Medicine has a long history of relying on anecdotal experiences, which runs the danger of promoting practices that are ineffective, inefficient, and in some cases, produce less than optimal outcomes. Evidence-based practice is therefore an increasingly important element of clinical care.
The delivery of rehabilitation is typically done by a rehabilitation clinician/team on a one-on-one basis. The chronic and ever-evolving nature of many patients’ conditions makes it difficult to decide the optimum amount of therapy at the outset of treatment (Purtillo, 1992). Further, ABI rehabilitation outcomes reflect a process in which various decisions are made by different stakeholders. These stakeholders consider what is desirable, acceptable, reasonable, and appropriate, and how these decisions produce an outcome to which subjective assessments of worth or value will be attached (Banja, 1997). While evidence-based reviews may focus on the evidence existing for different interventions, the importance of the rehabilitation team cannot be underestimated when the results are being interpreted. It is the objective of this evidence-based review to provide information and support for clinicians at all levels of ABI rehabilitation.
1.3 Defining Acquired Brain Injury
1.3.1 Acquired Brain Injury
For the purposes of this evidence-based review, we used the definition of ABI employed by the Toronto Acquired Brain Injury Network (2005). ABI is defined as damage to the brain that occurs after birth and is not related to congenital disorders, developmental disabilities, or processes that progressively damage the brain. ABI is an umbrella term that encompasses traumatic and non-traumatic etiologies. ABI typically involves a wide range of impairments affecting physical, neurocognitive and/or psychological functioning. A person with an ‘ABI’ might therefore refer to an individual with a traumatic brain injury (TBI) of any severity, or a non-traumatic ABI such as a person with Herpes encephalitis, viral meningitis or acute hypertensive encephalopathy. As opposed to an insidious developmental process, an ‘ABI’ infers that a person, previously intact from a neurological perspective, subsequently ‘acquired’ some form of brain pathology during their lifespan. Common traumatic causes include motor vehicle accidents, falls, assaults, gunshot wounds, and sport injuries (Greenwald et al., 2003). Non-traumatic causes of ABI include focal brain lesions, anoxia, tumours, aneurysm, vascular malformations, and infections of the brain (Toronto Acquired Brain Injury Network, 2005).
Depending on the severity of the ABI, an individual can be left with physical, cognitive, sensory, and/ or social impairments. Eighteen module topics have been developed to address each of these specific issues. Module 6, for example, focuses on the challenges of cognitive impairments, which can result in memory or learning deficits that make it difficult for individuals to return to activities of daily living post ABI. These impairments can also make it difficult for individuals to establish the independence necessary to either return to work or reintegrate to community life. Related to that, Module 13 has been established to focus specifically on the challenges of vocational and community reintegration post ABI. By providing the evidentiary support for these interventions clinicians can apply them in the appropriate context to benefit each of their patients on an individual level.
Given that ‘ABI’ is a loosely defined term, studies with an ‘ABI’ population can be equally vague in terms of the sample composition. Such studies may include any combination of persons with TBI, diffuse cerebrovascular events (i.e., subarachnoid hemorrhage) or diffuse infectious disorders (i.e., encephalitis or meningitis). Most individuals with ABI have a traumatic etiology; therefore, much of the brain injury literature is specific to TBI. The terms ABI and TBI have been used intentionally throughout ERABI to provide more information about populations where relevant.
1.3.2 Defining Severity of Injury
ABI severity is usually classified according to the level of altered consciousness experienced by the patient following injury (Table 1.2). The use of level of consciousness as a measurement arose because the primary outcome to understand the severity of an injury is the Glasgow Coma Scale. Consciousness levels following ABI can range from transient disorientation to deep coma. Patients are classified as having a mild, moderate or severe ABI according to their level of consciousness at the time of initial assessment. Various measures of altered consciousness are used in practice to determine injury severity. Common measures include the Glasgow Coma Scale (GCS), the duration of loss of consciousness (LOC), and the duration of post-traumatic amnesia (PTA).
188.8.131.52 Glasgow Coma Scale
184.108.40.206 Duration of Loss of Consciousness
220.127.116.11 Post-Traumatic Amnesia
1.4.1 Literature Search Strategy
Specific subject headings related to ABI were used as the search terms for each database. These search terms were selected with the assistance of a medical staff librarian. The search was broadened by using each specific database’s subject headings, this allowed for all other terms in the database’s subject heading hierarchy related to ABI to also be included. The database subject headings used as search terms for CINAHL were “brain injuries” and “head injuries”; for EMBASE, “brain injury” and “head injury”; for MEDLINE, “brain injuries” and “craniocerebral trauma”; and for PsycINFO “brain injuries” and “traumatic brain injury”. Additional keywords were used specific to each module.
