1. Introduction and Methodology
ABI Acquired Brain Injury
ERABI Evidence-Based Review of Moderate to Severe Acquired Brain Injury
GCS Glasgow Coma Scale
LOC Loss of Consciousness
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. ERABI aims to identify all currently described rehabilitation interventions with their associated evidence, with the goal of facilitating evidence-based practice. In doing so, ERABI also identifies gaps in the literature deserving further research.
Knowledge translation is an iterative process that includes synthesis, dissemination, exchange and application of knowledge/research in clinical care. ERABI aspires to descriptively report, compare and synthesize research studies to determine the effectiveness of ABI rehabilitation interventions. This is done on an annual basis. ERABI is a platform used in the earlier stages of knowledge translation to inform clinical practice guidelines and to guide clinical practice in a way that benefits the patient and the caregiving team.
1.1 Objective of the Evidence Based Review of Acquired Brain Injury
The aim of this project is to conduct a comprehensive, evidence-based review of the research literature regarding rehabilitation interventions for moderate to severe ABI. The authors have systematically reviewed the research evidence to create a review that has benefit and relevance to both clinicians and researchers.
1.2 Defining Acquired Brain Injury
1.2.1 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 injury 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 diffuse brain lesions, anoxia, tumours, aneurysm, vascular malformations, and infections of the brain (Toronto Acquired Brain Injury Network, 2005). Although one can argue that stroke is an ABI, it is usually not included because of its focal nature; ABIs tend to be more diffuse.
Given that ‘ABI’ can have multiple definitions, studies with an ‘ABI’ population can be equally heterogeneous 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). The vast majority of 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.
1.2.2 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).
126.96.36.199 Glasgow Coma Scale
188.8.131.52 Duration of Loss of Consciousness
184.108.40.206 Post-Traumatic Amnesia
1.3.1 Literature Search Strategy
Specific subject headings related to ABI were used as the search terms for each database. 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 consistent search terms used were “head injur*”, “brain injur*”, and “traumatic brain injur*”. Additional keywords were used specific to each module. A medical staff librarian was consulted to ensure the searches were as comprehensive as possible.
1.3.2 Study Inclusion Criteria
Studies meeting the following criteria were included: (1) published in the English language, (2) at least 50% of the population included participants with ABI (as defined in Table 1.3) or the study independently reported on a subset of participants with ABI, (3) at least three participants, (4) ≥50% participants had a moderate to severe brain injury, and (5) involved the evaluation of a treatment/intervention with a measurable outcome. Both prospective and retrospective studies were considered. Articles that did not meet our definition of ABI were excluded.
1.3.3 Data Extraction
Once an article was selected for full review, the following data was extracted: author(s), country and year of publication, sample size, participant characteristics (i.e., type of injury, severity, sex, age, time since injury), treatment/intervention, outcome measure(s), and results. This data is summarized using tables presented in each module. Articles evaluating similar treatments were then grouped together under the appropriate subject headings.
1.3.4 Methodoloical Quality of Assessment of RCTs
The methodological quality of each randomized controlled trial (RCT) was assessed using the Physiotherapy Evidence Database (PEDro) rating scale developed by the Centre for Evidence-Based Physiotherapy in Australia (Moseley et al., 2002). The PEDro is an 11-item scale; a point is awarded for ten satisfied criterion yielding a score out of ten. The first criterion relates to external validity, with the remaining ten items relating to the internal validity of the clinical trial. The first criterion, eligibility criteria, is not included in the final score. A higher score is representative of a study with higher methodological quality.
1.3.5 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 instances, 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.
1.4 Interpretation of the Evidence
No Summary in this Module
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1.1 Objective of the Evidence Based Review of Acquired Brain Injury