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A multidisciplinary community based rehabilitation programme improved social functioning in severe traumatic brain injury
  1. Deirdre R Dawson, PhD, Ot(c)
  1. Kunin-Lunenfeld Applied Research Unit,
 Baycrest Centre for Geriatric Care, and University of Toronto
 Toronto, Ontario, Canada

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 QUESTION: In patients with severe traumatic brain injury (TBI), is a multidisciplinary community based outreach rehabilitation programme more effective than information only?

    Design

    Randomised (allocation concealed*), blinded (outcome assessors),* controlled trial with a mean follow up of 24.8 months.

    Setting

    An urban setting in east London, UK.

    Patients

    110 patients, 16 to 65 years of age, who sustained severe TBI 3 months to 20 years previously and had no other neurological conditions. 94 patients (85%, mean age 34y, 76% men) participated in the end of study assessment.

    Intervention

    54 patients were allocated to a multidisciplinary community based outreach rehabilitation programme, and 56 were allocated to an information only group. Rehabilitation was highly individualised in intensity, duration, and form of treatment, with patients seen in their homes or other community settings for 2 to 6 hours per week for an average of 27 weeks.

    Main outcome measures

    Scores on the Barthel Index (BI), the Brain Injury Community Rehabilitation Outcome-39 (BICRO-39), the Functional Independence/Assessment Measure (FIM+FAM), and the Hospital Anxiety and Depression Scale (HADS). An individually determined change score, the maximum gain index (MGI), was also calculated by identifying the subscale on which each patient showed the greatest improvement from intake to follow up.

    Main results

    Analysis was by intention to treat. On the BI, more patients in the outreach group (35%) showed improvement than did patients in the information only group (20%) (Mann-Whitney U test on ranked changed scores, mean rank 53.2 v 41.6, p < 0.05). Median change scores on the BICRO-39 were greater for those in the outreach group than for those in the information group for the total score, the MGI, and the self organisation and psychological wellbeing subscores (table). The FIM+FAM and HADS scores showed similar improvements in both groups. However, the MGI for the FIM+FAM was greater for those in the outreach group than for those in the information only group (mean rank 53.2 v 40.4, p < 0.03). The time since brain injury was not related to the magnitude of gain.

    Conclusion

    In patients with severe traumatic brain injury, a multidisciplinary community based outreach rehabilitation programme improved social functioning.

    Commentary

    In 1998, Chesnut et al 1 published an evidence-based analysis of TBI rehabilitation. They were able to draw few positive conclusions about the efficacy of rehabilitation because of the dearth of available evidence. The important study by Powell et al provides a welcome counterpoint because it supports the usefulness of ongoing community based rehabilitation for patients with TBI. Particularly noteworthy are the design — it is one of the few randomised controlled trials related to community based rehabilitation2 — the inexpensive intervention, the similarity of the intervention to other publicly funded community based rehabilitation programmes, and that change occurred many years after TBI.

    Several limitations exist in the study. First, the 2 primary outcome measures that were used had substantial ceiling and floor effects (BI and 2 subscales of the BICRO-39). Use of other available measures of community integration might have avoided this problem.3 Second, the outreach group did not make substantive gains in terms of returning to paid employment, school, or child care, or improving non-family social contact — 2 key indicators of successful community integration. It is possible, as the authors suggest, that obstacles beyond the control of therapist or patient are the reason for this. However, altering some of the elements of the treatment may have a positive effect. This study contributes to the growing body of evidence suggesting that multifaceted rehabilitation approaches provide the best outcomes,4 but also shows what more needs to be done.

    The take-home message is that functionally based rehabilitation shows promise for improving day to day life for patients with severe TBI even many years after injury. Although further evidence is needed to substantiate these findings and address questions about the content, intensity, duration, and timing of rehabilitation, time since injury should not preclude referral to community based services.

    References

    Community outreach programme v information only in traumatic brain injury at a mean of 24.8 months†

    
 
 QUESTION: In patients with severe traumatic brain injury (TBI), is a multidisciplinary community based outreach rehabilitation programme more effective than information only?

    View Abstract

    Footnotes

    • Sources of funding: Medical Research Council and Department of Health.

    • For correspondence: Dr J Powell, Goldsmiths College, London, UK. j.powell{at}gold.ac.uk.

    • Abstract and commentary also appear in Evidence-Based Mental Health.

    • * See glossary.

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