1.4.2 Study Inclusion Criteria
For inclusion in ERABI, the study population must have had ≥50% ABI (as defined in Table 1.3) or the study independently reports on a subset of participants with ABI. The study population must also have a minimum sample size of three. Further, the focus is on the efficacy of interventions for moderate to severe ABI; consequently, any studies dealing with mild forms of ABI were excluded.
1.4.3 Data Extraction
1.4.4 Quality Assessments of Methodological Designs
18.104.22.168 Interpreting the Results of Individual Studies
22.214.171.124 Formulating Conclusions Based on Levels of Evidence
Using this system, conclusions were easily formed when the results of multiple studies were in agreement. However, in cases where RCTs differed in conclusions and methodological quality, the results of the study (or studies) with the higher PEDro score(s) were more heavily weighted. In rare instances the authors needed to make a judgment when the results of a single study of higher quality conflicted with those of several studies of inferior quality. In these cases we provided rationale for our decision and made the process as transparent as possible. In the end the reader is encouraged to be a “critical consumer” of the material presented.
1.5.1 Limitations of Evidence-Based Reviews
1.5.2 Limitations in Neurorehabilitation Research
There are ethical considerations that limit neurorehabilitation research. In ABI populations, many individuals lack the mental capacity to give fully informed consent. Another consideration is the expanding body of evidence for effectiveness of multidisciplinary rehabilitation in other conditions, particularly stroke, makes it increasingly unethical to randomize patients to ‘no treatment’ or even ‘standard’ care. The length of time, typically months or years, over which rehabilitation may have its effects is typically longer than the funding for research projects and hinders the use of ‘wait-list’ control groups. Control group interventions must be selected carefully for current neurorehabilitation research.
The application of randomized controlled trial (RCT) designs is limited by small numbers of patients at each site due to potential ethical considerations. Current trends towards the acceptance of RCTs as the gold standard source of evidence may also limit the knowledge base needed to make sound decisions about ABI rehabilitation priorities and policies. It I important to remember that rigorous observational alternatives to the RCT are still of significant value (Whyte, 2002). Given the existing literature base for ABI rehabilitation, evidence-based rehabilitation must rely on a variety of types of evidence, often in combination (Victora et al., 2004). The inclusion of alternate study designs can provide a more complete picture of the existing evidence, particularly where RCTs are lacking, and thereby advise ABI practice, albeit not as strongly. Excluding data collected under other research designs could bias the evidence base toward interventions that are “easier” to evaluate but not necessarily more effective or cost-effective (Des Jarlais et al., 2004). As a result of the challenges explained above, there are few large experimental design studies in this field.
No Summary in this Module
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Des Jarlais, D. C., Lyles, C., Crepaz, N., & Group, T. (2004). Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: the TREND statement. American journal of public health, 94(3), 361.
Greenwald, B. D., Burnett, D. M., & Miller, M. A. (2003). Congenital and acquired brain injury. 1. Brain injury: epidemiology and pathophysiology. Archives of physical medicine and rehabilitation, 84(3 Suppl 1), S3-7.
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Purtillo. (1992). Whom to treat first, and how much is enough? Ethical dilemmas that physical therapists confront as they compare individual patients’ needs for treatment. International Journal of Technology Assessment in Health Care, 8, 26-34.
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Teasdale, G., & Jennett, B. (1976). Assessment and prognosis of coma after head injury. Acta neurochirurgica, 34(1-4), 45-55.
Toronto Acquired Brain Injury Network. (2005). Definition of acquired brain injury. Retrieved from http://www.abinetwork.ca/downloads/binder-b3.pdf
Turner-Stokes, L. (2004). The evidence for the cost-effectiveness of rehabilitation following acquired brain injury. Clinical Medicine, 4(1), 10-12.
Victora, C. G., Habicht, J.-P., & Bryce, J. (2004). Evidence-based public health: moving beyond randomized trials. Journal Information, 94(3).
Whyte, J. (2002). Traumatic brain injury rehabilitation: Are there alternatives to randomized clinical trials? Archives of physical medicine and rehabilitation, 83(9), 1320-1322.
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1.2 Objective of the Evidence Based Review of Acquired Brain Injury